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Advanced Angioplasty 2005
Primary PCI making it happen
Data collection and Timings
Peter LudmanUniversity Hospital Birmingham
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Motto
‘Time is Muscle’
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Lysis - Treatment Delay
• 35/7 mortality reduction v delay
Boersma E Lancet 1996;348:771-75
Trials included in FTT analysis
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PPCI v Lysis
• PPCI (n=3872) v Lysis (n=3867)
Keeley Lancet 2003; 361: 13–20%
Fre
quen
cy
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However beautiful the strategy,
you should occasionally look at the results.
Winston Churchill
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Time to PPCIdelays after admission
GUSTO IIb Berger P 1999;100:14-201
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Time to ReperfusionBrodie BR et al JACC 1998;32:1312
4.3
9.0 9.3 9.5
0
2
4
6
8
10
12
% 3
0 D
ay M
orta
lity
< 2 2-4 4-6 > 6
Time to Reperfusion (hr)
• 1,352 patients treated by primary PTCA
n=164 n=581 n=332 n=275
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Time to ReperfusionBrodie BR et al JACC 1998;32:1312
• 1,352 patients treated by primary PTCA
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Time to PPCI
• 2635 patients (10 trials)
0
2
4
6
8
10
12
14
< 2 2 to 4 > 4
Time from Sx Onset to Presentation (hr)
Dea
th (
%)
PPCI
Lytic
Zijlstra F EHJ 2002;23:550-557
n=325 n=414 n=218
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NRMI-2: Time to PTCACannon CP JAMA 2000;283:2941-2947
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Time to Rx – myocardial salvage• 264 PPCI patients• 3 tertiles• Tc-99m Sestamibi SPECT
Schomig A Circ 2003;108:1084
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Prague 2Mortality benefit by time to randomisation
6.8 7.36
10
7.4
15.3
02468
1012141618
All patients < 3 hrs 3 to 12 hrs
% 30/7
Mortality
PPCISK
• Transfer for PPCI v on site SK• n=850
Widimsky P. EHJ 2003;24: 94–104
Time from Sx to Randomisation
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Prague 2Mortality benefit by time to randomisation
6.8 7.36
10
7.4
15.3
02468
1012141618
All patients < 3 hrs 3 to 12 hrs
% 30/7
Mortality
PPCISK
• Transfer for PPCI v on site SK• n=850
Widimsky P. EHJ 2003;24: 94–104
Time from Sx to Randomisation
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Time to PPCI – the early timesSteg PG for CAPTIM Circ 2003;108:2851
Mor
talit
y• n = 840 (planned 1200)• prehospital tPA + rescue v PPCI
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‘Loosing an hour’to implement a strategy for transferhas a differential impact on those seenearly rather than late
Time to PPCI – the early timesSteg PG for CAPTIM Circ 2003;108:2851
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Early v late presentersDoor to Balloon time
Brodie Moses Cone registry Data ACC 2004
Early Presenters (≤ 2hrs) Late Presenters (>2hrs)
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Time to PPCI in Shock
• LeBauer Cardiovascular Research Foundation Registry of consecutive PPCI
• n = 1843, shock in 138
Brodie BR JACC 2003;145:708-15
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• Very early Rx (1 to 3 hours)
– Excellent results with PCI or lysis
• Door to balloon– Keep as short as possible– Particularly important in early presenters– ? also in high risk late presenters
• Late presenters– PPCI >> Lysis
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Acceptable Time Delay for Transfer?
• Randomised trials of lysis v transfer– Maastricht trial– Prague– Air PAMI– Captim– Danami 2– Prague 2
Dalby M Circulation 2003;108:1809-1814
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108
103
173
59
87
90
110
110
95
108
19
17
60
50
12
63
52
34
68
156
73
45
73
42
26
18
40
105
166
105
195
39
32
?
?
183
0 60 120 180 240 300 360
Sx to hosp
SAMU
Door needle
Transport
Door to Balloon
Transfer Time DelaysDifference
60
111
92
61
69
90
48
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Time delays PPCI v Lysis• Meta analysis of 23 trials• Door to balloon v door to needle
Nallamothu BK AJC 2003;92:824
Risk reduction of PCI over
lysis
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012345678
% F
aile
d P
CI
08:00-18:00 18:00-08:00
Time
Sx onsetAdmission1st balloon inflation
Circadian Variation
• 1702 consecutive PPCI (Zwolle 1994 to 2000)
Henriques JPS JACC 2003;41:2138–42
* P=0.02
# P<0.01* * #
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Circadian Variation
• 1702 consecutive PPCI (Zwolle 1994 to 2000)
Henriques JPS JACC 2003;41:2138–42
0
1
2
3
4
5
% 3
0 D
ay
Mo
rta
lity
08:00-18:00 18:00-08:00
Time
SxAdmission1st balloon inflation
* P<0.01
# P=0.03# * *
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Circadian Variation
PathophysiologyPlatelet aggregation
Coronary flowViscosityCortisol
EpinephrineAPTT
Endogenous tPAFibrinogen
Fibrinolytic factors
Patient characteristics
Risk profileDelayed conscious awareness of pain
Performanceof the
Healthcareteam
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Lady Astor 'Sir, you're drunk!‘
Winston ChurchillYes, madam, I am drunk.But in the morning I will be sober andyou will still be ugly.
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Circadian VariationDawson D. Nature 1997;388:235
Cognitive psychomotor performance of hand–eye coordination
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Circadian VariationDawson D. Nature 1997;388:235
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Guidelines and Data Collection
• Circulation. 2004;110:588-636
• Eur Heart J. 2003; 24: 28–66
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ACC/AHA GuidelinesGoal: ‘ischaemic time’ < 120 mins
(Sx to lysis or PCI)
PCI centre Door to balloon <90 min
Non PCI centre Door to needle < 30 min
EMS Prehosp lysis < 30 min of arrival at scene
If < 90 min (total) to balloonor
if transport will not addmore than 60 to time to balloon v local lysis
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• Fibrinolysis preferred if– Early presentation < 3hr (and delay to PPCI)
– PPCI not an option• Lab busy• No lab / inappropriate lab
– Delay to invasive strategy• > extra 1 hr over lysis time• > 90 min medical contact to balloon
ACC/AHA GuidelinesCirculation. 2004;110:588-636
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• PPCI Preferred if– Skilled PCI service with surgical backup
• Operator > 75 Primary PCI pa• Team > 36 Primary PCI pa• Timings as before
– High risk for STEMI• Shock• Killip ≥ 3
– Contraindication to lysis– Late presentation (> 3 hours)– STEMI diagnosis in doubt
ACC/AHA GuidelinesCirculation. 2004;110:588-636
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ESC Guidelines
• Fast Track patients (clear indication for reperfusion)
– Door to needle < 20 min– Door to Balloon < 60 min
Eur Heart J. 2003; 24: 28–66
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MINAPVersion 6.1
Symptom onsetCall for helpArrival of first professional helpArrival of emergency servicesArrival at hospital
First balloon inflation
Date onlyangio (local)1st intervention or surgery (local)
Symptom onset
Arrival in first hospitalAdmission route(Arrival in PCI hospital)Start of procedureFirst balloon inflationFlow in IRA
BCIS – CCADVersion 5.1.3
Date and Time
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UK data collectionThe future
2003 data: Ludman
BCIS dataset
Office of National StatisticsMortality register
MINAP datasetCardiothoracic surgical datasetEP dataset
Event free survival
NHS Number
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Swedish Coronary Angiography and Angioplasty Registry - SCAAR
SCAAR
Swedish Population RegisterDate of Death
Swedish Patient AdministrationRegisterReadmissions (all events)
Data from year 2001Survival data to end 20029,496 of 9,535 patients
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Swedish Coronary Angiography and Angioplasty Registry - SCAAR
Nilsson T http://www.sos.se/
6% 1yr9% 2yr
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Mottos
‘Time is Muscle’
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David Beckam’s Brain surgeon
‘Mind the Gap’
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Joe’s Shoe Company
‘Always knowingly undersold’
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‘Piston Broke?’
We can help
Alf’s Garage
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The Literal Society
We are the literal society
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British Rail
This motto has been withdrawn
Due to it being the wrong kind of motto
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Primary PCI
‘………………………..’
Suggestions ?
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The End