Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough.

Patient TransferPatient Transfer

Mark de Belder

The James Cook University Hospital

Middlesbrough

Current Management Strategies for ACSCurrent Management Strategies for ACS

ACS

No ST Elevation

EarlyConservative

EarlyInvasive

Fibrinolysis

ST Elevation

PrimaryPCI

Fibrinolysis

ST Elevation

PrimaryPCI

Fibrinolysis

ST Elevation

PRIMARYPCI

Guidelines for the management of non-STEMIGuidelines for the management of non-STEMIAcute Coronary SyndromesAcute Coronary Syndromes

Coping with ACS angiographyCoping with ACS angiography

• Rapid turnover of patients required (pressure on ambulance services)

• Organisation of diagnostic and revascularisation services

• Cath lab spaces required every day in interventional centres

• Referral to a specific cath lab slot rather than a specific Consultant

• Increased use of Cath ? Proceed slots (for elective work as well)

• Referring hospitals need to take some patients back after revascularisation (?swaps)

• Weekend working?

• Elective work may have to slow pending an increase in the infrastructure for angiography

• Clinical networks with appropriate support from commissioners

Patient TransferPatient Transferin the setting ofin the setting of

STEMISTEMI

Meta-analysis of 23 randomised trialsMeta-analysis of 23 randomised trials7739 patients: 4-6 week data

Keeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20

0%

2%

4%

6%

8%

10%

12%

14%

Death Exc.Shock Non-fatal MI CVA Combined

PCILysis

P=0.0002 P=0.0003 P<0.0001 P=0.0004 P<0.0001

Meta-analysis of 8 randomised trialsMeta-analysis of 8 randomised trials

Streptokinase trials - 1837 patientsStreptokinase trials - 1837 patientsKeeley EC, Boura JA, Grines CL

The Lancet 2003;361:13-20

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Death Non-fatal MI CVA Combined

PCILysis

0.53 (0.37-0.75) 0.11 (0.05-0.26) 0.32 (0.09-1.21) 0.40 (0.28-0.58)


Fibrin-specific trials - 5902 patientsFibrin-specific trials - 5902 patientsKeeley EC, Boura JA, Grines CL

The Lancet 2003;361:13-20

0%

2%

4%

6%

8%

10%

12%

14%


PCILysis

0.80 (0.66-0.96) 0.42 (0.31-0.55 0.49 (0.31-0.77) 0.57 (0.48-0.69)


Transfer for PCI vs On-Site LysisTransfer for PCI vs On-Site Lysis2909 patients: 4-6 week data2909 patients: 4-6 week data

Keeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20

0%

2%

4%

6%

8%

10%

12%

14%

16%


PCILysis

P=0.057 P<0.0001 P=0.049 P<0.0001

Mortality by time to presentationMortality by time to presentation

0%

2%

4%

6%

8%

10%

12%

14%

<2 hrs 2-4hrs >4hrs

PCILysis

Ziljstra EHJ 2002;23:556

30-day mortality by time from enrollment 30-day mortality by time from enrollment to first balloon inflationto first balloon inflation

0%

2%

4%

6%

8%

10%

12%

14%

16%

<60mins 61-75mins 76-90mins >91mins No PTCA

PCI

Berger P et al, Circ 1999;100:14-20 (GUSTO-IIb)

Door-to-Balloon times in Primary PCI Door-to-Balloon times in Primary PCI outside of trialsoutside of trials

N=27,080N=27,080Cannon CP, Gibson CM, et al. JAMA 2000

11.14 1.15

1.41

1.62 1.61

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

0-60 61-90 91-120 121-150 151-180 >180

P=NS P=NS P=0.01 P=0.0007 P=0.0003

N=2,230 N=5734 N=6616 N=4461 N=2627 N=5412

Corrected for age, anterior MI location & gender

CAPTIMCAPTIMComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction

Bonnefoy E et al, The Lancet 2002;360:825-29Bonnefoy E et al, The Lancet 2002;360:825-29A trial of prehospital fibrinolysis A trial of prehospital fibrinolysis plus selected PCIplus selected PCI

5 p rim ary P C I1 4 n o lys is

134 (33% )unscheduled Urgent PCI

295 (70% )unscheduled PCI w ithin 30 days

4 0 0p re -h osp ita l

a ltep lase

4 1 9p re -h osp ita l

a ltep lase

1 6 h ad n o an g iog rap h y4 1 n o P C I

1 6 (4 % )u n sch ed u led u rg en t P C I

6 0 (1 4 % )u n sch ed u led P C I w ith in 3 0 d ays

3 6 4p rim ary P C I

4 2 1p rim ary

P C I

8 4 0 ran d om ised

CAPTIMCAPTIMComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction

Bonnefoy E et al, The Lancet 2002;360:825-29Bonnefoy E et al, The Lancet 2002;360:825-29

Pre-hospital lysis n=419

Primary PCI n=421

P value

30 day Composite

34 (8.2%) 26 (6.2%) 0.29

Death 16 (3.8%) 20 (4.8%) 0.61

Reinfarction 15 (3.7%) 7 (1.7%) 0.13

Death & recurrent ischaemia

57 (13.5%) 41 (9.8%) 0.06

Disabling Stroke 4 (1%) 0 0.12

Physician-manned mobile emergency-care units (Service d’Aide Medicale d’Urgence – SAMU)Planned for 1200 patientsTrial terminated early due to lack of funding

Pre-hospital lysis - ER-TIMI19Pre-hospital lysis - ER-TIMI19Morrow DA et al, JACC 2002;40:71-7Morrow DA et al, JACC 2002;40:71-7

315 pts (65 cath’d) vs 650 in-hospital lysis pts

0 30 60 90 120 150 mins

0 30 60 90 120 150

mins

EMSArrival

EMSArrival

Pre-hosprPA

In-hospitallysis

EDArrival

13%>70% STres

90mins post-lysis49%

>70% STres

33%>70% STres

90mins post-lysis48%

>70% STres

4.7% death3.3% reMI1% ICH65 (21%) cath’d56 (18%) PCI

Why so little primary PCI in UK?Why so little primary PCI in UK?• Lack of evidence?

• Belief in pre-hospital lysis?

• Insufficient PCI centres?

• Too few cardiologists?

• (Interventional) cardiologists have too many other things to do?

• Reluctance to take on nocturnal work?

• Competing demands for finances (statins, ACE-I, DES, ICDs etc)?

• Lack of organisation?

Transferring patients for Primary PCITransferring patients for Primary PCIZijlstra F et al, Heart 1997;78:333-6Zijlstra F et al, Heart 1997;78:333-6The Weezenlanden Hospital, ZwolleThe Weezenlanden Hospital, Zwolle

Local patients

N=416

Transferred

N=104

Symptom-onset to admission

129 (69) mins 90 (60) mins

Local admission to WZL admission

- 70 (27) mins

WZL door-to-balloon time

67 (28) mins 39 (31) mins

Total ischaemia time 196 (74) mins 200 (62) mins

10 in shock (1 died)1 ventilated prior to transfer1 intubated during transfer1 VT – lignocaine2 VF – defibrillated2 required IV fluids

Transfer patients (104)

Helicopter vs Ambulance transfer for Helicopter vs Ambulance transfer for Primary PCIPrimary PCI

Straumann E et al, Heart 1999;82:415-9Straumann E et al, Heart 1999;82:415-9Triemli Hospital, ZurichTriemli Hospital, Zurich

Ambulance N=54

Helicopter N=14

Total N=68

Sig

Distance (km)

8 (5-68) 42 (24-122) 9 (5-122) 0.0001

Journey time (mins)

47 (15-126) 37 (7-60)

Total transfer time (mins)

50 (18-110) 63 (40-115) 55 (18-115) 0.02

3 patients died in shock prior to transfer0 patients transferred died8 patients were ventilated during transfer0 defibrillation during transfer (15 resuscitated prior to transfer)

AIR PAMIAIR PAMI138 patients: 30 day data (trial stopped for poor recruitment)138 patients: 30 day data (trial stopped for poor recruitment)

Grines CL et al, JACC 2002;39:1713-9

0%

5%

10%

15%

20%

25%

30%

35%

Death Non-fatalreMI

CVA MACE Ischaemia

PCILysis

P=0.46 P=1.0 P=0.11 P=0.33 P=0.007

79% ambulance transfer 26±28 miles; 21% Helicopter 57±50 miles0 patients needed resuscitation during transfer, 0 patients diedER to treatment times 174±80 for transfer vs 63±39 mins for local lysis

DANAMI-2DANAMI-2• 22 referring hospitals

• 5 PCI centres

• Serving two thirds of the Danish population (5.4million)

• Plan for 1100 patients at referring hospitals and 800 patients at invasive centres

• Average distance 35 miles (56km)

• Up to 95 miles (153km)

• Halted by Safety & Efficacy Committee after 1129 patients enrolled because of clear efficacy in PCI patients

DANAMI-2 Trial designDANAMI-2 Trial design

Primary Endpoint: Death, Reinfarction, or Disabling Stroke through

30 days

ST-elevation MI < 12 hours

Randomization (total planned 1900 pts)* Referral Hospital: Planned 1100 pts at 24 sites* Angioplasty Center: Planned 800 pts at 5 sites

FibrinolysisAccelerated tPA

(max. 100 mg)

StentAcute transfer for

1° PTCA + stent

Anderson HR et al, ACC 2002; Oral Presentation

DANAMI-2 - Time from Symptom Onset DANAMI-2 - Time from Symptom Onset to Admission and Time from Door to Rxto Admission and Time from Door to Rx

Door to t-PA

Door to PCI (Balloon)

transferadmit to transfer

Symptom to Hosp.

Symptom to Hosp.

Symptom to Hosp.

Door to PCI

0 60 120 180 240minutes

Referral

Invasive

Referral

Invasive

Lys

is1°

PC

I

Hospital

Average Door to Balloon (jncludestransfer) < 120 minutes

Door to t-PASymptom to Hosp.

ACC 2002; Oral presentation

DANAMI-2 DANAMI-2 Transfer problemsTransfer problems

• AF in 2.5%

• VT in 0.2%

• VF 1.4%

• 2/3 heart block in 2.3%

• 0 intubations

• 0 deaths

DANAMI-2: 30 day Primary EndpointDANAMI-2: 30 day Primary Endpoint

13.7

7.66.3

2.0

6.6

1.6 1.1

8.0

0

5

10

15

20p = 0.0003

p = 0.35p < 0.001

p = 0.15

Accel. t-PA (n=782) PCI (n=790)

Combined* Death Reinfarction DisablingStroke

*Primary Endpoint: Death, Reinfarction, or Stroke

% o

f P

atie

nts

All Patients


DANAMI-2: 30 day Primary Endpoint*DANAMI-2: 30 day Primary Endpoint*

13.7 14.2

12.3

8.56.7

8.0

0

5

10

15

20

p=0.0003 p=0.002

p=0.048

Accel. t-PA PCI

All patients(n=1572)

Referral hospitals(n=1129)

Invasive Centers(n=443)

*Primary Endpoint: Death or Reinfarction or Stroke

% o

f P

atie

nts

Referral vs. Invasive Hospitals


DANAMI 2: Time to treatmentDANAMI 2: Time to treatment30 day results30 day results

0%

2%4%

6%8%

10%12%

14%16%

18%20%

<1.5hrs 1-5-2.5hrs 2.5-4hrs >4-12hrs

PCItPA

Combined end-point - All significant

DANAMI 2: Results by age groupDANAMI 2: Results by age group30 day results30 day results

0%

5%

10%

15%

20%

25%

30%

<55yrs 55-64 65-74 75+

PCItPA

Combined end-point - All significant

PRAGUE 2PRAGUE 2

Tim e to trea tm en t2 4 5 m in u tes

4 2 1T'lys is

T im e to trea tm en t2 7 7 m in u tes

(+ 3 2 m in u tes )

4 2 5 tran sp orted2 d ied an d 3 V F

in tran s it1 .2 % com p lica tion s

4 s tayedE arly S h ock

T 'lys is3 d ied

4 2 9Tran sp ort

Widimsky P et al, ESC 2002

PRAGUE 2: 30 day mortalityPRAGUE 2: 30 day mortality

0%

2%

4%

6%

8%

10%

12%

14%

16%

Death 0-3hrs 3-12hrs

PCISK

P<0.02P=0.12 P=NS

Widimsky P et al, ESC 2002

Trial stopped early because of reluctance to enrol patients >3 hours

Shock patientsShock patientsHochman JS et al, NEJM 1999;341:625-34Hochman JS et al, NEJM 1999;341:625-34

Revascularisationpatients n=152

Medical Therapypatients n=150

Transfer patients 55.3% 55.3%Thrombolysis 49.3% 63.3%IABP 86.2% 86%PCI 54.6% 14%CABG 37.5% 11.3%PCI or CABG 86.8% 25.3%

Ambulance transferAmbulance transfer

Strategy for centres with door-to-balloon Strategy for centres with door-to-balloon times >120 mins?times >120 mins?

• Send anyway for primary PCI?

• Make do with best lysis strategy?

• As above and select out patients for rescue?

• Conventional lysis and send for rescue on arrival if required?

• Half-dose lysis ± GP IIb/IIIa inhibitor and send?

Facilitated PCIFacilitated PCI

• Studies such as PACT, SPEED, TIMI-14 and GUSTO V suggest that

– combination pharmacotherapy may improve effects of fibrinolysis, and

– pharmacotherapy combined with a PCI strategy may improve results of PCI

• FINESSE and ASSENT IV ongoing

• High risk patients who cannot be treated with early PCI

Current Process for Infarct Current Process for Infarct AngioplastyAngioplasty

MI

AmbulanceCentre

MI CentresMI Centres

MI

AmbulanceCentre

DANAMI-2 - DANAMI-2 - Time from Symptom Onset Time from Symptom Onset to Admission and Time from Door to Rxto Admission and Time from Door to Rx

Potential impact of MI centresPotential impact of MI centres

Door to t-PA

Door to PCI (Balloon)

transfer

Symptom to Hosp.

Symptom to Hosp.

Symptom to Hosp.

Door to PCI

0 60 120 180 240minutes

Referral

Invasive

Referral

Invasive

Lys

is1°

PC

I

Hospital

Could reduce time by 50-60 mins

Door to t-PASymptom to Hosp.

Paradox: referral patients might get more rapid reperfusion!

MI CentresMI Centres

MI

AmbulanceCentre

MI

AmbulanceCentre

As per C-PORT

Emergency Ambulance ServiceEmergency Ambulance Service

Hartlepool 3Stockton 3Carlton How 1Redcar 3Middlesbrough 3Coulby Newham 1/2

Blue light trained 1

Government policyGovernment policy

• Get the best out of the old treatments before looking at new ones

• Pilot studies of pre-hospital lysis– But data already available from Scotland, N. Ireland,

France, Holland, Germany, Belgium, USA and Israel!

Is there one?

• Get the best out of the old treatments and look at new ones

• Look at studies of pre-hospital lysis and allow (ie fund) introduction (?via NICE)

• Look at studies of primary PCI and allow (ie fund) introduction (?via NICE)

A better approach?

ConclusionsConclusions

If clinical investigators can organise trials, then governments, commissioners and clinical cardiologists should be able to organise an infarct angioplasty service

ConclusionsConclusionsPatient transfer in AMIPatient transfer in AMI

• Feasible

• Cardiovascular events are uncommon

• Need paramedics, ALS trained nurses or doctors

• Appropriately equipped ambulances– Continuous ECG monitoring– Defibrillation– Mechanical ventilation– Thrombolytic agents– IV fluids– Resuscitation drugs– Ability to transfer IABP

• Need new law to oblige rapid ambulance response to AMI transfer requests (<8 minute response time)

ConclusionsConclusionsPrimary PCI vs FibrinolysisPrimary PCI vs Fibrinolysis

• If hospital fibrinolysis is local strategy, change to primary PCI, at least for all patients presenting >3 (?>2) hours after symptom onset

• If pre-hospital fibrinolysis is local strategy, need appropriate numbers of appropriately equipped and staffed ambulances

• Such a strategy requires a PCI strategy – Contraindication to lysis– Early shock– High risk rescues– Re-infarction

• If such ambulance crews exist, then use them for transfer for primary PCI (as the PCI team exists anyway)!


• For PCI centres (on-site surgery) with 4 or more interventionists –

– primary PCI should be preferred treatment for STEMI

– ??offer fibrin-specific lysis to patients presenting in first 3 hours at night)

• For PCI centres with off-site surgery - Local arrangements needed for surgical candidates.


• For centres that cannot offer PCI but transfer possible within 3 hours -

– transfer patients to local PCI centre for primary PCI

– ??offer fibrin-specific lysis to patients presenting in first 3 hours – but respond to ongoing problems).

• For centres that cannot offer PCI, when transfer within 3 hours not possible -

– use fibrinolysis but consider protocol for immediate transfer of patients to PCI centre (?all-comers or selective).

• Role of facilitated PCI to be determined

DANAMI 2: 30 day resultsDANAMI 2: 30 day results

0%

5%

10%

15%

20%

25%

Death

reMINo reMI

P<0.0001

DANAMI-2DANAMI-2600 day data (6months-4 years)600 day data (6months-4 years)

300.111.9%15.3%Mortality - Referral hospitals

400.2613.4%16%Mortality - All patients

150.00416.9%23.3%Combined - Referral hospitals

180.00217.8%24.2%Combined - All patients

NNTP valuePCIFibrinolysisEnd-point

Anderson HR et al, XIVth World Congress of Cardiology 2002

Is simple primary PCI still going to be best?Is simple primary PCI still going to be best?Vermeer et al, Heart 1999;82:426-31Vermeer et al, Heart 1999;82:426-31

0%

2%

4%

6%

8%

10%

12%

14%

16%

In-hospital mortality

ConservativeRescuePrimary PCI

Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough.

Documents

Transcript of Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough.