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  • Clinical, hemodynamic, and electrocardiographic factors can be used in combination to predict the risk of death in any patient with AMI. Similarly, the benefits and risks of therapy can be predicted using readily available parameters. Tailored risk stratification allows the physician to assess the combined risk benefit ratio of treatment of AMI, therefore maximizing positive outcomes and minimizing complications. The majority of patients benefit from rapid reperfusion with fibrinolysis and maximal medical therapy. Patients at the extremes of risk – of the disease, or of complications of therapy – need to be assessed and managed appropriately. For example, a frail elderly patient with significant hypertension and an isolated inferior myocardial infarction (without significant anterior ST depression or RV involvement) has a relatively low mortality rate from the AMI but has an increased risk of complication, including intracranial hemorrhage (ICH), from fibrinolytic therapy. At the other extreme, a young patient with a massive anterior wall AMI and cardiogenic shock may need an aggressive reperfusion strategy, ideally in a centre capable of interventional approaches either isolated or combined with fibrinolysis.

03-welsh-acc-lake-20.. 03-welsh-acc-lake-20.. Presentation Transcript

  • Robert Welsh, MD FRCPC FACC Associate Professor of Medicine, University of Alberta Director of Cardiac Catheterization and Interventional Cardiology, University of Alberta Hospitals Director of the Cardiology Residency Training Program and Co-Director of the Chest Pain Program Chair of Capital Health’s Vital Heart Response Protocol Edmonton, Alberta, Canada
  • Development of systems of care for STEMI Time, Treatment and Triage Robert C. Welsh, MD, FRCPC Associate Professor of Medicine Director, Adult Cardiac Catheterization and Interventional Cardiology Director, University of Alberta Cardiology Residency Training Program Co-director, U of A Chest Pain Program Chair, Vital Heart Response
  • Disclosure
    • Research (other) Grant:
      • Astra Zeneca, Boehringer-Ingelheim, Eli Lilly, Hoffman LaRoche, Johnson and Johnson, Pfizer, Portola, sanofi-aventis, Shering
    • Speaking honorarium/consulting:
      • AstraZeneca, Boehringer-Ingelheim, BMS, Eli Lilly, Hoffman la Roche, Johnson and Johnson, sanofi-aventis, Servier, Pfizer
  • Regional System’s Approach to ST-Elevation Myocardial Infarction: Moving Upstream to the First Point of Care Strategies for diagnosis, triage, and treatment. Canadian Cardiovascular Society Workshop, 2007 Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: Executive Summary Alice K. Jacobs, Elliott M. Antman, David P. Faxon, Tammy Gregory and Penelope Solis Circulation 2007;116;217-230; originally published online May 30, 2007 Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: Current State of ST-Elevation Myocardial Infarction Care David P. Faxon Circulation 2007;116;217-230; originally published online May 30, 2007 Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: The Patient and Public Perspective George A. Mensah, Mary M. Hand, Elliott M. Antman, Thomas J. Ryan, Jr, Robert Schriever and Sidney C. Smith, Jr Circulation 2007;116;217-230; originally published online May 30, 2007 Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: Policy Recommendations Penelope Solis, Ezra A. Amsterdam, Vincent Bufalino, Barbara J. Drew and Alice K. Jacobs Circulation 2007;116;217-230; originally published online May 30, 2007
  • Development of systems of care for STEMI
    • Mortality benefit of early reperfusion is well established
      • with either fibrinolytic therapy or primary PCI
    • Care gaps remain prominent
      • 30% of STEMI patients do not receive any reperfusion therapy despite its availability and the absence of contraindications to its use
      • Those treated with reperfusion
        • fewer than 50% receive treatment with a door-to-needle time within 30 minutes
        • Fewer than 40% are treated with a door-to-balloon time within 90 minutes
    Jacobs et al, Circulation 2007;116;217-230
  • Development of systems of care for STEMI
    • ‘ Fibrinolytic therapy is the mainstay of treatment in the United States and around the globe because it is more widely available’
    • Nearly 5000 acute care hospitals in US, 2200 have catheterization laboratories and among those, only 1200 are capable of performing PCI
    • Therefore, the delivery of timely primary PCI to the majority of STEMI patients is extremely challenging, particularly in rural areas
    Jacobs et al, Circulation 2007;116;217-230
  • Systematic approach to STEMI: United States
    • Patients suffering STEMI and trauma share an essential feature: rapid triage and treatment by highly trained personnel improve survival in both conditions
    • However, the trauma system may be limited as a model for regionalizing STEMI care
      • trauma systems has been hindered by the struggle for sufficient and stable funding
      • competing interests among individual stakeholders
    • These same obstacles would need to be overcome if STEMI care is regionalized.
    • Unique characteristics related to STEMI care:
      • varied clinical presentation
      • lucrative reimbursement
    Nallamothu Am Heart J. 2006 Oct;152(4):613-8.
  • Time is a companion that goes with us on a journey. It reminds us to cherish each moment, because it will never come again. What we leave behind is not as important as how we have lived. Jean-luc Picard - "Star Trek: Generations"
  • The impact of early treatment Adapted from Weaver et al. JAMA . 1993;270:1211-1216. 30 Day % Mortality Taher et al., JACC 13.3% 25% <60 2:42 % of patients with no heart damage Time to treatment Early treatment of a heart attack : Greatly reduces the risk of death Treatment of a heart attack within the first hour: 1 in 4 patients end up with no heart damage Mortality (%) P = .03 <70 min 70-180 min Time since onset of symptoms 8.7 1.2 0 5 1 0 1 5
  • Nallamothu, B. K. et al. Circulation 2005;111:761-767 Door to balloon time in patients transferred for primary PCI - NRMI 3/4 16.2% < 120 minutes Goal door to balloon time < 90 minutes 50.6% door to balloon > 3 hours
  • Outcome in patients transferred for percutaneous coronary intervention (NRMI 2/3/4) Shavelle DM et al, Am J Cardiol. 2005 Nov 1;96(9):1227-32. Epub 2005 Sep 2 N=7,133 Door to balloon = 99 +/- 16 minutes Door to balloon = 264 +/- 178 minutes Hospital stay 4.4 +/- 3.5 days 5.4 +/- 4.7 days P<0.0001 P<0.001 P<0.001 P<0.001
  • Understanding time to Treatment: Fibrinolysis and Primary PCI ECG MD Patient Drug ECG MD Patient Primary PCI Fibrinolysis Primary PCI Goal – 1 st medical contact to needle 30 min. Goal – 1 st medical contact to needle 90 min. 10 min. 10 min. 10 min. 10 min. 10 min. 70 min. Inform/activate cath. lab staff, transport patient & prep for angio. Sheath insertion – 1 st balloon 25 min. 25 min. 10 min. 10 min.
  • Thune, J. J. et al. Circulation 2005;112:2017-2021 DANAMI – 2: Impact of patient baseline risk on mortality and interaction with mode of reperfusion therapy 25% of patients high risk (TIMI ≥5) PCI Fibrinolysis 1527 patients 3 year follow-up Risk: TIMI 0 – 4 n = 1134 Mortality with lytic 5.6% Mortality with PCI 8.0% P = 0.11 Risk: TIMI > 5 n = 393 Mortality with lytic 36.2% Mortality with PCI 25.3% P = 0.02
  • Pinto et al, Circulation 2006; 114:2019-2025. Adjusted analysis of PCI related delay in stratified STEMI populations NRMI 192,509 STEMI 645 hospitals Multi variable analysis – treatment type, age, gender, DM, HTN, Killip class, prior MI, infarct location, stroke, etc. Also corrected for hospital covariates: STEMI volume, primary PCI volume, etc 65% of patients presented within 120 minutes of symptoms onset Mean age was 61 years
  • Systems of care for STEMI in Canada
  • A citywide protocol for primary PCI in STEMI – Ottawa STEMI program
    • 344 consecutive STEMI patients
      • May 1/05 to April 30/06
    • System based protocol with primary PCI for majority patients (proviso for in-hospital fibrinolysis with delay to PCI)
      • pre-hospital system with direct transfer of pre-hospital STEMI patients to cardiac cath lab
        • Paramedics activate cath lab directly
      • Transferring hospitals (all within 7 miles)
        • Activate STEMI transfer direct from ED
    M LeMay et al, NEJM 2008; 358: 231 – 40.
  • A citywide protocol for primary PCI in STEMI – Ottawa STEMI program M LeMay et al, NEJM 2008; 358: 231 – 40. 49.8% 100% Arrival to 1 st hosp by ambulance 108 91 104 ECG to 1 st balloon 5.7% 3.0% 4.7% In-hospital mortality 230 158 201 Symptom onset to 1 st balloon 51 69 57 Time from arrival at cath hosp to 1 st balloon inflation 123 69 101 Arrival at 1 st hospital to 1 st balloon Transfer (209) Pre-hosp (135) All (344)
  • A citywide protocol for primary PCI in STEMI – Ottawa STEMI program M LeMay et al, NEJM 2008; 358: 231 – 40. First medical contact to first balloon inflation 138 101 1 st medical contact to 1 st balloon 49.8% 100% Arrival to 1 st hosp by ambulance 108 91 104 ECG to 1 st balloon 5.7% 3.0% 4.7% In-hospital mortality 230 158 201 Symptom onset to 1 st balloon 51 69 57 Time from arrival at cath hosp to 1 st balloon inflation 123 69 101 Arrival at 1 st hospital to balloon Transfer (209) Pre-hosp (135) All (344)
  • W hich E arly S T Elevation Myocardial Infarction T herapy?
  • Time to reperfusion and point of first medical contact in STEMI 328 STEMI patients 183 In-hospital 145 Pre-hospital 90 In-hospital Ambulance 93 In-hospital other Mode of transport to hospital Bata I et al, CCC 2006
  • Time from symptom onset to 1 st drug by point of randomization N=145 N=183 N=93 N=90 87 min (65-147) 135 min (95-186) 140 min (91-185) 130 min (96-189) 48 min. p<0.001 43 min. p<0.001 Bata I et al, CCC 2006
  • Time from symptom onset to first balloon by point of randomization 148 min 204 min 207 min 201 min N=44/40 N=63/58 N=34/31 N=29/27 56 min. p<0.001 53 min. p=0.006 Bata I et al, CCC 2006
  • Time from 1 st medical contact to reperfusion Bata I et al, CCC 2006 Transfer in majority <0.001 <0.001 <0.001 <0.001 P= 160 77 76 76 In-hospital: amb (n=90) 108 48 46 47 In-hospital: alternative (n=93) 105 41 43 43 Pre-hospital (n=145) Primary PCI ( n=98) Primary PCI (n=103) Lytic (n=218) All (n=321)   Median time to 1 st balloon inflation (min) Median time to 1st drug (min) Mode of transport
  • Development of systems of care for STEMI Premise for dual reperfusion strategies
    • ‘ Fibrinolytic therapy is the mainstay of treatment in the United States and around the globe because it is more widely available’
    • Nearly 5000 acute care hospitals in US, 2200 have catheterization laboratories and among those, only 1200 are capable of performing PCI
    • Therefore, the delivery of timely primary PCI to the majority of STEMI patients is extremely challenging, particularly in rural areas.
    Jacobs et al, Circulation 2007;116;217-230
  • Vital Heart Response Implementation of a regional reperfusion protocol Best Therapy, Best Time, Best Place We are currently at a juncture were medical knowledge has established excellent treatment options but practical implementation remains a major limitation to best medical care in many regions worldwide.
  • CCU ED EMS Patient Myocardial necrosis occurs minutes after coronary occlusion Not on arrival to hospital Opportunities to enhance time to Treatment: Enhanced pre-hospital systems
  • Reflections on STEMI care Research translation into practice
    • A region wide systematic approach to STEMI care based on best evidence and regional expertise
    • Focused on earliest point of care
    Vital Heart Response (2006 - onwards)
    • Expanded pre-hospital reperfusion opportunities
    • Demonstrated the benefit of a systematic approach with abbreviated time to treatment and excellent clinical outcomes
    WEST (2003 -2005) - Established paramedic based pre-hospital fibrinolysis in Canada ASSENT 3+ (2000 - 2002)
  • Patient Risk Tertiary hospital Contemporary Management of STEMI Community hospital Rescue PCI Pre-hospital fibrinolysis Pre-hospital triage for PCI or in-hospital fibrinolysis Pre-hospital fibrinolysis 0 higher lower Adapted from Welsh et al AHJ, Jan 2003 Pre-hospital ambulance Transfer for Primary PCI Pre-hospital triage for in-hospital fibrinolysis Empower decision makers “ Avoid reperfusion paralysis”
  • Approach to STEMI treatment
    • Step 1: Assess the Time and Patient Risk
    • Time since symptom onset
    • Risk of the presentation STEMI (clinical and ECG characteristics)
    • Risk of fibrinolysis
    • Time required until angiography and PCI could be performed
    J Am Coll Cardiol 2004;44:671-679 , Circulation 2004;110:588-636
  • Managing patient ‘risk’ during a heart attack Risk modulates reperfusion decision Risk of Disease Risk of Therapy Isolated inferior AMI Large AMI, cardiogenic shock ASA, heparin, (fibrinolysis) Transfer for urgent cardiac Catheterization ASA, heparin, +/- reperfusion Majority of ST elevation AMI Young patient, no comorbid disease Elderly, frail HTN Relative contraindications ASA, heparin, reperfusion Ongoing risk stratification Preferred therapy Adapted from Welsh RC & Armstrong PW, New Horizons in AMI Death 50-80% Death 1.5-2.5% ICH 0.3% ICH 3.5%
  • Step 2: Determine whether fibrinolysis or an invasive strategy is preferred
    • Fibrinolysis is generally preferred if:
    • Early presentation < 3 hrs from symptom onset
    • Invasive strategy is not an option (cath lab occupied, vascular access difficult, lack of access to skilled PCI laboratory)
    • Delay to invasive strategy (prolonged transportation, door to balloon time is > than 1 hour, or medical contact-to-balloon is greater than 90 minutes
    J Am Coll Cardiol 2004;44:671-679 , Circulation 2004;110:588-636
    • An Invasive strategy is generally preferred if:
    • Skilled PCI laboratory is available with medical contact to balloon time less than 90 minutes
    • High risk STEMI with cardiogenic shock or Killip class >=3
    • Contraindications to fibrinolysis
    • Late presentation
    • Diagnosis is in doubt
    Step 2: Determine whether fibrinolysis or an invasive strategy is preferred J Am Coll Cardiol 2004;44:671-679 , Circulation 2004;110:588-636
  • VHR – lessons learned
    • Implement best evidence based care in STEMI
      • Timely access to reperfusion, mechanical or pharmacological
      • Initial and ongoing risk stratification
      • Implementation of evidence based medicine
        • Acute, in-hospital, and chronic therapy
      • Risk factor modification and cardiac rehabilitation
    • Emergency Medical Services – key contributor
    • Collaboration – all stake holders involved
      • Regional administrative support
    • Patient centered approach
    • Continuous Quality Improvement program
  • Current STEMI Management in Nova Scotia
    • CVHNS STEMI Guidelines:
    • “ Comprehensive STEMI patient care – acute, in-hospital and post-discharge’
  • Heart attack Heart function Arrhythmia/device Patient navigation Evaluation
    • Improve outcomes and process of care
    • in STEMI patients
    • Reduced reperfusion delay
    • Increased collaboration/communication between
      • and among health disciplines and Health Regions
    • Increased resources for clinicians
    • Improved quality of care
    • Enhance patient follow-up following STEMI
        • Post STEMI clinics and cardiac rehabilitation
  • Alberta Cardiac Access Committee Heart Attack Initiative, STEMI Management in Central and Northern Alberta
    • Central mechanism to respond - diagnosis
      • Respond to paramedics engaged in pre-hospital fibrinolysis program
      • Respond to physicians in referral hospitals
      • Respond to nurses in centres where a physician is not readily available
  • Alberta Cardiac Access Committee Heart Attack Initiative, STEMI Management in Central and Northern Alberta
    • Central mechanism to respond - triage
      • Direct transfer of all patients to appropriate hospital
        • CCU/ICU centre
        • Transfer to tertiary care region/hospital
    • Central mechanism to respond – risk stratify
      • Continuous process
        • Acute reperfusion decision
        • Post fibrinolysis reperfusion
        • Post reperfusion – risk stratification
  • Alberta Cardiac Access Collaboration Heart Attack Initiative Implementation of STEMI resources to Alberta Pre-hospital programs
  •  
  • QE II Hospital (Process Opt.) Region – Wide Implementation of pre-hospital fibrinolysis Phases I - IV 1. Fairview Health Complex 2. High Prairie Regional Health Complex
  • Reflections on STEMI care patient Paramedic Emergency Physicians Cardiologists Acute Care Nurses Success Through Co-operation System wide integration Administration Internal Med FP’s
  • CAPTIM – mortality benefit of early treatment Pre Hospital Lysis Primary PCI NS 30 day mortality Steg et al, Circulation, 2003. P=0.058 30 day mortality Sx < 2 hours Pre Hospital Lysis Primary PCI Pre Hospital Lysis Primary PCI Bonnefoy et al, Lancet 2002 GW Symposium, AHA 2002 NS One year mortality
  • STREAM ST rategic R eperfusion E arly A fter M yocardial Infarction Randomize STEMI < 3 hrs Cannot reliably undergo primary PCI <60’ from diagnostic ECG ASA Clopidogrel 600 mg ASA, TNK < 50% ST resolution @ 90 min Hemodynamic/Electrically Unstable No Yes CatheterizationRevas12-24 h Primary PCI Rescue PCI ASAP End Points: Death, Shock, Re-MI, abort MI, CHF <= 30 d <75 yr Enox 30mg IV &1mg/kg sc Clopidogrel 300 mg ≥ 75 yr Enox 0.75mg/kg sc Clopidogrel 75mg
  • Development of systems of care for STEMI Time, Treatment and Triage