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Primary Angioplasty for Acute STEMI

Dr Adam Jacques

Dr Sola Odemuyiwa

February 2010

2

Reperfusion Therapy in STEMI

Improves survival by reestablishing blood flow within the occluded infarct-related artery(Keeley NEJM 2007)

Primary PCI is superior to fibrinolytic therapy when performed rapidly by expert teams(Keeley Lancet 2003)

Its effectiveness may be limited by delays in delivery(Giugliano, Circ 2003)

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Some patients -have a contraindication to fibrinolysis

No effective thrombolysis in about 15% of patients given fibrinolytic therapy

Reocclusion within 3 months in about a quarter of those receiving fibrinolytic therapy.

Limitations of Fibrinolytic Therapy

4

5

6

7

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Hospital Mortality for STEMI

D2B Time in minutes Mortality< 90 3.0%

91 -120 4.2%

121-150 5.7%

>150 7.4%

McNamara JACC 2006

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St. Peter’s Based Strategies for Shorter Door-to-Balloon Times

Pre-hospital ECG and early cath lab activationEmergency department bypassDirect access to cath labRapid triage of patients in ER with rapidly obtaining ECG in ERER department activation of cath labSingle call activationRapid arrival of PCI team at hospitalProcess of performing PCIPrompt data feedbackTeam-based approach D2B

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“Heart Attack Rap”Well let me tell you about the heart attack storyHow we achieved the point of PISC gloryYou came clutching your chest with your artery closedYou left the lab smiling with flow like a hoseI said flow like a hose, flow like a hose-The Cuban Rapper

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Trends since 2001Patients receiving Pre-Hospital Thrombolysis and PPCI

0

100

200

300

400

500

600

700

No.PHTPPCI

12

2020thth October, 2008 October, 2008

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NIAP ProjectMain points from initial analysisBCS ASC, Glasgow, 2007

Compared with the patients treated with thrombolysis identified by these networks, the PPCI treated cohort: Had a low in-hospital mortality Involved fewer ambulance journeys Had fewer complications (re-infarction, major

and minor bleeds [inc. i-c bleeds]) Were less likely to require additional

angiography and revascularisation (PCI/CABG) during the index hospitalisation

Had a shorter length of stay

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% of all cases with DTB times <90 mins

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Mortality: PPCI direct admissions (DTB time)

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Median LOS [days]

BCS, Glasgow June 7, 2007BCS, Glasgow June 7, 2007

0

1

2

3

4

5

6

PPCI Lysis None

PPCILysisNone

1399 467 378

33

66

44

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In-hospital Mortality (all patients)

[Index hospitalisation PLUS “convalescent” hospital, includes shock]

4.4

6.6

16.9

0

2

4

6

8

10

12

14

16

18

%

PPCI Lysis Nil62/1399 31/467 64/378

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p<0.0001

(Unadjusted data)

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p=0.017

(Unadjusted data)

20

p=0.004

(Unadjusted data)

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Cardiac re-admissions and re-infarction

9.4

17.6

12.7

2.7

9.4

4.5

0

2

4

6

8

10

12

14

16

18

%

Cardiac readmissions All reinfarction

PPCILysisNil

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Additional procedures

0.16

0.67

0.35

0.12

0.46

0.13

0.0290.0580.066

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

per patient

Angio PCI CABG

PPCILysisNil

Given as procedures per pt as some patients had more than one procedure

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Myocardial Ischaemia National Audit Project (MINAP)

How the HNS Manages Heart Attacks

Eighth Public Report 2009

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Development of PPCI servicesMINAP data

2007 -8 2008-9

No. of hospitals providing PPCI

54 66

No. of patients receiving PPCI

4,471 7,919

% of STEMI patients treated by PPCI

27% 33%

% of STEMI patients treated with lysis

43% 41%

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Total Lysis & PPCI (2005-2009) (MINAP Data)

0

1000

2000

3000

4000

5000

6000

7000

Q1 2 3 4 Q1 2 3 4 Q1 2 3 4 Q1 2 3 4 Q1

LysisPPCI

200720072005 200920092008200820062006

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6 month mortality for STEMI (MINAP Data 2005-7, patients <80 yrs)

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Cardiac Networks providing PPCI to > 60% of STEMI patientsMINAP 2008-9 data

NC LONDON NE LONDON NW LONDON SE LONDON SW LONDON

BLACK COUNTRY COVENTRY + WARWICK (BIRMINGHAM)

WEST YORKS

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Cardiac Networks providing PPCI to 30-60% of STEMI patientsMINAP 2008-9 data

BIRMINGHAM, SAND, SOLIHULL 57% NORTH OF ENGLAND 59% PENINSULA 21%

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Cardiac Networks providing PPCI to < 30% of STEMI patientsMINAP 2008-9 data

ANGLIA AGWS BEDS + HERT CHESHIRE DORSET EAST MIDLANDS ESSEX GR MANCHESTER HERTS + WORCESTER

KENT LANCS + CUMBRIA NORTH OF ENGLAND NORTH TRENT N + E YORKS SHROPS AND STAFFS SOUTH CENTRAL SURREY SUSSEX

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How are STEMI patients treated?MINAP 2008-9 data

2008-9

In-hospital lysis 7533 (31 %)

Pre-hospital lysis 2515 (10 %)

PPCI 7919 (33 %)

No reperfusion treatment 6126 (25 %)

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Acceptable PCI-Related Time Delay

Nallamothu 60 mins - inaccurate data

Terkelsen 119 mins

Boersma ≥120 mins

Pinto 114 mins

RIKS-HIA >>90 mins

Vienna 138 mins

ASSENT-4 >>102 mins

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MortalityCath lab

(n=287)Ward/CCU

(n=149)A&E(n=448)

In hospital 3.5 2.7 6.0

30 day 3.8 4.0 6.9

1 year 5.9 * 8.7 10.7 *

18 month 7.0 * 12.1 11.8 *

Mortality for PPCI by route of admission

* - statistically significant difference between valuesExcluded: patients in-hospital and transfers via non-PCI centres

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Median door to balloon times(MINAP Data)

0

20

40

60

80

100

120

140

160

2003 2004 2005 2006 2007 2008

minutes

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PCI Mortality (stratified by syndrome)

BCIS audit 2008BCIS audit 2008

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Hospital Mortality after PCI for STEMI and NSTEMI patients:

Quartiles of PCI volumeQuartiles of PCI volumeHeart 2008;94:329-335Heart 2008;94:329-335

0

1

2

3

4

5

4 - 190 196 - 323 327 - 520 521 - 2204

Mortality (%)

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97% PPCI COVERAGE: IS IT ACHIEVABLE?

NETWORK 2007-8

BLACK COUNTRY 97 %

NC LONDON 97 %

NE LONDON 100 %

NW LONDON 97 %

SE LONDON 93 %

SW LONDON 81 %

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Intra Aortic Balloon Pump