Transcript Slide 1

“Saving Time,
Saving Lives”
Paul M. Murray, MD, FACC
March 10, 2009
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III.
TRMC Experience
A. Primary
B. Elective
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A.
B.
National Overview
Case Review
III. TRMC Experience
A.
B.
Primary
Elective
STEMI
ST Elevation Myocardial Infarction
Emergency Management of
Complicated STEMI (2004)
Chest pain pattern suggesting an STEMI
Initial 12 lead ECG; if not diagnostic repeat at 5 to 10 minute intervals
ST elevation or new or presumably new LBBB
•Beta blocker
•IV nitroglycerin if persistent chest pain
•IV Heparin or Angiomax
•Clopidogrel (Plavix)
•GP IIb/IIIa inhibitor if primary PCI
Primary PCI, if available, with goal less than 90 minutes
OR thrombolysis with goal of 30 minutes
Goal = 10 minutes
Triage
Aspirin (chewed)
SL nitroglycerin
(3 doses)
Establish IV
Morphine
Continuous ECG
monitoring
Oxygen therapy
Obtain History & Physical
Draw blood for labwork
Initial labwork should include:
Cardiac biomarkers
(cTnI or cTnT preferred)
CBC with platelet count
PT and INR
aPTT
Electrolytes
Magnesium
BUN
Creatinine
Blood glucose
Lipid profile
Conditions other than MI that can
elevate Troponin
Thrombolysis In Myocardial Infarction
(TIMI) Score for STEMI
DM, history or HTN or history of Angina (1 point)
Systolic blood pressure less than 100 mm Hg (3 points)
Heart rate greater than 100 BPM (2 points)
Killip class II-IV (2 points)
Body weight less than 150 lb or 67 kg (1 point)
Anterior lead ST elevation or left BBB (1 point)
Time to treat more than 4 hours (1 point)
Age
>=75 years old (3 points)
65 – 74 years old (2 points)
Less than 65 (0 points)
TIMI Risk Score Predicts
30 Day Mortality
0 points
1 point
2 points
3 points
4 points
5 points
6 points
7 points
8 points
9 to 14 points
=
=
=
=
=
=
=
=
=
=
0.8%
1.6%
2.2%
4.4%
7.3%
12%
16%
23%
27%
36%
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III.
TRMC Experience
A. Primary
B. Elective
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III.
TRMC Experience
A. Primary
B. Elective
“Strategies for Reducing the
Door-to-Balloon Time in Acute
Myocardial Infarction”
N ENGL J MED 2006; 355:2308-20
80
No. of Hosptials
70
60
50
40
30
20
10
0
50
100
150
200
Door-to-Balloon Time (min)
362 Hospitals
Figure 1. Frequency Distribution for Median Door-to-Balloon Times among Study Hospitals.
The mean (±SD) of these median times was 100.4±23.5 minutes, which is considerably longer than the
90-minute interval recommended in the 2004 guidelines of the American Heart Association and the
American College of Cardiology.4
D2B: An Alliance for Quality
ED activation of Cath Lab
One call activation (Group page)
Pre-hospital ECG
Cath Team ready in 20-30 minutes
In-hospital cardiologist
Prompt data feedback
D2B Time According to the Number of Key
Strategies Used
Number of Key
Strategies
0
1
2
3
4
Hospitals with the Average of Median
Number of
Door-to-Balloon
Times Î
Key Strategies
(N=362)
minutes
no. (%)
137 (37.8)
130 (35.9)
56 (15.5)
31 (8.6)
8 (2.2)
110
100
88
88
79
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III.
TRMC Experience
A. Primary
B. Elective
CASE STUDY
60 year-old Caucasian male
History & Risk Factors include:
♥Hypertension
♥Hyperlipidemia
♥Hyperglycemia
♥ETOH abuse
CASE STUDY
♥Onset of “indigestion” just after McDonald’s
double cheeseburger
♥Indigestion progressed to severe
discomfort within minutes
♥Associated SOB and profound diaphoresis
♥Took 2 Aspirin and called 911
♥ECG at scene revealed acute changes
12 lead ECG from EMS
Timeline
14:57
EMS
performs ECG
15:21
15:45
Arrival to
Cath Lab
PTCA
(balloon
angioplasty)
CASE STUDY SUMMARY
Day 1
PTCA & DES in 100% prox RCA
(D2B = 24 minutes)
Day 2
Nutrition consult and Cardiac
Rehab consult
Day 3
Discharged home on Aspirin,
Plavix, Lopressor, Lipitor
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III.
TRMC Experience
A. Primary
B. Elective
Outline
I.
II.
STEMI (ST Elevation Myocardial Infraction)
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III. TRMC Experience
A. Primary
B. Elective
Trends in Bypass and PCI Procedures
United States: 1990-2002
Procedures in Thousands
750
650
550
450
350
CABG
250
PCI
150
90
95
00
Years
Source: CDC/NCHS.
01
02
PCI With or Without Onsite
Surgery Standby
ACC-NCDR 2001-2004
In-hospital Mortality : Offsite vs Onsite CVSx
Mortality
No Acute MI (n=482,018)
STEMI (n= 90,050)
NSTEMI (n=94,347)
0.54% vs 0.41%
4.65% vs 4.83%
1.94% vs 2.09%
P-value
0.87
0.75
0.12
Primary PCI
without on-site cardiac surgery
PRIMARY PCI INCLUSION CRITERIA
Chest pain > 20 minutes AND
– > 1 mm ST-segment elevation in two
contiguous ECG lead
OR
– New or presumed new LBBB
OR
– > 1 mm ST-segment depression in V1/V2
compatible with true posterior MI
Patients with chest pain >12 hours were allowed in the
registry but were considered thrombolytic-ineligible
Average Monthly D2B Times
July 2007-June 2008
40 total patients with a yearly average of 79 minutes
130
120
110
100
Time (in minutes)
90
80
70
60
50
40
30
20
10
0
July
Aug
Sept
Oct
Nov
Dec
Jan
Month
D2B
D2CCL
Feb
Mar
Apr
May
June
Outline
I.
STEMI (ST Elevation Myocardial Infraction)
II.
Primary PCI (Door to Balloon -D2B- time)
A. National Overview
B. Case Review
III.
TRMC Experience
A. Primary
B. Elective
C-PORT Elective Trial
32 active sites
• 7 states
• NJ, GA, IL, OH, OR, AL, PA
• 6 new sites in enrollment process
9500 randomized patients as of March 2009
Goal of 16,000–18,000 randomized patients
C-PORT Elective
Non-inferiority trial
Primary Endpoints
– Death at 6 weeks
– MACE (death+MI+TVR) at 9 months
Secondary Endpoints at 6 weeks and 9 months
–
–
–
–
–
–
–
–
Emergency CABG
Myocardial Infarction
Stroke
TVR (Target Vessel Revascularization)
Subsequent PCI or CABG
Bleeding
Heart Failure/Angina
Direct Medical Costs
C-PORT Elective
Patient for Diagnostic Cath
Informed consent
Refuse
Refuse
Registry
Catheterization
Exclusion
criteria
Meets
inclusion
criteria
PCI no SOS
PCI with SOS
TRMC CPORT ENROLLMENT
June 2006 – February 2009
Total Patients
2453
Total Patients Consented
– Elective
– Primary
2287 (93.2%)
2087
200
No Consent Patients
– Not approached
– Refused
166
147
19 (0.8% of total)
Randomized Patients
387
– TRMC
– Tertiary
Primary Patients
– PCI
– No PCI
290 (75%)
97 (25%)
200
159
41
QUESTIONS??