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

2. Europe

3. Denmark DANAMI

4. Denmark Netherlands Amsterdam Zwolle

5. Denmark Netherlands Germany Schomig Kastrati

6. Denmark Netherlands Germany Czech PRAGUE 1 and 2

7. Denmark Netherlands Germany Czech Poland

8. Denmark Netherlands Germany Czech Poland France CAPTIM

9. Denmark Netherlands Germany Czech Poland France Italy

10. Denmark Netherlands Germany Czech Poland France Italy Spain

11. Denmark Netherlands Germany Czech Poland France Italy Spain Sweden

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

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

14. 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

15. 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

17. 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

19. Published data point

22. Meta analysis (published data)

23. PCI Related Delay Nallamothu AJC 2003;92:824–826 62 min

24. 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 2009 95 362

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

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

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

28. PCI Related Delay Terkelsen Heart 2009 95 362 p=0.6

29. t = 171 min PCI Related Delay Terkelsen Heart 2009 95 362 p=0.6

30. PCI Related Delay Terkelsen Heart 2009 95 362 1197486171 AllAll, Danami split FSFS, Danami split

31. Meta analysis (published data)

33. Patient level meta-analysis

34. PCI Related Delay Boersma EHJ 2006 27 779

35. PCI Related Delay 105 15 120 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 135 15

36. PCI Related Delay 105 15 120 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 135 15

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

38. 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

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

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

41. Observed Outcome v Delay GRACE registry Lysis PPCI

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

43. The Impossible Trial

44. Randomise to delay of: 0 to 120 min

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

46. PCI Related Delay Time delay to presentation / Rx Mortality %

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

48. PCI Related Delay Mortality % Time delay to presentation / Rx

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

50. PCI Related Delay Terkelsen Heart 2009 95 362 Time delay to presentation / Rx Mortality % Benefit from PPCI

51. 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!

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

53. IHT causes delay NIAP and Provisional analysis of BCIS data

54. IHT causes delay NIAP and Provisional analysis of BCIS data

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

56. 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

57. The End

58. ESC Guidelines EHJ 2008;29:2909

59. PCI related delay Pinto Circulation 2006;114:2019

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

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

62. PCI related delay Tarantini EHJ 2009 Nov (ahead of print) Reduction in Mortality by PPCI (over lysis) = 0.033 x PPCI Delay 0.59 x Pre Rx Mortality Risk 0.0003 x Presentation Delay - - +

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

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