Primary Angioplasty The Interventional Centres Experience

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Primary AngioplastyThe Interventional Centres
Experience

• Hammersmith Hospitals NHS Trust

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Primary angioplasty is here to stay Its progress
is unstoppable
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Current Management Strategies for MI
MI
ST Elevation
No ST Elevation
Fibrinolysis
Primary PCI
Early Invasive
Early Conservative
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The Limitations of Thrombolysis

• Increased risk of haemorrhagic stroke
• Despite therapeutic advances in thrombolytics
  only 50 reach TIMI 3 flow after 90 minutes
• Lack of reliable non-invasive methods for
  assessing patency of infarct related artery
• Most centres now advocate systematic coronary
  angiography for these patients while an
  in-patient

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Meta-analysis of 23 randomised trials comparing
Primary PTCA to Thrombolysis7739 patients 4-6
week data
Plt0.0001
P0.0002
P0.0003
Plt0.0001
P0.0004
Grines et al 2003NEJM36113-20
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Thrombolysis Versus Primary PCI - Time Dependancy
Absolute 35 day mortality reduction v treatment
delay
N50246
Primary PCI
Boersma et al, Lancet 1996 348771
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The Hammersmith Hospital Experience
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Initial Catchment Area

• Hammersmith Charing Cross 173,000
• West Middlesex 217,000
• To date approx 400,000 population

1 Patient per day
Proposed extension Ealing 308,000 St
Marys 252,000 Central Middlesex
220,000 Northwick Park 245,000
4 Patients per day
Figures from Coronary Revascularisation in NW
London
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Hammersmith Hospital
Ealing Hospital
Critical care transfer
Charing Cross Hospital
Critical care transfer
West Middlesex Hospital
500 MIs /year
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Traditional Flow of STEMI Patients
Hammersmith Hospital
Ealing Hospital
Ambulance service
MI
Acute admission 1-6 hours
Charing Cross Hospital
Transfer for rehabilitation and discharge 1-3
days
West Middlesex Hospital
Triage for Invasive investigation 3-5days
Total 5 - 41 inpatient days
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Flow of Patients for Primary Angioplasty
Hammersmith Hospital
Ealing Hospital
Acute admission 1-6 hours
Ambulance service
MI
Charing Cross Hospital
Transfer for rehabilitation and discharge 1-3
days
West Middlesex Hospital
Total 2-3 inpatient days
10,000 bed days
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HH Primary Angioplasty Pilot

• October 2003 Service begins HH only
• Limited to weekdays
• November 2003 HH 24 Hours
• Service extends to CXH Limited to
  weekdays
• January 2004 CXH and HH 24/ 7 Service
• February 2004 Service extends to WMH
  Limited to weekdays
• April 2004 CXH, HH and WMH 24/7 Service
• July 2004 Proposed extension to Ealing

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PPCI Pilot 100 Referred So Far PCI performed
in 73
Real World Mortality 1.4
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Median Times from Symptom Onset to Balloon
Inflation
Presentation to Reperfusion (min)
167
108
87
100
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Median Hospital StayThrombolysis vs Primary PCI
N38
N73
663 Saving per patient
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Patients Intervened by Time of Day
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Future Developments

• Facilitating Pre-hospital Diagnosis of Acute
  Myocardial Infarction
• Introduction of ECG transmission between LAS and
  CCU

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Summary

• Primary angioplasty is associated with a
  substantial reduction in mortality compared to
  thrombolysis
• More efficient patient pathway in terms of
  presentation, treatment and rehabilitation
• Likely to be more cost effective too

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Primary angioplasty is here to stay Its progress
is unstoppable