2DEFER STEMI Presentation Slides

TIMI 1 flow post-PCI
MRI - cine
Contrast MRI
Deferred stenting
Negligible scar
TIMI 3 flow post-PCI
MRI - cine
Contrast MRI
Results Primary endpoint
35 30 25
Immediate stenting Deferred stenting p = 0.003 29
•Hemodynamic instability
•Eligible but not randomized
Deferred stenting (4 - 16 hrs later) n = 52
Usual care (immediate stent) n = 49
Assessment - endpoints
Hypothesis
In primary PCI, after initial coronary reperfusion, brief deferral of stenting might reduce no-reflow and it’s sequelae vs. usual care with immediate stenting.
DEFER STEMI
No conflict of interest
Background
No-reflow
- A cause of acute and chronic heart failure after primary PCI - Predictable: Clinical risk factors e.g. duration of ischemia, thrombus burden
Independent core lab analyses blind to treatment group
Primary endpoint:
Incidence of no-reflow / slow-reflow (TIMI 2) Main secondary endpoints: No reflow (TIMI 0/1) Intra-procedural thrombotic events (IPTEs) Main vessel or side branch • New or worsened thrombus • Abrupt closure • Distal embolization
N = 411 (March – Nov 2012)
Excluded n=310 (75%)
•Lack inclusion criteria TIMI 3 flow asp thrombectomy+/ - POBA
Enrolment Randomized n=101
•Patient unfit for research
Acknowledgements
British Heart Foundation
NHS Colleagues & patients
Angiographic Core Laboratory, CRF & Columbia University Medical Center, New York, NY.
Immediate stenting
Deferred stenting
80 60 % 40 20 0
62
p = 0.22
48 19
p = 0.32
12
Incidence MVO
Median Infarct size
Conclusions
• In selected STEMI patients, no-reflow and thrombotic events were reduced with deferred stenting compared with immediate stenting.
Thank you for your attention
colin.berry@
DEFER STEMI A randomised Trial of
Deferred vs. Immediate Stenting to Prevent No-reflow in Acute STEMI
Carrick D, McEntegart M, Haig C, Petrie M, Eteiba H, Hood S, Owens C, Watkins S, Layland J, Behan M, Sood A, Hillis W, Mordi I, Mahrous, A, Ahmed N, Wilson R, Lasalle L, Lindsay MML, Peat E, Rae A, Généreux P, Ford I, Oldroyd KG, Berry C
Golden Jubilee National Hospital, Scotland, UK; University of Glasgow; Cardiovascular Research Foundation and Columbia University Medical Center, New York City ACC Featured Session, March 9, 2013
p < 0.0001
33
p = 0.03
14
10 6 2
%
20 15 10 5 0
No-reflow (TIMI 0/1)
No/slow-reflow Complications (TIMI<3) (IPTEs)
MRI results Secondary endpoint
Median time to deferred stenting: 9(6-12)h Median time to deferred stenting : 9 (6 – 12) hrs
TIMI thrombus score ≥ 2
Small vessel diameter (≤2.5 mm)
Exclusion criteria
•
Absence of normal flow in culprit artery Cardiogenic shock
All comers – STEMIs assessed for eligibility
Eligibility
Inclusion criteria, one or more of:
• • Previous MI Age ≥ 65 yrs
• Long plaque (>24mm)
• Persistent ST-elevation • Ischemic time ≥ 6 h
•
• •
•
Initial TIMI flow 0/1

• Our intervention is potentially a novel, pragmatic and widely applicable preventative therapy for no- reflow.
• The safety and cost-effectiveness of deferred stenting in selected patients merits further prospective assessment in a multicenter trial.
• No-reflow (TIMI 0/1) • Slow-reflow (TIMI 2) • Stent thrombosis
McEntegart et al. JACC Interventional Cardiology. 2012
MRI findings 2 days post-MI
Immediate stenting Microvascular obstruction
- No evidence-based preventative treatments
Prevention of no-reflow
Primary PCI
LAD
Rationale
In selected patients with risk factors for noreflow, restored flow & anti-thrombotic therapies reduce thrombus burden such that stenting 4 – 16 hrs later is safe and effective.