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

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

3. 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

4. Trends in mortality from AMI 1993-2002 from: Griffiths C, Brock A, Rooney C. Impact of introducing ICD-10 on trends in mortality from circulatory diseases in England & Wales. www.statistics.gov.uk/articles/hsq/hsq22ICD-10 (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?

5. GRACE Registry The Global Registry of Acute Coronary Events ST elevation audit 1999-2002 - reperfusion Carruthers KF et al, Heart 2005;91:290-8

6. MINAP Report 2005/06 Drug Therapy

7. Trends since 2001 Patients receiving Pre-Hospital Thrombolysis and PPCI

8. MINAP 2006 3.3% John Birkhead, personal communication Lysis patients: 54% IHL and 68% PHL undergo subsequent angiography ?

9. BCIS CCAD data 2006 2.3% of total, 4.6% of ACS 6.6% of total, 13.5% of ACS 48.7% 0.2%

10. 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%

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

12. 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

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

14. UK Centres - 2006 Angiography (90) PCI (91)

15. Distance from hub and expected distribution of STEMI cases

16. London results: Time to nearest hospital: drivetime zones

17. UK Centres - 2006 PCI (91) NIAP sites

18. 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

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

20. Median LOS [days] BCS, Glasgow June 7, 2007 1399467 378 364

21. NIAP: Indications for PCI in lysis group

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

23. All as % No.Success Partial success Fail no comp Re- PCI QMI Em CABG Death NSTEMI / UA no shock 13667 93.52.73.00.30.20.090.62 All STEMI no shock 365693.02.02.40.60.142.5 Primary PCI 254990.42.22.70.50.24.6 Rescue PCI 118791.11.92.60.404.8 Shock 43065.64.12.20.50.9330.2 Outcome 2006 CCAD data only 2006 data: Ludman

24. p<0.0001 (Unadjusted data)

25. p=0.06 (Unadjusted data)

26. p=0.017 (Unadjusted data)

27. p=0.004 (Unadjusted data)

28. Cardiac re-admissions and re-infarction

29. Readmission days Reperfusion strategy Total readmissions Readmissions per pt Readmissions per hospital survivor Total daysDays per ptDays per hospital survivor PPCI5480.390.4127291.952.04 Lysis2600.560.6019474.174.47 Nil1770.470.5614643.874.67

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

31. 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