Acute Myocardial Acute Myocardial Infarction: Results Infarction: Results

from the DHMC from the DHMC Regional Registry Regional Registry

Nathaniel Niles, MDNathaniel Niles, MD

Cardiology Grand RoundsCardiology Grand RoundsJanuary 13, 2005January 13, 2005

Dartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical Center

MyocardialMyocardial

perfusionperfusion

Plaque rupturePlaque rupture→ → thombotic occlusion thombotic occlusion of epicardial artery of epicardial artery

Downstream Downstream Infarct zoneInfarct zone

ThrombolyticThrombolyticTherapyTherapy

Primary Primary PCIPCI

Restore flow to Restore flow to epicardial vesselepicardial vessel

Current Management Goals Current Management Goals for Treating Acute STEMIfor Treating Acute STEMI

Treatment goal: Treatment goal: prevent death by restoring prevent death by restoring

coronary blood flowcoronary blood flow

High risk of in-hospital death High risk of in-hospital death (~10%)(~10%)

“No Flow”“No Flow” “Slow Flow”“Slow Flow” “Normal Flow”“Normal Flow”

TIMI 0 / TIMI 1Flow

TIMI 0 / TIMI 1Flow

TIMI 2Flow

TIMI 2Flow

TIMI 3Flow

TIMI 3Flow

9.3%9.3%

6.1%6.1%

3.7%3.7%

p<0.0001 vs TIMI 0/1p<0.0001 vs TIMI 2

p<0.0001 vs TIMI 0/1p<0.0001 vs TIMI 2

P=0.003 vs TIMI 0/1P=0.003 vs TIMI 0/1

Tea

m 2

Tea

m 2

Tea

m 2

Tea

m 2

Tea

m 2

Tea

m 2

Ger

man

Ger

man

Ger

man

Ger

man

Ger

man

Ger

man

GU

ST

O 1

GU

ST

O 1

GU

ST

O 1

GU

ST

O 1

GU

ST

O 1

GU

ST

O 1

TA

M I

1-7

TA

M I

1-7

TA

M I

1-7

TA

M I

1-7

TA

M I

1-7

TA

M I

1-7

TIM

I 1

,45,

10B

TIM

I 1

,45,

10B

TIM

I 1

,45,

10B

TIM

I 1

,45,

10B

TIM

I 1

,45,

10B

TIM

I 1

,45,

10B

CM Gibson 1998 in Acute Coronary SyndromesCM Gibson 1998 in Acute Coronary SyndromesSample Size of Pooled Analysis: 5,498Sample Size of Pooled Analysis: 5,498

0

2

4

6

8

10

12

Epicardial Flow After Thrombolysis Epicardial Flow After Thrombolysis and Mortality Outcomesand Mortality OutcomesEpicardial Flow After Thrombolysis Epicardial Flow After Thrombolysis and Mortality Outcomesand Mortality Outcomes

““Time is nature’s way of keeping Time is nature’s way of keeping everything from happening at once”everything from happening at once”

- Woody Allen - Woody Allen

““Time is muscle”Time is muscle”- A. Schwarzenegger- A. Schwarzenegger

0

25

50

75

100

0 30 60 90 120 150

Reperfusion Strategy Reperfusion Strategy and TIMI-3 Flow Rateand TIMI-3 Flow Rate

Time from presentation (min)

(30 min angio) (60 min angio) (90 min angio)210 240

TIM

I 3

Flo

w (

%)

TIM

I 3

Flo

w (

%)

54%"Door-to-needle"

time30 min

t-PA

39%

89%

Primary angioplasty

10% spontaneousreperfusion

““Door-to-Door-to-BalloonBalloon

Time” inTime” inDANAMI 2DANAMI 2

114 min114 min

Lytic TxLytic Txgaingain

11oo PCI PCIgaingain

Reperfusion Strategy Reperfusion Strategy and TIMI-3 Flow Rateand TIMI-3 Flow Rate

0

25

50

75

100

0 30 60 90 120 150

Time from presentation (min)

(30 min angio) (60 min angio) (90 min angio)210 240

TIM

I 3

Flo

w (

%)

TIM

I 3

Flo

w (

%)

54%"Door-to-needle"

time30 min

t-PA

39%

89%

Primary angioplasty

10% spontaneousreperfusion

““Door-to-Door-to-BalloonBalloon

Time” inTime” inDANAMI 2DANAMI 2

114 min114 min

Lytic TxLytic Txgaingain

11oo PCI PCIgaingain

87

14

9

0

10

20

30

Death Death,reinfarction,

stroke

Primary PCI

Thrombolytic Therapy

p=0.0002p=0.0002

p=0.0001p=0.0001

Fre

quen

cy (

%)

Fre

quen

cy (

%)

23 study review23 study review

vs.vs.

87

14

9

0

10

20

30

Death Death,reinfarction,

stroke

Transfer for Primary PCI

On-site TTx

p=0.057p=0.057

p=0.0001p=0.0001

Fre

quen

cy (

%)

Fre

quen

cy (

%)

5 study review5 study review

vs.vs.

Average Transfer Time Average Transfer Time = 39 minutes= 39 minutes

Mortality rates with primary PCI as Mortality rates with primary PCI as a function of PCI-relateda function of PCI-related time delaytime delay

P = 0.006

0 20 40 60 80 100

PCI-Related Time Delay (door-to-balloon - door-to-needle)

Ab

solu

te R

isk

Dif

fere

nce

in D

eath

(%

)A

bso

lute

Ris

k D

iffe

ren

ce in

Dea

th (

%)

-50

510

15

Circle sizes = sample size of the individual study.

Solid line = weighted meta-regression.

Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-6

62 min62 min BenefitFavors PCIBenefitFavors PCI

HarmFavors LysisHarmFavors Lysis

Typical Typical “Door-to-“Door-to-

balloon” time balloon” time for transfer for transfer

patientspatients>200 min>200 min

Delayed primary angioplasty

0

25

50

75

100

0 30 60 90 120 150

Prolonged Delays→Facilitated PCIProlonged Delays→Facilitated PCI

Time from presentation (min)

(30 min angio) (60 min angio) (90 min angio)180 210

TIM

I 3

Flo

w (

%)

TIM

I 3

Flo

w (

%)

½ dose t-PA + abciximab and“facilitated” thrombolysis(TIMI 14)

““facilitated PCI”facilitated PCI”

Trials Examining Facilitated PCI Trials Examining Facilitated PCI after Thrombolysis vs. Thrombolysis after Thrombolysis vs. Thrombolysis alonealone

TrialTrial YearYear NN Thrombolytic Thrombolytic RegimenRegimen

Increased Increased bleedingbleeding

ConclusionsConclusions

SPEEDSPEED 20002000 528528 Combination Combination TxTx

NoNo Decreased reinfarction Decreased reinfarction and urgent revasc.and urgent revasc.

TIMI TIMI 10B/14B10B/14B

20012001 19381938 Combination Combination TxTx

NoNo Reduction in Death + Reduction in Death + Recurrent MIRecurrent MI

GARCIA-1GARCIA-1 20042004 500500 FD r-PAFD r-PA NoNo Lower post-hospital Lower post-hospital cardiac events at 30 d.cardiac events at 30 d.

SIAM 3SIAM 3 20032003 197197 FD r-PAFD r-PA NoNo Lower MACE at 6 mos.Lower MACE at 6 mos.

CAPITAL CAPITAL AMIAMI

20042004 170 (high 170 (high risk)risk)

FD TNKFD TNK NoNo Reduced MACE at 30 d.Reduced MACE at 30 d.

Trials Examining Facilitated PCI vs. Trials Examining Facilitated PCI vs. Primary PCIPrimary PCI

TrialTrial YearYear NN ThrombolytiThrombolytic Regimenc Regimen

Increased Increased bleedingbleeding

ConclusionsConclusions

PACTPACT 19991999 606606 Half doseHalf dose

t-PAt-PA

NoNo Better TIMI 3 flow at Better TIMI 3 flow at initial Angioinitial Angio

SPEEDSPEED 20002000 528528 FD r-PA, FD r-PA, Combo TxCombo Tx

NoNo Better TIMI 3 flow, lower Better TIMI 3 flow, lower TIMI frame countTIMI frame count

GARCIA-2GARCIA-2 20042004 205205 FD TNKFD TNK NoNo Better ST resolution, Better ST resolution, better TIMI 3 flow, No better TIMI 3 flow, No difference in cardiac difference in cardiac

functionfunction

BRAVEBRAVE 20042004 253253 Combination Combination TxTx

Trend?Trend? Better TIMI 3 flow, no Better TIMI 3 flow, no difference in infarct sizedifference in infarct size

ASSENT 4ASSENT 4 OngoingOngoing 40004000 FD TNKFD TNK -- --

FINESSEFINESSE OngoingOngoing 30003000 Combination Combination TxTx

-- --

II IIaIIa IIbIIb IIIIIIUpdated Guidelines (2004)Updated Guidelines (2004)

STEMI patients presenting to a facility without prompt primary PCI capability (within 90 minutes) should receive thrombolytic therapy unless contraindicated. (Level of Evidence: A)

Facilitated PCI might be performed as a reperfusion strategy in higher-risk patients when PCI is not immediately available and bleeding risk is low. (Level of Evidence: B)

If immediately available, primary PCI should be performed in patients with STEMI as quickly as possible (Level of Evidence: A)

If the symptom duration is within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is:≤ 1 hour, primary PCI is preferred. (Level of Evidence: B)> 1 hour, thrombolytic therapy is preferred. (Level of Evidence: B)

Combination therapy for reperfusion and prevention of reinfarction with abciximab and half-dose reteplase or tenecteplase for selected high risk patients at low risk for bleeding. (Level of Evidence: A)

APD or VA Transfers

6%

DHMC ER23%

Outside ER Transfers

71%

Source of Patients Presenting to Source of Patients Presenting to DHMC Cath Lab for Treatment of DHMC Cath Lab for Treatment of STEMI within 24 hoursSTEMI within 24 hours

DHMC STEMI Patient DHMC STEMI Patient Mortality: 2001Mortality: 2001Primary PCI vs Transfer PatientsPrimary PCI vs Transfer Patients

8.17.6

0123456789

10

4

8.5

0123456789

10

Mor

talit

y (%

)M

orta

lity

(%)

ObservedObserved in-hospitalin-hospital

Transfer Transfer PatientsPatients

Primary PCI Primary PCI PatientsPatients

TIMI RiskTIMI Risk(expected 30 day)(expected 30 day)

Transfer Transfer PatientsPatients

Primary PCI Primary PCI PatientsPatients

““When you come to a fork in the When you come to a fork in the road, take it”road, take it”

- Yogi Berra- Yogi Berra

Transport to DHMC for Transport to DHMC for potential salvage PCI potential salvage PCI

ASAPASAP

Transport to DHMC Cath Lab Transport to DHMC Cath Lab ASAPASAP

Oxygen, ASA, low dose heparin, beta blocker, nitrates,

Morphine, 2 IV lines, treat pain, CHF, shock, arrhythmias

Non-DHMC Emergency DeptNon-DHMC Emergency DeptAMI diagnosedAMI diagnosed

>30 min of CP and/or>30 min of CP and/orECG with 1mmST elevation or LBBBECG with 1mmST elevation or LBBB

Primary Thrombolytic TherapyPrimary Thrombolytic Therapy

Full Dose Full Dose ThrombolyticThrombolytic

Alice Peck Day or Alice Peck Day or VA HospitalVA Hospital

Administer Administer abciximababciximab

Contraindication for Contraindication for Thrombolytic therapy/Thrombolytic therapy/

abciximababciximab

Remote ER and Remote ER and Age < 75Age < 75

Administer Administer abciximababciximab

and ½ Dose and ½ Dose ThrombolyticThrombolytic

Primary PCIPrimary PCIFacilitated PCIFacilitated PCI Acute ST elevation MI is Acute ST elevation MI is now on the DHMC now on the DHMC

“ALWAYS TAKE” list“ALWAYS TAKE” list

December 2001December 2001

DHMC STEMI RegistryDHMC STEMI RegistryGoalsGoals

• Assess safety and effectiveness of Assess safety and effectiveness of specific novel management specific novel management strategies (facilitated PCI for strategies (facilitated PCI for transfer patients)transfer patients)

• Monitor regional outcomes over Monitor regional outcomes over time in order to assess the impact of time in order to assess the impact of overall quality improvement effortsoverall quality improvement efforts

STEMI Database - STEMI Database - Case Case Report FormReport Form• Emergency Room Emergency Room

• Presentation (Hx/PE)Presentation (Hx/PE)• ECGsECGs• TreatmentTreatment• Timing of TreatmentTiming of Treatment

• Cath LabCath Lab• TIMI FlowTIMI Flow• Timing of reperfusionTiming of reperfusion• InterventionIntervention• Extent of CADExtent of CAD

• Follow-upFollow-up• DeathDeath• StrokeStroke• Recurrent MIRecurrent MI• CHFCHF• Bleeding ComplicationsBleeding Complications• Repeat Revascularization ProceduresRepeat Revascularization Procedures

STEMI DatabaseSTEMI Database

• Initiated 12/01Initiated 12/01

• Cath lab database query of all patients Cath lab database query of all patients cathed with hx of MI within 24 hrscathed with hx of MI within 24 hrs• 1/01-12/01 retrospective chart review1/01-12/01 retrospective chart review• 1/02-3/04 prospective chart review1/02-3/04 prospective chart review

• 4/04-7/04 prospective cath lab data 4/04-7/04 prospective cath lab data entryentry

Safety and Effectiveness of Safety and Effectiveness of specific novel management specific novel management

strategies:strategies:

Facilitated PCI in Moderate to Facilitated PCI in Moderate to High Risk Patients Requiring High Risk Patients Requiring

Hospital Transfer for PCIHospital Transfer for PCI

Presented at:Presented at:TransCatheter Therapeutics (TCT)TransCatheter Therapeutics (TCT)

Washington, DCWashington, DCSeptember, 2004September, 2004

“Non-Committed Strategy”•± full dose TTx•± GP 2b3a Inhib•Transfer/cath as 2° strategyN= 276 (49%)

“Facilitated Strategy”•½ dose TTx•GP 2b3a Inh•Emergent transfer for cathN= 163 (29%)

“Primary Strategy”•No TTx•± GP 2b3a Inh•Emergent cath

N= 107 (19%)

Clinical history consistent with acute myocardial infarctionand ST elevation, LBBB or anterior ST depression consistent

with acute posterior MIN=564

Presenting to DHMC or Local HospitalN= 125 (22%)

Presenting to Remote HospitalN= 439 (78%)

“Non-Committed Strategy”•± TTx•± GP 2b3a Inh•Cath as 2° Strategy

N= 18 (3%)

TIMI Score < 2N = 22 (4%)

TIMI Score ≥ 2N = 85 (15%)

TIMI Score < 2N = 51 (9%)

TIMI Score ≥ 2N = 112 (20%)

Door-to-Balloon TimeDoor-to-Balloon Time

154

227

0

50

100

150

200

250

300

Mean Door-to-balloon time

Primary strategyFacilitated stretegy

p<0.0001

Tim

e i

n m

inu

tes

Tim

e i

n m

inu

tes

• Reperfusion was delayed on average more than 70 minutes among facilitated PCI strategy patients

Pre-Cath Lab OutcomesPre-Cath Lab Outcomes

64

32

66

38

0

10

20

30

40

50

60

70

80

% o

f P

ati

en

ts

Ongoing CPon arrival to

cath lab

PersistentST on

arrival tocath lab

p<0.0001 p<0.0003

7.1

5.3

10.5

8.9

0

2

4

6

8

10

12

14

% o

f P

ati

en

tsPre-cathclinical

deteriorationto intubation

or shock

Shock uponarrival to cath

lab

Primary Strategy

Facilitated Strategy

p=ns

p=ns

• Facilitated PCI strategy patients arrived at the cath lab in more stable condition

Cath Lab Findings and OutcomesCath Lab Findings and Outcomes

TIMI 319%

TIMI 223% TIMI 3

50%

TIMI 225%

0

10

20

30

40

50

60

70

80

90

PrimaryStrategy

FacilitatedStrategy

p<0.0001

p<0.0001

17.6

5.4

0

5

10

15

20

25

PrimaryStrategy

FacilitatedStrategy

p=0.0056

Initial TIMI Flow in IRA Cath Lab Intubation or IABP

% o

f P

atie

nts

% o

f P

atie

nts

• Facilitated Strategy yielded more patent arteries and was Facilitated Strategy yielded more patent arteries and was associated with less complcated proceduresassociated with less complcated procedures

In-hospital OutcomesIn-hospital Outcomes

10.6

4.4

5.9

2.7

14.1

9.8

4.7

2.7 2.3

0.9

3.5

6.3

10.6

6.3

18.8

8

5.7 5.7

0

2

4

6

8

10

12

14

16

18

20

22

Death Recurrent MI Clin. CHF Stroke ICH TIMI MajorHem.

RepeatPCI/CABG

Composite* Length of Stay(days)

Primary strategy

Facilitated strategy

*Composite = Death, Recurrent MI, ICH, Repeat Revascularization

% o

f P

atie

nts p=0.098

ns

ns

ns

ns

ns

ns

p=0.025

ns

““Optimal” 1° PCI vs. transfer for Optimal” 1° PCI vs. transfer for facilitated PCI facilitated PCI Conclusions:Conclusions:

• had longer delays before reperfusion (avg. >70 had longer delays before reperfusion (avg. >70 minutes)minutes)

But…But…• had no greater likelihood of deterioration pre-cathhad no greater likelihood of deterioration pre-cath

• were less likely to have ischemia in lab and had less were less likely to have ischemia in lab and had less complicated procedurescomplicated procedures

• had better initial infarct artery flow and overall had better initial infarct artery flow and overall better clinical outcomesbetter clinical outcomes

• tended to have more bleeding problems tended to have more bleeding problems

But…But…• no increase in ICHno increase in ICH

Monitoring Regional Monitoring Regional Outcomes Over TimeOutcomes Over Time

•Transfer for PCI PatientsTransfer for PCI Patients•Primary PCI Patients (DHMC, Primary PCI Patients (DHMC, VAMC, APD)VAMC, APD)

DHMC STEMI Transfer DHMC STEMI Transfer Volumes Q1(01)-Q2(04)Volumes Q1(01)-Q2(04)

0

10

20

30

40

50

60

Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04)

Nu

mb

er

of S

TE

MI P

atie

nts

Nu

mb

er

of S

TE

MI P

atie

nts

AMI Transfer Patients: AMI Transfer Patients: 01→ 04 01→ 04 In-hospital MortalityIn-hospital Mortality

8.5

10.4

5.13.8

0

5

10

15

2001 2002 2003 2004

p=0.0375

% M

orta

lity

Year

AMI Transfer Patients: 01→ AMI Transfer Patients: 01→ 0404In-hospital MACE*In-hospital MACE*

13.614.4

10.2

6.4

0

2

4

6

8

10

12

14

16

2001 2002 2003 2004

% M

AC

E

Year

**Death, Recurrent MI, ICH, Repeat revascularizationDeath, Recurrent MI, ICH, Repeat revascularization

AMI Transfer Patients AMI Transfer Patients In-hospital Bleeding In-hospital Bleeding ComplicationsComplications

6.7

0

4

0.8

5.1

1.1

6.4

00

5

10

15

2001 2002 2003 2004

TIMI MajorHemorrhage

ICH

%

Year

Possible Explanations Possible Explanations for Improving for Improving OutcomesOutcomes• Lower risk patients now Lower risk patients now

transferredtransferred• Reduction in delays to Reduction in delays to

reperfusionreperfusion• Volume effect – Improved Volume effect – Improved

outcomes with increased volumeoutcomes with increased volume• Effect of half dose lytic protocolEffect of half dose lytic protocol

DHMC STEMI: DHMC STEMI: Mean TIMI Risk Mean TIMI Risk Score Q1(01)-Q2(04)Score Q1(01)-Q2(04)

0

1

2

3

4

5

6

Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04)

TIM

I Ris

k S

core

TIM

I Ris

k S

core**

**Composite of advanced age, CV risk factors, hypotension, tachycardia,Composite of advanced age, CV risk factors, hypotension, tachycardia,

high Killip class, low body weight, anterior MI location, delay in Txhigh Killip class, low body weight, anterior MI location, delay in Tx

DHMC STEMI: DHMC STEMI: Mean Door-to-Mean Door-to-Balloon time Q1(01)-Q2(04)Balloon time Q1(01)-Q2(04)

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04) Q3(04)

Do

or-

to-B

allo

on

time

(min

)D

oo

r-to

-Ba

lloo

n tim

e (m

in)

QuarterQuarter

DHMC STEMI Transfer DHMC STEMI Transfer Volumes Q1(01)-Q2(04)Volumes Q1(01)-Q2(04)

0

10

20

30

40

50

60

Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04)

No Lytic GivenFull DoseHalf Dose

Nu

mb

er

of S

TE

MI P

atie

nts

Nu

mb

er

of S

TE

MI P

atie

nts

AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseIn-hospital MortalityIn-hospital Mortality

13.5

6

3

0

2

4

6

8

10

12

14

16

18

20

None Given Full Dose Half Dose

% M

orta

lity

Lytic Dose Strategy

p<0.04

p<0.0009

p=ns

AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseTIMI Risk ScoreTIMI Risk Score

3.73.1 3

0

1

2

3

4

5

6

None Given Full Dose Half Dose

Ave

rage

TIM

I R

isk

Sco

re

Lytic Dose Strategy

p<0.06

p=0.007

p=ns

AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseReperfusion and “Facilitated” CourseReperfusion and “Facilitated” Course

75

61

53

0

20

40

60

80

100

Persistant CP or ST elevation

15

36

44

0

10

20

30

40

50

60

TIMI 3 Flow on

Initial Angio

22.8

14.7

4.8

0

5

10

15

20

25

Cath Lab IABP or

Intubation

12

6.25.4

0

2

4

6

8

10

12

14

Clinical Deterioration

Pre-Cath

No lytic givenNo lytic given Half dose lyticHalf dose lyticFull dose lyticFull dose lytic

AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseDoor-to-Balloon TimeDoor-to-Balloon Time

353

274

219

050

100150200250300350400450500

None Given Full Dose Half Dose

Doo

r-to

-Bal

loon

Tim

e (m

in)

Lytic Dose Strategy

p=0.0023p=0.0023

p=0.0001p=0.0001

p=0.0164p=0.0164

AMI Transfer Patients: AMI Transfer Patients: 01→ 0401→ 04In-hospital Mortality by In-hospital Mortality by Treatment strategyTreatment strategy

9.1

2.3

13.5

2.6

7.6

4.53

0

5

10

15

2001 2002 2003 2004

Half dose

All others

% M

orta

lity

Year

Monitoring Outcomes Monitoring Outcomes Over TimeOver TimeTransfer for PCI PatientsTransfer for PCI Patients

• Outcomes are improving Outcomes are improving • Explanation of improvement is Explanation of improvement is

unclear:unclear:• Half-dose lytic regimenHalf-dose lytic regimen• Expedited care in half-dose groupExpedited care in half-dose group• Non-specific improvement Non-specific improvement

(“Hawthorne effect”)(“Hawthorne effect”)• Still Room for improvementStill Room for improvement

• Faster transfersFaster transfers• Better regimens (reduce bleeding)Better regimens (reduce bleeding)

Oxygen, ASA, heparin, Oxygen, ASA, heparin, beta blocker, nitrates, beta blocker, nitrates,

Morphine, 2 IV lines, treat Morphine, 2 IV lines, treat pain, CHF, shock, pain, CHF, shock,

arrhythmiasarrhythmias

Oxygen, ASA, heparin, Oxygen, ASA, heparin, beta blocker, nitrates, beta blocker, nitrates,

Morphine, 2 IV lines, treat Morphine, 2 IV lines, treat pain, CHF, shock, pain, CHF, shock,

arrhythmiasarrhythmias

After hour or weekendsAfter hour or weekends(technician not on site)(technician not on site)

Page Cardiology fellow on callPage Cardiology fellow on call

Administer abciximabAdminister abciximabunless contraindication or unless contraindication or

significant cautionssignificant cautions

Weekday hoursWeekday hoursCall 5-7783,Call 5-7783,

Notify “charge-person”Notify “charge-person”

Administer abciximabAdminister abciximabunless contraindication or unless contraindication or

significant cautionssignificant cautions

No Cath lab readyNo Cath lab readyCath lab readyCath lab ready

DHMC Emergency DeptDHMC Emergency DeptAMI diagnosed:AMI diagnosed:

>30 min of CP and/or>30 min of CP and/orECG with 1mmST elevation or LBBBECG with 1mmST elevation or LBBB

DHMC Emergency DeptDHMC Emergency DeptAMI diagnosed:AMI diagnosed:

>30 min of CP and/or>30 min of CP and/orECG with 1mmST elevation or LBBBECG with 1mmST elevation or LBBB

Consent and transport to Catheterization Lab on CallConsent and transport to Catheterization Lab on CallConsent and transport to Catheterization Lab on CallConsent and transport to Catheterization Lab on Call

Non-transfer STEMI PatientsNon-transfer STEMI Patients (Presenting to DHMC, VAMC, APD)(Presenting to DHMC, VAMC, APD)Q1(01)-Q2(04)Q1(01)-Q2(04)

0

5

10

15

20

25

Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04)

Nu

mb

er

of S

TE

MI P

atie

nts

Nu

mb

er

of S

TE

MI P

atie

nts

STEMI Patients presenting STEMI Patients presenting to DHMC, VAMC, APD to DHMC, VAMC, APD

n=112n=112

Not initially admitted to Not initially admitted to or transferred to DHMCor transferred to DHMC

Time to Cath Lab Time to Cath Lab table table ≥ 10 hrs≥ 10 hrs

PCI not attemptedPCI not attempted

n=109n=109

n=98n=98

n=93n=93

True 1True 1° PCI ° PCI strategystrategy

True 1True 1° PCI ° PCI

1° PCI Strategy Patients 1° PCI Strategy Patients

5.2

10.0

0

5

10

15

2001-2002 2003-2004

ns

Years

2.9

3.8

0

2

4

6

2001-2002 2003-2004

p=0.051

Actual In-hospital Actual In-hospital Mortality (%)Mortality (%)

TIMI Risk ScoreTIMI Risk Score

1° PCI Patients1° PCI Patients(with PCI actually attempted)(with PCI actually attempted)

5.2 5.7

0

5

10

15

2001-2002 2003-2004

ns

Year Grouping

2.9

3.8

0

2

4

6

2001-2002 2003-2004

p=0.069

Actual In-hospital Actual In-hospital Mortality (%)Mortality (%) TIMI Risk ScoreTIMI Risk Score

1° PCI Strategy Patients1° PCI Strategy PatientsTable Time and MortalityTable Time and Mortality

3.1

15.2

0

5

10

15

20

0-2hours

>2hours

0.028

Door-to-Table Time

3

3.9

0

1

2

3

4

5

6

0-2hours

>2 hours

0.041

Actual In-Actual In-hospital hospital

Mortality (%)Mortality (%)

TIMI Risk TIMI Risk ScoreScore

Pre-Cath Pre-Cath Shock or Shock or

IntubationIntubation

3.1

24.2

0

10

20

30

0-2hours

>2hours

0.001

1° PCI Strategy 1° PCI Strategy Patients:Patients:ER to Cath LabER to Cath Lab

Cath Lab ReadinessCath Lab Readiness““Ideal” Ideal”

(weekday 7 AM to 5 (weekday 7 AM to 5 PM)PM)

““Suboptimal” Suboptimal” (after hours or on (after hours or on

weekend)weekend)

TargetTarget <45 min.<45 min. <75 min.<75 min.

MeanMean 89 min.89 min. 142 min.142 min.

MedianMedian 83 min.83 min. 108 min.108 min.

Median Tabletop-to-balloon time = 38 min.Median Tabletop-to-balloon time = 38 min.

Median Door-to-balloon time (ideal readiness) = 122 min.Median Door-to-balloon time (ideal readiness) = 122 min.

Door-to-Table TimeDoor-to-Table Time

Times Over TimeTimes Over Time

158

44

179

108

30

133118

47

158

100

41

151

0

50

100

150

200

2001 2002 2003 2004

Door-to-tabletopTabletop-to-balloonDoor-to-balloon)

66

35

110

68

33

101 108

73

165

97

53

149

0

50

100

150

200

2001 2002 2003 2004

Door-to-tabletopTabletop-to-balloonDoor-to-balloon

““Ideal” (Weekdays 7 AM to 5 PM)Ideal” (Weekdays 7 AM to 5 PM)

““Suboptimal” (After hours and Weekends)Suboptimal” (After hours and Weekends)

1° PCI Strategy Patients1° PCI Strategy PatientsEarly GP 2b3a inhibitor use and Early GP 2b3a inhibitor use and MortalityMortality

3.7

11.4

0

5

10

15

ER2b3a

No ER2b3a

ns

GP 2b3a Inhibitor Initiation

3.53.1

0

1

2

3

4

5

ER2b3a

No ER2b3a

ns

Actual In-Actual In-hospital hospital

Mortality (%)Mortality (%)

TIMI Risk TIMI Risk ScoreScore

TIMI 317

TIMI 229

TIMI 316

TIMI 218

0

20

40

60

80

ER2b3a

No ER2b3a

ns

46

34

Infarct Vessel Infarct Vessel Patency (%)Patency (%)

30

51

76

64

0

25

50

75

100

2001 2002 2003 2004

1° PCI Strategy Patients1° PCI Strategy PatientsEarly GP 2b3a inhibitor Use Over Early GP 2b3a inhibitor Use Over TimeTime

%%p=0.01

0 0 0 0

5.9

11.8

0

5

10

15

20

25

Tirofiban Abciximab Eptifibatide

DeathMACE

n=3n=3 n=17n=17 n=34n=34

1° PCI Strategy Patients1° PCI Strategy PatientsEarly GP 2b3a inhibitor Choice and Early GP 2b3a inhibitor Choice and OutcomesOutcomes

Monitoring Outcomes Monitoring Outcomes Over TimeOver TimePrimary PCI PatientsPrimary PCI Patients

• Outcomes of patients actually receiving Outcomes of patients actually receiving PCI are stable despite increasing risk PCI are stable despite increasing risk over time over time

• Time intervals - process is too slow Time intervals - process is too slow • getting to the cath labgetting to the cath lab• in the cath labin the cath lab

• GP 2b3a Inhibitors – appear to be GP 2b3a Inhibitors – appear to be effectiveeffective• may improved patency but not TIMI 3 flowmay improved patency but not TIMI 3 flow• our utilization is increasingour utilization is increasing• agent of choice?agent of choice?

DHMC STEMI RegistryDHMC STEMI RegistryConclusionsConclusions

• useful in assessing the safety and useful in assessing the safety and efficacy of novel management efficacy of novel management strategies strategies

• useful in assessing the impact of useful in assessing the impact of new protocols over timenew protocols over time

• May be useful for providing May be useful for providing benchmark data to individual benchmark data to individual institutions for QA/QCIinstitutions for QA/QCI

DHMC STEMI RegistryDHMC STEMI RegistryLimitationsLimitations

• Enrollment bias - cath lab enrollment Enrollment bias - cath lab enrollment will miss patients who are not sent to will miss patients who are not sent to the cath lab emergentlythe cath lab emergently• Patients admitted to the initial hospital Patients admitted to the initial hospital

rather than transferred acutelyrather than transferred acutely• Patients in whom the decision is made Patients in whom the decision is made

not to cathnot to cath• Patients who decline transfer and/or cathPatients who decline transfer and/or cath• Patients who die before they get to cath Patients who die before they get to cath

lablab

DHMC STEMI RegistryDHMC STEMI RegistryNext StepsNext Steps• ER enrollment of all STEMI patients in the ER enrollment of all STEMI patients in the

regionregion• Web-based, secure, registry interface Web-based, secure, registry interface • On-line decision supportOn-line decision support

• Risk assessment toolsRisk assessment tools• GuidelinesGuidelines• Treatment protocolsTreatment protocols

• Regular feedback to participating ERs/hospitals Regular feedback to participating ERs/hospitals • STEMI patient outcomes overall and by treatment STEMI patient outcomes overall and by treatment

strategystrategy• Process metrics (e.g. time intervals)Process metrics (e.g. time intervals)

• Partnership in process improvementPartnership in process improvement• Novel treatment regimensNovel treatment regimens• Transfer delay reductionTransfer delay reduction• Pre-hospital triage??Pre-hospital triage??

• Other Nest Steps – WritingOther Nest Steps – Writing

““Writing is easy, all you have to do is Writing is easy, all you have to do is stare at a blank sheet of paper until stare at a blank sheet of paper until droplets of blood begin to form on droplets of blood begin to form on your forehead”your forehead”

- anonymous- anonymous

Questions?Questions?

The Throw Backs The Throw Backs (Patients Not Receiving PCI at Acute (Patients Not Receiving PCI at Acute Procedure)Procedure)Incidence per YearIncidence per Year

6.5 9.5 12.94.7

0

20

40

60

80

100

2001 2002 2003 2004

%%

Throw back Mortality Throw back Mortality vs TIMI Riskvs TIMI Risk

5.5

25.9

0

5

10

15

20

25

30

PCIAttempted

No PCIAttempted

3.2

3.9

0

1

2

3

4

5

PCIAttempted

No PCIAttempted

In-hospital MortalityIn-hospital Mortality TIMI Risk ScoreTIMI Risk Score

Throw BacksThrow BacksComponents of TIMI RiskComponents of TIMI Risk

0

10

20

30

40

50

60

70

Age =>75 DM, HTN,or Angina

BP<100mmHg

HR>100bpm

Killip Cl >1

Weight<67 kg

AnteriorMI

Sx-Txtime>4

hrs

PCI AttemptedNo PCI Attempted

All STEMI PatientsAll STEMI Patients

PCI Attempted Acutely 89%PCI Attempted Acutely 89% No PCI Attempted Acutely 11%No PCI Attempted Acutely 11%

CABGCABG 1.5%1.5%

No CABG No CABG 98.5%98.5%

CABG CABG 38%38%

No CABGNo CABG 62%62%

MortalityMortality18.1%18.1%

MortalityMortality31.4%31.4%

MortalityMortality5.1%5.1%

MortalityMortality25%25%