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%