Primary Angioplasty for Acute STEMI
Dr Adam Jacques
Dr Sola Odemuyiwa
February 2010
1
Reperfusion Therapy in STEMI
Improves survival by reestablishing blood flow within the occluded infarctrelated 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)
2
Limitations of Fibrinolytic Therapy
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.
3
4
5
6
7
Hospital Mortality for STEMI
D2B Time in minutes
< 90
Mortality
3.0%
91 -120
4.2%
121-150
5.7%
>150
7.4%
McNamara JACC 2006
8
St. Peter’s Based Strategies for Shorter Door-toBalloon Times
Pre-hospital ECG and early cath lab activation
Emergency department bypass
Direct access to cath lab
Rapid triage of patients in ER with rapidly obtaining ECG in ER
ER department activation of cath lab
Single call activation
Rapid arrival of PCI team at hospital
Process of performing PCI
Prompt data feedback
Team-based approach D2B
9
“Heart Attack Rap”
Well let me tell you about the heart attack
story
How we achieved the point of PISC glory
You came clutching your chest with your
artery closed
You left the lab smiling with flow like a hose
I said flow like a hose, flow like a hose
-The Cuban Rapper
10
Trends since 2001
Patients receiving Pre-Hospital Thrombolysis and PPCI
700
600
500
400
PHT
PPCI
No.
300
200
100
0
Q1
01
20
Q2
Q3
Q 4 2Q 1
0
20
Q2
Q3
Q 4 3Q 1
0
20
Q2
Q3
Q 4 4Q 1
0
20
Q2
Q3
Q 4 5Q 1
0
20
Q2
Q3
Q 4 6Q 1
0
20
11
20th October, 2008
12
NIAP Project
Main points from initial analysis
BCS 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
13
% of all cases with DTB times <90 mins
14
Mortality: PPCI direct admissions (DTB time)
15
Median LOS [days]
6
6
5
4
3
4
PPCI
Lysis
None
3
2
1
0
PPCI
1399
Lysis
467
None
378
BCS, Glasgow June 7, 2007
16
In-hospital Mortality (all patients)
[Index hospitalisation PLUS “convalescent” hospital, includes shock]
18
16.9
16
14
12
%
10
8
6
6.6
4.4
4
2
0
PPCI
62/1399
Lysis
Nil
31/467
64/378
17
p<0.0001
(Unadjusted data)
18
p=0.017
(Unadjusted data)
19
p=0.004
(Unadjusted data)
20
Cardiac re-admissions and re-infarction
17.6
18
16
14
%
12
10
12.7
9.4
9.4
8
6
4.5
4
2
0
PPCI
Lysis
Nil
2.7
Cardiac readmissions
All reinfarction
21
Additional procedures
0.7
0.67
0.6
0.5
per patient
0.46
0.4
PPCI
Lysis
Nil
0.35
0.3
0.2
0.16
0.1
0
0.12
0.13
0.0580.066
0.029
Angio
PCI
CABG
Given as procedures per pt as some patients had more than one procedure
22
 Myocardial Ischaemia National Audit Project
(MINAP)
 How the HNS Manages Heart Attacks
 Eighth Public Report 2009
23
Development of PPCI services
MINAP data
2007 -8
No. of hospitals providing
PPCI
No. of patients receiving
PPCI
2008-9
54
66
4,471
7,919
% of STEMI patients treated
by PPCI
27%
33%
% of STEMI patients treated
with lysis
43%
41%
24
Total Lysis & PPCI (2005-2009)
(MINAP Data)
7000
6000
5000
4000
Lysis
PPCI
3000
2000
1000
0
Q1 2
2005
3
4 Q1 2
2006
3
4
Q1 2
2007
3
4 Q1 2
2008
3
4 Q1
2009
25
6 month mortality for STEMI
(MINAP Data 2005-7, patients <80 yrs)
26
Cardiac Networks providing PPCI
to > 60% of STEMI patients
MINAP 2008-9 data





NC LONDON
NE LONDON
NW LONDON
SE LONDON
SW LONDON
 BLACK COUNTRY
 COVENTRY + WARWICK
 (BIRMINGHAM)
 WEST YORKS
27
Cardiac Networks providing PPCI
to 30-60% of STEMI patients
MINAP 2008-9 data
 BIRMINGHAM, SAND, SOLIHULL
 NORTH OF ENGLAND
 PENINSULA
57%
59%
21%
28
Cardiac Networks providing PPCI
to < 30% of STEMI patients
MINAP 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
29
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 %)
30
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
31
Mortality for PPCI by route of admission
Cath lab
Ward/CCU
A&E
(n=287)
(n=149)
(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
* - statistically significant difference between values
Excluded: patients in-hospital and transfers via non-PCI centres
32
Median door to balloon times
minutes
(MINAP Data)
160
140
120
100
80
60
40
20
0
2003
2004
2005
2006
2007
2008
33
PCI Mortality (stratified by syndrome)
BCIS audit 2008
34
Hospital Mortality after PCI for STEMI and NSTEMI patients:
5
4
3
Mortality (%)
2
1
0
4 - 190
196 - 323
327 - 520
521 - 2204
Quartiles of PCI volume
Heart 2008;94:329-335
35
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 %
36
Intra Aortic Balloon Pump
37