advanced cardiovascular intervention 2009 timings in ppci: have we learnt the lessons from our...
TRANSCRIPT
Advanced Cardiovascular Intervention
2009
Timings in PPCI:
Have we learnt the lessons from our European Colleagues?
Peter F Ludman
Europe
Denmark
DANAMI
DenmarkNetherlands
Amsterdam
Zwolle
DenmarkNetherlandsGermany
SchomigKastrati
DenmarkNetherlandsGermanyCzech
PRAGUE 1 and 2
DenmarkNetherlandsGermanyCzechPoland
DenmarkNetherlandsGermanyCzechPolandFrance
CAPTIM
DenmarkNetherlandsGermanyCzechPolandFranceItaly
DenmarkNetherlandsGermanyCzechPolandFranceItalySpain
DenmarkNetherlandsGermanyCzechPolandFranceItalySpain
Sweden
DenmarkNetherlandsGermanyCzechPolandFranceItalySpainAustria (Vienna)
Sweden
Timings in PPCI
Patient delay
EMS delay
15 min DTBTransport to PCI centre
Onset ofSTEMI
FMC Reperfusion
Timings in PPCI
Patient delay
EMS delay
EMS arrivalto needle (30 min)
Patient delay
EMS delay
15 min DTBTransport to PCI centre
PCI Related Delay
Onset ofSTEMI
FMC Reperfusion
Timings in PPCI
Patient delay
EMS delay
EMS arrivalto needle (30 min)
Patient delay
EMS delay
15 min DTBTransport to PCI centre
PCI Related Delay
Onset ofSTEMI
FMC Reperfusion
Timings in PPCI
Patient delay
EMS delay
EMS arrivalto needle (30 min)
Patient delay
EMS delay
15 min DTBTransport to PCI centre
PCI Related Delay
Onset ofSTEMI
FMC Reperfusion
Published data point
Meta analysis (published data)
PCI Related DelayNallamothu AJC 2003;92:824–826
62 min
• Errors
PCI Related Delay
Nallamothu AJC 2003;92:824–826
Nallamothu Am J Cardiol 2004;94:772–4
Betriu A, Masotti M Am J Cardiol 2005;95:100
Asseburg Heart 2007;93:1244–50
Terkelsen Heart 2009 95 362
Prague-1
Prague-2
Veermer
Danami-2
Garcia
Ribicini
Gibbons
Prague-1
Prague-2
Veermer
Danami-2
Garcia
Ribicini
Gibbons
Prague-1
Prague-2
Veermer
Danami-2
Garcia
Ribicini
Gibbons
Terkelsen
PCI Related DelayTerkelsen Heart 2009 95 362
p=0.6
t = 171 min
PCI Related DelayTerkelsen Heart 2009 95 362
p=0.6
PCI Related DelayTerkelsen Heart 2009 95 362
11974 86 171
All All, Danami splitFS FS, Danami split
Meta analysis (published data)
Meta analysis (published data)
Patient level meta-analysis
PCI Related DelayBoersma EHJ 2006 27 779
PCI Related Delay
105
15
120
Patient delay
EMS delay
EMS arrivalto needle (30 min)
on scene delay
Patient delay
EMS delay
15 min DTB(30 min)
Maximum acceptable transport time(105 min)
PCI Related Delay
135
15
PCI Related Delay
105
15
120
Patient delay
EMS delay
EMS arrivalto needle (30 min)
on scene delay
Patient delay
EMS delay
15 min DTB(30 min)
Maximum acceptable transport time(105 min)
PCI Related Delay
135
15
But.....
• PCI– 40% stents– <30% GP IIb/IIIa blockers– Clopidogrel dosing– No Prasugrel
• Lytic– No mandated cath / PCI– Little rescue
Timings in PPCI
Patient delay
EMS delay
EMS arrivalto needle (30 min)
Patient delay
EMS delay
15 min DTBTransport to PCI centre
PCI Related Delay
Onset ofSTEMI
FMC Reperfusion
Time Delays v Observed Mortality
Zijlstra EHJ 2002:23;550%
Mor
talit
y
Lysis
PPCI
Time Delays v Observed Mortality
Zijlstra EHJ 2002:23;550%
Mor
talit
y
Lysis
PPCI
No rush if doing PPCI?
The Impossible Trial
Randomise to delay of:0 to 120 min
Randomise to delay of:0 to 120 min
Start PPCI / Lytic
0
20
40
60
80
100
120
0 1 2 3 4
PPCI (120 min delay)
PCI Related Delay
Time delay to presentation / Rx
Mor
talit
y %
0
20
40
60
80
100
120
0 1 2 3 4
PPCI (120 min delay)
PCI Related Delay
Time delay to presentation / Rx
Mor
talit
y %
PPCI relatively time independentONLY
If all patients present with same pre Rx risk
0
20
40
60
80
100
120
0 1 2 3 4
No Rx
PPCI (120 min delay)
PCI Related DelayM
orta
lity
%
Time delay to presentation / Rx
0
20
40
60
80
100
120
0 1 2 3 4
No Rx
PPCI (120 min delay)
PCI Related DelayM
orta
lity
%
Time delay to presentation / Rx
Early presentersHigh risk
Late presentersLow risk
0
20
40
60
80
100
120
0 1 2 3 4
No Rx
PPCI (120 min delay)
PCI Related DelayTerkelsen Heart 2009 95 362
Time delay to presentation / Rx
Mor
talit
y % Benefit from PPCI
What are the lessons?
• PPCI preferred to lysis in almost all settings
• Time matters– Rx a quick as possible– Networks of care required– Paramedic diagnosis + drive to PPCI
• (? 100 min drive time)
• Significant uncertainty about details!
Have we learnt the lessons?• PPCI is becoming the dominant strategy
IHT causes delay
Call to Balloon Time
119
162
0 50 100 150 200
DirectAdmissions
All Transfers
Time (min)
BCIS 2009NIAP
NIAP and Provisional analysis of BCIS data
IHT causes delay
Call to Balloon Time
119
162
106
165
0 50 100 150 200
DirectAdmissions
All Transfers
Time (min)
BCIS 2009NIAP
NIAP and Provisional analysis of BCIS data
PPCI for STEMIAdmission route
• % of patients admitted direct to PCI centre
69 70 72
0
10
20
30
40
50
60
70
80
2007 2008 2009 (prov)
Conclusions
• lessons– PPCI dominant strategy– Speed matters
• Suggested delay dependency of PPCI misleading• Public awareness campaigns • Networks
– Pre hospital diagnosis– Avoid IHT if possible
– ‘PCI related delay’• Uncertain• Varies with clinical presentation
The End
ESC GuidelinesEHJ 2008;29:2909