Transcript STEMI: What’s the Rush? A PCI Center perspective. William Phillips, MD, FACC, FSCAI

STEMI: What’s the Rush?
A PCI Center
perspective.
William Phillips, MD, FACC, FSCAI
Director of Cardiology
CMMC
MV Adjusted Odds of Death
NRMI 2: Primary PCI Door-to-Balloon Time
vs. Mortality
2.2
P=0.01
P=0.0007 P=0.0003
1.8
1.62
1.61
1.41
1.4
1.14
1
1.15
0.6
0.2
0-60
n = 2,230
61-90
91-120
5,734
6,616
121-150 151-180
4,461
2,627
>180
5,412
Door-to-Balloon Time (minutes)
Patients Transported by EMS After Calling 9-1-1
Hospital Fibrinolysis:
Door-to-needle
within<30 min
Onset of
STEMI
Symptoms
9-1-1
EMS
Dispatch
EMS on-scene
•Encourage 12-lead ECG
•Consider prehospital fibrinolytic
if capable and EMS-to-needle <
30 min
Not PCI
Capable
Hospital
PCI
Capable
Hospital
Goals
Patient
5 min after
Symptom
onset
Dispatch
1 min
EMS on
scene
Within
8 min
EMS transport
EMS transport:EMS to Balloon within 90 min
Patient self-transport: Hospital Door-toBalloon within 90 min
Total ischemic time: Within 120 min*
* Golden hour = First 60 min
Adapted from Panel A Figure 1
Antman et al. JACC 2004;44:676
ACC/AHA Guidelines for the Management of
Patients With ST-Elevation Acute Myocardial
Infarction- Focus Emergency Care
A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the 1999
Guidelines for the Management of Patients with Acute Myocardial Infarction)
Available as full text or executive versions at http://www.acc.org
Antman et al. JACC 2004;44:671-719.
Achieve Coronary Patency

Initial Reperfusion Therapy
• Defined as the initial strategy employed to restore
blood flow to the occluded coronary artery

3 Major Options:




Pharmacological Reperfusion
PCI
Acute Surgical Reperfusion
Under both Pharmacological and PCI are listed several lower
recommendations & investigational reperfusion strategies
Class I All patients should undergo rapid evaluation for reperfusion therapy &
have a reperfusion strategy implemented promptly after contact with the
medical system
Antman et al. JACC 2004;44:680.
Importance of Early
Reperfusion Therapy in STEMI
Outcomes Dependent Upon:



Time to treatment-TIME IS STILL MUSCLE!
Early and full restoration in coronary blood flow
(TIMI 3 flow)
Sustained restoration of flow (no reinfarction and
effective treatment for recurrent ischemia)
Comparison of Approved
Fibrinolytic Agents
Streptokinase
•Dose
•Bolus Admin.
•Antigenic
•Allergic React
•Systemic
Alteplase
Reteplase Tenecteplase
1.5 MU over
Up to 100mg in
30-60 min
90 min (wt-based)
No
Yes
Yes
Marked
No
No
No
10U x 2
30-50mg
each over 2 min
based on weight
Yes
Yes
No
No
No
No
Mild
Moderate
Minimal
75
75?
75
54
60
63
Fibrinogen Depletion
• ~90-min patency
50
rates (%)
•TIMI grade 3 flow, % 32
Adapted from Table 15, pg 53.Accessed on August 6, 2004
http://www.acc.org/clinical/guidelines/stemi/index.pdf.
Reperfusion Choices
Step 2:
Determine Whether Fibrinolysis or
an Invasive Strategy is Preferred
If presentation is less than 3 hours and there is no delay to an invasive
strategy, there is no preference for either strategy.
Fibrinolysis is generally preferred if:
An invasive strategy is generally preferred if:
• Early presentation (3 hours or less from
symptom onset & delay to invasive strategy;
see below)
• Invasive strategy is not an option
Catheterization lab occupied/not available
Vascular access difficulties
Lack of access to a skilled PCI labOperator experience > 75 PCI cases per
year
Team experience >36 PPCI cases per year
• Delay to invasive strategy
Prolonged transport such that the
(Door-to Balloon) – (Door-to- needle) time is
> 1 HR
Medical contact-to- balloon time is > than 90
min (But how much more is too long?)
• Skilled PCI laboratory available with surgical
backup
Medical contact-to- balloon time is < than 90
min
(Door-to Balloon) – (Door-to- needle time) is <
1 hr
• High risk from STEMI
Cardiogenic shock
Killip class greater than or equal to 3
• Contraindications to fibrinolysis, including
increased
risk of bleeding and ICH
• Late presentation
Symptom onset was more than 3 hours ago
• Diagnosis of STEMI is in doubt
Adapted from Figure 3; Antman et al. JACC 2004;44:682.
CAPTIM
Comparison of Angioplasty and Prehospital
Thrombolysis in Acute Myocardial Infarction
AMI within 6 hours
1200 planned
840 enrolled
Prehospital
Thrombolysis
n=419
Primary
Angioplasty
n=421
Primary Composite Endpoint- Death, Reinfarction, Disabling Stroke
Bonnefoy E, et al. Lancet 2002;360:825-9
CAPTIM -1Year Results
Sx to Treatment Analysis
Sx  2 h
Sx  2 h
7.5
10.0
Death
Death
P=0.057
Death
P=0.47
5.7
7.5
5.0
Percent
5.9
2.2% absolute
Risk Reduction
=37% Relative
RR (NS)
5.0
3.7
2.5
2.2
2.5
0.0
0.0
Pre-hospital Lysis Primary PCI
Pre-hospital Lysis Primary PCI
Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute
Myocardial Infarction - George Washington University Symposium; November 16, 2002; Chicago, Ill.
Time Dependence of
Reperfusion in STEMI
Time from Symptom Onset to Treatment
Predicts 1-year Mortality after Primary PCI
n=1791
The relative risk of 1-year mortality increases by
7.5% for each 30-minute delay
De Luca et al, Circulation 2004;109:1223-1225
Register of Information and Knowledge about Swedish
Heart Intensive care Admissions
General information
74 (77) hospitals in Sweden
National registry since 1995 (1992)
> 550.000 ICCU-admissions (95%)
Annually 60,000 new admissions
Annually 20,000 acute MI
Follow up by merging with public
registries on hospital care and death
Over 26,000 patients included.
Mortality in relation to therapy and
delay
Prehospital thrombolysis (PHT)
7-day mortality
Primary PCI (PCI)
Any time
30-day mortality
1-year mortality
Adjusted outcome by Cox regression analysis including 23 variables plus propensity score.
30-day mortality
Reperfusion started <=2 h
1-year mortality
30-day mortality
Reperfusion started >2 h
1-year mortality
0,1
PCI or PHT better
0,4
0,6
0,8
1 1,2
1,5
2
in-hospital thrombolysis better
10
JAMA 2006;296:1749
Primary PCI vs prehospital in inhospital trombolysis
over 5 years – adjusted cumulative 1 year mortality
0.10
Reperfusion > 2h
3993
1155
979
0
3571
1077
936
100
3530
1066
928
200
Time (days)
3490
1060
916
300
400
In-hosp Tlys
Prehosp Tlys
Primary PCI
0.05
0.00
Cumulative mortality
In-hosp Tlys
Prehosp Tlys
Primary PCI
0.05
0.00
Cumulative mortality
0.10
Reperfusion < 2h
8892
1135
3592
0
7675
1020
3375
100
7519
1004
3344
200
7417
997
3318
300
400
Time (days)
JAMA 2006;296:1749
0.20
Primary PCI vs trombolysis
age-adjusted 1 year mortality in relation to delay time
0.10
0.05
Time for reperfusion (h)
139
703
31
332
10-15
196
1061
41
458
7-10
121
658
17
282
6-7
159
946
37
453
5-6
4-5
332
239
2199 1438
50
43
776
567
3-4
2-3
PCI
Deaths / Patients
122
503
503
1248 4375 3659
7
61
81
125
895 1126
1-2
Tlys
0-1
0.00
1-year mortality
0.15
Tlys
PCI
JAMA 2006;296:1749
Primary Percutaneous Coronary
Intervention
Interhospital Transfer for Primary PCI
“To achieve optimal results, time from the first
hospital door to the balloon inflation in the second
hospital should be as short as possible, with a goal
of within 90 minutes.
Significant reductions in door-to-balloon times
might be achieved by directly transporting patients
to PCI centers rather than transporting them to the
nearest hospital, if interhospital transfer will
subsequently be required to obtain primary PCI”.
Antman et al. JACC 2004;44:686.
Barriers to Interhospital
Transfer for PPCI







Distance
Weather!
Road conditions
Ambulance and/or helicopter availability
Economics
EMTALA regulations
Lack of a well-rehearsed transfer protocol
by a committed team with ongoing QI
reviews
Criteria for Level 1
Heart Attack Center










24/7 Cardiac cath lab
24/7 Cardiovascular surgery
Comprehensive interventional team
>200 interventional Pts/yr
>36 PPCI/yr
>75 PCI/interventional Cardiologist
Standardized protocols at referral and receiving
hospitals
Transfer agreements in place
Education and training programs
Quality Assurance ongoing
Henry, et al, JACC vol.47: April 4, 2006, 1339-45
Achieving Rapid Treatment
Summary: Selection of the Optimal Reperfusion
Options for the STEMI Patient: 2004
Invasive Strategy if…
Full Dose Fibrinolytic
Monotherapy if…
Door to balloon (D-B)
> 90 min (?how much
greater)

Lack of access to skilled
PCI center


Cardiogenic shock (age < 75)

Bleeding risk

Diagnosis in doubt
(pericarditis/aneurysm)

Door to balloon < 90 min

Symptoms > 2-3 h
Lytic failure or post lysis

(D-B) – (D-N) > 1 h


< 3 h from symptom onset


(TNK—62% TIMI 3 flow)
Skilled PCI center available, defined
by:
• Operator experience > 75 cases/yr
• Team experience > 36 primary
PCI/yr

Age > 75

(90+% TIMI 3 flow)
Technical Aspects of PPCI







Direct to Cath Lab (meet patient at door…consent
& history enroute to lab). Confirm diagnosis and
appropriateness.
Rapid prep (if not done by sending hospital)
Adjunctive pharmocotherapy?
Careful vascular access (goal is one
stick…Ultrasound guidance?)
Angiographic preferences: Infarct artery first?
Cross, Dotter, Assess, Inflate, ?Thrombectomy,
Stent (?not DES)
LV gram at end if stable, LVEDP at least.
The end….of the beginning.
Knowing is not enough, we must apply.
Willing is not enough, we must do.
Goethe