Inter-Hospital Transfer of High Risk STEMI Patients for

PCI is Safe and Feasible

David M. Larson , Katie M. Menssen, Scott W. Sharkey,Marc C. Newell, Anil K. Poulose, Ivan J. Chavez, Yale L. Wang,

Barbara T. Unger, Timothy D. HenryMinneapolis Heart Institute Foundation at Abbott

Northwestern Hospital, Minneapolis, MN

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DISCLOSURE INFORMATION:None

David M. Larson, MD

Inter-Hospital Transfer of High Risk ST-Segment Elevation Myocardial Infarction Patients for Percutaneous Coronary Intervention is Safe and Feasible

Background

• Primary PCI is superior to fibrinolysis for treatment of STEMI if performed in a timely manner at experienced centers

• Only 25% of US hospitals have PCI capability• Recent ACC/AHA guideline recommends

transfer for PCI in high risk patients (cardiogenic shock, Killip class ≥3), although the risk of transfer of this group of patients has not been well documented

Fibrinolysis generally preferred •Invasive strategy not an option

Cath lab occupied/not availableVascular access difficultiesNo access to skilled PCI center

• Delay to invasive strategyProlonged transportDoor to balloon >90 minutes>1 hour vs. lysis now

•Very early presentation<1-2 hours from symptoms

ACC/AHA STEMI Guideline

Invasive Strategy generally preferred • Skilled PCI center available/short delay

Operator experience 75 cases/yrTeam experience 36 PCI/yrDoor to balloon <90 minutes

• High risk from STEMICardiogenic shock (age <75)Killip 3

• Increased bleeding riskEspecially ICH

• Late presentation >2-3 hours from symptoms

• Diagnosis in doubt

Number of pts transferred

Exclusions Deaths During Transfer

V-fib During Transfer

Danami 2(n=559)

Cardiogenic shock

Mechanical ventilation0 8

Prague 2(n=425)

None 2 3

Prague (n=201)

Terminal cardiogenic shock

Problems with transport

0 2

Maastricht(n=149)

Age ≥80

Cardiogenic shock0 2

Air PAMI(n=71)

Cardiogenic shock 0 0

Total(n=1405)

2 (0.14%) 15 (1.1%)

Complications During Transfer

Study Objective

• To assess the risk of inter-hospital transfer of an unselected high risk cohort of STEMI patients for primary or facilitated PCI

• With particular focus on high risk patients including cardiogenic shock, out of hospital cardiac arrest, advanced age, long distance

Minneapolis Heart Institute/Abbott Northwestern Hospital (ANW)

A tertiary Cardiovascular Center in Minneapolis, MN

2,500 PCI/year

600 STEMI-PCI

46 Cardiologists

10 Interventional Cardiologists

Methods

• A standardized protocol (“Level 1 MI program”) for transfer of STEMI patients for primary or facilitated PCI from 28 rural and community hospitals was implemented based on the Trauma system concept in 2003

• Consecutive patients presenting with ST-elevation or new LBBB with symptoms <24 hours were included

Methods

• No patients were excluded from transfer or analysis including elderly, cardiogenic shock and post cardiac arrest patients

• Extensive clinical and angiographic data including time intervals, complications during transfer and clinical outcomes were entered in to a prospective registry

Results

• From 7/03 to 6/06, 861 consecutive STEMI patients were transferred from the emergency department for PCI from 28 non-PCI hospitals

• Transfer distances ranged from 17-210 miles

Mode of Transfer

Helicopter – 69% Ground ALS – 31%

Zone 1 – 55 %

Zone 2 – 93%

Zone 1 – 45 %

Zone 2 – 7%

High Risk Patients

• Age 80: 117 (13.5%)

• Cardiogenic shock: 98 (11.4%)

• Cardiac arrest (pre-transfer): 61 (7.1%)

• Endotracheal intubation (pre-transfer): 44 (5.1%)

Time Intervals (median)

59 33 19

49 22 21

66

0 20 40 60 80 100 120

Zone 2

Zone 1

ANW

ED Transport ANW to Balloon

66

95

120

Complications During Transfer

• Cardiopulmonary arrest - 17 (2%)

• Intubation - 6 (0.7%)

• Death - 1 (0.1%)

Cardiopulmonary Arrest During Transfer

• 15 patients transferred by helicopter

• 2 patients transferred by ground ambulance

Cardiopulmonary Arrest During Transfer – 17 (2%)

• Ventricular fibrillation - 12 (1.4%)

• Asystole – 4 (0.4%)

• Respiratory arrest – 1 (0.1%)

13/17 (76%) of the patients were Killip 4 pre-transfer

Outcomes of Cardiac Arrest During Transfer

• Of the 17 patients who arrested, all but 1 were resuscitated with return of spontaneous circulation on arrival to cath lab

• 3 died in the cath lab before PCI due to refractory cardiogenic shock

• 2 died post PCI in hospital

• 11 discharged and alive at 30 days

Conclusion• Transfer of STEMI patients including high risk,

unstable patients with cardiogenic shock and post cardiac arrest from community hospitals for PCI utilizing an established transfer protocol is safe and effective.

• Death during transfer occurred in 0.1% similar to previous clinical data of 0.14% despite the inclusion of very high risk patients

• This data represents the largest reported series to date of STEMI patients transferred for Primary PCI