1. Lysis and Beyond: ESC Guidelines and Reality J N Townend Queen Elizabeth Hospital Birmingham

2. NO CONFLICT OF INTEREST TO DECLARE

3. Lytic Therapy: Class I recommendation when PPCI cannot be performed within 2 hours (or 90 minutes) NB must be <90 mins if present early with a large amount of viable myocardium

4. Lytic Therapy: Not Yet Redundant in the UK

5. PPCI and Lysis for STEMI : The View from the Clent Hills Lytic therapy PPCI for some in 2010 The long term ? PPCI West: Herefordshire, Worcestershire, Wales North East: Birmingham & West Midlands

6. Beyond Lysis: ESC Guidelines The pharmaco-invasive strategy: –“Rescue PCI should be considered when there is evidence of failed fibrinolysis…or if there is uncertainty” Class IIa recommendation, level of evidence B –“If it is likely that fibrinolysis was successful angiography is recommended… time window of 3-24 hours” Class IIa recommendation, level of evidence A

7. Rescue PCI: REACT Rescue PCI vs. repeat lytic vs. conservative therapy for failed reperfusion @ 90 mins N = 427 Primary end point: –Death, re-MI, CVA,CHF reduced by >50% Mortality reduced by 50% Gershlick et al. NEJM 2005

8. How Often is Rescue PCI Required? CAPTIM(n=419)26% CARESS-in-AMI (n=300)30% TRANSFER AMI (n=522)34%? At least 1 in 4 cases

9. Trials demonstrating efficacy of routine early angiography and PCI after STEMI Trial DateN SIAM III2003197 GRACIA-12004500 CAPITAL AMI2005170 CARESS-in -AMI2008600 TRANSFER-AMI NORDISTEMI 2009 1059 266

10. RR = 0.64, p=0.004 Death, re-MI, CHF, shock Days from randomization

11. PCI Rate after Lytic Therapy PCI rates in studies of routine post lytic angiography/PCI after STEMI: GRACIA 180% CARESS86% TRANSFER AMI85% FAST MI registry84%

12. According to treatmentPropensity matched Circulation 2008

13. How to Avoid Bleeding Associated with PCI Following Lytic Therapy

14. REALITY Angiography and PCI rates following lytic therapy in 12297 cases in 2008 in England and Wales MINAP: data on STEMI cases from all acute hospitals in England and Wales BCIS: data on (almost) all UK centres performing PCI –Rescue PCI –PCI within one month of lytic therapy

15. Rescue 14% Protocol driven 20% Not performed 32% Angiography rate after STEMI = 62% Reality according to MINAP: Angiography Rates in England and Wales after Lytic Therapy in 2008 Symptom driven 21% Post discharge 7%Unclear 4%Indication unclear 2% N=12297

16. Interval: Admission to Angiography STEMI admitted to Interventional Hospitals

17. Reality according to BCIS: PCI Rates after Lytic Therapy in 2008 Rescue = 18% Recent lytic therapy 22% The rest - No PCI(?) = 60% England and Wales PCI rate early after STEMI was 40% N=12297

18. In Conclusion In England and Wales, rescue PCI performance is quite good (about 70% predicted) The rest of post STEMI invasive angiographic / interventional care for lytic treated patients is too little and too late Could do better

19. Admission to a non-PCI Centre After Lytic Therapy : Wrong Place, Wrong Time