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1
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)
3
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
8
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
14
% of all cases with DTB times <90 mins
15
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
17
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)
19
p=0.017
(Unadjusted data)
20
p=0.004
(Unadjusted data)
21
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
23
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%
25
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)
27
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 %)
31
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
32
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
33
Median door to balloon times(MINAP Data)
0
20
40
60
80
100
120
140
160
2003 2004 2005 2006 2007 2008
minutes
34
PCI Mortality (stratified by syndrome)
BCIS audit 2008BCIS audit 2008
35
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 (%)
36
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 %
37
Intra Aortic Balloon Pump