1. Heart Attack Centres: Every Network Should Have (at least) One Dr Rod Stables The Liverpool Heart and Chest Hospital

2. The Key Role of the Network Local problems - unique circumstances

3. PCI in Acute Coronary Syndromes Growing proportion of the PCI caseload Most positive clinical impact - prognosis / cost Non-ST elevation ACS - high risk More prevalent - 3 x Adverse prognosis Possible shift to earlier PCI intervention The provision of Primary PCI in ST MI

4. Lessons From NIAPP Recognition and appreciation of the pioneers South Tees Primary Angioplasty Service (Middlesbrough & Durham) West Yorkshire Primary PCI Service (Leeds) Primary PCI for Greater Manchester (Manchester Royal Infirmary & Wythenshawe Hospitals) Royal Devon and Exeter Primary Angioplasty Project (Exeter) West London Primary Angioplasty Service (Hammersmith, St Mary’s & Harefield Hospitals) BAL Direct AMI service (Barts and the London) South East London Primary Angioplasty Pilot (Kings)

5. Lessons From NIAPP Performance requires ‘system change’ approach Performance determines ‘quality’ Quality determines patient outcome High quality PPCI is VERY hard to deliver Creation of the optimum service will be demanding

6. PCI Advantage May be Time Dependent 0 0 -5 5 5 10 15 0 0 20 40 60 80 100 PCI related time delay (mins) Absolute difference in 4 – 6 week mortality % Circles reflect trial sample size Blue line: weighted meta-regression Nallamothu & Bates, Am J Cardiol 2003;92:824

7. Door to Balloon Time and Outcome in NIAPP

8. Performance Reality ? NIAPP - not universal 24/7 service PPCI rates per million below expectation Reduced ‘out of hours’ activations Median door to balloon times variable Acceptable only in minority Leeds 24/7 service - first year experience Median door to balloon time = 98 minutes Clin Med 2008;8:259-263

9. The Complete 24/7 Service Meeting the door to balloon standard >95 % within 90 minutes Median 45 minutes Direct to lab 24/7 Resident on call ? Substantial human resource implications Non-medical workforce Migration to ‘routine hours only’ services Rotas with lots of bodies - big centres

10. Heart Attack Centres Critical mass - human and material resource Single catheter lab ? Two in-house operators ? Support for the sickest patients On site - shift - cardiology SpR and SHO Cardiothoracic anaesthetists and ICU Cardiothoracic surgery Case volume - The activity / outcome relationship

11. Volume and Outcome in Infarct PCI: ALKK Registry Zahn R et al, Heart 2008;94:329-35

12. Conclusions Acute coronary syndromes - Next growth area in PCI Substantial improvement in outcomes Magnitude of gain is quality dependent Optimum quality is very difficult to achieve Challenge convention ways of working Resource intensive Best performed in dedicated Heart Attack centres

13. Questions and Discussion