Gill Heart Institute
Strive to Revive Symposium
April 28, 2014
Susan Smyth, MD PhD
FINANCIAL DISCLOSURES: GRANT SUPPORT
Boehringer-Ingelheim
Astrazeneca
Core laboratory for PD substudy of TRACER
NIH/NHLBI
Department of Veterans Affairs
American Heart Association
OHCA: Out of Hospital
Cardiac Arrest
Each year, 424,000 people experience nontraumatic OHCA assessed by emergency medical
services (EMS) personnel.
Approximately 60 percent of OHCA victims are
treated by EMS.
OHCA: Out of Hospital
Cardiac Arrest
Twenty-five percent of OHCA victims treated by
EMS have no symptoms before the onset of
arrest.
Among EMS-treated OHCA cases, 23 percent
have an initial rhythm of ventricular fibrillation (VF)
or ventricular tachycardia (VT).
OCHA Survival: Cardiac Arrest Registry to
Enhance Survival (CARES)
Overall Survival
October 1, 2005 - December 31, 2010
N = 31,689 of cardiac etiology
OCHA Survival: Cardiac Arrest Registry to
Enhance Survival (CARES)
Survival to Discharge with Witness Arrest and VT/VF
October 1, 2005 - December 31, 2010
N = 31,689 of cardiac etiology
OHCA: Out of Hospital
Cardiac Arrest
Chain of Survival
Early recognition and management of
STEMI to prevent arrest
Heart attack survival in Kentucky
Second highest mortality in the United States
System Component Key Element
Identify at-risk patient
populations
Healthcare Providers
Aggressive primary prevention
System Component Key Element
Community
Bystander CPR
Public-access defibrillation
Bystander actions at actual out-of-hospital
cardiac arrest events.
Not Trained
Trained
Cave D M et al. Circulation. 2011;123:691-706
Kentucky State Bill 89
Requirement for all Kentucky high school
students to be trained in CPR before
graduation.
CPR training is already in Kentucky’s Academic Core
Standards for high school health education, and health
class is a graduation requirement.
1-800-372-7181 Members of Senate leadership – President
Robert Stivers, Majority Floor Leader Damon Thayer,
Caucus Chair Dan Seum, and Majority Whip Brandon Smith
System Component Key Element
9-1-1/EMS
Rapid first response
Dispatch Assisted CPR
High Quality CPR
Early Defibrillation
Prehospital EKG
Dispatch Assisted CPR
Detroit
Kanto, Japan
Seattle, King
County
Cave D M et al. Circulation. 2011;123:691-706
Prehospital EKG.
Adjusted Mortality Odds Ratio (95% CI) for
Prehospital vs No Prehospital ECG
Mortality
End Point
Total
(n=154 546)
STEMI
(n=72 638)
STEMI with PCI
(n=14 063)
NSTEMI
(n=81 908)
Hospital
0.85
0.88
0.89
0.76
30 d
0.94
0.94
0.91
0.84
288,990 patients admitted to hospitals for ACS from 2005 to 2009 after
emergency medical service transport
50.3% of the cohort underwent prehospital ECGs
Quinn et al. Heart. 2014
KBEMS: Kentucky Board of Emergency
Medical Services
Cardiovascular & Stroke Care Committee
•Implement and evaluate a comprehensive AMI and stroke access
assessment, targeting all 120 counties of the commonwealth
• Collaborate with system engineers to analyze EMS system capabilities
and those of regional healthcare facilities and specialty care centers
•Begin implementation of quality improvement initiatives
•Promote and advocate for educational programs, protocol updates and
a regionalized EMS system of care
•Establish a date set for cardiac and stroke care that can be reported by
EMS systems and healthcare facilities for ongoing research
William Dillion, MD, FACC, Committee Chair
KBEMS: Kentucky Board of Emergency
Medical Services
Cardiovascular & Stroke Care Committee
Recommendations on appropriate management of
STEMI and cardiac arrest
Emergency medical technicians (EMT) have within
their scope of practice to perform EKGs –
now includes BLS providers
Recommendation that all ALS units be EKG capable
“This alone will go a long way in identifying and appropriately triaging
patients with chest pain.” Vaughn Payne, MD, FACC
System Component Key Element
Hospital
STEMI Network
Early PCI
Cardiac arrest Network
Therapeutic hypothermia
Shock Network
24/7 MCS
ICD as appropriate
Cardiac rehab upon discharge
STEMI guidelines
 90 min from time of first medical contact to PCI
 120 min from time of first medical contact to PCI
if presenting to a non-PCI facility
 30 min from hospital arrival for fibrinolytics
University of Kentucky
STEMI Experience 2009 - 2011.
Transfers
■ 1-2
▲ 3-4
Ο >4
Wallace E et al. South Med J. 2013 Jul;106(7):391-8
University of Kentucky
STEMI Experience 2009 - 2011.
191 STEMIs
82 presented to UK
109 transferred from OSH
82 (75%) Primary PCI
27 (25%) Fibrinolytics
Wallace E et al. South Med J. 2013 Jul;106(7):391-8
University of Kentucky
STEMI Experience 2009 - 2011.
STEMI Time Guidelines Met (DTB/DTN)
Presented to UK : 80% within 90 min
Transferred from OSH
Primary PCI : 30% within 120 min
Fibrinolytics : 42% within 30 min
Wallace E et al. South Med J. 2013 Jul;106(7):391-8
University of Kentucky
STEMI Experience 2009 - 2011.
STEMI DTB Time (median)
Presented to UK : 72 min
Transferred from OSH : 145 min; P<0.01
Higher CPK-MB
Shock (7.3% vs. 4.9%)
Wallace E et al. South Med J. 2013 Jul;106(7):391-8
University of Kentucky
STEMI Experience 2009 - 2011.
Major Adverse Outcomes
Wallace E et al. South Med J. 2013 Jul;106(7):391-8
STEMI Experience in Kentucky
13 hospitals n = 1500
67% of patients present via EMS
45% of patients are transferred from initial facility
to PCI site (versus 23% nationally)
47% bypass ED at PCI facility
(up from 31% in 2011)
55 min door in-door out time
39 min transfer time
STEMI Experience in Kentucky
13 hospitals n = 1500
61% have PCI within 90 min of FMC
29% have PCI within 120 min of FMC with transfer
10% fibrinolytic use
61 – 67% of fibrinolytics are given within 30 min
Kentucky STEMI Network
.
coalescing and
coordinating EMS,
emergency
departments, nonPCI facilities, and
catheterization
laboratories
STEMI Network:
Involve EMS
Engage non-PCI hospitals
Consider lytics in settings of long door in/out times
High quality standards for receiving hospitals
Standard protocol
Establish benchmarking
STEMI Network:
Shared purpose
Physician leadership
Support from hospital systems
Support from EMS
Standard protocol
Data collection
Feedback
Quality improvement (across the continuun)
Funding
SHOCK Network
ECMO■
VAD ■
Transplant ■
Severe, persistent
cardiogenic shock
patients need
rapid intervention
to restore
adequate
circulation
□SBP < 90mmHg
□inadequate tissue perfusion
□low urine output
□rising lactate > 2mmol/l