Ambulance Victoria and MonashHEART
Acute Myocardial Infarction (Mon-AMI)
12 lead ECG project.
An update
On behalf of the MonAMI Team
A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg,
T Kambourakis, JD Cameron, IT Meredith.
Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine
(MMC), Monash University, Melbourne, Australia.
Metropolitan Ambulance Service, Melbourne Australia.
Southern Health Emergency, Southern Health, Melbourne Australia.
Emergency Coronary Angioplasty for Acute
Heart Attack at Monash
Rescue AMI
Primary AMI
Total AMI
Year
Time Delay to Treatment in Acute Heart
Attack Angioplasty & Mortality
Zwolle AMI Study
Group
1994-2001 n = 1791
Early recognition,
rapid transport
and treatment is
absolutely vital
1. Every minute delay in Rx affects mortality in both
Thrombolytic & 1o PCI groups.
2. Every 30 min delay = Relative
in 1 year mortality by 7.5%.
G.De Luca Circulation. 2004;109:1223 -1225
In patient Mortality %
Door to Balloon time affects
in hospital mortality
US National registry of myocardial infarction
J Am Coll Cardiol, 2006 47:2180-2186
Hospital Management of STEMI*
Symptom onset < 1 hour
before presentation
Symptom onset 1–3 hours
before presentation
Symptom onset 3–12
hours before presentation
PCI available
within 1 hour†
PCI available
within 90 minutes†
PCI available within 90 minutes
(onsite) or 2 hours
(offsite, including transport)†
YES
NO
YES
NO
YES
NO
PCI
Fibrinolysis‡
PCI
Fibrinolysis‡
PCI
Fibrinolysis‡
* Assuming no contraindications to fibrinolytic therapy; † Time delay refers to time from first medical contact to balloon;
‡ Patients with ongoing symptoms or instability should be transferred for PCI.
PCI = percutaneous coronary intervention
Acute Coronary Syndrome Guidelines Working Group
Med J Aust 2006;184(8 Suppl):S9-29.
Time to presentation
MonashHEART experience
Aims of MonAMI
To determine if paramedic performed field 12
lead ECG and activation of the infarct team, via
the emergency physician, reduced D2BT in
patients undergoing primary PCI (PPCI)
Methods


Prospective interventional study in a single Australian
metropolitan health care network.
560 patients
 MonAMI group

All patients (n=186) who underwent PPCI following
field ECG
 Non-MonAMI group

Patients (n=254) who underwent PPCI following
standard triage during the time of field ECG capability
 Pre-MonAMI group.

The D2BT of 120 consecutive patients who underwent
PPCI prior to initiation of field triage
12 Lead ECG Project
Traditional AMI Communication Strategy:
Patient with CP
MICA
MICA Transports
Patient to ED
Patient Triaged in
ED
12 Lead ECG
Performed by ED
Staff
Diagnosis Made
ED
Resident/Registrar
or Consultant
Calls Cardiology
Registrar
Cardiology Registrar
sights ECG & calls
CCU Ward Service
Consultant
Interventional
Cardiologist
Contact
Infarct Team
Activated
12 Lead ECG Project
New lines of Communication:
Patient with CP
MICA Attends &
Performs 12 Lead
ECG On Site
MICA Transports
Patient to Monash
Heart Cath Labs
12 Lead ECG
Electronically
Transmitted to ED
Page
Diagnosis Made by
ED Consultant
Interventional
Cardiologist
Contact
Infarct Team Ready &
Waiting in Cath Labs
Patient Demographics
Pre Mon-AMI
Non Mon-AMI
Mon-AMI
P value
Male
81%
74%
81%
0.20
Age (Years)
58.5
61.2
63.5
0.003
Hypertension
38%
47%
40%
0.22
Diabetes
16%
19%
14%
0.20
Hyperlipidaemia
32%
37%
41%
0.16
Smoker (current)
42%
40%
37%
0.42
Family History
19%
23%
24%
0.52
Out of hours
54%
63%
53%
0.08
MonAMI Pilot Study
December 2007 – July 2008
Field ECG faxed to MMC
204
ED stand down
N = 85 (41%)
STEMI
N=0
ACS
(excluding STEMI)
N = 35
Taken to Cath Lab
N = 119 (59%)
No ACS
N = 52
Primary PCI
N = 107
CAD no PCI
N = 3*
* Severe Triple Vessel Disease (CABG)
No overt CAD
N=9
Median D2B Times
P < 0.001
December 2007 – July 2009
Median Times
Pre MonAMI
Non MonAMI
MonAMI
P value
D2BT
102
102.5
56.5
<0.001
Door-to-cath
lab time
69
70
26
<0.001
Cath lab-toBalloon time
28
28
27
0.44
Ambulance times (minutes)
P = 0.31
Proportion of cases achieving D2B
time under 90 minutes
75%*
*AHA /ACC/SCAI guidelines
Conclusion
The performance of field 12 lead ECG to triage
and pre hospital activation of the infarct team
significantly improves door to balloon times
and results in a greater proportion of patients
achieving guideline recommendations.
MonAMI Pilot Study
Ambulance Victoria
Greg Cooper
Danny McGennisken
Eddy Watkins
Bill Barger
Ian Jarvie
Ambulance Victoria Group Manager
Operations Manager Paramedic Education & Training
Clinical support Officer
Manager Clinical Standards & Audits
Ambulance Victoria Clinical Support Officer
Monash Heart
Prof Ian Meredith
Dr Yuvi Malaiapan
Director MonashHeart
Head Interventional Services
SH Emergency Dept
Prof George Braitberg
Dr Tony Kambourakis
Mr Damien Gibney
Professor and Director SH Emergency Medicine
Director Emergency Monash Clayton
NUM Emergency Monash Clayton
Strategy Planning & Performance
Ms Fiona Webster
Ms Ruth Smith
Ms Karen Barker
Executive Director SPP
Director Access, Innovation & Service Improvement
Project Officer
Southern Health Information Technology
Mr Charles Burgess
Mr Peter Kinsman
Executive Director IT
Director IT
Monash Sector Executive
Mr Adam Horsburgh
Director Monash sector