STEMI: What’s the Rush?STEMI: What’s the Rush?

William Phillips, MD, FACC, FSCAIWilliam Phillips, MD, FACC, FSCAIDirector of CardiologyDirector of Cardiology

CMMCCMMC

A PCI Center perspective.

NRMI 2: Primary PCI Door-to-Balloon Time NRMI 2: Primary PCI Door-to-Balloon Time vs. Mortalityvs. Mortality

NRMI 2: Primary PCI Door-to-Balloon Time NRMI 2: Primary PCI Door-to-Balloon Time vs. Mortalityvs. Mortality

1.14 1.151.41

1.62 1.61

0.2

0.6

1

1.4

1.8

2.2

0-60 61-90 91-120 121-150 151-180 >180

1.14 1.151.41

1.62 1.61

0.2

0.6

1

1.4

1.8

2.2

0-60 61-90 91-120 121-150 151-180 >180

Door-to-Balloon Time (minutes)Door-to-Balloon Time (minutes)

MV

Ad

just

ed O

dd

s o

f D

eath

MV

Ad

just

ed O

dd

s o

f D

eath

P=0.01P=0.01 P=0.0007P=0.0007 P=0.0003P=0.0003

n = 2,230n = 2,230 5,7345,734 6,6166,616 4,4614,461 2,6272,627 5,4125,412

Patients Transported by EMS After Calling 9-1-1

Onset of STEMI

Symptoms

Call 9

11Cal

l Fas

t

9-1-1 EMS

Dispatch

EMS on-scene•Encourage 12-lead ECG

•Consider prehospital fibrinolytic if capable and EMS-to-needle <

30 min

EM

S T

riag

e P

lan

Not PCICapableHospital

PCICapableHospital

Interhospital

TransferHospital Fibrinolysis:Door-to-needle within<30 min

EMS transport:EMS to Balloon within 90 min

Patient self-transport: Hospital Door-to-Balloon within 90 min

EMS transportEMS on

scene Within 8 min

Dispatch

1 min

Patient

5 min afterSymptom onset

Goals

Total ischemic time: Within 120 min*

* Golden hour = First 60 min Adapted from Panel A Figure 1 Antman et al. JACC 2004;44:676.

ACC/AHA Guidelines for the Management of ACC/AHA Guidelines for the Management of Patients With ST-Elevation Acute Myocardial Patients With ST-Elevation Acute Myocardial

Infarction- Focus Emergency CareInfarction- Focus Emergency Care

A Report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Writing Committee to Revise the 1999Guidelines 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 2004;44:671-719.

Achieve Coronary PatencyAchieve Coronary Patency

Initial Reperfusion TherapyInitial Reperfusion Therapy

• Defined as the initial strategy employed to restore Defined as the initial strategy employed to restore blood flow to the occluded coronary artery blood flow to the occluded coronary artery

3 Major Options:3 Major Options: Pharmacological Reperfusion Pharmacological Reperfusion PCI PCI Acute Surgical Reperfusion Acute Surgical Reperfusion

Under both Pharmacological and PCI are listed several lower Under both Pharmacological and PCI are listed several lower recommendations & investigational reperfusion strategiesrecommendations & 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 2004;44:680.

Importance of EarlyImportance of EarlyReperfusion Therapy in STEMIReperfusion Therapy in STEMI

Outcomes Dependent Upon:Outcomes Dependent Upon:

Time to treatment-TIME IS STILL MUSCLE!Time to treatment-TIME IS STILL MUSCLE!

Early and full restoration in coronary blood flow Early and full restoration in coronary blood flow (TIMI 3 flow)(TIMI 3 flow)

Sustained restoration of flow Sustained restoration of flow (no reinfarction and (no reinfarction and effective treatment for recurrent ischemia)effective treatment for recurrent ischemia)

Comparison of ApprovedComparison of Approved Fibrinolytic Agents Fibrinolytic Agents

Adapted from Table 15, pg 53.Accessed on August 6, 2004http://www.acc.org/clinical/guidelines/stemi/index.pdf.

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

Reperfusion ChoicesReperfusion ChoicesStep 2:Step 2: Determine Whether Fibrinolysis or Determine Whether Fibrinolysis or an Invasive Strategy is Preferred an Invasive Strategy is Preferred

Adapted from Figure 3; Antman et al. JACC 2004;44:682.

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 availableVascular access difficultiesLack of access to a skilled PCI lab- Operator experience > 75 PCI cases per year Team experience >36 PPCI cases per year

• Delay to invasive strategyProlonged transport such that the(Door-to Balloon) – (Door-to- needle) time is > 1 HR Medical contact-to- balloon time is > 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 < than 90 min(Door-to Balloon) – (Door-to- needle time) is < 1 hr

• High risk from STEMICardiogenic shockKillip 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

CAPTIMCAPTIMComparison of Angioplasty and Prehospital Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionThrombolysis in Acute Myocardial Infarction

P reh osp ita lT hro m bo lys is

n = 4 19

P rim a ryA ng iop las ty

n = 4 21

A M I w ith in 6 h ou rs1 20 0 p lan ned8 40 enro lled

Primary Composite Endpoint- Death, Reinfarction, Disabling Stroke

Bonnefoy E, et al. Lancet 2002;360:825-9

CAPTIM -1Year ResultsCAPTIM -1Year ResultsSx to Treatment AnalysisSx to Treatment Analysis

Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in 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. Acute Myocardial Infarction - George Washington University Symposium; November 16, 2002; Chicago, Ill.

Sx Sx 2 h 2 hSx Sx 2 h 2 h

0.0

Death

Sx Sx 2 h 2 hSx Sx 2 h 2 h

5.0

7.5

2.5

Pre-hospital LysisPre-hospital Lysis Primary PCIPrimary PCI

2.2

5.7

Death

P=0.057

0.0

7.5

10.0

2.5

Pre-hospital LysisPre-hospital Lysis Primary PCIPrimary PCI

5.9

3.7

Death

P=0.47

5.0

Per

cen

tP

erce

nt

2.2% absolute Risk Reduction =37% Relative RR (NS)

Time Dependence of Time Dependence of Reperfusion in STEMIReperfusion in STEMI

Time from Symptom Onset to TreatmentTime from Symptom Onset to TreatmentPredicts 1-year Mortality after Primary PCIPredicts 1-year Mortality after Primary PCI

De Luca et al, Circulation 2004;109:1223-1225De Luca et al, Circulation 2004;109:1223-1225

The relative risk of 1-year mortality increases by7.5% for each 30-minute delay

n=1791

74 (77) hospitals in Sweden

National registry since 1995 (1992)

> 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.

RRegister of egister of IInformationnformation and and KKnowledgenowledge about about SSwedishwedish HHearteart IIntensive care ntensive care AAdmissionsdmissions

General information

Mortality in relation to therapy and Mortality in relation to therapy and delaydelay

7-day mortality

30-day mortality

1-year mortality

30-day mortality

1-year mortality

30-day mortality

1-year mortality

0,80,60,4 21,2 1,50,1 1 10in-hospital thrombolysis betterPCI or PHT better

Reperfusion started <=2 h

Reperfusion started >2 h

Prehospital thrombolysis (PHT)

Primary PCI (PCI)

Any time

Adjusted outcome by Cox regression analysis including 23 variables plus propensity score.

JAMA 2006;296:1749

Reperfusion < 2h

Time (days)

Cum

ulat

ive

mor

talit

y

In-hosp TlysPrehosp TlysPrimary PCI

0 100 200 300 400

0.00

0.05

0.10

3993 3571 3530 34901155 1077 1066 1060979 936 928 916

Reperfusion > 2h

Time (days)

Cum

ulat

ive

mor

talit

y

In-hosp TlysPrehosp TlysPrimary PCI

0 100 200 300 400

0.00

0.05

0.10

8892 7675 7519 74171135 1020 1004 9973592 3375 3344 3318

Primary PCI vs prehospital in inhospital trombolysisPrimary PCI vs prehospital in inhospital trombolysisover 5 years – adjusted cumulative 1 year mortalityover 5 years – adjusted cumulative 1 year mortality

JAMA 2006;296:1749

Time for reperfusion (h)

1-y

ea

r m

ort

alit

y

0 -

1

1 -

2

2 -

3

3 -

4

4 -

5

5 -

6

6 -

7

7-10

10-1

5

0.0

00

.05

0.1

00

.15

0.2

0

TlysPCI

Tlys 122 503 503 332 239 159 121 196 1391248 4375 3659 2199 1438 946 658 1061 703

PCI 7 61 81 50 43 37 17 41 31125 895 1126 776 567 453 282 458 332

Deaths / Patients

Primary PCI vs trombolysisPrimary PCI vs trombolysisage-adjusted 1 year mortality in relation to delay timeage-adjusted 1 year mortality in relation to delay time

JAMA 2006;296:1749

Primary Percutaneous Coronary Primary Percutaneous Coronary InterventionIntervention

Interhospital Transfer for Primary PCIInterhospital Transfer for Primary PCI

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

Antman et al. JACC 2004;44:686.

Barriers to InterhospitalBarriers to InterhospitalTransfer for PPCITransfer for PPCI

DistanceDistance Weather!Weather! Road conditionsRoad conditions Ambulance and/or helicopter availabilityAmbulance and/or helicopter availability EconomicsEconomics EMTALA regulationsEMTALA regulations Lack of a well-rehearsed transfer protocol Lack of a well-rehearsed transfer protocol

by a committed team with ongoing QI by a committed team with ongoing QI reviewsreviews

Criteria for Level 1 Criteria for Level 1 Heart Attack CenterHeart Attack Center

24/7 Cardiac cath lab24/7 Cardiac cath lab 24/7 Cardiovascular surgery24/7 Cardiovascular surgery Comprehensive interventional teamComprehensive interventional team >200 interventional Pts/yr>200 interventional Pts/yr >36 PPCI/yr>36 PPCI/yr >75 PCI/interventional Cardiologist>75 PCI/interventional Cardiologist Standardized protocols at referral and receiving Standardized protocols at referral and receiving

hospitalshospitals Transfer agreements in placeTransfer agreements in place Education and training programsEducation and training programs Quality Assurance ongoingQuality Assurance ongoing

Henry, et al, JACC vol.47: April 4, 2006, 1339-45

Achieving Rapid TreatmentAchieving Rapid Treatment

Summary: Selection of the Optimal Reperfusion Summary: Selection of the Optimal Reperfusion Options for the STEMI Patient: 2004Options for the STEMI Patient: 2004

Full Dose Fibrinolytic Full Dose Fibrinolytic MonotherapyMonotherapy if…if…Door to balloon (D-B) Door to balloon (D-B) > 90 min (?how much > 90 min (?how much greater)greater)

Lack of access to skilled Lack of access to skilled PCI centerPCI center

(D-B) – (D-N) > 1 h(D-B) – (D-N) > 1 h

< 3 h from symptom < 3 h from symptom onsetonset

(TNK—62% TIMI 3 flow)(TNK—62% TIMI 3 flow)

Full Dose Fibrinolytic Full Dose Fibrinolytic MonotherapyMonotherapy if…if…Door to balloon (D-B) Door to balloon (D-B) > 90 min (?how much > 90 min (?how much greater)greater)

Lack of access to skilled Lack of access to skilled PCI centerPCI center

(D-B) – (D-N) > 1 h(D-B) – (D-N) > 1 h

< 3 h from symptom < 3 h from symptom onsetonset

(TNK—62% TIMI 3 flow)(TNK—62% TIMI 3 flow)

Invasive StrategyInvasive Strategy if…if…

Cardiogenic shock (age < 75)Cardiogenic shock (age < 75)

Bleeding riskBleeding risk

Diagnosis in doubt Diagnosis in doubt (pericarditis/aneurysm)(pericarditis/aneurysm)

Door to balloon < 90 minDoor to balloon < 90 min

Symptoms > 2-3 hSymptoms > 2-3 h

Lytic failure or post lysisLytic failure or post lysis

Skilled PCI center available, defined Skilled PCI center available, defined by:by:• Operator experience > 75 Operator experience > 75

cases/yrcases/yr• Team experience > 36 primary Team experience > 36 primary

PCI/yrPCI/yr

Age > 75Age > 75

(90+% TIMI 3 flow)(90+% TIMI 3 flow)

Invasive StrategyInvasive Strategy if…if…

Cardiogenic shock (age < 75)Cardiogenic shock (age < 75)

Bleeding riskBleeding risk

Diagnosis in doubt Diagnosis in doubt (pericarditis/aneurysm)(pericarditis/aneurysm)

Door to balloon < 90 minDoor to balloon < 90 min

Symptoms > 2-3 hSymptoms > 2-3 h

Lytic failure or post lysisLytic failure or post lysis

Skilled PCI center available, defined Skilled PCI center available, defined by:by:• Operator experience > 75 Operator experience > 75

cases/yrcases/yr• Team experience > 36 primary Team experience > 36 primary

PCI/yrPCI/yr

Age > 75Age > 75

(90+% TIMI 3 flow)(90+% TIMI 3 flow)

Technical Aspects of PPCITechnical Aspects of PPCI

Direct to Cath Lab (meet patient at door…consent Direct to Cath Lab (meet patient at door…consent & history enroute to lab). Confirm diagnosis and & history enroute to lab). Confirm diagnosis and appropriateness.appropriateness.

Rapid prep (if not done by sending hospital)Rapid prep (if not done by sending hospital) Adjunctive pharmocotherapy?Adjunctive pharmocotherapy? Careful vascular access (goal is one stick…Careful vascular access (goal is one stick…

Ultrasound guidance?)Ultrasound guidance?) Angiographic preferences: Infarct artery first?Angiographic preferences: Infarct artery first? Cross, Dotter, Assess, Inflate, ?Thrombectomy, Cross, Dotter, Assess, Inflate, ?Thrombectomy,

Stent (?not DES)Stent (?not DES) LV gram at end if stable, LVEDP at least.LV gram at end if stable, LVEDP at least.

The end….of the beginning.The end….of the beginning.

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

GoetheGoethe