AA 2008Session III: STEMI

The UK data

Mark de Belder

The James Cook University Hospital

Middlesbrough

Disclosures/Conflicts of interest

• Research Grants– Cordis/Abbott

• Advisory Boards– Cordis/Boehringer Ingelheim

We do not have accurate data!

• We do not have precise figures for UK or for England & Wales on:– Numbers of MIs (in total), STEMIs and non-STEMIs– Numbers receiving lysis

• Numbers of these referred for rescue• Numbers receiving interval PPCI

– Numbers receiving PPCI– Numbers receiving no reperfusion therapy

• Possible sources of data:– Office for National Statistics– DoH HES data– CCAD: MINAP and BCIS datasets– National and International Registries

Trends in mortality from AMI 1993-2002from: Griffiths C, Brock A, Rooney C. Impact of introducing ICD-10 on trends in mortality

from circulatory diseases in England & Wales. www.statistics.gov.uk/articles/hsq/hsq22ICD-10

(adjusted from ICD-9 to ICD-10)

A matter of coding?A matter of coding?Better primary prevention?Better primary prevention?Better management of AMI?Better management of AMI?Better secondary prevention?Better secondary prevention?Something in the air?Something in the air?All of the above?All of the above?

GRACE RegistryThe Global Registry of Acute Coronary Events

ST elevation audit 1999-2002 - reperfusion

Carruthers KF et al, Heart 2005;91:290-8

0

10

20

30

40

50

60

70

80

%

Any Lysis PPCI

UKEurMultinat

MINAP Report 2005/06Drug Therapy

0102030405060708090

100

%

D-to-N<30min

C-to-N<60min

ASA BB Statins

TargetObserved

Trends since 2001Patients receiving Pre-Hospital Thrombolysis and PPCI

0

100

200

300

400

500

600

700

No.PHTPPCI

MINAP 2006

18289

597

3349

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

Lysis Referred forRescue

Interval PCI PPCI

3.3%3.3%

John Birkhead, personal communication

Lysis patients: 54% IHL and 68% PHL undergo subsequent angiography

??

BCIS CCAD data 2006

55823

27169

36791258 222 249 114

0

10000

20000

30000

40000

50000

60000

All

All ACS

PPCI

Rescue

ReMI

ReMI rescue

AT/SAT2.3% of total, 4.6% of ACS2.3% of total, 4.6% of ACS

6.6% of total, 13.5% of ACS6.6% of total, 13.5% of ACS

48.7%48.7%

0.2%0.2%

Primary PCI – the experience

0

200

400

600

800

Primary PCI pmp

UK population 60 million, at 500 pmp = 30,000 procedures pa

2004 data: Ludman

Primary PCIRoutine Rx for STEMI

13

28 32 37

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007

513 18 23

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007

2006 data: Ludman

NHS Centres only

Working Hours 24/7

Number of centres

Working Hrs includes all 24/7 sites

0

50

100

150

200

250

300

350

Number of procedures

Hospitals

Primary PCI for STEMI2006 data from NHS Centres

Total 3930 procedures

0 or No data

CCAD E&W + Scot

2006 data: Ludman

UK Centres - 2006Angiography (90) PCI (91)

A 1(M )

A 1(M )

A 1(M )

A 1(M )

A 57(M)

A 64 (M )

M 1

M 1

M 18

M 180

M 6

M 602

M 62

M 62

M 62

M 63

M 65

M 66

M 67

Barnsley

Batley

Bebington

Birkenhead

Bootle

Burnley

Bury

Cheadle and Gatley

Chester

Crosby

Darlington

Dewsbury

Doncaster

Ellesmere Port Grimsby

Halifax

Harrogate

Hartlepool

Huyton-with-Roby

Macclesfield

Morecambe

Morley

Rochdale

Runcorn

Sale

Salford

Scunthorpe

Southport

Stockton-on-Tees

Wakefield

Wallasey

Warrington

Widnes

Wigan

Blackburn

Blackpool

Bolton

Bradford

Huddersfield

Kingston upon Hull

Leeds

Liverpool Manchester

Middlesbrough

Oldham

Preston

Rotherham

Sheffield

St. Helens

Stockport

York

.

15-30 min

30-45 min

45-60 min

60+ min

below 15 min

Distance from hub andexpected distribution of STEMI cases

A 1

A 102A 329(M)

M 1

M 1

M 11

M 20

M 23

M 25

M 25

M 26

M 3

M 4

M 40

Havering

Kingstonupon Thames

Bromley

Greenwich

Barnet

Hillingdon

Bexley

Enfield

Barking and Dagenham

Hackney

Tower Hamlets

Newham

Waltham Forest S

Waltham Forest N

Redbridge

Haringey

Hammersmithand Fulham

Ealing

Hounslow

Brent

Harrow

Camden

Islington

Croydon

Kensington and Chelsea

Westminster

Lambeth

Southwark

Lewisham

Wandsworth

Richmond upon Thames

Sutton

Merton

City of London

Chest

Royal Free

St Thomas'

Kings College

St George's

HarefieldHospital

Hammersmith HeartHospital

St Mary's

10 km

A: <=5 min

B: <=10 min

C: <= 15 min

D: <= 20 min

E: <= 30 min

F: > 30 min

London results: Time to nearest hospital: drivetime zones

UK Centres - 2006PCI (91)

NIAP sites

NIAP ProjectMain 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

Median Door-to-Balloon times (minutes)

31

85

97

74

34

70

36

130

0 20 40 60 80 100 120 140

Direct Lab

Direct CCU

Direct A&E

Direct all

Transfer D2tB Lab

Transfer D2tB A&E

Transfer D2tB

Transfer D1tB

mins

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

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

NIAP: Indications for PCI in lysis group

12

0.4 1.9 2.1

18

1.3

64

0

10

20

30

40

50

60

70

%

Rescue AT/SAT ReMI ReMIRescue

Post-MI Unlisted None

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

All as % No. SuccessPartial

successFail no comp

Re-PCI

QMIEm

CABGDeath

NSTEMI / UA no shock 13667 93.5 2.7 3.0 0.3 0.2 0.09 0.62

All STEMI

no shock3656 93.0 2.0 2.4 0.6 0.14 2.5

Primary PCI 2549 90.4 2.2 2.7 0.5 0.2 4.6

Rescue PCI 1187 91.1 1.9 2.6 0.4 0 4.8

Shock 430 65.6 4.1 2.2 0.5 0.93 30.2

Outcome 2006CCAD data only

2006 data: Ludman

p<0.0001

(Unadjusted data)

p=0.06

(Unadjusted data)

p=0.017

(Unadjusted data)

p=0.004

(Unadjusted data)

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

Readmission days

Reperfusion strategy

Total readmissions

Readmissions per pt

Readmissions per hospital survivor

Total days Days per pt Days per hospital survivor

PPCI 548 0.39 0.41 2729 1.95 2.04

Lysis 260 0.56 0.60 1947 4.17 4.47

Nil 177 0.47 0.56 1464 3.87 4.67

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

Conclusions

• Need for more accurate data• Whether you are a believer in PPCI or lysis + rescue,

current activity is insufficient• We will get better outcomes if we change our strategies• Current data support a change to PPCI • Regional organisation of “Heart Attack Centres” is

essential• Triage in the field, and direct transfer to labs is the only

viable way to deliver PPCI, and is the best way to deliver PHL and timely rescue PCI

• STREAM will perhaps tell us what the options are for early presenters