Heart Alert Quandary

Kiran K. Cheruku, MD Interventional Cardiologist Heart And Vascular Institute of Texas

 Mr. W is a 76 yr old caucasian male with Pmhx of HTN and GERD was travelling through San Antonio. Staying at a RV park, while working on his trailer developed chest pain 10/10. Took 2 s/l ntg with no relief. Severely nauseated and diaphoretic. Wife called 911.

 911 call was placed at 09:33. EMS dispatched at 09:34  EMS arrived at scene 09:37  Found patient in severe distress with 10/10 worst chest pain in life, clutching his chest. Vitals signs showed BP 148/84 mmHg, P – 63 mmHg. One more s/l ntg was given with no relief.

 EKG done in field at 09:43 am. Heart Alert activated at 09:44 am.  EKG transmission attempted but unsuccessfull

 NE Methodist notified of the Heart Alert and patient transported to NEM as it was the closest hospital.

 Patient arrived at NE Methodist at 09:54 am

 Patient stable on arrival, but still in pain, 6/10.

 NE Methodist had another Heart Alert come in 15 minutes earlier and that patient was on the cath lab table. Only one team available as it was a weekend.

 WHAT TO DO NOW?

 Thrombolytics Vs transfer to nearest PPCI center

DANAMI-2: Study Design High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs 5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs Lytic therapy Front-loaded tPA 100 mg (n=782) Primary PCI with transfer (n=567) Primary PCI without transfer (n=223)

Death / MI / Stroke at 30 Days Stopped early by safety and efficacy committee 9

DANAMI-2: Primary Results

16% 12% 8% Combined P=0.0003

14% RRR 45% 8% 16% Transfer Sites P=0.002

14% RRR 40% 12% 9% 8% 16% Non-Transfer Sites P=0.048

12% 12% RRR 45% 8% 7% 4% 4% 4% 0% Lytic Primary PCI 0% Lytic Primary PCI 0% Lytic Primary PCI

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DANAMI-2: Results

8% 7.6% Death P=0.35

6.6% 6% Recurrent MI P<0.0001

8% 6% 6.3% 8% 6% Stroke P=0.15

4% 4% 4% 2% 2% 1.6% 2% 2.0% 1.1% 0% Lytic Primary PCI 0% Lytic Primary PCI 0% Lytic Primary PCI

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Primary PCI: Door-to-Balloon time vs. Mortality Stratified by Institutional Volume

<1 / month N=4,740

P = 0.0008

1-3 / month N=14,078

P < 0.0001

>3 / month N=14,078

P < 0.0001

Door-to-Balloon Time (minutes)

Hospital Volume of Primary PTCA vs. Mortality 1.2

1 0.8

0.6

0.4

0.2

0 0.87

0.83

P value for trend < 0.001

0.72

N: Pt = 2,825 5,245 9,303 19,162 Hosp =113 112 113 112 5 to 11 12 to 20 21 to 33 >33 Hospital Volume of Primary Angioplasty per Year

Canto. NEJM 2000 13

DANAMI 2 Conclusions

• Among patients transferred for primary PCI with a median door to balloon time of 114 minutes, the incidence of the composite endpoint of death, recurrent MI, and stroke is reduced compared with the administration of tPA and heparin when used in conjunction with a rescue / adjunctive PCI rate of 2.5%.

CM Gibson 2002

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 Cath lab at NE Baptist was activated and patient transported to NE Baptist.

 Patient left NE Methodist at 10:24 am  Arrived at NE Baptist at 10:33 am  Patient taken directly to the cath lab.

 Access obtained in right CFA at 10:51 am  Aspiration thrombectomy done at 11:07  RCA stented at 11:16 am with TIMI 3 flow and patient was chest pain free

 Door to balloon from NEM door to balloon – minutes

73

   Door to balloon at NEB –

34

minutes EKG in field to balloon time –

85

minutes 911 call to balloon time –

94

minutes 

Great Job Guys !!!!