1 UCSF Advances in Heart Disease UCSF Advances in Heart Disease Elliott M. Antman, MD Elliott M. Antman, MD Cardiovascular Division Cardiovascular Division Brigham and Women Brigham and Women’ s Hospital s Hospital Harvard Medical School Harvard Medical School Contemporary Management of STEMI: Contemporary Management of STEMI: Emphasis on Systems of Care Emphasis on Systems of Care December 2008
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UCSF Advances in Heart DiseaseUCSF Advances in Heart Disease
Elliott M. Antman, MDElliott M. Antman, MD
Cardiovascular DivisionCardiovascular Division
Brigham and WomenBrigham and Women’’s Hospitals Hospital
Harvard Medical SchoolHarvard Medical School
Contemporary Management of STEMI:Contemporary Management of STEMI:
Emphasis on Systems of CareEmphasis on Systems of Care
ScheringSchering--Plough Research InstitutePlough Research Institute
St Jude MedicalSt Jude Medical
The TIMI Study Group has received research / grant support in thThe TIMI Study Group has received research / grant support in the past 2 yrs e past 2 yrs
through the Brigham & Womenthrough the Brigham & Women’’s Hospital with funding froms Hospital with funding from
(in alphabetical order):(in alphabetical order):
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Case PresentationCase Presentation
• 55 year female--PCI of LAD (angina) at Hospital A
• 2 days later:4:30 PM SSCP--takes TNG4:35 PM calls 9114:43 PM EMS arrives--Hosp A on diversion
Shock develops during transport5:04 PM Arrive at Hosp B (no PCI capability)
6:00 PM Full cardiac arrest; CPR initiated7:03 PM Patient expires
Yr = 2000 Hospital A = Mount Auburn Hosp, Cambridge , MA
Hospital B = Cambridge Hospital, Cambridge , MA
133
min
Informed Patient Who “Did Everything Right”The System Failed Her
Sick: The Untold Story of America’s Health Care Crisis-And the People Who Pay the Price
Jonathan Cohn (Harper Collins; 2007)
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PCI vs. Fibrinolysis:PCI vs. Fibrinolysis:ShortShort--term Clinical Outcomes (23 RCTs)term Clinical Outcomes (23 RCTs)
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4.52.2
6
10
7 89
7 7
21
21
5
13
0
5
10
15
20
25
30
35
PCI
Fre
qu
en
cy (
%)
Keeley E, et al. Lancet. 2003;361:13.
P = 0.0002
P = 0.0003 P < 0.0001
P < 0.0001
P < 0.0001P = 0.0004
P = 0.032
P < 0.0001
Death Death, no
SHOCK
data
Re-MI Rec.
isch
Total
stroke
Hem.
stroke
Major
bleed
Death
MI
CVA
Fibrinolysis
N = 7,739N = 7,739
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Time and Myocardial SalvageTime and Myocardial Salvage
0
20
40
60
80
100
1 3 6 12 24
HoursHours
Mo
rta
lity
Re
du
cti
on
(%
)M
ort
ali
ty R
ed
uc
tio
n (
%)
Extent of salvage (% of area at risk)
Time to treatment is criticalTime to treatment is criticalOpening the artery is the Opening the artery is the
Options for Transport of Patients with STEMI Options for Transport of Patients with STEMI and Initial Reperfusion Treatmentand Initial Reperfusion Treatment
J Am J Am Coll CardiolColl Cardiol. 2004;44:671; . 2004;44:671; CirculationCirculation. 2004;110: 588.. 2004;110: 588.
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Improving Access to Primary PCIImproving Access to Primary PCI
PCIPCI
capablecapable
Not PCINot PCI
capablecapablePCI w/oPCI w/o
Surg Surg BUBUCommunity Community
CenterCenter
PCIPCI
CenterCenter
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Core StrategiesCore Strategies
1. ED physician activates the 1. ED physician activates the cath cath lab;lab;
2. One call activates the 2. One call activates the cath cath lab;lab;
3. 3. Cath Cath lab team ready in 20 lab team ready in 20 –– 30 minutes;30 minutes;