STEMI: Whats the Rush

1
STEMI Whats the Rush?
A PCI Center perspective.

• William Phillips, MD, FACC, FSCAI
• Director of Cardiology
• CMMC

2
NRMI 2 Primary PCI Door-to-Balloon Time vs.
Mortality
P0.01
P0.0007
P0.0003
MV Adjusted Odds of Death
n 2,230
5,734
6,616
4,461
2,627
5,412
Door-to-Balloon Time (minutes)
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Patients Transported by EMS After Calling 9-1-1
Hospital Fibrinolysis Door-to-needle withinlt30
min
Call 911 Call Fast
EMS Triage Plan
Not PCI Capable Hospital

• EMS on-scene
• Encourage 12-lead ECG
• Consider prehospital fibrinolytic if capable and
  EMS-to-needle lt 30 min

Onset of STEMI Symptoms
9-1-1 EMS Dispatch
Interhospital
Transfer
PCI Capable Hospital
Goals
EMS transport
EMS on scene
Dispatch
Patient
EMS transportEMS to Balloon within 90 min
5 min after Symptom onset
Within 8 min
Patient self-transport Hospital Door-to-Balloon
within 90 min
1 min
Total ischemic time Within 120 min
Adapted from Panel A Figure 1 Antman et al.
JACC 200444676.
Golden hour First 60 min
4
ACC/AHA Guidelines for the Management of Patients
With ST-Elevation Acute Myocardial Infarction-
Focus Emergency Care
A Report of the American College of
Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Committee to
Revise the 1999 Guidelines for the Management of
Patients with Acute Myocardial Infarction)
Available as full text or executive versions at
http//www.acc.org
Antman et al. JACC 200444671-719.
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Achieve Coronary Patency

• Initial Reperfusion Therapy
• Defined as the initial strategy employed to
  restore blood flow to the occluded coronary
  artery
• 3 Major Options
• Pharmacological Reperfusion
• PCI
• Acute Surgical Reperfusion
• Under both Pharmacological and PCI are listed
  several lower recommendations investigational
  reperfusion strategies

Class I All patients should undergo rapid
evaluation for reperfusion therapy have a
reperfusion strategy implemented promptly after
contact with the medical system
Antman et al. JACC 200444680.
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Importance of EarlyReperfusion Therapy in STEMI

• Outcomes Dependent Upon
• Time to treatment-TIME IS STILL MUSCLE!
• Early and full restoration in coronary blood flow
  (TIMI 3 flow)
• Sustained restoration of flow (no reinfarction
  and effective treatment for recurrent ischemia)

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Comparison of Approved Fibrinolytic Agents

• Streptokinase Alteplase
  Reteplase Tenecteplase
• Dose 1.5 MU over Up to 100mg in
  10U x 2 30-50mg
• 30-60 min 90 min (wt-based) each
  over 2 min based on weight
• Bolus Admin. No No
  Yes Yes
• Antigenic Yes No
  No No
• Allergic React Yes
  No No No
• Systemic Marked Mild
  Moderate Minimal
• Fibrinogen Depletion
• 90-min patency 50 75
  75? 75
• rates ()
• TIMI grade 3 flow, 32 54
  60 63

Adapted from Table 15, pg 53.Accessed on August
6, 2004 http//www.acc.org/clinical/guidelines/ste
mi/index.pdf.
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Reperfusion ChoicesStep 2 Determine Whether
Fibrinolysis or an Invasive
Strategy is Preferred
If presentation is less than 3 hours and there is
no delay to an invasive strategy, there is no
preference for either strategy.

• Fibrinolysis is generally preferred if
• Early presentation (3 hours or less from
• symptom onset delay to invasive strategy
• see below)
• Invasive strategy is not an option
• Catheterization lab occupied/not available
• Vascular access difficulties
• Lack of access to a skilled PCI lab-
• Operator experience gt 75 PCI cases per year
• Team experience gt36 PPCI cases per year
• Delay to invasive strategy
• Prolonged transport such that the
• (Door-to Balloon) (Door-to- needle) time is gt 1
  HR
• Medical contact-to- balloon time is gt than 90 min
  (But how much more is too long?)

• An invasive strategy is generally preferred if
• Skilled PCI laboratory available with surgical
  backup
• Medical contact-to- balloon time is lt than 90 min
• (Door-to Balloon) (Door-to- needle time) is lt 1
  hr
• High risk from STEMI
• Cardiogenic shock
• Killip class greater than or equal to 3
• Contraindications to fibrinolysis, including
  increased
• risk of bleeding and ICH
• Late presentation
• Symptom onset was more than 3 hours ago
• Diagnosis of STEMI is in doubt

Adapted from Figure 3 Antman et al. JACC
200444682.
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CAPTIMComparison of Angioplasty and Prehospital
Thrombolysis in Acute Myocardial Infarction
Primary Composite Endpoint- Death, Reinfarction,
Disabling Stroke
Bonnefoy E, et al. Lancet 2002360825-9
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CAPTIM -1Year ResultsSx to Treatment Analysis
Sx ? 2 h
Sx ? 2 h
7.5
10.0
Death
Death
Death
P0.057
P0.47
5.7
2.2 absolute Risk Reduction 37 Relative RR (NS)
7.5
5.0
5.9
5.0
Percent
3.7
2.2
2.5
2.5
0.0
0.0
Pre-hospital Lysis
Primary PCI
Pre-hospital Lysis
Primary PCI
Touboul P. Presented at The 18th International
Symposium on Thrombolysis and Interventional
Therapy in Acute Myocardial Infarction - George
Washington University Symposium November 16,
2002 Chicago, Ill.
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Time Dependence of Reperfusion in STEMI
12
Time from Symptom Onset to TreatmentPredicts
1-year Mortality after Primary PCI
n1791
The relative risk of 1-year mortality increases
by 7.5 for each 30-minute delay
De Luca et al, Circulation 20041091223-1225
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Register of Information and Knowledge about
Swedish Heart Intensive care Admissions
General information

• 74 (77) hospitals in Sweden
• National registry since 1995 (1992)
• gt 550.000 ICCU-admissions (95)
• Annually 60,000 new admissions
• Annually 20,000 acute MI
• Follow up by merging with public registries on
  hospital care and death
• Over 26,000 patients included.

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Mortality in relation to therapy and delay
Prehospital thrombolysis (PHT)
7-day mortality
Primary PCI (PCI)
Any time
30-day mortality
1-year mortality
Adjusted outcome by Cox regression analysis
including 23 variables plus propensity score.
30-day mortality
Reperfusion started lt2 h
1-year mortality
30-day mortality
Reperfusion started gt2 h
1-year mortality
0,4
1,2
1,5
0,8
0,6
2
0,1
1
10
in-hospital thrombolysis better
PCI or PHT better
JAMA 20062961749
15
Primary PCI vs prehospital in inhospital
trombolysisover 5 years adjusted cumulative 1
year mortality
JAMA 20062961749
16
Primary PCI vs trombolysisage-adjusted 1 year
mortality in relation to delay time
JAMA 20062961749
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Primary Percutaneous Coronary Intervention

• Interhospital Transfer for Primary PCI
• To achieve optimal results, time from the first
  hospital door to the balloon inflation in the
  second hospital should be as short as possible,
  with a goal of within 90 minutes.
• Significant reductions in door-to-balloon times
  might be achieved by directly transporting
  patients to PCI centers rather than transporting
  them to the nearest hospital, if interhospital
  transfer will subsequently be required to obtain
  primary PCI.

Antman et al. JACC 200444686.
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Barriers to InterhospitalTransfer for PPCI

• Distance
• Weather!
• Road conditions
• Ambulance and/or helicopter availability
• Economics
• EMTALA regulations
• Lack of a well-rehearsed transfer protocol by a
  committed team with ongoing QI reviews

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Criteria for Level 1 Heart Attack Center

• 24/7 Cardiac cath lab
• 24/7 Cardiovascular surgery
• Comprehensive interventional team
• gt200 interventional Pts/yr
• gt36 PPCI/yr
• gt75 PCI/interventional Cardiologist
• Standardized protocols at referral and receiving
  hospitals
• Transfer agreements in place
• Education and training programs
• Quality Assurance ongoing

Henry, et al, JACC vol.47 April 4, 2006, 1339-45
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Achieving Rapid Treatment
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Summary Selection of the Optimal Reperfusion
Options for the STEMI Patient 2004

• Invasive Strategy if
• Cardiogenic shock (age lt 75)
• Bleeding risk
• Diagnosis in doubt (pericarditis/aneurysm)
• Door to balloon lt 90 min
• Symptoms gt 2-3 h
• Lytic failure or post lysis
• Skilled PCI center available, defined by
• Operator experience gt 75 cases/yr
• Team experience gt 36 primary PCI/yr
• Age gt 75
• (90 TIMI 3 flow)

• Full Dose Fibrinolytic Monotherapy if
• Door to balloon (D-B) gt 90 min (?how much
  greater)
• Lack of access to skilled PCI center
• (D-B) (D-N) gt 1 h
• lt 3 h from symptom onset
• (TNK62 TIMI 3 flow)

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Technical Aspects of PPCI

• Direct to Cath Lab (meet patient at doorconsent
  history enroute to lab). Confirm diagnosis and
  appropriateness.
• Rapid prep (if not done by sending hospital)
• Adjunctive pharmocotherapy?
• Careful vascular access (goal is one
  stickUltrasound guidance?)
• Angiographic preferences Infarct artery first?
• Cross, Dotter, Assess, Inflate, ?Thrombectomy,
  Stent (?not DES)
• LV gram at end if stable, LVEDP at least.

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The end.of the beginning.

• Knowing is not enough, we must apply. Willing is
  not enough, we must do.
• 
  Goethe