OVERALL CATHETERIZATION LABORATORY NORMAL ANGIOGRAPHY RATE DOES NOT INCREASE WITH EMERGENCY ROOM ACTIVATION OF PRIMARY CORONARY INTERVENTION (PCI) FOR STEMI

Timothy J. Boyek M.D., Cindy Brockway, RN, Alain Efstratiou, M.D., Mian A. Jan, M.D., Joseph Lewis, M.D., Verdi J. DiSesa, M.D.

The Cardiovascular Center at the Chester County Hospital, West Chester, PA

Background

• Prior multivariate analyses have demonstrated that ER physician activation of the PCI/Reperfusion process can result in a significant impact on overall reperfusion times.

• One national survey reported a reduction in time to reperfusion of 8.3 ± 6.1 min (p=.010) if the ER physician activated the catheterization laboratory rather than the cardiologist (Bradley-2004)

• As a result of these findings current GAP-D2B Alliance strategy recommends ER physician activate the cath lab as a primary initiative for implementing a STEMI PCI process.

Background

• Interventional cardiologists may be reluctant to advocate this approach due to concerns for laboratory overutilization with resultant effect on normal angiography rate for STEMI events.

• If ER attendings (as opposed to Cardiologists) initiate a primary PCI process some would suggest a higher incidence of patients will be found to have normal coronary anatomy. (i.e. “False Alarms”)

• Prior database reports described normal angiogram percentages in the 10-20% range for STEMI events for all cases presenting to a primary PCI site but have not addressed the possible impact on overall laboratory normal angiography events for STEMI procedures if ER activation occurs.

Background

• We initiated such a protocol for activation of primary angioplasty by ER Attending (“Code PCI”) in a community hospital setting with PCI capability per current ACC/AHA guidelines in January 2005

• Hospital Characteristics include:

• (Non profit) Community hospital in suburban Philadelphia

• Total Beds=220

• Total Critical Care Beds=20

• Participant in ACC/NCDR since inception of PCI program in 2001

• 24/7 staffed ER with 9 Board Certified ED physicians

Study Objective

• We hypothesized the following:

• that ER Attending activation would increase the frequency of normal angiograms as reported by our institution to the ACC/NCDR registry. We were concerned that ER activation would increase utilization of the catheterization lab due to false positive activations.

• that despite an expected increase in normal angiography rate for STEMI events we predicted a decrease in D2B times.

Methods

• Data elements regarding door to reperfusion times (as defined by ACC/NCDR) were collected prospectively from January 2005 until December 2005 (Control observation population).

• In January 2006 a protocol directing ER Attending physicians to initiate the “Code PCI” process call began and similar elements were collected until March 2007.

Methods

• Training Process included:• Frequent ER physician didactic sessions with instruction to

equate their prior fibrinolytic therapy experience with “Code PCI” process (ie-”if you would give lytics…call a code PCI)

• ACC/NCDR Definition of normal angiography per current data element described as “when all coronary branches had <50% stenosis”

• ACC/NCDR Definition of Reperfusion time per current data element described as “date and time of intracoronary treatment device deployment” (flow is re-established)

• Door to reperfusion times and frequency of normal angiograms were compared before and after implementation of this process.

ResultsTotal Patient Case Mix/Demographics

Gender/Race

Pre n=958% 1%

1%

88%

2%

Black Hispanic Asian Other Caucasian

Post n=131

91%

2%3%

3% 1%

Black Hispanic Asian Other Caucasian

Pre n=95

Female33%

Male67%

Post n=131

Female31%

Male69%

ResultsTotal Patient Case Mix/Demographics

Risk Factors

Pre n=95Previous MI

8% CHF4%

Prev PCI6%

Prev CABG4%

Tobacco: Current

11%

Tobacco: Former

10%Diabetes9%

Dyslipidemia24%

Hypertension24%

Post n=131

Previous MI9% CHF

3%

Prev PCI7%

Prev CABG3%

Tobacco: Current

13%

Hypertension23%

Dyslipidemia21% Tobacco:

Former12%

Diabetes9%

ResultsTotal Cases: Normal/STEMI n=15 pre vs n=10 post

Results2005 2006-07Q1

Chest Pain 3 Pulmonary Sarcoid 1

Atrial Fib 2 Pleurisy 1

CAD 3 Respiratory Failure 1

Pulmonary HTN 1 Myocarditis 2

Pain in Shoulder Joint 1 GI Dysfunction 2

Cholecystitis 1 Chest Pain 3

RBBB 1

Syncope 1

MI 1

Cardiomyopathy 1

ResultsDoor to Reperfusion Median Times 85.7 min pre vs 77.2 min post

Limitations of this Observational Study

• Study size (n=95 vs 131, Normal n=15 pre vs n=10 post)

• Predominately Caucasian population

• Predominately Male population

• Unable to control for prior ER attending experience with lytic therapy which is not a universal learned experience prompting activation process

• Decrease in reperfusion times did not reach statistical significance

Conclusions

• There was no change in institutional normal angiography events in STEMI patients despite an actual increase in volume of primary angioplasty procedures recorded. (Total Cases n=95 pre vs n=131 post, Normal Angiography n=15 pre vs n=10 post p=0.941)

• We demonstrated a definite trend towards reduction in door to reperfusion times utilizing ER attending physician activation process (85.7m vs 77.2m)

• ER Attending activation is a simple process to implement allowing direct collaboration with the ED department and Interventional Cardiology Section.