Dr Martyn ThomasDr Martyn ThomasKings College HospitalKings College Hospital

Primary angioplastyPrimary angioplasty““A UK Experience”A UK Experience”

““The UK experience”The UK experience”

PAMI activity in the UKPAMI activity in the UK2003/20042003/2004

Data sourceData source

2003 data available via BCIS audit 2003 data available via BCIS audit Recent E mail request for data on Recent E mail request for data on

PAMI to all PCI centresPAMI to all PCI centres Returns from 20 centres………assumed Returns from 20 centres………assumed

they are the “active” centres????they are the “active” centres????

Kings data……….stopped thrombolysis Kings data……….stopped thrombolysis for casualty patients Sept 1for casualty patients Sept 1stst 2003 2003

UK Intervention UK Intervention CentresCentres

52 52 53 54 54 5358 61 63 66 64 64

73

01020304050607080

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

No.

cent

res

PCI for STEMIPCI for STEMI

633

0100200300400500600700800900

Primary PCI

2001200220032004

Data from units reporting cath or hosp outcome

900(20Centres)

Primary PCI for STEMIPrimary PCI for STEMI2003 data from 43 centres/2004 from 20 centres2003 data from 43 centres/2004 from 20 centres

0

5

10

15

20

Num

ber o

f C

entr

es

0-10 11-20

21-40 41-50 51-60 61-70 71-80 81-90 91-100

>100

No Procedures per Centre

20032004

Total 633 procedures 2003/ 900 procedures 2004.

HammersmithK Beatt

Hospital Outcome 2003Hospital Outcome 2003Data from 22 centresData from 22 centres

No.

Success Partial Success

Repeat PCI

CABG re-MI Death (Range)

Primary PTCA

475 83% (0-100)

2.7% (0-20)

1.1% (0-14)

0.4% (0-0.6)

0.5% (0-6)

4.5% (0-20)

Rescue PTCA

784 89% (40-100)

3.2% (0-14)

0.7% (0-6.7)

0.5% (0-7.7)

0.6% (0-8)

5.4% (0-60)

Re-MI PTCA

345 94.8% (80-100)

2.0% (0-50)

0.4% (0-7)

0.8% (0-20)

1.5% (0-20)

0.24% (0-6)

Shock 218 61% (0-100)

3.7% (0-33)

3.0% (0-67)

4.3% (0-67)

12% (0-100)

36.3% (0-100)

Patients Rx for STEMI

UK activity 2004UK activity 2004Audit of UK centres……….20 Audit of UK centres……….20

repliesreplies 7 centres perform 24/7 primary 7 centres perform 24/7 primary

angioplasty.angioplasty. Nos from 20 centres Nos from 20 centres 900900..

Mortality 0-14%Mortality 0-14% Door to balloon: 27’-205’………(some could Door to balloon: 27’-205’………(some could

not return data!). (2 hrs =120minutes…..4 not return data!). (2 hrs =120minutes…..4 centres recorded times >120 minutes)centres recorded times >120 minutes)

Length of stay: 3 days[3];4 days[6];5 Length of stay: 3 days[3];4 days[6];5 days[3];6 days[2];7days[2]days[3];6 days[2];7days[2]

Echo day 3.Echo day 3. EF >40% discharge on day 3.EF >40% discharge on day 3. EF <40% refer to EP team, EF <40% refer to EP team,

discharge planning of arrhythmia discharge planning of arrhythmia risk, discharge day 5. risk, discharge day 5.

Developed discharge Developed discharge protocol KCHprotocol KCH

TimingsTimings

Time/timing is importantTime/timing is important

PAMI and pre-hospital PAMI and pre-hospital thrombolysis are NOT mutually thrombolysis are NOT mutually exclusiveexclusive

You must record data!!You must record data!!

Recent “guideline document” for Recent “guideline document” for UK Primary Angioplasty:….times!!UK Primary Angioplasty:….times!!

• As a general guide transfer of patients to a PCI centre should be As a general guide transfer of patients to a PCI centre should be considered if this can be considered if this can be achieved within 60’.achieved within 60’.

• It is recommended that the time from call for professional help It is recommended that the time from call for professional help

to treatment with angioplasty to treatment with angioplasty (‘call to balloon’ time) is no (‘call to balloon’ time) is no more than three hours.more than three hours.

• There is little evidence to support angioplasty beyond 12 hours. There is little evidence to support angioplasty beyond 12 hours. Assuming there may be a 1-hour transfer time and Assuming there may be a 1-hour transfer time and up to 2-up to 2-hour ‘door to balloon’ timehour ‘door to balloon’ time it is recommended that, in it is recommended that, in general, patients presenting to ambulance staff (or in an general, patients presenting to ambulance staff (or in an Emergency Centre) more than 9 hours beyond the onset of Emergency Centre) more than 9 hours beyond the onset of their symptoms should not be considered for a primary their symptoms should not be considered for a primary angioplasty programme angioplasty programme

Kings Data: A UK Kings Data: A UK experienceexperience

Do you have to get out of bedDo you have to get out of bed (EWTD…………………job plan…….new (EWTD…………………job plan…….new

contract!!)contract!!) Can you deliver…………timesCan you deliver…………times

What message from the data What message from the data (record it!!) should you take away!!(record it!!) should you take away!!

Time of Presentation in Cath Lab

0

5

10

15

20

25

30

35

40

45

0-1am

1-2am

2-3am

3-4am

4-5am

5-6am

6-7am

7-8am

8-9am

9-17pm

17-18

18-19

19-20

20-21

21-22

22-23

23-00

Time of Presentation

Num

ber o

f Pat

ient

s

Series2

Do you have to get out of bed: sadly YES!!

Door to Balloon Time

0

5

10

15

20

25

30

35

40

Upto 30min

30-60min 60-90min 90-120min 120-150min

150-180min

180-210min

210-240min

>240min

Time

Num

ber

Series1

Record dataSo “system” issuesCan be examined.

Onset ofchest pain

Arrivalin A&E

Balloon inflation/restoration of flow

3hrs 18 mins

1hr 15 mins

4hrs 33mins

TimingTiming

Most importantMessage for “us”

May be publiceducation

ConclusionsConclusions The UK is preparing…………numbers are still The UK is preparing…………numbers are still

small.small. WE now have to prove we can deliver!!WE now have to prove we can deliver!! The exciting potential that the UK could be The exciting potential that the UK could be

converted to “optimal” revascularisation for converted to “optimal” revascularisation for AMI.AMI.

Replacing optimal thrombolysis (MINAP) with Replacing optimal thrombolysis (MINAP) with suboptimal PCI would not be acceptable.suboptimal PCI would not be acceptable.

Collect data!!Collect data!! For audit centres in the UK pilot……………the For audit centres in the UK pilot……………the

pressure is on……………..we have to pressure is on……………..we have to deliver………….deliver………….

This is a major opportunity to change the face This is a major opportunity to change the face of Rx of acute MI in the UK for years to come.of Rx of acute MI in the UK for years to come.