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Disease Management
Acute Myocardial Infarction
University Hospital Bern
Background:
1995/96
1997
1998
1999/2000
Med.Klinik
Department of Internal Medicine
Cardio- vascular
Department
Emergency Department
Reperfusion Therapy 1995/96
% pat
70
60
50
40
30
20
64
53
36
27
15
11
10
0
1995
1996
PTCA
Lyse
No Reperf.
Reperfusion Therapy 1995/96
60
56
Prehospital delay < 6h
% pat
50
44
40
35
PTCA
Lyse
No Reperf.
30
20
10
12
9
0
1995
44
1996
Background:
1995/96
1997
1998
1999/2000
Primary PTCA
Disease Management
Acute Myocardial Infarction
Disease Management:
Acute Myocardial Infarction (I).
• Objectives:
• Analysis and graphic visualization of patient flow from
admission – discharge
• Development and implementation of updatable
guidelines for the treatment of patients with AMI
• Quality control
Disease Management:
Acute Myocardial Infarction (II).
• Objectives:
• Improvement of patient flow
• Reduction of time to reperfusion
• Shortening of hospital stay
• Improvement of clinical outcome
• Contain costs
Simplified Patient Flow of Patients With
Acute Myocardial Infarction
Cath.Lab.
ER
Int.C
ICU
WARD
Rehab.
Disease Management: Participants
Emergency Department
Cardiology
total 15 persons
Intensive Care Unit
4 days (half time)
Rehabilitation
1 fellow (cardiology)
- 100% three months
Administration,
Cost accounting,
Controlling
1 attending (cardiology)
- 50% three months
Health insurance
Behandlungsgrundsätze
Akutes Koronarsyndrom
Bei Aufnahme
Diagnostik: Anamnese, klin. Status, EKG, (Troponinschnelltest)
BE (Hämatologie, Elektroyte, Gerinnung, Kreatinin, Lipidstatus, CK + CK-MB, Troponin I, LDH, ASAT,
Röhrchen für Testblut)
Therapie: - 2 l 02 nasal
- Nitroglycerinkapsel s.l. 2x
- ASS (Aspégic®) 500 mg iv
- Morphin iv bei persist. Schmerzen
- Heparin 5000 E im Bolus I.v., dann 1000 E/h i.v.
- Betablocker i.v. (z. B. Lopresor® 5 mg i.v. max. 3x in 15 min, dann p.o. 3x25 mg/d).
Vorsicht: Hypotonie vermeiden, insbes. unmittelbar vor Koronarografie
- Bei persist. Symptomen Perlinganit i.v.
Diagnose
Diagnose
Akuter
Myokardinfarkt
UAP/NQWMI
Hochrisiko
UAP/NQWMI
Hochrisiko
Symptome
anhaltender
Thoraxschmerz
plus vegetative
Symptome
Persistierende
ST-Hebung
Neuer LSB
2 von 3
Kardiale
Marker
Troponin +
CK +
Prolongierte AP
(>20 min)
AP + Linksherzinsuffizienz
Dynamische
ST-Hebung
Dynamische
ST-Senkung
Troponin +
(CK (+))
Mindestzahl
pos.
Kriterien
2 von 3
1 von 3
EKG
UAP/NQWMI
Niedriges Risiko
Ruhe-AP
UAP/NQWMI
Mittleres
Risiko
Ruhe-AP
Nächtliche AP
Nächtliche AP
ST-Senkung
(<1mm)
T-inversion
ST-Senkung
(<1mm)
T-inversion
Erhöhte APFrequenz
Normal
Troponin +
CK -
Troponin (initial und
nach 4 h)
CK 2 von 3
Erstmalige AP
Unverändert
Troponin (initial und
nach 4 h)
CK 2 von 3
Akuter
Myokardinfarkt
- Direkt PTCA
Inselspital: alle Patienten falls
keine KI
Andere Spitäler: bei KI für
Thrombolyse oder
Hochrisikopatienten
(ausgedehnte Ischämie, nach
Kammerflimmern, hämodyn.
Instabilität, etc.)
Begleitherapie: Heparin,
GP IIb/IIIa (laut Verordnung
Kardiologie)
- Syst. Thrombolyse
Reteplase (Rapilysin®)
2x10 Ei.v. im Abstand von 30
min.,oder
Alteplase (Actilyse) bei >
65kg: 15 mg Bolus iv. über 1
min, 50 mg iv über 30 min, 35
mg iv als Infusion über 60 min
UFH 1000E/h iv (TZ II: 2040 sec), oder LMWH s.c.
- Rescue PTCA
Bei erfolgloser Thrombolyse
(Persistierende ST-,
Schmerz) nach 60-90 min.,
v.a. bei Vorderwandinfarkt
oder hämodyn.
Verschlechterung
UAP/NQWMI
hohes Risiko
- Schnelle
Koronarografie und
Revaskularisation (< 12
h)
- Fortfahren mit
UFH/LMWH
und antianginöser
Therapie
- GP IIb/IIIa:
Andere Spitäler:
Beginn mit Tirofiban
(Aggrastat)
oder
Abciximab (Reopro ),
Verlegung zur
Revaskularisation.
Inselspital: Entscheid
nach diagn.
Koronarografie.
Ausnahme: Wartezeit auf
Koronarografie > 1 h
Abkürzungen:
LSB: Linksschenkelblock
UFH= unfraktioniertes Heparin/
LMWH=niedermolekulares
Heparin
AP=Angina pectoris/
TZ=Thrombinzeit
/KI=Kontraindikationen
UAP/NQWMI
mittleres Risiko
- LMWH (z.B.
Enoxaparine
(Clexane) 1
mg/kg 2x/d s.c. oder
Nadroparin
(Fraxiparine) 120
IU/kg s.c. 2x/d)
UAP/NQWMI
niedriges Risiko
- Absetzen des
Heparins
- Antianginöse
Therapie
(Betablocker per os)
- Mobilisation
- Mobilisation
- Ischämienachweis
- Ischämienachweis
mittels
Belastungstest
- Koronarografie bei
1) Auftreten eines
Hochrisikokriterium
2) Wiederauftreten
von Ischämie
3) nach
Ischämienachweis
- Koronarografie
bei
Ischämienachweis,
sonst
Spitalentlassung
Anmeldung und Information:
Von extern: 031/632 21 11
Tagesarzt Kardiologie: 181 62 48
Invasiver Oberarzt: 181 76 30
Tages-Oberarzt: 181 71 84
Implementation of Disease
Management
1995/96
1997
1998
1999/2000
Primary PTCA
Disease Management
Acute Myocardial Infarction
Patient Flow Sheet for Data
Collection and Quality Control
First Evaluation
Disease Management for the Treatment
of Acute Myocardial Infarction
G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch,
S. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. Eberli
Patients and Methods
• Patients with ST-elevation myocardial infarction
admitted within 12 hours after onset of chest pain
(excl.: Rescue-PTCA).
• Analysis of patient flow:
– Door to balloon time, Hospital stay
• Analysis of patient outcome:
– In hospital cardiac adverse events
– 6 month clinical follow-up
• Comparison of the years before (1998) with the
years after (1999, 2000) introduction of DM
Patient Characteristics
1998
1999
2000
(first half)
Number of pat.
67
91
58
Age (mean±SD)
64±12
61±13
63±13
Female (%)
22
16
24
Pre-hospital delay
(min., mean±SD)
206±194
199±157
235±173
Measure of Quality of Care for
Successful Reperfusion Therapy
*
2.2
2.0
*
*
1.8
1.6
1.4
1.2
1.0
0.8
0.6
No. of Patients
Time, min
0-60
61-90
91-120
2230
5734
6616
121-150 151-180
4461
C. Cannon et al. JAMA 2000;283:2941-2947
2627
>180
5412
D.M.: Improvement of Patient
Flow in the Hospital
Door to Balloon Time = Time from Hospital
Admission to Restoration of Normal Flow
300
270
240
minutes
210
180
150
120
100
90
82
60
74
30
0
0
1
2
3
1998
1999
2000
4
D. M.: Improved Pre-Cath. Lab. Steps
Time from Hospital Admission to Cath. Lab.
minutes
40
20
49
(15-245)
43
(5-165)
35
(5-150)
1998
1999
2000
0
median (range)
In-Hospital Outcome
In-Hospital Mortality and Re-Infarction
16
p<0.003 (Mortality)
% patients
14
12
10
8
Mortality
Re-MI
6
4
2
0
1998
1999
2000
Outcome: 6 Mt. Follow-up
Mortality (all-cause and cardiovascular)
25
p<0.003
% patients
20
15
All-Cause
Cardiovascular
10
5
0
1998
1999
2000
Outcome: 6 Mt. Follow-up
Rehospitalisation for Acute Myocardial
Infarction or Unstable Angina
14
% patients
12
10
8
MI
UAP
6
4
2
0
1998
1999
2000
Outcome: 6 Mt. Follow-up
Target Vessel Revascularisation
(CABG and/or PTCA)
40
% patients
p<0.0003
30
20
10
0
1998
1999
2000
Comparison of Treatment for
Acute Myocardial Infarction
Before and After Introduction of
Disease Management
Patients
1995/96
1998
1999
2000
(first half)
Number of pat.
56/55
67
91
58
Age (mean±SD)
65±13
64±12
61±13
63±13
Female
29%
22%
16%
24%
Known CAD
32%
27%
23%
S/P CABG
5%
6%
10%
13%
2%
Time from Onset of Symptoms to Hospital
Admission in Patients with AMI
720
630
540
450
360
106
85
270
180
180
85.5
180
120
220
160
90
0
0
1
1995
2
1998
1996
3
199
1998
9
4
5
19992000 2000
6
Cardiogenic Shock (% patients)
p<0.02
35
31
% pat
30
25
20
15
10
5
16
13
8
4
0
1995
1996
1998
1999
2000
Length of Hospital Stay
(Insel;days)
40
35
days
30
25
20
15
14
10
13
7
5
5.5
5
1999
2000
0
1995
1996 1998
Length of Hospital Stay
(total;days)
40
35
days
30
25
20
14
15
10
13
10
7
7
5
0
0
1
2
3
4
5
1995
1996
1998
1999
2000
6
Patient Outcome: 6 Mt Mortality
p<0.003
25
20.4
18.5
% pat
20
15
10
all cause
cardiovascular
11.5
9.3
7
5
3.5
3.5
0
1995
1996 1998 1999
2000
Summary
• The project Disease Management
– had no influence on prehospital delay
– improved patient flow within the hospital, as
assessed by door to balloon time
– shortened length of hospital stay
– had a favorable effect on patient outcome, as assessed
by a trend towards decreased MACE (death, MI, UAP)
and decreased need for target vessel revascularization
Conclusions (I)
• The project Disease Management
– improved interdisciplinary patient management
– resulted in a uniform treatment according to
evidence based medicine
• Surprisingly, Disease Management changed referral
patterns. Patients were also referred for primary PTCA
to the tertiary center, when they presented with
uncomplicated myocardial infarction in an outside
hospital
Conclusion (II)
• Disease Management is a helpful tool for
improving treatment of patients with
acute myocardial infarction.