Advanced Cardiovascular Intervention 2009 Timings in PPCI: Have we learnt the lessons from our European Colleagues? Peter F Ludman

Europe

Denmark DANAMI

Denmark Netherlands Amsterdam Zwolle

Denmark Netherlands Germany Schomig Kastrati

Denmark Netherlands Germany Czech PRAGUE 1 and 2

Denmark Netherlands Germany Czech Poland

Denmark Netherlands Germany Czech Poland France CAPTIM

Denmark Netherlands Germany Czech Poland France Italy

Denmark Netherlands Germany Czech Poland France Italy Spain

Denmark Netherlands Germany Czech Poland France Italy Spain Sweden

Denmark Netherlands Germany Czech Poland France Italy Spain Austria (Vienna) Sweden

Timings in PPCI Patient delay EMS delay 15 minDTBTransport to PCI centre Onset of STEMI FMC Reperfusion

Timings in PPCI Patient delay EMS delay EMS arrival to needle (30 min) Patient delay EMS delay 15 minDTBTransport to PCI centre PCI Related Delay Onset of STEMI FMC Reperfusion

Timings in PPCI Patient delay EMS delay EMS arrival to needle (30 min) Patient delay EMS delay 15 minDTBTransport to PCI centre PCI Related Delay Onset of STEMI FMC Reperfusion

Timings in PPCI Patient delay EMS delay EMS arrival to needle (30 min) Patient delay EMS delay 15 minDTBTransport to PCI centre PCI Related Delay Onset of STEMI FMC Reperfusion

Published data point

Meta analysis (published data)

PCI Related Delay Nallamothu AJC 2003;92:824– min

Errors PCI Related Delay Nallamothu AJC 2003;92:824–826 Nallamothu Am J Cardiol 2004;94:772–4 Betriu A, Masotti M Am J Cardiol 2005;95:100 Asseburg Heart 2007;93:1244–50 Terkelsen Heart

Prague-1 Prague-2 Veermer Danami-2 Garcia Ribicini Gibbons

Prague-1 Prague-2 Veermer Danami-2 Garcia Ribicini Gibbons

Prague-1 Prague-2 Veermer Danami-2 Garcia Ribicini Gibbons Terkelsen

PCI Related Delay Terkelsen Heart p=0.6

t = 171 min PCI Related Delay Terkelsen Heart p=0.6

PCI Related Delay Terkelsen Heart AllAll, Danami split FSFS, Danami split

Meta analysis (published data)

Patient level meta-analysis

PCI Related Delay Boersma EHJ

PCI Related Delay Patient delay EMS delay EMS arrival to needle (30 min) on scene delay Patient delay EMS delay 15 minDTB (30 min) Maximum acceptable transport time (105 min) PCI Related Delay

PCI Related Delay Patient delay EMS delay EMS arrival to needle (30 min) on scene delay Patient delay EMS delay 15 minDTB (30 min) Maximum acceptable transport time (105 min) PCI Related Delay

But..... PCI –40% stents –<30% GP IIb/IIIa blockers –Clopidogrel dosing –No Prasugrel Lytic –No mandated cath / PCI –Little rescue

Timings in PPCI Patient delay EMS delay EMS arrival to needle (30 min) Patient delay EMS delay 15 minDTBTransport to PCI centre PCI Related Delay Onset of STEMI FMC Reperfusion

Time Delays v Observed Mortality Zijlstra EHJ 2002:23;550 % Mortality Lysis PPCI

Time Delays v Observed Mortality Zijlstra EHJ 2002:23;550 % Mortality Lysis PPCI No rush if doing PPCI?

Observed Outcome v Delay GRACE registry Lysis PPCI

Observed mortality Vienna STEMI registry, Kalla Circulation 2006;113;2398

The Impossible Trial

Randomise to delay of: 0 to 120 min

Randomise to delay of: 0 to 120 min Start PPCI / Lytic

PCI Related Delay Time delay to presentation / Rx Mortality %

PCI Related Delay Time delay to presentation / Rx Mortality % PPCI relatively time independent ONLY If all patients present with same pre Rx risk

PCI Related Delay Mortality % Time delay to presentation / Rx

PCI Related Delay Mortality % Time delay to presentation / Rx Early presenters High risk Late presenters Low risk

PCI Related Delay Terkelsen Heart Time delay to presentation / Rx Mortality % Benefit from PPCI

What are the lessons? PPCI preferred to lysis in almost all settings Time matters –Rx a quick as possible –Networks of care required –Paramedic diagnosis + drive to PPCI (? 100 min drive time) Significant uncertainty about details!

Have we learnt the lessons? PPCI is becoming the dominant strategy

IHT causes delay NIAP and Provisional analysis of BCIS data

IHT causes delay NIAP and Provisional analysis of BCIS data

PPCI for STEMI Admission route % of patients admitted direct to PCI centre

Conclusions lessons –PPCI dominant strategy –Speed matters Suggested  delay dependency of PPCI misleading Public awareness campaigns Networks –Pre hospital diagnosis –Avoid IHT if possible –‘PCI related delay’ Uncertain Varies with clinical presentation

The End

ESC Guidelines EHJ 2008;29:2909

PCI related delay Pinto Circulation 2006;114:2019

PCI related delay NRMI database –PCI related delay v Mortality by subset Pinto Circulation 2006;114:2019

PCI related delay NRMI database –PCI related delay v Mortality by subset Pinto Circulation 2006;114:2019 Younger, Anterior MI need quicker PPCI

PCI related delay Tarantini EHJ 2009 Nov (ahead of print) Reduction in Mortality by PPCI (over lysis) = x PPCI Delay 0.59 x Pre Rx Mortality Risk x Presentation Delay - - +

PCI related delay Tarantini EHJ 2009 Nov (ahead of pub)

PCI related delay Tarantini EHJ 2009 Nov (ahead of pub)