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

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8 Hospital Mortality for STEMI D2B Time in minutes Mortality < % % % > % McNamara JACC 2006

9 St. Peter’s Based Strategies for Shorter Door-to- Balloon Times Pre-hospital ECG and early cath lab activation Emergency department bypass Direct access to cath lab Rapid triage of patients in ER with rapidly obtaining ECG in ER ER department activation of cath lab Single call activation Rapid arrival of PCI team at hospital Process of performing PCI Prompt data feedback Team-based approach D2B

10 “Heart Attack Rap” Well let me tell you about the heart attack story How we achieved the point of PISC glory You came clutching your chest with your artery closed You left the lab smiling with flow like a hose I said flow like a hose, flow like a hose -The Cuban Rapper

11 Trends since 2001 Patients receiving Pre-Hospital Thrombolysis and PPCI

12 20 th October, 2008

13 NIAP Project Main 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

14 % of all cases with DTB times <90 mins

15 Mortality: PPCI direct admissions (DTB time)

16 Median LOS [days] BCS, Glasgow June 7,

17 In-hospital Mortality (all patients) [Index hospitalisation PLUS “convalescent” hospital, includes shock] 62/ /467 64/378

18 p< (Unadjusted data)

19 p=0.017 (Unadjusted data)

20 p=0.004 (Unadjusted data)

21 Cardiac re-admissions and re-infarction

22 Additional procedures 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

24 Development of PPCI services MINAP data No. of hospitals providing PPCI 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 ( ) (MINAP Data)

26 6 month mortality for STEMI (MINAP Data , patients <80 yrs)

27 Cardiac Networks providing PPCI to > 60% of STEMI patients MINAP data  NC LONDON  NE LONDON  NW LONDON  SE LONDON  SW LONDON  BLACK COUNTRY  COVENTRY + WARWICK  (BIRMINGHAM)  WEST YORKS

28 Cardiac Networks providing PPCI to 30-60% of STEMI patients MINAP data  BIRMINGHAM, SAND, SOLIHULL57%  NORTH OF ENGLAND59%  PENINSULA21%

29 Cardiac Networks providing PPCI to < 30% of STEMI patients MINAP 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

30 How are STEMI patients treated? MINAP data In-hospital lysis 7533 (31 %) Pre-hospital lysis 2515 (10 %) PPCI 7919 (33 %) No reperfusion treatment 6126 (25 %)

31 Acceptable PCI-Related Time Delay  Nallamothu60 mins - inaccurate data  Terkelsen119 mins  Boersma≥120 mins  Pinto114 mins  RIKS-HIA>>90 mins  Vienna138 mins  ASSENT-4>>102 mins

32 Mortality Cath lab (n=287) Ward/CCU (n=149) A&E (n=448) In hospital day year 5.9 * * 18 month 7.0 * * Mortality for PPCI by route of admission * - statistically significant difference between values Excluded: patients in-hospital and transfers via non-PCI centres

33 Median door to balloon times (MINAP Data) minutes

34 PCI Mortality (stratified by syndrome) BCIS audit 2008

35 Hospital Mortality after PCI for STEMI and NSTEMI patients: Quartiles of PCI volume Heart 2008;94:

36 97% PPCI COVERAGE: IS IT ACHIEVABLE? NETWORK BLACK COUNTRY 97 % NC LONDON 97 % NE LONDON 100 % NW LONDON 97 % SE LONDON 93 % SW LONDON 81 %

37 Intra Aortic Balloon Pump