stemi care in wv mission: lifeline -aha...

STEMI Care in WV Mission: Lifeline -AHA initiative

STEMI Care in WV Mission: Lifeline -AHA initiative

Christopher B. Granger, MD, FACC Mayme Lou Roettig, RN, MSN

Christopher B. Granger, MD, FACC Mayme Lou Roettig, RN, MSN

Christopher B. Granger, MD, F.A.C.CChristopher B. Granger, MD, F.A.C.C

Director of Cardiac Care Unit

Duke University Medical Center

Duke Clinical Research Institute

Durham, NC

Director of Cardiac Care Unit

Duke University Medical Center

Duke Clinical Research Institute

Durham, NC

AMI- Just the FactsAMI- Just the Facts

Myocardial infarction is a major cause of mortality worldwideMore than 3 million people each year are estimated to have acuteSTEMIMore than 4 million having a non-STEMI#1 Killer of Americans

Shifting from being an illness observed predominantly in developed countries to → becoming increasingly more common in developing countries.

Progressive urbanization yields ‘Diobesity’ (Diabetes/Obesity) & a newly emerging epidemic of CAD

Problem- health-care services are not as well developed

? How well are systems working in ‘developed’ countries? In the US? In North Carolina? In WV?

Myocardial infarction is a major cause of mortality worldwideMore than 3 million people each year are estimated to have acuteSTEMIMore than 4 million having a non-STEMI#1 Killer of Americans

Shifting from being an illness observed predominantly in developed countries to → becoming increasingly more common in developing countries.

Progressive urbanization yields ‘Diobesity’ (Diabetes/Obesity) & a newly emerging epidemic of CAD

Problem- health-care services are not as well developed

? How well are systems working in ‘developed’ countries? In the US? In North Carolina? In WV?

White HD, Lancet September 2008

ACUTE CORONARY SYNDROMEACUTE CORONARY SYNDROME

No ST ElevationNo ST Elevation

ST ElevationST ElevationST Elevation

Unstable Angina

NSTEMI~400,000 a year

1.2 million

Pathophysiology of AMIPathophysiology of AMI

Generally caused by a partially occlusive, platelet-rich

thrombus in a coronary artery

Generally caused by a completely occlusive

thrombus in a coronary artery

FibrinolyticTherapyOverview

FibrinolyticTherapyOverview

— Lancet, 1994

Mor

talit

y

Weeks

BBB or ST Elevation < 12 hours

BBB or ST Elevation < 12 hours

Fibrinolytic 10.1% (1600/15837)

Fibrinolytic 10.1% (1600/15837)

Control 13.0% (2018/15576)

Control 13.0% (2018/15576)

FTT Overview FTT Overview

ReperfusionReperfusion•• STEMI patients presenting to a hospital with STEMI patients presenting to a hospital with

PCI capability should be treated with primary PCI PCI capability should be treated with primary PCI within 90 minutes of first medical contact.within 90 minutes of first medical contact.

•• Modified recommendationModified recommendation

•• STEMI patients presenting to a hospital without STEMI patients presenting to a hospital without PCI capability and PCI capability and who cannot be transferred to a who cannot be transferred to a PCI center for intervention within 90 minutes of PCI center for intervention within 90 minutes of first medical contactfirst medical contact should be treated with should be treated with fibrinolytic therapy within 30 minutes of hospital fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated.presentation, unless contraindicated.

•• Modified recommendationModified recommendation

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

ACC/AHA 2007 STEMI Focused Update Slide SetACC/AHA 2007 STEMI Focused Update Slide Set

CASE Study

Patient journey through systems of AMI care

STEMI Patient

Primary PCI Center

STEMIPatient

STEMIPatient

EMS

Non-PCI Hospital

EMSEMS

EMS Primary PCI Center

EMS

EMS

Patient featuresTime from sx onsetSize of MI/CHF/shockFibrinolytic eligibilityAge

Reperfusion StrategiesReperfusion Strategies

When should patients receive lyticsversus transfer for primary PCI?

When getting lytics, what should be strategy of transfer and cath?

Is there a role for “facilitated” PCI?




Earliest diagnosis and activation of reperfusion plan

Selected use of “destination protocols” of EMS bypass of non-PCI centers

Single reperfusion plan for each hospital emergency department

Earliest diagnosis and activation of reperfusion plan

Selected use of “destination protocols” of EMS bypass of non-PCI centers

Single reperfusion plan for each hospital emergency department

CRUSADE to ACTION Door-to-Balloon Times –Median Times for Transfer In and Non-Transfer In Patients

Transfer in DTB Times Non-Transfer in DTB Times

130

176

231

67

90

119

Q3 06

122

148

211

6787

119

Q4 06

123

170

236

6279

Q1 07

122

159

223

5978

103

Q2 07

Tim

e (m

in)

50

220210

60708090

110100

120130140150160170

200

180190

240230

103

403020

250

100

Transfer in DTB Times Are Static

Opportunities to Improve PlanOpportunities to Improve Plan

White HD, Lancet September 2008

Reperfusion StrategiesReperfusion Strategies







9803mo01, 16

Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial InfarctionThe TRANSFER-AMI trial

Warren J. Cantor, David Fitchett, Bjug Borgundvaag, Michael Heffernan, Eric A. Cohen, Laurie J. Morrison, John Ducas, Anatoly Langer, Shamir Mehta, Charles Lazzam, Brian Schwartz, Vladimir Dzavik, Amparo Casanova, Paramjit Singh, Shaun G. Goodman on behalf of the TRANSFER-AMI Investigators

Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial InfarctionThe TRANSFER-AMI trial

Warren J. Cantor, David Fitchett, Bjug Borgundvaag, Michael Heffernan, Eric A. Cohen, Laurie J. Morrison, John Ducas, Anatoly Langer, Shamir Mehta, Charles Lazzam, Brian Schwartz, Vladimir Dzavik, Amparo Casanova, Paramjit Singh, Shaun G. Goodman on behalf of the TRANSFER-AMI Investigators

9803mo01, 17

ObjectiveObjective

To compare:

Pharmacoinvasive strategy (transfer to PCI centre for routine early PCI within 6 hrs) with

Standard treatment (early transfer only for failed reperfusion, otherwise cath > 24 hrs)

for high-risk STEMI patients receiving thromboysis at non-PCI centres.

To compare:

Pharmacoinvasive strategy (transfer to PCI centre for routine early PCI within 6 hrs) with

Standard treatment (early transfer only for failed reperfusion, otherwise cath > 24 hrs)

for high-risk STEMI patients receiving thromboysis at non-PCI centres.

9803mo01, 18

PCI CentrePCI CentreCath LabCath Lab

CommunityCommunityHospitalHospitalEmergencyEmergencyDepartmentDepartment

CathCath / PCI within 6 / PCI within 6 hrs regardless of hrs regardless of

reperfusion statusreperfusion status

Cath and Rescue Cath and Rescue PCI PCI ±± GP IIb/IIIa GP IIb/IIIa

InhibitorInhibitor

TNK + ASA + Heparin / Enoxaparin + ClopidogrelTNK + ASA + Heparin / Enoxaparin + Clopidogrel

““PharmacoinvasivePharmacoinvasiveStrategy”Strategy”

UrgentUrgent Transfer to PCI CentreTransfer to PCI CentreAssess chest pain, STAssess chest pain, ST↑↑ resolutionresolution

at 60at 60--90 minutes after 90 minutes after randomizationrandomization

‘‘High Risk’ ST Elevation MI within 12 hours of symptom onsetHigh Risk’ ST Elevation MI within 12 hours of symptom onset

Failed Reperfusion*Failed Reperfusion* Successful ReperfusionSuccessful Reperfusion

Elective Elective CathCath±± PCIPCI

> 24 hrs later> 24 hrs later

““Standard Treatment”Standard Treatment”

* ST segment resolution < 50% & persistent chest pain, or hemody* ST segment resolution < 50% & persistent chest pain, or hemodynamic instabilitynamic instability

Repatriation of stable patients within 24 hrs of PCI

Randomization stratified by age (Randomization stratified by age (≤≤75 vs. > 75) and by enrolling site75 vs. > 75) and by enrolling site

9803mo01, 19

Inclusion CriteriaInclusion Criteria

Within 12 hrs of symptom onset

≥ 2 mm ST-segment elevation in 2 anterior leads

OR

≥ 1 mm ST-segment elevation in 2 inferior leads and at least one of the following:

SBP < 100HR > 100Killip Class II-III≥ 2mm ST-segment depression in anterior leads≥ 1 mm ST-segment elevation in V4R

Within 12 hrs of symptom onset

≥ 2 mm ST-segment elevation in 2 anterior leads

OR

≥ 1 mm ST-segment elevation in 2 inferior leads and at least one of the following:

SBP < 100HR > 100Killip Class II-III≥ 2mm ST-segment depression in anterior leads≥ 1 mm ST-segment elevation in V4R

9803mo01, 20

PCI for Pharmacoinvasive GroupPCI for Pharmacoinvasive Group

PCI of culprit lesion at time of cath if ≥ 70% stenosis or 50-70% stenosis with high-risk features (thrombus, ulceration, spontdissection) regardless of coronary flow

Stents used whenever technically possible, use of Abbott vascular stents (ML Vision, Mini Vision) encouraged

GP IIb/IIIa inhibitors left to operator’s discretion

PCI of culprit lesion at time of cath if ≥ 70% stenosis or 50-70% stenosis with high-risk features (thrombus, ulceration, spontdissection) regardless of coronary flow

Stents used whenever technically possible, use of Abbott vascular stents (ML Vision, Mini Vision) encouraged

GP IIb/IIIa inhibitors left to operator’s discretion

9803mo01, 21

ProceduresProcedures

Cardiac Cardiac CathCath performed (%)performed (%)TimeTime-- TNK to TNK to CathCath (hrs)(hrs)

PCI performed (%)PCI performed (%)StentStent used (% of PCI cases)used (% of PCI cases)TimeTime-- TNK to PCI (hrs)TNK to PCI (hrs)PCI within 6 hrs of TNK (%)PCI within 6 hrs of TNK (%)PCI within 12 hrs of TNK (%)PCI within 12 hrs of TNK (%)GP IIb/IIIa inhibitor use (%)GP IIb/IIIa inhibitor use (%)TimeTime-- TNK to GP IIb/IIIa TNK to GP IIb/IIIa inhibinhib. (hrs) . (hrs)

IABP use (%)IABP use (%)CABG performed (%)CABG performed (%)

Standard Standard TreatmentTreatment

(n=508)(n=508)8282

27 (4, 69)27 (4, 69)62629898

18 (4, 73)18 (4, 73)383847475353

11 (4, 63)11 (4, 63)6688

PharmacoinvasivePharmacoinvasiveStrategyStrategy(n=522)(n=522)

97973 (2, 4)3 (2, 4)

84849898

4 (3, 5)4 (3, 5)898997977373

4 (3, 5)4 (3, 5)7766

9803mo01, 22

Selected Medications UsedSelected Medications Used

ASA 1ASA 1stst 6 hrs6 hrsClopidogrel 1Clopidogrel 1stst 6 hrs *6 hrs *HeparinHeparinEnoxaparinEnoxaparinBeta Blocker 1Beta Blocker 1stst 6 hrs6 hrsASA at dischargeASA at dischargeClopidogrel at dischargeClopidogrel at dischargeBeta Blocker at dischargeBeta Blocker at dischargeACE Inhibitor at dischargeACE Inhibitor at dischargeLipid Lowering at dischargeLipid Lowering at discharge


(n=508)(n=508)9797696957575555616185857373797974748080


9898878757575151555585857979818173738181

* p< 0.05* p< 0.05

9803mo01, 23

0022446688

10101212141416161818

00 55 1010 1515 2020 2525 3030

10.610.6

16.616.6

Days from RandomizationDays from Randomization

% of Patients% of Patients

Standard (n=496)Standard (n=496)Pharmacoinvasive (n=508)Pharmacoinvasive (n=508)

n=496n=496n=508n=508

422422468468

415415466466

415415463463

414414461461

414414460460

412412457457

Primary Endpoint: 30Primary Endpoint: 30--Day Death, reDay Death, re--MI, MI, CHF, Severe Recurrent Ischemia, Shock CHF, Severe Recurrent Ischemia, Shock

OR=0.537 (0.368, 0.783); p=0.0013

9803mo01, 24

Components of Primary EndpointComponents of Primary Endpoint

DeathDeathReinfarctionReinfarctionRecurrent IschemiaRecurrent IschemiaDeath/MI/IschemiaDeath/MI/IschemiaNew / worsening CHFNew / worsening CHFCardiogenic ShockCardiogenic Shock


(n=498)(n=498)3.63.66.06.02.22.211.711.75.25.22.62.6


3.73.73.33.30.20.26.56.52.92.94.54.5

PP--ValueValue

0.940.940.0440.0440.0190.0190.0040.0040.0690.0690.110.11

9803mo01, 25

Safety Endpoints - BleedingSafety Endpoints - Bleeding

Intracranial hemorrhageIntracranial hemorrhageTIMI scaleTIMI scale

MajorMajorMajor (nonMajor (non--CABG)CABG)

GUSTO scaleGUSTO scaleModerateModerateSevereSevereSevere (nonSevere (non--CABG)CABG)

TransfusionsTransfusions


(n=498)(n=498)1.21.2

4.64.63.23.2

2.22.21.41.41.21.25.55.5


0.20.2

4.34.32.22.2

3.53.50.60.60.60.67.17.1

PP--ValueValue

0.0660.066

0.880.880.330.33

0.260.260.220.220.340.340.310.31

9803mo01, 26

ConclusionsConclusions

For high-risk STEMI patients receiving thrombolysis at non-PCI centres, urgent transfer and PCI within 6 hours is associated with significantly less ischemic complications and no excess in bleeding

Transfers to PCI centres should be initiated immediately after thrombolysis without waiting to see whether reperfusion is successful

Regional systems should be developed to ensure timely transfers of STEMI patients to PCI centres

For high-risk STEMI patients receiving thrombolysis at non-PCI centres, urgent transfer and PCI within 6 hours is associated with significantly less ischemic complications and no excess in bleeding

Transfers to PCI centres should be initiated immediately after thrombolysis without waiting to see whether reperfusion is successful

Regional systems should be developed to ensure timely transfers of STEMI patients to PCI centres

30 Day Mortality30 Day Mortality

Number at riskNumber at riskBivalirudinBivalirudin 18001800 17581758 17511751 17461746

17421742 17291729 16661666Heparin + Heparin + GPIIb/IIIaGPIIb/IIIa 18021802 17641764 17481748 17361736

17281728 17071707 16301630

Dea

th (%

)D

eath

(%)

Time in DaysTime in Days

3.1%

2.1%

HR [95%CI] =0.66 [0.44, 1.00]

P=0.048

Heparin + GPIIb/IIIa inhibitor (n=1802)Bivalirudin monotherapy (n=1800)

Efficacy endpoints at 30 days

Montalescot et al. ESC 2008

* ARC def/probable

0

2

4

6

8

10

All Death MI UTVR StentThrombosis*

CV Death/MI

CV Death/MI/UTVR

CV Death/MI/Stroke

Prop

ortio

n of

pop

ulat

ion

(%)

p= 0.04

p= 0.01

p= 0.13 p= 0.008

p= 0.004 p= 0.02p= 0.002

Clopidogrel

Prasugrel

Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE)

Project

RACE Objectives

•Establish a state-wide system for reperfusion, as exits for trauma care, to overcome systematic barriers to:

1) Increase speed of reperfusion

2) Increase reperfusion rate

Organizeregions

Baselinedata

Intervention Postdata

2005 Q3 2005 2006 Q1 2007

10 PCI centers16 Transfer for PCI28 Lytics11 Mixed

RACE Centers and Regions65 hospitals (10 PCI, 55 non PCI)

Asheville

Winston-SalemDurham-Chapel Hill-

Greensboro

Charlotte

East Carolina

Each non-PCI center was assessed forreperfusion designation based on resources, transfer ability, and transfer time to PCI center

RACEInterventions

• OPERATIONS MANUAL

• Optimal system specifications by point of care– EMS– Non-PCI and PCI ED– Transfer– Catheterization lab– Other system issues – payers,

regulations– Choice of PCI or lytic

reperfusion regimens

New version available at www.race-er.org

RACEInterventions

Focus on SYSTEMATIC BARRIERS to careSTEMI team – hospital administration, ED, EMS, nursing, cardiology, QIPrespecified reperfusion plan for hospital and regionPrehospital ECGs, interpretation, and earliest activationEmergency physician (or paramedic) able to activate the cath labIntense education with focus on EMS and EDs

RACEInterventions

PCI Hospitals Single number cath lab activationAccept all STEMI patients regardless of bed availabilityOngoing QI and data feedback–NRMI database

Transitioning to the NCDR ACTION Registry-GWTG tool

RACE Regional CoordinatorResponsible for improving process in every hospital -EMS system in the region

Available online at http://jama.ama-assn.org/

RACE resultsArrival and transfer features

PCI hospital Non-PCI hospitalPre Post Pre Post

n 579 585 518 407Arrival mode

Self-transport 11% 12% 57% 56%Ambulance 71% 63% 42% 44%Helicopter 16% 21% -- --

Pre-hosp ECG 41% 61% 38% 43%Transferred from another hosp 61% 53% -- --Transferred to a PCI hosp -- -- 92% 95%Transfer mode

EMS ground 40% 43%Critical care transport 34% 24%Helicopter 25% 43%

AMI Hotline used 32% 85%

RACE resultsNon-reperfusion rates

1523

15 11

0

20

40

60

80

100

Non-PCI hospitals PCI Hospitals

PrePost

% w

ithou

t rep

erfu

sion

P<0.001

RACE resultsPCI hospitals: Door to device times

1088590

74

128106149

165

0

30

60

90

120

150

180

All patients Directpresenters

All transfers Transfer forPCI hospitalsPre Post

P<0.001* P<0.001

med

ian

times

in m

inut

es

P<0.001 P=0.01

* Remained significant in analysis accounting for clustering

RACE resultsNon-PCI hospitals: Reperfusion times

12097

7145

2935

0

30

60

90

120

150

180

Door-in door-out,all hospitals

Door-in door-out,transfer hosps

Fibrinolysis, door-to-needle

PrePost

P<0.001* P<0.001

med

ian

times

in m

inut

es P=0.002

* Remained significant in analysis accounting for clustering

RACE results vs secular trends:PCI hospitals

Pre Post Change

TransferNational* 150 143 7

RACE 165 128 37Non transfer

National* 88 81 7RACE 85 74 11

Median time in minutes *NRMI participating hospitals

Summary and Conclusions

RACE represents the largest regional STEMI reperfusion system in the United States.We focused on moving care forward: enabling EMS to diagnose and ED personnel to initiate treatment, with improved communication, integration, and data feedback.All times – door-to-balloon at PCI centers, door-in to door out in non-PCI centers, 1st door-to-balloon in transfer patients, and door-to-needle for fibrinolysis –were significantly improved.Improved application of reperfusion care on a broad scale is possible and should be a high national priority.

122 emergencydepartments

540 EMS systems

5,240 paramedics

18,000EMTs

21 primary PCI labs

RACE-Emergency ResponseRACE-ER

www.race-er.org

PCI centersTransfer for PCILyticsMixed

RACE Centers and Regions122 hospitals (21 PCI, 101 non PCI)

Western NC

Metro Charlotte

Triad Triangle

Coastal Plains

Integrated, Systematic

Integrated, Systematic

AMI CareAMI Care

North Carolina-WV Stats

• Population– 9.06 million (10th most populous)– 1.18 million WV (37th)

• Size (sq. miles)– 53,819 (28th in total area)– 24.077 KS (41st)

• Hospitals122 Acute care hospitals

*21 PCI hospitals with Surgical Backup

Acute care hospitals? Primary PCI hospitals WV

• Counties – 100 (101 Cherokee Nation)– 55 WV counties

NC has multiple metro highly populated citiesNC has multiple metro highly populated citiesCharlotte, Raleigh and Greensboro in the top 100Charlotte, Raleigh and Greensboro in the top 100-- WV has noneWV has none

Caution Big MTNS

Strategies for STEMI in WVStrategies for STEMI in WV

Emergency Cardiovascular Care 2009: Building STEMI Systems of CareMay 29-30 Rosemont, IL

Emergency Cardiovascular Care 2009: Building STEMI Systems of CareMay 29-30 Rosemont, IL

Co-sponsored by: American College of Cardiology & American College of Emergency Physicians

In Cooperation with: The Society for Academic Emergency Medicine

Program Co-directors: Christopher B. Granger, M.D., F.A.C.C., James G. Jollis, M.D., F.A.C.C. Mayme Lou Roettig, R.N., M.S.N.

Co-sponsored by: American College of Cardiology & American College of Emergency Physicians

In Cooperation with: The Society for Academic Emergency Medicine

Program Co-directors: Christopher B. Granger, M.D., F.A.C.C., James G. Jollis, M.D., F.A.C.C. Mayme Lou Roettig, R.N., M.S.N.

Mayme Lou Roettig, RN, MSNMayme Lou Roettig, RN, MSNExecutive Director, RACEExecutive Director, RACE

Duke University/Duke Clinical Research InstituteDuke University/Duke Clinical Research InstituteDurham, North Carolina, USADurham, North Carolina, USA

National Director, Mission: LifelineNational Director, Mission: LifelineAmerican Heart Association, ConsultantAmerican Heart Association, Consultant

Mission: Lifeline™™ is a national community- based multidisciplinary initiative

Overarching Goal→ Improve the mortality and morbidity and quality of care for the AMI population, specifically through thedevelopment of STEMI systems of care

Guiding principle:Patient centric, addressing the continuum of care for STEMI patients from symptom onset into the point of entry into the healthcare system, touching each aspect of the system, and return the patient back to the local community and physician

Mission :Lifeline™Mission :Lifeline™ DefinedDefined

To meet the overarching goal, Mission: Lifeline™™ will bring together the necessary partnerships between:

• Patients• EMS• Non-PCI capable (STEMI Referral) hospitals• PCI capable (STEMI-Receiving) hospitals• Healthcare providers- (Physicians, nurses, EMT-P, EMT-I and B, and other

providers)• Departments of Health• EMS regulatory authority/ Office of EMS• State hsopital associations• Rural Health Association• Quality Improvement Organizations• State and local policymakers• Third-party payers

Mission :Lifeline™Mission :Lifeline™ Defined (Cont)Defined (Cont)

51

May 2007May 2007––Eleven manuscripts Eleven manuscripts were published in were published in CirculationCirculation

––Mission: Lifeline was Mission: Lifeline was formally launchedformally launched

HistoryHistory

•• May 2004May 2004•• Advisory Working Group (AWG) recruited to Advisory Working Group (AWG) recruited to

explore the issue of increasing the number of explore the issue of increasing the number of STEMI patients with timely access to primary STEMI patients with timely access to primary PCIPCI

•• June 2005June 2005•• Presented market research conducted by Presented market research conducted by

Price Waterhouse Coopers to AWGPrice Waterhouse Coopers to AWG

•• March 2006March 2006•• AWG Consensus Statement Published in AWG Consensus Statement Published in

CirculationCirculation–– Market research resultsMarket research results–– Stakeholder Call To ActionStakeholder Call To Action

Circulation 2006;113:2152Circulation 2006;113:2152--21632163..

54

ECCTask Force

Chair: Robert O'Conner,MD

Model EvaluationTask Force

Chair: Elliott Antman, MD

AdvisoryWorking Group

Chair: Alice Jacobs,MD

Administrative Structure

• EMS System Assessment and Improvement• Evaluate Existing Models• Establish Local Initiatives• Explore Possibility of National STEMI Certification

Elliott Antman, MDBob O’Connor, MDGray Ellrodt, MDChris Granger, MD (VC)Mary Hand, RNTim Henry, MDNeil MeltzerBob Harrington, MDGeorge Mensah, MDJean McSweeny, pHD, RNEric Peterson, MDDavid Williams, MD

Peter Berger, MDChris Granger, MDTim Henry, MDJames Jollis, MD (VC)Peter Moyer, MDFrank Pratt, MDIvan Rokos, MDJohn Rumsfeld, MD

David Burt, MDGraham Nichol, MD (VC)Lee Garvey, MDLouis Gonzalas, EMT-PDavid Larson, MDPeter Moyer, MDIvan Rokos, MDMichael Sayer, MDRobert Solomon, MDGary Windgrove, EMT-P

AMI Guidelines AMI Guidelines Consider time and riskConsider time and risk

•• Fibrinolysis preferredFibrinolysis preferred

–– < 3 hours from symptom onset< 3 hours from symptom onset–– > 90 min 1st door to balloon> 90 min 1st door to balloon–– Delay to PCI vs Lysis > 60 minDelay to PCI vs Lysis > 60 min–– PCI not an optionPCI not an option

•• PCI preferredPCI preferred

–– Late presentationLate presentation–– PCI availablePCI available–– Cardiogenic shock / Killip class 3+Cardiogenic shock / Killip class 3+–– Lysis contraindicationLysis contraindication–– Dx. of STEMI in doubtDx. of STEMI in doubt JACC 2004;44:686

No Longer a debate over which is best- Follow the Guidelines& Apply RAPID Reperfusion ! ! !

Preferred if you can make the

Time line goal

How do we increase the number of patients with timely access to

reperfusion therapy?For the preferred Primary PCI?

State of the SystemState of the System

–– Approximately 30% of STEMI patients do Approximately 30% of STEMI patients do not receive any reperfusion therapy (with not receive any reperfusion therapy (with PCI or fibrinolysis)PCI or fibrinolysis)

–– Up to 20% of STEMI patients are not Up to 20% of STEMI patients are not eligible for fibrinolytic therapy, yet 70% of eligible for fibrinolytic therapy, yet 70% of these patients do not receive primary PCIthese patients do not receive primary PCI


•• Of the 70% of STEMI patients who are Of the 70% of STEMI patients who are •• treated with reperfusion therapy, lesstreated with reperfusion therapy, less•• than half are treated within the than half are treated within the

guideline guideline •• recommended time frames.recommended time frames.

STEMI STEMI –– D2B and D2N Times:D2B and D2N Times:Cumulative 12 Month Data Cumulative 12 Month Data ACTION Registry DataACTION Registry Data

67%

7%

39%

0%

20%

40%

60%

80%

DTB <= 90 min -Non-Transfer In

DTB <= 90 min -Transfer In

DTN <= 30 min - All

Mission: LifelineMission: Lifeline

–– EMS System Assessment and ImprovementEMS System Assessment and Improvement–– Evaluate Existing ModelsEvaluate Existing Models–– Establishing Local InitiativesEstablishing Local Initiatives–– Explore possibility of National STEMI Explore possibility of National STEMI

Certification ProgramCertification Program

PCIPCIcapablecapable

NonNon--PCIPCIcapablecapable

SYSTEMSYSTEMOF CAREOF CARE CENTER OF CENTER OF

CARECARE

CENTER OF CENTER OF CARECARE

EMSED

12-lead ECG9-1-1 interhospital transport

Activate team

Jacobs. Circulation 2007;116:217-230.

STEMI System of CareSTEMI System of CareActivate EMSAvoid delay

STEMI Referral

STEMI Receiving

Focus on EMS ED POE


•• Many EMS vehiclesMany EMS vehicles•• with out12 lead with out12 lead

ECG equipmentECG equipment

•• Little information onLittle information on•• integration of integration of

ECGsECGs into the into the system of caresystem of care

•• Is EMS prepared for Is EMS prepared for championing STEMI championing STEMI systems?systems?

EMS System Assessment and EMS System Assessment and ImprovementImprovement

•• The American Heart Association is currently The American Heart Association is currently •• participating in a needs assessment/survey in participating in a needs assessment/survey in •• collaboration with EMS organizations and willcollaboration with EMS organizations and will•• analyze the effectiveness of EMS for STEMI analyze the effectiveness of EMS for STEMI •• patients as part of a STEMI system of care.patients as part of a STEMI system of care.

Evaluate Existing ModelsEvaluate Existing Models

•• Grandfathers in EMS BypassGrandfathers in EMS Bypass–– Boston EMS Point of EntryBoston EMS Point of Entry--LA County EMS ModelLA County EMS Model

•• Grandfather in USA Transfer for PCIGrandfather in USA Transfer for PCI–– Level 1 MNPLS Heart/Abbott NWLevel 1 MNPLS Heart/Abbott NW

•• State Model for BothState Model for Both–– RACERACE-- North CarolinaNorth Carolina

The American Heart Association convened a group of thought leaders to review existing local or regional STEMI Systems of Care models.

Boston Boston

•••• Population:Population:•• 580,000 by night 580,000 by night •• 1.2 million by day 1.2 million by day

•• Boston POEBoston POE

Southern California STEMI Southern California STEMI ConsortiumConsortium

•• Regional STEMIRegional STEMI•• NetworksNetworks•• URBAN URBAN

SETTINGSETTING•• Ventura Co.Ventura Co.•• Los Angeles Los Angeles

Co.Co.•• Orange Co.Orange Co.•• San Diego CoSan Diego Co

Red– Zone II (90-120 mins)

Blue– Zone I (< 90 mins)

Establishing Local InitiativesEstablishing Local Initiatives

•• The American Heart Association will The American Heart Association will •• convene the task force initiative at the convene the task force initiative at the •• state and local levels to identify ways state and local levels to identify ways •• to implement national to implement national •• recommendations for STEMI systems recommendations for STEMI systems •• in local communitiesin local communities

STEMI System Evaluation & STEMI System Evaluation & RegistrationRegistration

69

www.americanheart.org/missionlifeline

Explore Possibility of National Explore Possibility of National STEMI Certification ProgramSTEMI Certification ProgramThe American Heart Association will develop recommendations for a STEMI certification program. Possible models include:

- two-tiered hospital certification (STEMI referral and treatment centers)

- EMS System Certification- Regional System Certification

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State Health Alliances

Cultural Health Initiatives ECC

State Advocacy

Quality Improvement

Communications

AHA StaffAHA Staff

DevelopmentMission: Lifeline

Heartland AffiliateGlenn Horn, EVP

Greater Midwest AffiliateIL, IN, MI, MN, ND, SD & WI

KS

NE

Mission: Lifeline Mission: Lifeline Implementation Phase 1Implementation Phase 1



KS

NEDE

NH

HI

Mission: Lifeline Implementation Mission: Lifeline Implementation Phase 2 (Vision)Phase 2 (Vision)



KS

NE

Mission: Lifeline Implementation Mission: Lifeline Implementation Phase 3 (Vision)Phase 3 (Vision)

PCIPCIcapablecapable

NonNon--PCIPCIcapablecapable

SYSTEMSYSTEMOF CAREOF CARE CENTER OF CENTER OF

CARECARE

CENTER OF CENTER OF CARECARE

Patient

EMSED

STEMI Referral

STEMI Receiving

Policy Makers

Activate EMSAvoid delay

12-lead ECG9-1-1 interhospital transport

Activate teamNo diversion

Consider integrated paymentNo penalty to patients

Protocols and toolkitsSTEMI Center CertificationQuality improvement measures

Treatment protocols and clinical pathways

Payer

Jacobs. Circulation 2007;116:217-230.

STEMI System of CareSTEMI System of Care

stemi care in wv mission: lifeline -aha...

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