AA 2008 Session III: STEMI The UK data Mark de Belder The James Cook University Hospital Middlesbrough

Disclosures/Conflicts of interest Research Grants –Cordis/Abbott Advisory Boards –Cordis/Boehringer Ingelheim

We do not have accurate data! We do not have precise figures for UK or for England & Wales on: –Numbers of MIs (in total), STEMIs and non-STEMIs –Numbers receiving lysis Numbers of these referred for rescue Numbers receiving interval PPCI –Numbers receiving PPCI –Numbers receiving no reperfusion therapy Possible sources of data: –Office for National Statistics –DoH HES data –CCAD: MINAP and BCIS datasets –National and International Registries

Trends in mortality from AMI from: Griffiths C, Brock A, Rooney C. Impact of introducing ICD-10 on trends in mortality from circulatory diseases in England & Wales. (adjusted from ICD-9 to ICD-10) A matter of coding? Better primary prevention? Better management of AMI? Better secondary prevention? Something in the air? All of the above?

GRACE Registry The Global Registry of Acute Coronary Events ST elevation audit reperfusion Carruthers KF et al, Heart 2005;91:290-8

MINAP Report 2005/06 Drug Therapy

Trends since 2001 Patients receiving Pre-Hospital Thrombolysis and PPCI

MINAP % John Birkhead, personal communication Lysis patients: 54% IHL and 68% PHL undergo subsequent angiography ?

BCIS CCAD data % of total, 4.6% of ACS 6.6% of total, 13.5% of ACS 48.7% 0.2%

BCIS CCAD data 2006 and 2007 data to date 2.3% of total, 4.6% of ACS 6.6% of total, 13.5% of ACS 48.7% 0.2% 54.4% 8.8% of total, 16.7% of ACS 2.7% of total, 4.9% of ACS 0.2%

Primary PCI – the experience UK population 60 million, at 500 pmp = 30,000 procedures pa 2004 data: Ludman

Primary PCI Routine Rx for STEMI 2006 data: Ludman NHS Centres only Working Hours24/7 Number of centres Working Hrs includes all 24/7 sites

Primary PCI for STEMI 2006 data from NHS Centres Total 3930 procedures 0 or No data CCAD E&W + Scot 2006 data: Ludman

UK Centres Angiography (90) PCI (91)

Distance from hub and expected distribution of STEMI cases

London results: Time to nearest hospital: drivetime zones

UK Centres PCI (91) NIAP sites

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

Median Door-to-Balloon times (minutes) BCS, Glasgow June 7, 2007

Median LOS [days] BCS, Glasgow June 7,

NIAP: Indications for PCI in lysis group

In-hospital Mortality (all patients) [Index hospitalisation PLUS “convalescent” hospital, includes shock] 62/139931/46764/378

All as % No.Success Partial success Fail no comp Re- PCI QMI Em CABG Death NSTEMI / UA no shock All STEMI no shock Primary PCI Rescue PCI Shock Outcome 2006 CCAD data only 2006 data: Ludman

p< (Unadjusted data)

p=0.06 (Unadjusted data)

p=0.017 (Unadjusted data)

p=0.004 (Unadjusted data)

Cardiac re-admissions and re-infarction

Readmission days Reperfusion strategy Total readmissions Readmissions per pt Readmissions per hospital survivor Total daysDays per ptDays per hospital survivor PPCI Lysis Nil

Additional procedures Given as procedures per pt as some patients had more than one procedure

Conclusions Need for more accurate data Whether you are a believer in PPCI or lysis + rescue, current activity is insufficient We will get better outcomes if we change our strategies Current data support a change to PPCI Regional organisation of “Heart Attack Centres” is essential Triage in the field, and direct transfer to labs is the only viable way to deliver PPCI, and is the best way to deliver PHL and timely rescue PCI STREAM will perhaps tell us what the options are for early presenters