PPCI - it’s 24/7 or not at all? Dr JIM HALL CONSULTANT CARDIOLOGIST JAMES COOK UNIVERSITY HOSPITAL MIDDLESBROUGH

NO CONFLICT OF INTEREST TO DECLARE

PPCI Is it justifiable to have a system that includes treating STEMI patients with PPCI in some units ‘when available’ e.g. 9-5 Mon-Fri and not uniformly in a Heart Attack Centre where PPCI is available ‘all the time’ (24/7) ?  S  n

PPCI Is it justifiable to have a system that includes treating STEMI patients with PPCI in some units ‘when available’ e.g. 9-5 Mon-Fri and not uniformly in a Heart Attack Centre where PPCI is available ‘all the time’ (24/7) ?  Systems with part-time PPCI produce inferior patient outcomes

PPCI Is it justifiable to have a system that includes treating STEMI patients with PPCI in some units ‘when available’ e.g. 9-5 Mon-Fri and not uniformly in a Heart Attack Centre where PPCI is available ‘all the time’ (24/7) ?  Systems with part-time PPCI produce inferior patient outcomes  Not justifiable in England in 2009

PPCI 24/7 – the key issues  PROCESS EFFICIENCY  INSTITUTIONAL COMPETENCE  TRANSPORT TIMES

PPCI 24/7 – key issue  PROCESS EFFICIENCY

ST ELEVATION ACUTE MYOCARDIAL INFARCTION STEMI EFFECTIVE PATHWAY FOR STEMI PATIENTS RIGHT PATIENT RIGHT PLACE RIGHT TIME

EFFECTIVE PATHWAY FOR STEMI PATIENTS RIGHT TIME? AS SOON AS POSSIBLE ISCHAEMIC TIME onset to call call to diagnosis diagnosis to PCI facility = drive timeC2B PCI facility to balloon = D2B

EFFECTIVE PATHWAY FOR STEMI PATIENTS SYSTEM DESIGN  Understand the steps in the process  Simplify the system  Set your metrics  Monitor Modernisation Agency: Improving flow

Pre Hospital Barn door STEMI No significant co-morbidities A&E & AAU Barn door STEMI No significant co-morbidities Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards STEMI / PPCI PATHWAY Wards Barn door STEMI No significant co-morbidities Contact Cardiologist on call and Cath Lab team Contact Cath Lab Co-ordinator and interventionist in Cath Lab

Pre Hospital Barn door STEMI No significant co-morbidities A&E & AAU Barn door STEMI No significant co-morbidities Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards STEMI / PPCI PATHWAY Wards Barn door STEMI No significant co-morbidities Contact Cardiologist on call and Cath Lab team Contact Cath Lab Co-ordinator and interventionist in Cath Lab SINGLE POINT OF CONTACT DIRECT TO CATH LAB

REMOVING A STEP - IMPACT ON PPCI D2B TIMES CCU nurse initiation SpR initiation

Pre Hospital Barn door STEMI No significant co-morbidities A&E & AAU Barn door STEMI No significant co-morbidities Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred directly to Cath Labs from Ambulance/ A&E / AAU/CCU/Wards STEMI / PPCI PATHWAY 24/7 HAC Wards Barn door STEMI No significant co-morbidities Contact Cardiologist on call and Cath Lab team Contact Cath Lab Co-ordinator and interventionist in Cath Lab

Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred to DGH Cath Lab if lab available

Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred to DGH Cath Lab if lab available <25% of STEMI

Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred to DGH Cath Lab if lab available INEVITABLE CONFUSION AND DELAY

Pre Hospital STEMI A&E & AAU STEMI Patient transferred to Heart Attack Centre Cath Lab STEMI / PPCI PATHWAY 24/7 HAC DGH Wards STEMI C ontact DGH Cath Lab Co-ordinator and speak to interventionist in Cath Lab 9 am – 5pm / Mon – Fri 5pm – 9am / Weekends Contact Cardiologist on Call Switchboard contacts on call Cath Lab team Contact CCU Co-ordinator External: (ambulance) Internal: 54801/53624/52458 Fax ECG: Patient transferred to DGH Cath Lab if lab available 100% of STEMI INEVITABLE CONFUSION AND DELAY

Effect of Part-time PPCI NRMI mixed system v PPCI 88% PPCI mortality PPCI DTB Nallamothu et al Circ 2006;113:

Effect of Part-time PPCI NRMI mixed system v PPCI 88% PPCI mortality 0.64 (0.46 – 0.88) PPCI DTB Nallamothu et al Circ 2006;113:

PPCI 24/7 – key issue  INSTITUTIONAL COMPETENCE

INSTITUTIONAL EXPERIENCE ALKK database PPCI 67 hospitals Annual institutional PPCI volume and outcome mortality Zhan et al Heart 2008;94:

INSTITUTIONAL EXPERIENCE ALKK database PPCI 67 hospitals Annual institutional PPCI volume and outcome lowest quartile v highest quartile 300 mortality Zhan et al Heart 2008;94:

INSTITUTIONAL EXPERIENCE ALKK database PPCI 67 hospitals Annual institutional PPCI volume and outcome lowest quartile v highest quartile 300 mortality 7.7% 4.8% Zhan et al Heart 2008;94:

INSTITUTIONAL EXPERIENCE ALKK database PPCI 67 hospitals Annual institutional PPCI volume and outcome lowest quartile v highest quartile 300 mortality 7.7% 4.8% more contrast longer flouro less TIMI 3 Zhan et al Heart 2008;94:

INSTITUTIONAL EXPERIENCE NRMI database IABP for cardiogenic shock lowest tercile v highest tercile IABP/yr mortality Chen et al Circ 2003;108:951-7

INSTITUTIONAL EXPERIENCE NRMI database IABP for cardiogenic shock lowest tercile v highest tercile IABP/yr mortality Chen et al Circ 2003;108:951-7

INSTITUTIONAL EXPERIENCE NRMI database IABP for cardiogenic shock lowest tercile v highest tercile IABP/yr mortality p<0.001 Chen et al Circ 2003;108:951-7

JCUH database PPCIs IABP10% VENTILATION3% SHOCK 8%

PPCI 24/7 – key issue  TRANSPORT TIMES

TRADE-OFFS DOWNSIDE OF TRANSFER TO 24/7 HEART ATTACK CENTRE –INCREASED ISCHAEMIA TIME mortality increase ~ 1%/hr drive time m

EFFECTIVE PATHWAY FOR STEMI PATIENTS STEADY DECLINE IN EFFICACY ~ 1% MORTALITY/HR deLuca et al Circ 2004:109;

TRADE-OFFS DOWNSIDE OF TRANSFER TO HEART ATTACK CENTRE –INCREASED ISCHAEMIA/DRIVE TIME mortality increase ~ 1%/hr drive time DOWNSIDE OF LOCAL DELIVERY –DECREASED INSTITUTIONAL VOLUME mortality increase ~ 3% LOW v HIGH

Trade-off: drive time - institutional volume High Low INSITUTIONAL PPCI VOLUME ISOMORTALITY BREAK-EVEN LINE DRIVE TIME 3% ACCEPTABLE DRIVE TIMES

Trade-off: drive time - institutional volume High Low INSITUTIONAL PPCI VOLUME ISOMORTALITY BREAK-EVEN LINE DRIVE TIME 3% ACCEPTABLE DRIVE TIMES ACCEPTABLE DRIVE TIMES PROCESS DELAY

Part time PPCI (9-5) Justifiable if >3 hour drive time to HAC or > 1 hour drive time to HAC + zero process delay volume ~200/yr (requires >1M pop n )

Part time PPCI (9-5) Justifiable if >3 hour drive time to HAC or > 1 hour drive time to HAC + zero process delay volume ~200/yr (requires >1M pop n ) not applicable to England in 2009

PPCI - it’s 24/7 or not at all!