Advanced Cardiovascular Intervention 2009 Timings in PPCI: Have we learnt the lessons from our European Colleagues? Peter F Ludman.

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