“Saving Time, Saving Lives” Paul M. Murray, MD, FACC March 10, 2009

““Saving Time,Saving Time,Saving Lives”Saving Lives”

Paul M. Murray, MD, FACCPaul M. Murray, MD, FACCMarch 10, 2009March 10, 2009

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I.I. STEMI (ST Elevation Myocardial Infraction)STEMI (ST Elevation Myocardial Infraction)

II.II. Primary PCI (Door to Balloon -D2B- time)Primary PCI (Door to Balloon -D2B- time)

A.A. National OverviewNational Overview

B.B. Case ReviewCase Review

III.III. TRMC ExperienceTRMC Experience

A.A. PrimaryPrimary

B.B. ElectiveElective

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I.I. STEMI STEMI (ST Elevation Myocardial Infraction)(ST Elevation Myocardial Infraction)

II.II. Primary PCI Primary PCI (Door to Balloon -D2B- time)(Door to Balloon -D2B- time)

A.A. National OverviewNational OverviewB.B. Case ReviewCase Review

III.III. TRMC ExperienceTRMC ExperienceA.A. PrimaryPrimaryB.B. ElectiveElective

STEMISTEMI

ST Elevation Myocardial InfarctionST Elevation Myocardial Infarction

Emergency Management of Emergency Management of Complicated STEMI (2004)Complicated STEMI (2004)

Chest pain pattern suggesting an STEMI Chest pain pattern suggesting an STEMI

Initial 12 lead ECG; if not diagnostic repeat at 5 to 10 minute intervals

ST elevation or new or presumably new LBBB

•Beta blocker

•IV nitroglycerin if persistent chest pain

•IV Heparin or Angiomax

•Clopidogrel (Plavix)

•GP IIb/IIIa inhibitor if primary PCI

Primary PCI, if available, with goal less than 90 minutes

OR thrombolysis with goal of 30 minutes

Goal = 10 minutesGoal = 10 minutes

TriageTriage

Aspirin (chewed)Aspirin (chewed)

SL nitroglycerin SL nitroglycerin (3 doses)(3 doses)

Establish IVEstablish IV

MorphineMorphine

Continuous ECG Continuous ECG monitoringmonitoring

Oxygen therapy Oxygen therapy

Obtain History & PhysicalObtain History & Physical

Draw blood for labworkDraw blood for labwork

Initial labwork should include:Initial labwork should include:

Cardiac biomarkers Cardiac biomarkers (cTnI or cTnT preferred)(cTnI or cTnT preferred)

CBC with platelet countCBC with platelet count

PT and INRPT and INR

aPTTaPTT

ElectrolytesElectrolytes

MagnesiumMagnesium

BUNBUN

CreatinineCreatinine

Blood glucoseBlood glucose

Lipid profileLipid profile

Conditions other than MI that can Conditions other than MI that can elevate Troponinelevate Troponin

TThrombolysis hrombolysis IIn n MMyocardial yocardial IInfarction nfarction (TIMI) Score for STEMI(TIMI) Score for STEMI

DM, history or HTN or history of Angina DM, history or HTN or history of Angina (1 point)(1 point)

Systolic blood pressure less than 100 mm Hg Systolic blood pressure less than 100 mm Hg (3 points)(3 points)

Heart rate greater than 100 BPM Heart rate greater than 100 BPM (2 points)(2 points)

Killip class II-IV Killip class II-IV (2 points)(2 points)

Body weight less than 150 lb or 67 kg Body weight less than 150 lb or 67 kg (1 point)(1 point)

Anterior lead ST elevation or left BBB Anterior lead ST elevation or left BBB (1 point)(1 point)

Time to treat more than 4 hours Time to treat more than 4 hours (1 point)(1 point)

AgeAge>=75 years old >=75 years old (3 points)(3 points)

65 – 74 years old 65 – 74 years old (2 points)(2 points)

Less than 65 Less than 65 (0 points)(0 points)

TIMI Risk Score Predicts TIMI Risk Score Predicts 30 Day Mortality30 Day Mortality

0 points 0 points == 0.8%0.8%1 point1 point = = 1.6%1.6%2 points 2 points = = 2.2%2.2%3 points 3 points = = 4.4%4.4%4 points 4 points = = 7.3%7.3%5 points 5 points = = 12%12%6 points 6 points = = 16%16%7 points 7 points = = 23%23%8 points 8 points = = 27%27%9 to 14 points 9 to 14 points == 36%36%

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““Strategies for Reducing the Door-to-Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Balloon Time in Acute Myocardial

Infarction”Infarction”

N ENGL J MED 2006; 355:2308-20 N ENGL J MED 2006; 355:2308-20

Door-to-Balloon Time (min)

362 Hospitals

20015010050

0

10

20

30

40

50

60

70

80

No

. of

Ho

sp

tia

ls

Figure 1. Frequency Distribution for Median Door-to-Balloon Times among Study Hospitals.Figure 1. Frequency Distribution for Median Door-to-Balloon Times among Study Hospitals.The mean (The mean (±SD) of these median times was 100.4±23.5 minutes, which is considerably longer than the ±SD) of these median times was 100.4±23.5 minutes, which is considerably longer than the

90-minute interval recommended in the 2004 guidelines of the American Heart Association and the 90-minute interval recommended in the 2004 guidelines of the American Heart Association and the American College of Cardiology.American College of Cardiology.44

D2B: An Alliance for QualityD2B: An Alliance for Quality

ED activation of Cath LabED activation of Cath Lab

One call activation (Group page)One call activation (Group page)

Pre-hospital ECGPre-hospital ECG

Cath Team ready in 20-30 minutesCath Team ready in 20-30 minutes

In-hospital cardiologistIn-hospital cardiologist

Prompt data feedbackPrompt data feedback

D2B Time According to the Number of Key D2B Time According to the Number of Key Strategies UsedStrategies Used

Number of Key Number of Key StrategiesStrategies

Hospitals with the Hospitals with the Number of Number of Key Strategies Key Strategies

(N=362)(N=362)

no. (%)no. (%)

Average of Median Average of Median Door-to- Door-to-

Balloon Times Balloon Times ÎÎ

minutesminutes

00

11

22

33

44

137 (37.8)137 (37.8)

130 (35.9)130 (35.9)

56 (15.5)56 (15.5)

31 (8.6)31 (8.6)

8 (2.2)8 (2.2)

110110

100100

8888

8888

7979

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I.I. STEMI STEMI (ST Elevation Myocardial Infraction)(ST Elevation Myocardial Infraction)




60 year-old Caucasian male60 year-old Caucasian male

History & Risk Factors include:History & Risk Factors include:♥♥Hypertension Hypertension ♥♥HyperlipidemiaHyperlipidemia♥♥HyperglycemiaHyperglycemia♥♥ETOH abuseETOH abuse

CASE STUDYCASE STUDY

CASE STUDYCASE STUDY

♥♥Onset of “indigestion” just after McDonald’s Onset of “indigestion” just after McDonald’s double cheeseburger double cheeseburger

♥♥Indigestion progressed to severe Indigestion progressed to severe discomfort within minutesdiscomfort within minutes

♥♥Associated SOB and profound diaphoresisAssociated SOB and profound diaphoresis♥♥Took 2 Aspirin and called 911Took 2 Aspirin and called 911♥♥ECG at scene revealed acute changesECG at scene revealed acute changes

12 lead ECG from EMS12 lead ECG from EMS

TimelineTimeline

14:5714:57 15:2115:21 15:4515:45

EMS EMS

performs ECGperforms ECG

Arrival to Arrival to

Cath LabCath Lab

PTCA PTCA

(balloon (balloon angioplasty)angioplasty)

CASE STUDY SUMMARYCASE STUDY SUMMARY

Day 1 Day 1 PTCA & DES in 100% prox RCA PTCA & DES in 100% prox RCA

(D2B = 24 minutes)(D2B = 24 minutes)

Day 2Day 2 Nutrition consult and Cardiac Nutrition consult and Cardiac Rehab consultRehab consult

Day 3Day 3 Discharged home on Aspirin, Discharged home on Aspirin, Plavix, Lopressor, LipitorPlavix, Lopressor, Lipitor

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II.II. Primary PCI (Door to Balloon -D2B- time)Primary PCI (Door to Balloon -D2B- time)A.A. National OverviewNational OverviewB.B. Case ReviewCase Review


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Trends in Bypass and PCI Procedures

United States: 1990-2002

Source: CDC/NCHS.

150

250

350

450

550

650

750

90 95 00 01 02

Years

Pro

ced

ure

s in

Th

ou

san

ds

CABG

PCI

PCI With or Without Onsite PCI With or Without Onsite Surgery StandbySurgery Standby

ACC-NCDR 2001-2004ACC-NCDR 2001-2004

In-hospital Mortality In-hospital Mortality : Offsite vs Onsite CVSx: Offsite vs Onsite CVSx MortalityMortality P-valueP-value

No Acute MINo Acute MI (n=482,018)(n=482,018) 0.54% vs 0.41%0.54% vs 0.41% 0.870.87

STEMISTEMI (n= 90,050)(n= 90,050) 4.65% vs 4.83%4.65% vs 4.83% 0.750.75

NSTEMINSTEMI (n=94,347(n=94,347)) 1.94% vs 2.09%1.94% vs 2.09% 0.120.12

Primary PCIPrimary PCIwithout on-site cardiac surgerywithout on-site cardiac surgery

Risk

Benefit

PRIMARY PCI INCLUSION CRITERIA

Chest pain > 20 minutes AND– > 1 mm ST-segment elevation in two

contiguous ECG lead

OR– New or presumed new LBBB

OR– > 1 mm ST-segment depression in V1/V2

compatible with true posterior MI

Patients with chest pain >12 hours were allowed in the registry but were considered thrombolytic-ineligible

Average Monthly D2B Times Average Monthly D2B Times July 2007-June 2008July 2007-June 2008

40 total patients with a yearly average of 79 minutes40 total patients with a yearly average of 79 minutes

0

10

20

30

40

50

60

70

80

90

100

110

120

130

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June

Month

Tim

e (i

n m

inu

tes)

D2B D2CCL

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C-PORT Elective TrialC-PORT Elective Trial

32 active sites• 7 states

• NJ, GA, IL, OH, OR, AL, PA• 6 new sites in enrollment process

9500 randomized patients as of March 2009

Goal of 16,000–18,000 randomized patients

C-PORT ElectiveC-PORT ElectiveNon-inferiority trialNon-inferiority trial

Primary EndpointsPrimary Endpoints– Death at 6 weeksDeath at 6 weeks– MACE (death+MI+TVR) at 9 monthsMACE (death+MI+TVR) at 9 months

Secondary Endpoints at 6 weeks and 9 monthsSecondary Endpoints at 6 weeks and 9 months– Emergency CABGEmergency CABG– Myocardial InfarctionMyocardial Infarction– StrokeStroke– TVR (Target Vessel Revascularization)TVR (Target Vessel Revascularization)– Subsequent PCI or CABGSubsequent PCI or CABG– BleedingBleeding– Heart Failure/AnginaHeart Failure/Angina– Direct Medical CostsDirect Medical Costs

C-PORT ElectiveC-PORT Elective

RegistryRefuse

Patient for Diagnostic Cath

Informed consent

Catheterization

Meetsinclusioncriteria

PCI no SOS PCI with SOS

Exclusioncriteria

RegistryRefuse

TRMC CPORT ENROLLMENTTRMC CPORT ENROLLMENTJune 2006 – February 2009June 2006 – February 2009

Total PatientsTotal Patients 24532453

Total Patients ConsentedTotal Patients Consented 2287 (93.2%)2287 (93.2%)– ElectiveElective 20872087– PrimaryPrimary 200200

No Consent PatientsNo Consent Patients 166166– Not approachedNot approached 147147– RefusedRefused 19 (0.8% of total)19 (0.8% of total)

Randomized PatientsRandomized Patients 387387– TRMCTRMC 290 (75%)290 (75%)– TertiaryTertiary 97 (25%)97 (25%)

Primary PatientsPrimary Patients 200200– PCIPCI 159159– No PCINo PCI 4141

QUESTIONS??QUESTIONS??

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“Saving Time, Saving Lives” Paul M. Murray, MD, FACC March 10, 2009