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Patient Transfer

Patient Transfer. Mark de Belder The James Cook University Hospital Middlesbrough. ST Elevation. No ST Elevation. ST Elevation. ST Elevation. PRIMARY PCI. Fibrinolysis. Primary PCI. Early Invasive. Early Conservative. Fibrinolysis. Primary PCI. Fibrinolysis.

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Patient Transfer

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  1. Patient Transfer Mark de Belder The James Cook University Hospital Middlesbrough

  2. ST Elevation No ST Elevation ST Elevation ST Elevation PRIMARY PCI Fibrinolysis Primary PCI Early Invasive Early Conservative Fibrinolysis Primary PCI Fibrinolysis Current Management Strategies for ACS ACS

  3. Guidelines for the management of non-STEMIAcute Coronary SyndromesCoping with ACS angiography • Rapid turnover of patients required (pressure on ambulance services) • Organisation of diagnostic and revascularisation services • Cath lab spaces required every day in interventional centres • Referral to a specific cath lab slot rather than a specific Consultant • Increased use of Cath ? Proceed slots (for elective work as well) • Referring hospitals need to take some patients back after revascularisation (?swaps) • Weekend working? • Elective work may have to slow pending an increase in the infrastructure for angiography • Clinical networks with appropriate support from commissioners

  4. Patient Transferin the setting ofSTEMI

  5. Meta-analysis of 23 randomised trials7739 patients: 4-6 week dataKeeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20 P=0.0002 P=0.0003 P<0.0001 P=0.0004 P<0.0001

  6. Meta-analysis of 8 randomised trialsStreptokinase trials - 1837 patientsKeeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20 0.53 (0.37-0.75) 0.11 (0.05-0.26) 0.32 (0.09-1.21) 0.40 (0.28-0.58)

  7. Meta-analysis of 15 randomised trialsFibrin-specific trials - 5902 patientsKeeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20 0.80 (0.66-0.96) 0.42 (0.31-0.55 0.49 (0.31-0.77) 0.57 (0.48-0.69)

  8. Meta-analysis of 5 randomised trialsTransfer for PCI vs On-Site Lysis2909 patients: 4-6 week dataKeeley EC, Boura JA, Grines CLThe Lancet 2003;361:13-20 P=0.057 P<0.0001 P=0.049 P<0.0001

  9. Mortality by time to presentation Ziljstra EHJ 2002;23:556

  10. 30-day mortality by time from enrollment to first balloon inflation Berger P et al, Circ 1999;100:14-20 (GUSTO-IIb)

  11. Door-to-Balloon times in Primary PCI outside of trialsN=27,080Cannon CP, Gibson CM, et al. JAMA 2000 P=NS P=NS P=0.01 P=0.0007 P=0.0003 N=2,230 N=5734 N=6616 N=4461 N=2627 N=5412 Corrected for age, anterior MI location & gender

  12. CAPTIMComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionBonnefoy E et al, The Lancet 2002;360:825-29A trial of prehospital fibrinolysis plus selected PCI

  13. CAPTIMComparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial InfarctionBonnefoy E et al, The Lancet 2002;360:825-29 Physician-manned mobile emergency-care units (Service d’Aide Medicale d’Urgence – SAMU) Planned for 1200 patients Trial terminated early due to lack of funding

  14. Pre-hospital lysis - ER-TIMI19Morrow DA et al, JACC 2002;40:71-7315 pts (65 cath’d) vs 650 in-hospital lysis pts 90mins post-lysis 49% >70% STres Pre-hosp rPA 13% >70% STres 4.7% death 3.3% reMI 1% ICH 65 (21%) cath’d 56 (18%) PCI ED Arrival EMS Arrival mins 0 30 60 90 120 150 90mins post-lysis 48% >70% STres In-hospital lysis 33% >70% STres EMS Arrival 0 30 60 90 120 150 mins

  15. Why so little primary PCI in UK? • Lack of evidence? • Belief in pre-hospital lysis? • Insufficient PCI centres? • Too few cardiologists? • (Interventional) cardiologists have too many other things to do? • Reluctance to take on nocturnal work? • Competing demands for finances (statins, ACE-I, DES, ICDs etc)? • Lack of organisation?

  16. Transferring patients for Primary PCIZijlstra F et al, Heart 1997;78:333-6The Weezenlanden Hospital, Zwolle Transfer patients (104) 10 in shock (1 died) 1 ventilated prior to transfer 1 intubated during transfer 1 VT – lignocaine 2 VF – defibrillated 2 required IV fluids

  17. Helicopter vs Ambulance transfer for Primary PCIStraumann E et al, Heart 1999;82:415-9Triemli Hospital, Zurich 3 patients died in shock prior to transfer 0 patients transferred died 8 patients were ventilated during transfer 0 defibrillation during transfer (15 resuscitated prior to transfer)

  18. AIR PAMI138 patients: 30 day data (trial stopped for poor recruitment)Grines CL et al, JACC 2002;39:1713-9 P=0.46 P=1.0 P=0.11 P=0.33 P=0.007 79% ambulance transfer 26±28 miles; 21% Helicopter 57±50 miles 0 patients needed resuscitation during transfer, 0 patients died ER to treatment times 174±80 for transfer vs 63±39 mins for local lysis

  19. DANAMI-2 • 22 referring hospitals • 5 PCI centres • Serving two thirds of the Danish population (5.4million) • Plan for 1100 patients at referring hospitals and 800 patients at invasive centres • Average distance 35 miles (56km) • Up to 95 miles (153km) • Halted by Safety & Efficacy Committee after 1129 patients enrolled because of clear efficacy in PCI patients

  20. DANAMI-2 Trial design ST-elevation MI < 12 hours Randomization (total planned 1900 pts) * Referral Hospital: Planned 1100 pts at 24 sites * Angioplasty Center: Planned 800 pts at 5 sites Fibrinolysis Accelerated tPA (max. 100 mg) Stent Acute transfer for 1° PTCA + stent Primary Endpoint: Death, Reinfarction, or Disabling Stroke through 30 days Anderson HR et al, ACC 2002; Oral Presentation

  21. Hospital Referral Symptom to Hosp. Door to t-PA Lysis Invasive Symptom to Hosp. Door to t-PA Average Door to Balloon (jncludestransfer) < 120 minutes Referral Symptom to Hosp. admit to transfer transfer 1° PCI Door to PCI Invasive Symptom to Hosp. Door to PCI (Balloon) 0 120 240 60 180 minutes DANAMI-2 - Time from Symptom Onset to Admission and Time from Door to Rx ACC 2002; Oral presentation

  22. DANAMI-2 Transfer problems • AF in 2.5% • VT in 0.2% • VF 1.4% • 2/3 heart block in 2.3% • 0 intubations • 0 deaths

  23. 20 p = 0.0003 Accel. t-PA (n=782) PCI (n=790) 13.7 15 p = 0.35 p < 0.001 10 % of Patients 8.0 7.6 6.6 6.3 p = 0.15 5 2.0 1.6 1.1 0 Combined* Death Reinfarction Disabling Stroke *Primary Endpoint: Death, Reinfarction, or Stroke DANAMI-2: 30 day Primary Endpoint All Patients ACC 2002; Oral presentation

  24. 20 Accel. t-PA PCI p=0.002 p=0.0003 p=0.048 14.2 15 13.7 12.3 % of Patients 10 8.5 8.0 6.7 5 0 All patients (n=1572) Referral hospitals (n=1129) Invasive Centers (n=443) *Primary Endpoint: Death or Reinfarction or Stroke DANAMI-2: 30 day Primary Endpoint* Referral vs. Invasive Hospitals ACC 2002; Oral presentation

  25. DANAMI 2: Time to treatment30 day results Combined end-point - All significant

  26. DANAMI 2: Results by age group30 day results Combined end-point - All significant

  27. PRAGUE 2 Widimsky P et al, ESC 2002

  28. PRAGUE 2: 30 day mortality P=0.12 P=NS P<0.02 Widimsky P et al, ESC 2002 Trial stopped early because of reluctance to enrol patients >3 hours

  29. Shock patientsHochman JS et al, NEJM 1999;341:625-34

  30. Ambulance transfer

  31. Strategy for centres with door-to-balloon times >120 mins? • Send anyway for primary PCI? • Make do with best lysis strategy? • As above and select out patients for rescue? • Conventional lysis and send for rescue on arrival if required? • Half-dose lysis ± GP IIb/IIIa inhibitor and send?

  32. Facilitated PCI • Studies such as PACT, SPEED, TIMI-14 and GUSTO V suggest that • combination pharmacotherapy may improve effects of fibrinolysis, and • pharmacotherapy combined with a PCI strategy may improve results of PCI • FINESSE and ASSENT IV ongoing • High risk patients who cannot be treated with early PCI

  33. Current Process for Infarct Angioplasty MI Ambulance Centre

  34. MI Centres MI Ambulance Centre

  35. DANAMI-2 - Time from Symptom Onset to Admission and Time from Door to RxPotential impact of MI centres Hospital Referral Symptom to Hosp. Door to t-PA Lysis Invasive Symptom to Hosp. Door to t-PA Could reduce time by 50-60 mins Referral Symptom to Hosp. transfer 1° PCI Door to PCI Invasive Symptom to Hosp. Door to PCI (Balloon) 0 120 240 60 180 minutes Paradox: referral patients might get more rapid reperfusion!

  36. Ambulance Centre MI MI Centres MI Ambulance Centre As per C-PORT

  37. Emergency Ambulance Service Hartlepool 3 Stockton 3 Carlton How 1 Redcar 3 Middlesbrough 3 Coulby Newham 1/2 Blue light trained 1

  38. Government policy Is there one? • Get the best out of the old treatments before looking at new ones • Pilot studies of pre-hospital lysis • But data already available from Scotland, N. Ireland, France, Holland, Germany, Belgium, USA and Israel! A better approach? • Get the best out of the old treatments and look at new ones • Look at studies of pre-hospital lysis and allow (ie fund) introduction (?via NICE) • Look at studies of primary PCI and allow (ie fund) introduction (?via NICE)

  39. Conclusions If clinical investigators can organise trials, then governments, commissioners and clinical cardiologists should be able to organise an infarct angioplasty service

  40. ConclusionsPatient transfer in AMI • Feasible • Cardiovascular events are uncommon • Need paramedics, ALS trained nurses or doctors • Appropriately equipped ambulances • Continuous ECG monitoring • Defibrillation • Mechanical ventilation • Thrombolytic agents • IV fluids • Resuscitation drugs • Ability to transfer IABP • Need new law to oblige rapid ambulance response to AMI transfer requests (<8 minute response time)

  41. ConclusionsPrimary PCI vs Fibrinolysis • If hospital fibrinolysis is local strategy, change to primary PCI, at least for all patients presenting >3 (?>2) hours after symptom onset • If pre-hospital fibrinolysis is local strategy, need appropriate numbers of appropriately equipped and staffed ambulances • Such a strategy requires a PCI strategy • Contraindication to lysis • Early shock • High risk rescues • Re-infarction • If such ambulance crews exist, then use them for transfer for primary PCI (as the PCI team exists anyway)!

  42. Conclusions • For PCI centres (on-site surgery) with 4 or more interventionists – • primary PCI should be preferred treatment for STEMI • ??offer fibrin-specific lysis to patients presenting in first 3 hours at night) • For PCI centres with off-site surgery - Local arrangements needed for surgical candidates.

  43. Conclusions • For centres that cannot offer PCI but transfer possible within 3 hours - • transfer patients to local PCI centre for primary PCI • ??offer fibrin-specific lysis to patients presenting in first 3 hours – but respond to ongoing problems). • For centres that cannot offer PCI, when transfer within 3 hours not possible - • use fibrinolysis but consider protocol for immediate transfer of patients to PCI centre (?all-comers or selective). • Role of facilitated PCI to be determined

  44. DANAMI 2: 30 day results P<0.0001

  45. End-point Fibrinolysis PCI P value NNT Combined - All patients 24.2% 17.8% 0.002 18 Combined - Referral hospitals 23.3% 16.9% 0.004 15 Mortality - All patients 16% 13.4% 0.26 40 Mortality - Referral hospitals 15.3% 11.9% 0.1 30 DANAMI-2600 day data (6months-4 years) Anderson HR et al, XIVth World Congress of Cardiology 2002

  46. Is simple primary PCI still going to be best?Vermeer et al, Heart 1999;82:426-31

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