Advanced Angioplasty 2005

Primary PCI making it happen

Data collection and Timings

Peter LudmanUniversity Hospital Birmingham

Motto

‘Time is Muscle’

Lysis - Treatment Delay

• 35/7 mortality reduction v delay

Boersma E Lancet 1996;348:771-75

Trials included in FTT analysis

PPCI v Lysis

• PPCI (n=3872) v Lysis (n=3867)

Keeley Lancet 2003; 361: 13–20%

Fre

quen

cy

However beautiful the strategy,

you should occasionally look at the results.

Winston Churchill

Time to PPCIdelays after admission

GUSTO IIb Berger P 1999;100:14-201

Time to ReperfusionBrodie BR et al JACC 1998;32:1312

4.3

9.0 9.3 9.5

0

2

4

6

8

10

12

% 3

0 D

ay M

orta

lity

< 2 2-4 4-6 > 6

Time to Reperfusion (hr)

• 1,352 patients treated by primary PTCA

n=164 n=581 n=332 n=275

Time to ReperfusionBrodie BR et al JACC 1998;32:1312

• 1,352 patients treated by primary PTCA

Time to PPCI

• 2635 patients (10 trials)

0

2

4

6

8

10

12

14

< 2 2 to 4 > 4

Time from Sx Onset to Presentation (hr)

Dea

th (

%)

PPCI

Lytic

Zijlstra F EHJ 2002;23:550-557

n=325 n=414 n=218

NRMI-2: Time to PTCACannon CP JAMA 2000;283:2941-2947

Time to Rx – myocardial salvage• 264 PPCI patients• 3 tertiles• Tc-99m Sestamibi SPECT

Schomig A Circ 2003;108:1084

Prague 2Mortality benefit by time to randomisation

6.8 7.36

10

7.4

15.3

02468

1012141618

All patients < 3 hrs 3 to 12 hrs

% 30/7

Mortality

PPCISK

• Transfer for PPCI v on site SK• n=850

Widimsky P. EHJ 2003;24: 94–104

Time from Sx to Randomisation

Prague 2Mortality benefit by time to randomisation

6.8 7.36

10

7.4

15.3

02468

1012141618

All patients < 3 hrs 3 to 12 hrs

% 30/7

Mortality

PPCISK

• Transfer for PPCI v on site SK• n=850

Widimsky P. EHJ 2003;24: 94–104

Time from Sx to Randomisation

Time to PPCI – the early timesSteg PG for CAPTIM Circ 2003;108:2851

Mor

talit

y• n = 840 (planned 1200)• prehospital tPA + rescue v PPCI

‘Loosing an hour’to implement a strategy for transferhas a differential impact on those seenearly rather than late

Time to PPCI – the early timesSteg PG for CAPTIM Circ 2003;108:2851

Early v late presentersDoor to Balloon time

Brodie Moses Cone registry Data ACC 2004

Early Presenters (≤ 2hrs) Late Presenters (>2hrs)

Time to PPCI in Shock

• LeBauer Cardiovascular Research Foundation Registry of consecutive PPCI

• n = 1843, shock in 138

Brodie BR JACC 2003;145:708-15

• Very early Rx (1 to 3 hours)

– Excellent results with PCI or lysis

• Door to balloon– Keep as short as possible– Particularly important in early presenters– ? also in high risk late presenters

• Late presenters– PPCI >> Lysis

Acceptable Time Delay for Transfer?

• Randomised trials of lysis v transfer– Maastricht trial– Prague– Air PAMI– Captim– Danami 2– Prague 2

Dalby M Circulation 2003;108:1809-1814

108

103

173

59

87

90

110

110

95

108

19

17

60

50

12

63

52

34

68

156

73

45

73

42

26

18

40

105

166

105

195

39

32

?

?

183

0 60 120 180 240 300 360

Sx to hosp

SAMU

Door needle

Transport

Door to Balloon

Transfer Time DelaysDifference

60

111

92

61

69

90

48

Time delays PPCI v Lysis• Meta analysis of 23 trials• Door to balloon v door to needle

Nallamothu BK AJC 2003;92:824

Risk reduction of PCI over

lysis

012345678

% F

aile

d P

CI

08:00-18:00 18:00-08:00

Time

Sx onsetAdmission1st balloon inflation

Circadian Variation

• 1702 consecutive PPCI (Zwolle 1994 to 2000)

Henriques JPS JACC 2003;41:2138–42

* P=0.02

# P<0.01* * #

Circadian Variation

• 1702 consecutive PPCI (Zwolle 1994 to 2000)

Henriques JPS JACC 2003;41:2138–42

0

1

2

3

4

5

% 3

0 D

ay

Mo

rta

lity

08:00-18:00 18:00-08:00

Time

SxAdmission1st balloon inflation

* P<0.01

# P=0.03# * *

Circadian Variation

PathophysiologyPlatelet aggregation

Coronary flowViscosityCortisol

EpinephrineAPTT

Endogenous tPAFibrinogen

Fibrinolytic factors

Patient characteristics

Risk profileDelayed conscious awareness of pain

Performanceof the

Healthcareteam

Lady Astor 'Sir, you're drunk!‘

Winston ChurchillYes, madam, I am drunk.But in the morning I will be sober andyou will still be ugly.

Circadian VariationDawson D. Nature 1997;388:235

Cognitive psychomotor performance of hand–eye coordination

Circadian VariationDawson D. Nature 1997;388:235

Guidelines and Data Collection

• Circulation. 2004;110:588-636

• Eur Heart J. 2003; 24: 28–66

ACC/AHA GuidelinesGoal: ‘ischaemic time’ < 120 mins

(Sx to lysis or PCI)

PCI centre Door to balloon <90 min

Non PCI centre Door to needle < 30 min

EMS Prehosp lysis < 30 min of arrival at scene

If < 90 min (total) to balloonor

if transport will not addmore than 60 to time to balloon v local lysis

• Fibrinolysis preferred if– Early presentation < 3hr (and delay to PPCI)

– PPCI not an option• Lab busy• No lab / inappropriate lab

– Delay to invasive strategy• > extra 1 hr over lysis time• > 90 min medical contact to balloon

ACC/AHA GuidelinesCirculation. 2004;110:588-636

• PPCI Preferred if– Skilled PCI service with surgical backup

• Operator > 75 Primary PCI pa• Team > 36 Primary PCI pa• Timings as before

– High risk for STEMI• Shock• Killip ≥ 3

– Contraindication to lysis– Late presentation (> 3 hours)– STEMI diagnosis in doubt

ACC/AHA GuidelinesCirculation. 2004;110:588-636

ESC Guidelines

• Fast Track patients (clear indication for reperfusion)

– Door to needle < 20 min– Door to Balloon < 60 min

Eur Heart J. 2003; 24: 28–66

MINAPVersion 6.1

Symptom onsetCall for helpArrival of first professional helpArrival of emergency servicesArrival at hospital

First balloon inflation

Date onlyangio (local)1st intervention or surgery (local)

Symptom onset

Arrival in first hospitalAdmission route(Arrival in PCI hospital)Start of procedureFirst balloon inflationFlow in IRA

BCIS – CCADVersion 5.1.3

Date and Time

UK data collectionThe future

2003 data: Ludman

BCIS dataset

Office of National StatisticsMortality register

MINAP datasetCardiothoracic surgical datasetEP dataset

Event free survival

NHS Number

Swedish Coronary Angiography and Angioplasty Registry - SCAAR

SCAAR

Swedish Population RegisterDate of Death

Swedish Patient AdministrationRegisterReadmissions (all events)

Data from year 2001Survival data to end 20029,496 of 9,535 patients

Swedish Coronary Angiography and Angioplasty Registry - SCAAR

Nilsson T http://www.sos.se/

6% 1yr9% 2yr

Mottos

‘Time is Muscle’

David Beckam’s Brain surgeon

‘Mind the Gap’

Joe’s Shoe Company

‘Always knowingly undersold’

‘Piston Broke?’

We can help

Alf’s Garage

The Literal Society

We are the literal society

British Rail

This motto has been withdrawn

Due to it being the wrong kind of motto

Primary PCI

‘………………………..’

Suggestions ?

The End