STEMI Management in Belgium

Belgian STEMI registry

2007-2011

Prof dr M Claeys

University Hospital

Antwerp

Belgian Working Group of Acute cardiology

Age-standardized mortality from ischaemic heart

disease in European regions

(men; 45–74 years;

year 2000)

European Heart Journal (2008) 29, 1316–1326

Minimal Data Base

Patient characteristics

(TIMI risk score)

Reperfusion strategy

In Hospital Outcome

Electronic CRF

Enrolment STEMI patients 1/1/2007 – 31/12/2011

2847

553

631

76

843

2186

1435

13701526

n= 11468

110 hospitals

75 hospitals with

>10 pts/y

0

1000

2000

3000

20072008200920102011

Regional data on baseline characteristics

4.3

4,3

4.2

3.3

3.8

4.2

3,9

4.24,4

TIMI risk score

0

2

4

6

8

10

12

14

16

18

Perc

ent

0 1 2 3 4 5 6 7 8 9 >9

TIMI >>9

Histogram

4,2 +/- 2,9

3,6

3,8

4

4,2

4,4

2007 2008 2009 2010 2011

Time Evolution TIMI risk factors

5958

59

6364

54565860626466

20072008200920102011

Tot ischemic time<4h

11 119 8 8

0

5

10

15

20072008200920102011

Peripheral Artery Disease

46

44 4443

41

38

40

42

44

46

48

20072008200920102011

Arterial Hypertension

25 24 22 20 18

0

10

20

30

20072008200920102011

Killip class >1

Regional data on Reperfusion therapy

84

88

93

26

82

90

71

8684

Primary PCI

6

84

3 26

0

10

20

30

40

50

60

70

80

90

thromb. PPCI ResPCI facPCI no rep

reperfusion therapy

78 81 87 90 94

0

50

100

Evolution reperfusion therapy

12 11 9 7 4

3625

15 105

5365

7683

91

0

20

40

60

80

100

2007 2008 2009 2010 2011

no reperf

TT

PCI

4 4 4 3,5 35 3 2 1,5 1

90 93 94 95 96

0

20

40

60

80

100

120

2007 2008 2009 2010 2011

no reperf

TT

PCI

PCI center

No-PCI center

Regional data on in hospital mortality

8.8

6

6.3

6.5

3.8

7.0

4.5

6.87

Average:

6,8%

Mortality

30d mortility (n=4697)

5.4 % (vs 4.7% in hospital)

6,47,6 7,6

5,9 6,2

0

2

4

6

8

2007 2008 2009 2010 2011

Regional data on duration of hospital stay

8.1

6.8

6.8

5.5

6.2

7.1

5.4

9.88.1

Average:

7 +/- 8 d

>7d: 21%

Duration

N=2842 (alive)

86,5

0

5

10

2010 2011

Hospital duration and TIMI risk score

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7 8 9 >9

IQ75%

median

N=2638 living patients (without CPR)

Risk factors for long hospital stay: age, female, PAD, Killip>1, no reperfusion, PCI center

Global Analyis: mortality data

• Mortality versus reperfusion strategy

• Mortality versus door to balloon/needle time

• Mortality versus cardiac care program

• Mortality and gender/age

• Mortality: independent predictors

Mortality versus Reperfusion strategy

0

5

10

15

20

25

30

Perc

ent

0 1 2 3 4 5 6 7 8 9 >9

TIMI risk score

N= 11467

TrombolysisN=665

Rescue PCIN=299

PCIN= 9617

Faciliated PCIN=250

No Reperfus.636

0

2

4

6

8

10

12

14

16

18

Perc

ent

0 1 2 3 4 5 6 7 8 9 >9

TIMI risk score

0

2

4

6

8

10

12

14

16

Perc

ent

0 1 2 3 4 5 6 7 8 9 >9

TIMI risk score

3.9

N = 954 ( 8%)* N=9867(86%) N= 636 (6%)

4.1 5.9

MORTALITY

6.0 %6,7% 19%

*Elective Invasive evaluation:502+299=801( 84%)

Mortality benefit PCI over TT is dependent

on baseline risk profile

0

5

10

15

20

25

30

35

40

45

50

0 1 2 3 4 5 6 7 8 >8

PCI thrombolysis

PCI vs TT : P=0.02

InTIME II

Mortality versus door to balloon/needle time

Ealry PCI: < 60 min

Interm PCI: 60-120

Late PCI: > 120 min

Early TT: <30 min

Interm T: 30-60 min

Late T: > 60 min

Claeys et al, Arch of Inter Med.2011;171:544-549

0

2

4

6

8

10

12

14

16

18

Perc

ent

0 1 2 3 4 5 6 7 8 9 >9

TIMI risk score

0

2

4

6

8

10

12

14

16

18

20

Perc

ent

0 1 2 3 4 5 6 7 8 9 >9

TIMI risk score

Mortality versus Acute cardiac care program

4.2 4.1MORTALITY

6.7%

PCI centreN=7024(60%)

trombolysis: 2%

Rescue PCI: 1%

Prim –facilat PCI: 93%

No reperfusion: 4 %

No-PCI centreN=4443 (40%)

trombolysis: 15%

Rescue PCI: 5%

Prim –facilat PCI:75%

No reperfusion: 8 %

6.9%

EHJ-ACC 2012, in press

Mortality versus gender

Men

N=8594

Female

N=2873(25%)

age

DM

Time to T<4h

shock

PCI/throm/no

61

14%

63 %

7%

87/9/5

68 *

19% *

53% *

11 % *

83/8/9 *

Mortality 6% 11 % *

* p<0.0001

Indepedent predictors of mortality

P value 0R (95%CI)

Killip > 1 <.0001 5 (4 - 7)

CPR <.0001 5 ( 4-6)

age <.0001 1.04 (1.03-1.05)

PCI vs TT

No reperf

0.01

<0,0001

1.5 ( 1.1 – 2.7)

2,3 (1,7-3,1)

Ischemia>4h 0.0001 1.5 (1.3-2.0)

PAD <0.0001 1,8 (1.4-2.4)

Female

Anterior infarct

0.04

0.001

1.3 (1. 1-2.0)

1.4 (1.1-1.6)

Conclusions

• The Belgian STEMI registry is the first prospectiveregistry enroling patients from both PCI and no-PCIcentres.

• The overall in hospital mortality is 6.9 % and compares well with current European ACS surveys.

• In the setting of STEMI networking with low threshold for invasive evaluation , the mortality of STEMI in PCI and no-PCI centers is identical.

• Participation to the STEMI registry increasesadherence to guidelines as was evidenced by a significant gradual increase in primary PCI particularly in non-PCI centers.

Steering committee of STEMI database

• Prof dr P Sinnaeve, UZ Leuven

• Prof dr P Evrard , UCL Mont-Godinne

• Dr C Convens, ZNA Antwerpen

• Dr P Dubois, CHU Charleroi

• Dr J Boland, CHR Citadelle Liège

• Dr P Vranckx, Virga Jesse Hasselt

• Dr S Gevaert, UZ Gent

• Dr A de Meester, Hôpital Jolimont

• Dr P Coussement , AZ Brugge

• Dr De Raedt, OLV Ziekenhuis Aalst

• Prof C Beauloye, UCL Louvain

• Prof M Renard, ULB Brussels

Conclusions

• Mortality benefit of PPCI over trombolysis (6.0 versus 6.7) is smaller than in previously reportedrandomised clinical trials. This is related, at leastpartly, to the selective use of trombolytic therapymainly in low risk patients and to better outcome of thrombolytic therapy (related the high rate of subsequent invasive evaluation in Belgium. )

• In the setting of STEMI networking with low threshold for invasive evaluation , the mortality of STEMI in PCI and no-PCI centers is identical.

• Participation to the STEMI registry increasesadherence to guidelines as was evidenced by a significant gradual increase in primary PCI particularly in non-PCI centers.

STEMI in octogenerians (12%)

05

10152025303540

<80 years ≥80 years KC = I

≥80 years KC >1

5.1

31.6

4.8

34.6

17.9

8.5

36.3

in-hosp mort TL (%) in-hosp mort PCI (%) in-hosp mort no-reperfusion (%)

12

5.7

Killip class>1 :

40%vs20%

Shock: 12% vs 7%

Ischemic time>4h

53% vs 38%

PCI : 76% vs 84

Conservative

14% vs 5%

Abstract presentation ESC 2011 E Vandecasteele et al

AUDIT STEMI REGISTRY:2007-2010

Centre Source doc. Correct item

2007-2008 (16)

2008-2009 (15)

2009-2010 (14)

2007-2010 (45)

2468/3255= 76%

2541/2877= 88%

2445/2793= 88%

7454/8925= 84%

2356/2468=95%

2460/2541=97%

2349/2445=96%

7165/7454=96%

TIMI risk score (automatically calculated)

Circulation: 2000;102:2031