Robert Welsh, MD FRCPC FACC

1
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 Healths Vital Heart Response
  Protocol
• Edmonton, Alberta, Canada

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Development of systems of care for
STEMITime, 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

3
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

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Regional Systems Approach to ST-Elevation
Myocardial Infarction Moving Upstream to the
First Point of Care Strategies for diagnosis,
triage, and treatment.
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 Circula
tion 2007116217-230 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 2007116217-230 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 2007116217-230 originally
published online May 30, 2007
Canadian Cardiovascular Society Workshop, 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 2007116217-230
originally published online May 30, 2007
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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 2007116217-230
6
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 2007116217-230
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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 Oct152(4)613-8.
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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"
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The impact of early 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
30 Day Mortality
of patients with no heart damage
25
13.3
lt60
242
Time to treatment
Taher et al., JACC
Adapted from Weaver et al. JAMA.
19932701211-1216.
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Door to balloon time in patients transferred for
primary PCI - NRMI 3/4
16.2 lt 120 minutes
Goal door to balloon time lt 90 minutes
50.6 door to balloon gt 3 hours
Nallamothu, B. K. et al. Circulation
2005111761-767
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Outcome in patients transferred for percutaneous
coronary intervention (NRMI 2/3/4)
Hospital stay 4.4 /- 3.5 days 5.4 /- 4.7 days
Door to balloon 99 /- 16 minutes
Plt0.001
Door to balloon 264 /- 178 minutes
N7,133
Plt0.0001
Plt0.001
Plt0.001
Shavelle DM et al, Am J Cardiol. 2005 Nov
196(9)1227-32. Epub 2005 Sep 2
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Understanding time to Treatment Fibrinolysis and
Primary PCI
Fibrinolysis
Goal 1st medical contact to needle 30 min.
10 min.
10 min.
10 min.
ECG
Drug
MD
Patient
Primary PCI
Goal 1st medical contact to needle 90 min.
10 min.
10 min.
70 min.
ECG
Patient
Primary PCI
MD
Inform/activate cath. lab staff,
transport patient prep for angio.
Sheath insertion 1st balloon
10 min.
10 min.
25 min.
25 min.
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DANAMI 2 Impact of patient baseline risk on
mortality and interaction with mode of
reperfusion therapy
25 of patients high risk (TIMI 5)
Thune, J. J. et al. Circulation 20051122017-2021
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Adjusted analysis of PCI related delay in
stratified STEMI populations
65 of patients presented within 120 minutes of
symptoms onset Mean age was 61 years
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
Pinto et al, Circulation 2006 1142019-2025.
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Systems of care for STEMI in Canada
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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.
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A citywide protocol for primary PCI in STEMI
Ottawa STEMI program
M LeMay et al, NEJM 2008 358 231 40.
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A citywide protocol for primary PCI in STEMI
Ottawa STEMI program
First medical contact to first balloon inflation
M LeMay et al, NEJM 2008 358 231 40.
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Which Early ST Elevation Myocardial Infarction
Therapy?
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Time to reperfusion and point of first medical
contact in STEMI
328 STEMI patients
145 Pre-hospital
183 In-hospital
Mode of transport to hospital
90 In-hospital Ambulance
93 In-hospital other
Bata I et al, CCC 2006
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Time from symptom onset to 1st drug by point of
randomization
135 min (95-186)
N183
140 min (91-185)
N93
48 min. plt0.001
130 min (96-189)
N90
43 min. plt0.001
87 min (65-147)
N145
Bata I et al, CCC 2006
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Time from symptom onset to first balloon by
point of randomization
204 min
N63/58
207 min
N34/31
56 min. plt0.001
201 min
53 min. p0.006
N29/27
148 min
N44/40
Bata I et al, CCC 2006
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Time from 1st medical contact to reperfusion
Transfer in majority
Bata I et al, CCC 2006
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Development of systems of care for STEMIPremise
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 2007116217-230
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Vital Heart ResponseImplementation of a
regional reperfusion protocolBest Therapy, Best
Time, Best PlaceWe 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.
26
Opportunities to enhance time to Treatment
Enhanced pre-hospital systems
ED
Patient
CCU
EMS
Myocardial necrosis occurs minutes after coronary
occlusion Not on arrival to hospital
27
Reflections on STEMI care Research translation
into practice
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Contemporary Management of STEMI
Pre-hospital ambulance
Pre-hospital fibrinolysis
0
Pre-hospital fibrinolysis
Pre-hospital triage for in-hospital
fibrinolysis
Pre-hospital triage for PCI or in-hospital
fibrinolysis
Patient Risk
Empower decision makers Avoid reperfusion
paralysis
higher
lower
Community hospital
Tertiary hospital
Rescue PCI
Transfer for Primary PCI
Adapted from Welsh et al AHJ, Jan 2003
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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 200444671-679 , Circulation
2004110588-636
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Managing patient risk during a heart
attackRisk modulates reperfusion decision
Preferred therapy
ICH 0.3
Death 50-80
Large AMI, cardiogenic shock
Young patient, no comorbid disease
ASA, heparin, (fibrinolysis) Transfer for urgent
cardiac Catheterization
ASA, heparin, reperfusion Ongoing risk
stratification
Risk of Therapy
Majority of ST elevation AMI
Risk of Disease
Death 1.5-2.5
ICH 3.5
Isolated inferior AMI
Elderly, frail HTN Relative contraindications
ASA, heparin, /- reperfusion
Adapted from Welsh RC Armstrong PW, New
Horizons in AMI
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Step 2 Determine whether fibrinolysis or an
invasive strategy is preferred

• Fibrinolysis is generally preferred if
• Early presentation lt 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 gt than 1
  hour, or medical contact-to-balloon is greater
  than 90 minutes

J Am Coll Cardiol 200444671-679 , Circulation
2004110588-636
32
Step 2 Determine whether fibrinolysis or an
invasive strategy is preferred

• 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 gt3
• Contraindications to fibrinolysis
• Late presentation
• Diagnosis is in doubt

J Am Coll Cardiol 200444671-679 , Circulation
2004110588-636
33
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

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Current STEMI Management in Nova Scotia

• CVHNS STEMI Guidelines
• Comprehensive STEMI patient care acute,
  in-hospital and post-discharge

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• 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

Heart attack Heart function Arrhythmia/device Pati
ent navigation Evaluation
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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

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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

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Alberta Cardiac Access Collaboration Heart
Attack Initiative Implementation of STEMI
resources to Alberta Pre-hospital programs
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(No Transcript)
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Region Wide Implementation of pre-hospital
fibrinolysis
Phases I - IV
QE II Hospital (Process Opt.)
41
Reflections on STEMI care
Success Through Co-operation
System wide integration
Administration
Paramedic
patient
Emergency Physicians
Cardiologists
Internal Med FPs
Acute Care Nurses
42
CAPTIM mortality benefit of early treatment
Sx lt 2 hours
30 day mortality
30 day mortality
One year mortality
P0.058
NS
NS
Pre Hospital Lysis
Primary PCI
Pre Hospital Lysis
Primary PCI
Pre Hospital Lysis
Primary PCI
Bonnefoy et al, Lancet 2002
Steg et al, Circulation, 2003.
GW Symposium, AHA 2002
43
STREAM
STrategic Reperfusion Early After Myocardial
Infarction
Randomize STEMI lt 3
hrs Cannot reliably undergo primary PCI lt60 from
diagnostic ECG
ASA, TNK
ASA Clopidogrel 600 mg
lt75 yr Enox 30mg IV 1mg/kg sc Clopidogrel 300 mg
Primary PCI
lt 50 ST resolution _at_ 90 min Hemodynamic/Electrica
lly Unstable
No
Yes
End Points Death, Shock, Re-MI, abort
MI, CHF lt 30 d
CatheterizationRevas12-24 h
Rescue PCI ASAP
44
Development of systems of care for
STEMITime, Treatment and Triage