1. Advanced Angioplasty 2005 Primary PCI making it happen Data collection and Timings Peter Ludman University Hospital Birmingham

5. Motto ‘Time is Muscle’

6. Lysis - Treatment Delay 35/7 mortality reduction v delay Boersma E Lancet 1996;348:771-75 Trials included in FTT analysis

7. PPCI v Lysis PPCI (n=3872) v Lysis (n=3867) Keeley Lancet 2003; 361: 13–20 % Frequency

8. However beautiful the strategy, you should occasionally look at the results. Winston Churchill

9. Time to PPCI delays after admission GUSTO IIb Berger P 1999;100:14-201

10. Time to Reperfusion Brodie BR et al JACC 1998;32:1312 1,352 patients treated by primary PTCA n=164 n=581 n=332 n=275

11. Time to Reperfusion Brodie BR et al JACC 1998;32:1312 1,352 patients treated by primary PTCA

12. Time to PPCI 2635 patients (10 trials) Zijlstra F EHJ 2002;23:550-557 n=325n=414n=218

13. NRMI-2: Time to PTCA Cannon CP JAMA 2000;283:2941-2947

14. Time to Rx – myocardial salvage 264 PPCI patients 3 tertiles Tc-99m Sestamibi SPECT Schomig A Circ 2003;108:1084

15. Prague 2 Mortality benefit by time to randomisation Transfer for PPCI v on site SK n=850 Widimsky P. EHJ 2003;24: 94–104 Time from Sx to Randomisation

16. Prague 2 Mortality benefit by time to randomisation Transfer for PPCI v on site SK n=850 Widimsky P. EHJ 2003;24: 94–104 Time from Sx to Randomisation

17. Time to PPCI – the early times Steg PG for CAPTIM Circ 2003;108:2851 Mortality n = 840 (planned 1200) prehospital tPA + rescue v PPCI

18. ‘Loosing an hour’ to implement a strategy for transfer has a differential impact on those seen early rather than late Time to PPCI – the early times Steg PG for CAPTIM Circ 2003;108:2851

19. Early v late presenters Door to Balloon time Brodie Moses Cone registry Data ACC 2004 Early Presenters (≤ 2hrs)Late Presenters (>2hrs)

20. Time to PPCI in Shock LeBauer Cardiovascular Research Foundation Registry of consecutive PPCI n = 1843, shock in 138 Brodie BR JACC 2003;145:708-15

21. Very early Rx (1 to 3 hours) –Excellent results with PCI or lysis Door to balloon –Keep as short as possible –Particularly important in early presenters –? also in high risk late presenters Late presenters –PPCI >> Lysis

22. Acceptable Time Delay for Transfer? Randomised trials of lysis v transfer –Maastricht trial –Prague –Air PAMI –Captim –Danami 2 –Prague 2 Dalby M Circulation 2003;108:1809-1814

23. Transfer Time Delays Difference 60 111 92 61 69 90 48

24. Time delays PPCI v Lysis Meta analysis of 23 trials Door to balloon v door to needle Nallamothu BK AJC 2003;92:824 Risk reduction of PCI over lysis

26. Circadian Variation 1702 consecutive PPCI (Zwolle 1994 to 2000) Henriques JPS JACC 2003;41:2138–42 * P=0.02 # P<0.01 * * #

27. Circadian Variation 1702 consecutive PPCI (Zwolle 1994 to 2000) Henriques JPS JACC 2003;41:2138–42 * P<0.01 # P=0.03 # * *

28. Circadian Variation Pathophysiology Platelet aggregation Coronary flow Viscosity Cortisol Epinephrine APTT Endogenous tPA Fibrinogen Fibrinolytic factors Patient characteristics Risk profile Delayed conscious awareness of pain Performance of the Healthcare team

29. Lady Astor 'Sir, you're drunk!‘ Winston Churchill Yes, madam, I am drunk. But in the morning I will be sober and you will still be ugly.

30. Circadian Variation Dawson D. Nature 1997;388:235 Cognitive psychomotor performance of hand–eye coordination

31. Circadian Variation Dawson D. Nature 1997;388:235

32. Guidelines and Data Collection Circulation. 2004;110:588-636 Eur Heart J. 2003; 24: 28–66

33. ACC/AHA Guidelines Goal: ‘ischaemic time’ < 120 mins (Sx to lysis or PCI) PCI centre Door to balloon <90 min Non PCI centre Door to needle < 30 min EMS Prehosp lysis < 30 min of arrival at scene If < 90 min (total) to balloon or if transport will not add more than 60 to time to balloon v local lysis

34. Fibrinolysis preferred if –Early presentation < 3hr (and delay to PPCI) –PPCI not an option Lab busy No lab / inappropriate lab –Delay to invasive strategy > extra 1 hr over lysis time > 90 min medical contact to balloon ACC/AHA Guidelines Circulation. 2004;110:588-636

35. PPCI Preferred if –Skilled PCI service with surgical backup Operator > 75 Primary PCI pa Team > 36 Primary PCI pa Timings as before –High risk for STEMI Shock Killip ≥ 3 –Contraindication to lysis –Late presentation (> 3 hours) –STEMI diagnosis in doubt ACC/AHA Guidelines Circulation. 2004;110:588-636

36. ESC Guidelines Fast Track patients (clear indication for reperfusion) –Door to needle < 20 min –Door to Balloon < 60 min Eur Heart J. 2003; 24: 28–66

37. MINAP Version 6.1 Symptom onset Call for help Arrival of first professional help Arrival of emergency services Arrival at hospital First balloon inflation Date only angio (local) 1 st intervention or surgery (local) Symptom onset Arrival in first hospital Admission route (Arrival in PCI hospital) Start of procedure First balloon inflation Flow in IRA BCIS – CCAD Version 5.1.3 Date and Time

38. UK data collection The future 2003 data: Ludman BCIS dataset Office of National Statistics Mortality register MINAP dataset Cardiothoracic surgical dataset EP dataset Event free survival NHS Number

39. Swedish Coronary Angiography and Angioplasty Registry - SCAAR SCAAR Swedish Population Register Date of Death Swedish Patient Administration Register Readmissions (all events) Data from year 2001 Survival data to end 2002 9,496 of 9,535 patients

40. Swedish Coronary Angiography and Angioplasty Registry - SCAAR Nilsson T http://www.sos.se/ 6%1yr 9%2yr

41. Mottos ‘Time is Muscle’

42. David Beckam’s Brain surgeon ‘Mind the Gap’

43. Joe’s Shoe Company ‘Always knowingly undersold’

44. ‘Piston Broke?’ We can help Alf’s Garage

45. The Literal Society We are the literal society

46. British Rail This motto has been withdrawn Due to it being the wrong kind of motto

47. Primary PCI ‘………………………..’ Suggestions ?

48. The End