Acute Myocardial Acute Myocardial Infarction: Infarction: Results from the Results from the DHMC Regional DHMC Regional Registry Registry Nathaniel Niles, MD Nathaniel Niles, MD Cardiology Grand Rounds Cardiology Grand Rounds January 13, 2005 January 13, 2005 Dartmouth-Hitchcock Medical Center Dartmouth-Hitchcock Medical Center
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Acute Myocardial Infarction: Results from the DHMC Regional Registry Nathaniel Niles, MD Cardiology Grand Rounds January 13, 2005 Dartmouth-Hitchcock Medical.
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CM Gibson 1998 in Acute Coronary SyndromesCM Gibson 1998 in Acute Coronary SyndromesSample Size of Pooled Analysis: 5,498Sample Size of Pooled Analysis: 5,498
0
2
4
6
8
10
12
Epicardial Flow After Thrombolysis Epicardial Flow After Thrombolysis and Mortality Outcomesand Mortality OutcomesEpicardial Flow After Thrombolysis Epicardial Flow After Thrombolysis and Mortality Outcomesand Mortality Outcomes
““Time is nature’s way of keeping Time is nature’s way of keeping everything from happening at once”everything from happening at once”
- Woody Allen - Woody Allen
““Time is muscle”Time is muscle”- A. Schwarzenegger- A. Schwarzenegger
GARCIA-2GARCIA-2 20042004 205205 FD TNKFD TNK NoNo Better ST resolution, Better ST resolution, better TIMI 3 flow, No better TIMI 3 flow, No difference in cardiac difference in cardiac
II IIaIIa IIbIIb IIIIIIUpdated Guidelines (2004)Updated Guidelines (2004)
STEMI patients presenting to a facility without prompt primary PCI capability (within 90 minutes) should receive thrombolytic therapy unless contraindicated. (Level of Evidence: A)
Facilitated PCI might be performed as a reperfusion strategy in higher-risk patients when PCI is not immediately available and bleeding risk is low. (Level of Evidence: B)
If immediately available, primary PCI should be performed in patients with STEMI as quickly as possible (Level of Evidence: A)
If the symptom duration is within 3 hours and the expected door-to-balloon time minus the expected door-to-needle time is:≤ 1 hour, primary PCI is preferred. (Level of Evidence: B)> 1 hour, thrombolytic therapy is preferred. (Level of Evidence: B)
Combination therapy for reperfusion and prevention of reinfarction with abciximab and half-dose reteplase or tenecteplase for selected high risk patients at low risk for bleeding. (Level of Evidence: A)
APD or VA Transfers
6%
DHMC ER23%
Outside ER Transfers
71%
Source of Patients Presenting to Source of Patients Presenting to DHMC Cath Lab for Treatment of DHMC Cath Lab for Treatment of STEMI within 24 hoursSTEMI within 24 hours
DHMC STEMI Patient DHMC STEMI Patient Mortality: 2001Mortality: 2001Primary PCI vs Transfer PatientsPrimary PCI vs Transfer Patients
Alice Peck Day or Alice Peck Day or VA HospitalVA Hospital
Administer Administer abciximababciximab
Contraindication for Contraindication for Thrombolytic therapy/Thrombolytic therapy/
abciximababciximab
Remote ER and Remote ER and Age < 75Age < 75
Administer Administer abciximababciximab
and ½ Dose and ½ Dose ThrombolyticThrombolytic
Primary PCIPrimary PCIFacilitated PCIFacilitated PCI Acute ST elevation MI is Acute ST elevation MI is now on the DHMC now on the DHMC
“ALWAYS TAKE” list“ALWAYS TAKE” list
December 2001December 2001
DHMC STEMI RegistryDHMC STEMI RegistryGoalsGoals
• Assess safety and effectiveness of Assess safety and effectiveness of specific novel management specific novel management strategies (facilitated PCI for strategies (facilitated PCI for transfer patients)transfer patients)
• Monitor regional outcomes over Monitor regional outcomes over time in order to assess the impact of time in order to assess the impact of overall quality improvement effortsoverall quality improvement efforts
STEMI Database - STEMI Database - Case Case Report FormReport Form• Emergency Room Emergency Room
• Presentation (Hx/PE)Presentation (Hx/PE)• ECGsECGs• TreatmentTreatment• Timing of TreatmentTiming of Treatment
• Cath LabCath Lab• TIMI FlowTIMI Flow• Timing of reperfusionTiming of reperfusion• InterventionIntervention• Extent of CADExtent of CAD
• Cath lab database query of all patients Cath lab database query of all patients cathed with hx of MI within 24 hrscathed with hx of MI within 24 hrs• 1/01-12/01 retrospective chart review1/01-12/01 retrospective chart review• 1/02-3/04 prospective chart review1/02-3/04 prospective chart review
• 4/04-7/04 prospective cath lab data 4/04-7/04 prospective cath lab data entryentry
Safety and Effectiveness of Safety and Effectiveness of specific novel management specific novel management
strategies:strategies:
Facilitated PCI in Moderate to Facilitated PCI in Moderate to High Risk Patients Requiring High Risk Patients Requiring
Hospital Transfer for PCIHospital Transfer for PCI
“Non-Committed Strategy”•± full dose TTx•± GP 2b3a Inhib•Transfer/cath as 2° strategyN= 276 (49%)
“Facilitated Strategy”•½ dose TTx•GP 2b3a Inh•Emergent transfer for cathN= 163 (29%)
“Primary Strategy”•No TTx•± GP 2b3a Inh•Emergent cath
N= 107 (19%)
Clinical history consistent with acute myocardial infarctionand ST elevation, LBBB or anterior ST depression consistent
with acute posterior MIN=564
Presenting to DHMC or Local HospitalN= 125 (22%)
Presenting to Remote HospitalN= 439 (78%)
“Non-Committed Strategy”•± TTx•± GP 2b3a Inh•Cath as 2° Strategy
N= 18 (3%)
TIMI Score < 2N = 22 (4%)
TIMI Score ≥ 2N = 85 (15%)
TIMI Score < 2N = 51 (9%)
TIMI Score ≥ 2N = 112 (20%)
Door-to-Balloon TimeDoor-to-Balloon Time
154
227
0
50
100
150
200
250
300
Mean Door-to-balloon time
Primary strategyFacilitated stretegy
p<0.0001
Tim
e i
n m
inu
tes
Tim
e i
n m
inu
tes
• Reperfusion was delayed on average more than 70 minutes among facilitated PCI strategy patients
Pre-Cath Lab OutcomesPre-Cath Lab Outcomes
64
32
66
38
0
10
20
30
40
50
60
70
80
% o
f P
ati
en
ts
Ongoing CPon arrival to
cath lab
PersistentST on
arrival tocath lab
p<0.0001 p<0.0003
7.1
5.3
10.5
8.9
0
2
4
6
8
10
12
14
% o
f P
ati
en
tsPre-cathclinical
deteriorationto intubation
or shock
Shock uponarrival to cath
lab
Primary Strategy
Facilitated Strategy
p=ns
p=ns
• Facilitated PCI strategy patients arrived at the cath lab in more stable condition
Cath Lab Findings and OutcomesCath Lab Findings and Outcomes
TIMI 319%
TIMI 223% TIMI 3
50%
TIMI 225%
0
10
20
30
40
50
60
70
80
90
PrimaryStrategy
FacilitatedStrategy
p<0.0001
p<0.0001
17.6
5.4
0
5
10
15
20
25
PrimaryStrategy
FacilitatedStrategy
p=0.0056
Initial TIMI Flow in IRA Cath Lab Intubation or IABP
% o
f P
atie
nts
% o
f P
atie
nts
• Facilitated Strategy yielded more patent arteries and was Facilitated Strategy yielded more patent arteries and was associated with less complcated proceduresassociated with less complcated procedures
In-hospital OutcomesIn-hospital Outcomes
10.6
4.4
5.9
2.7
14.1
9.8
4.7
2.7 2.3
0.9
3.5
6.3
10.6
6.3
18.8
8
5.7 5.7
0
2
4
6
8
10
12
14
16
18
20
22
Death Recurrent MI Clin. CHF Stroke ICH TIMI MajorHem.
““Optimal” 1° PCI vs. transfer for Optimal” 1° PCI vs. transfer for facilitated PCI facilitated PCI Conclusions:Conclusions:
• had longer delays before reperfusion (avg. >70 had longer delays before reperfusion (avg. >70 minutes)minutes)
But…But…• had no greater likelihood of deterioration pre-cathhad no greater likelihood of deterioration pre-cath
• were less likely to have ischemia in lab and had less were less likely to have ischemia in lab and had less complicated procedurescomplicated procedures
• had better initial infarct artery flow and overall had better initial infarct artery flow and overall better clinical outcomesbetter clinical outcomes
• tended to have more bleeding problems tended to have more bleeding problems
But…But…• no increase in ICHno increase in ICH
Monitoring Regional Monitoring Regional Outcomes Over TimeOutcomes Over Time
•Transfer for PCI PatientsTransfer for PCI Patients•Primary PCI Patients (DHMC, Primary PCI Patients (DHMC, VAMC, APD)VAMC, APD)
DHMC STEMI Transfer DHMC STEMI Transfer Volumes Q1(01)-Q2(04)Volumes Q1(01)-Q2(04)
AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseIn-hospital MortalityIn-hospital Mortality
13.5
6
3
0
2
4
6
8
10
12
14
16
18
20
None Given Full Dose Half Dose
% M
orta
lity
Lytic Dose Strategy
p<0.04
p<0.0009
p=ns
AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseTIMI Risk ScoreTIMI Risk Score
3.73.1 3
0
1
2
3
4
5
6
None Given Full Dose Half Dose
Ave
rage
TIM
I R
isk
Sco
re
Lytic Dose Strategy
p<0.06
p=0.007
p=ns
AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseReperfusion and “Facilitated” CourseReperfusion and “Facilitated” Course
75
61
53
0
20
40
60
80
100
Persistant CP or ST elevation
15
36
44
0
10
20
30
40
50
60
TIMI 3 Flow on
Initial Angio
22.8
14.7
4.8
0
5
10
15
20
25
Cath Lab IABP or
Intubation
12
6.25.4
0
2
4
6
8
10
12
14
Clinical Deterioration
Pre-Cath
No lytic givenNo lytic given Half dose lyticHalf dose lyticFull dose lyticFull dose lytic
AMI Transfer Patients: By AMI Transfer Patients: By Intended DoseIntended DoseDoor-to-Balloon TimeDoor-to-Balloon Time
353
274
219
050
100150200250300350400450500
None Given Full Dose Half Dose
Doo
r-to
-Bal
loon
Tim
e (m
in)
Lytic Dose Strategy
p=0.0023p=0.0023
p=0.0001p=0.0001
p=0.0164p=0.0164
AMI Transfer Patients: AMI Transfer Patients: 01→ 0401→ 04In-hospital Mortality by In-hospital Mortality by Treatment strategyTreatment strategy
9.1
2.3
13.5
2.6
7.6
4.53
0
5
10
15
2001 2002 2003 2004
Half dose
All others
% M
orta
lity
Year
Monitoring Outcomes Monitoring Outcomes Over TimeOver TimeTransfer for PCI PatientsTransfer for PCI Patients
• Outcomes are improving Outcomes are improving • Explanation of improvement is Explanation of improvement is
unclear:unclear:• Half-dose lytic regimenHalf-dose lytic regimen• Expedited care in half-dose groupExpedited care in half-dose group• Non-specific improvement Non-specific improvement
(“Hawthorne effect”)(“Hawthorne effect”)• Still Room for improvementStill Room for improvement
>30 min of CP and/or>30 min of CP and/orECG with 1mmST elevation or LBBBECG with 1mmST elevation or LBBB
Consent and transport to Catheterization Lab on CallConsent and transport to Catheterization Lab on CallConsent and transport to Catheterization Lab on CallConsent and transport to Catheterization Lab on Call
Non-transfer STEMI PatientsNon-transfer STEMI Patients (Presenting to DHMC, VAMC, APD)(Presenting to DHMC, VAMC, APD)Q1(01)-Q2(04)Q1(01)-Q2(04)
• Outcomes of patients actually receiving Outcomes of patients actually receiving PCI are stable despite increasing risk PCI are stable despite increasing risk over time over time
• Time intervals - process is too slow Time intervals - process is too slow • getting to the cath labgetting to the cath lab• in the cath labin the cath lab
• GP 2b3a Inhibitors – appear to be GP 2b3a Inhibitors – appear to be effectiveeffective• may improved patency but not TIMI 3 flowmay improved patency but not TIMI 3 flow• our utilization is increasingour utilization is increasing• agent of choice?agent of choice?
• useful in assessing the safety and useful in assessing the safety and efficacy of novel management efficacy of novel management strategies strategies
• useful in assessing the impact of useful in assessing the impact of new protocols over timenew protocols over time
• May be useful for providing May be useful for providing benchmark data to individual benchmark data to individual institutions for QA/QCIinstitutions for QA/QCI
• Enrollment bias - cath lab enrollment Enrollment bias - cath lab enrollment will miss patients who are not sent to will miss patients who are not sent to the cath lab emergentlythe cath lab emergently• Patients admitted to the initial hospital Patients admitted to the initial hospital
rather than transferred acutelyrather than transferred acutely• Patients in whom the decision is made Patients in whom the decision is made
not to cathnot to cath• Patients who decline transfer and/or cathPatients who decline transfer and/or cath• Patients who die before they get to cath Patients who die before they get to cath
lablab
DHMC STEMI RegistryDHMC STEMI RegistryNext StepsNext Steps• ER enrollment of all STEMI patients in the ER enrollment of all STEMI patients in the
• Regular feedback to participating ERs/hospitals Regular feedback to participating ERs/hospitals • STEMI patient outcomes overall and by treatment STEMI patient outcomes overall and by treatment
strategystrategy• Process metrics (e.g. time intervals)Process metrics (e.g. time intervals)
• Partnership in process improvementPartnership in process improvement• Novel treatment regimensNovel treatment regimens• Transfer delay reductionTransfer delay reduction• Pre-hospital triage??Pre-hospital triage??
• Other Nest Steps – WritingOther Nest Steps – Writing
““Writing is easy, all you have to do is Writing is easy, all you have to do is stare at a blank sheet of paper until stare at a blank sheet of paper until droplets of blood begin to form on droplets of blood begin to form on your forehead”your forehead”
- anonymous- anonymous
Questions?Questions?
The Throw Backs The Throw Backs (Patients Not Receiving PCI at Acute (Patients Not Receiving PCI at Acute Procedure)Procedure)Incidence per YearIncidence per Year
6.5 9.5 12.94.7
0
20
40
60
80
100
2001 2002 2003 2004
%%
Throw back Mortality Throw back Mortality vs TIMI Riskvs TIMI Risk