Primary Angioplasty The Interventional Centre's Experience

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Primary Angioplasty The Interventional Centre's Experience

  1. 1. Primary Angioplasty The Interventional Centre’s Experience Hammersmith Hospitals NHS Trust
  2. 2. Primary angioplasty is here to stay Its progress is unstoppable
  3. 3. Current Management Strategies for MI MI No ST Elevation Early Invasive Early Conservative ST Elevation Fibrinolysis Primary PCI
  4. 4. The Limitations of Thrombolysis <ul><li>Increased risk of haemorrhagic stroke </li></ul><ul><li>Despite therapeutic advances in thrombolytics only 50% reach TIMI 3 flow after 90 minutes </li></ul><ul><li>Lack of reliable non-invasive methods for assessing patency of infarct related artery </li></ul><ul><li>Most centres now advocate systematic coronary angiography for these patients while an in-patient </li></ul>
  5. 5. Meta-analysis of 23 randomised trials comparing Primary PTCA to Thrombolysis 7739 patients: 4-6 week data P=0.0002 P=0.0003 P<0.0001 P=0.0004 P<0.0001 Grines et al 2003;NEJM361:13-20
  6. 6. Boersma et al, Lancet 1996 348:771 Thrombolysis Versus Primary PCI - Time Dependancy Absolute 35 day mortality reduction v treatment delay N=50246 Primary PCI
  7. 7. The Hammersmith Hospital Experience
  8. 8. Initial Catchment Area <ul><li>Hammersmith & Charing Cross 173,000 </li></ul><ul><ul><li>West Middlesex 217,000 </li></ul></ul><ul><ul><li> To date approx 400,000 population </li></ul></ul>Figures from “Coronary Revascularisation in NW London” <ul><ul><li>Proposed extension </li></ul></ul><ul><ul><li>Ealing 308,000 </li></ul></ul><ul><ul><li>St Mary’s 252,000 </li></ul></ul><ul><ul><li>Central Middlesex 220,000 </li></ul></ul><ul><ul><li>Northwick Park 245,000 </li></ul></ul>1 Patient per day 4 Patients per day
  9. 9. Hammersmith Hospital Charing Cross Hospital West Middlesex Hospital Ealing Hospital Critical care transfer Critical care transfer 500 MIs /year
  10. 10. Traditional Flow of STEMI Patients Hammersmith Hospital Charing Cross Hospital West Middlesex Hospital Ealing Hospital Ambulance service Acute admission 1-6 hours Transfer for rehabilitation and discharge 1-3 days Total 5 - 41 inpatient days MI Triage for Invasive investigation 3-5days
  11. 11. Flow of Patients for Primary Angioplasty Hammersmith Hospital Charing Cross Hospital West Middlesex Hospital Ealing Hospital Ambulance service Acute admission 1-6 hours Transfer for rehabilitation and discharge 1-3 days Total 2-3 inpatient days MI 10,000 bed days
  12. 12. HH Primary Angioplasty Pilot <ul><li>October 2003 Service begins HH only </li></ul><ul><li>Limited to weekdays </li></ul><ul><li>November 2003 HH 24 Hours </li></ul><ul><li>Service extends to CXH Limited to weekdays </li></ul><ul><li>January 2004 CXH and HH 24/ 7 Service </li></ul><ul><li>February 2004 Service extends to WMH Limited to weekdays </li></ul><ul><li>April 2004 CXH, HH and WMH 24/7 Service </li></ul><ul><li>July 2004 Proposed extension to Ealing </li></ul>
  13. 13. PPCI Pilot – 100 Referred So Far PCI performed in 73 Real World Mortality 1.4%
  14. 14. Median Times from Symptom Onset to Balloon Inflation 167 108 100 87 Presentation to Reperfusion (min)
  15. 15. Median Hospital Stay Thrombolysis vs Primary PCI N=38 N=73 £663 Saving per patient
  16. 16. Patients Intervened by Time of Day
  17. 17. Future Developments <ul><li>Facilitating Pre-hospital Diagnosis of Acute Myocardial Infarction </li></ul><ul><li>Introduction of ECG transmission between LAS and CCU </li></ul>
  18. 18. Summary <ul><li>Primary angioplasty is associated with a substantial reduction in mortality compared to thrombolysis </li></ul><ul><li>More efficient patient pathway in terms of presentation, treatment and rehabilitation </li></ul><ul><li>Likely to be more cost effective too </li></ul>
  19. 19. Primary angioplasty is here to stay Its progress is unstoppable

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