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On behalf of the MonAMI Team

Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon-AMI) 12 lead ECG project. An update. On behalf of the MonAMI Team A Hutchison, Y Malaiapan , B Barger, I Jarvie , E Watkins, G Braitberg , T Kambourakis , JD Cameron, IT Meredith.

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On behalf of the MonAMI Team

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  1. Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon-AMI) 12 lead ECG project.An update On behalf of the MonAMI Team A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Meredith. Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine (MMC), Monash University, Melbourne, Australia. Metropolitan Ambulance Service, Melbourne Australia. Southern Health Emergency, Southern Health, Melbourne Australia.

  2. Rescue AMI Primary AMI Total AMI Emergency Coronary Angioplasty for Acute Heart Attack at Monash Year

  3. Time Delay to Treatment in Acute Heart Attack Angioplasty & Mortality Zwolle AMI Study Group 1994-2001 n = 1791 Early recognition, rapid transport and treatment is absolutely vital • Every minute delay in Rx affects mortality in both Thrombolytic & 1o PCI groups. • Every 30 min delay = Relative in 1 year mortality by 7.5%. G.De Luca Circulation. 2004;109:1223 -1225

  4. Door to Balloon time affects in hospital mortality In patient Mortality % US National registry of myocardial infarction J Am CollCardiol, 2006 47:2180-2186

  5. Symptom onset < 1 hour before presentation Symptom onset 1–3 hours before presentation Symptom onset 3–12 hours before presentation PCI available within 1 hour† PCI available within 90 minutes† PCI available within 90 minutes(onsite) or 2 hours (offsite, including transport)† YES NO YES NO YES NO PCI Fibrinolysis‡ PCI Fibrinolysis‡ PCI Fibrinolysis‡ Hospital Management of STEMI* * Assuming no contraindications to fibrinolytic therapy; † Time delay refers to time from first medical contact to balloon; ‡ Patients with ongoing symptoms or instability should be transferred for PCI. PCI = percutaneous coronary intervention Acute Coronary Syndrome Guidelines Working Group Med J Aust 2006;184(8 Suppl):S9-29.

  6. Time to presentation MonashHEART experience

  7. Aims of MonAMI To determine if paramedic performed field 12 lead ECG and activation of the infarct team, via the emergency physician, reduced D2BT in patients undergoing primary PCI (PPCI)

  8. Methods • Prospective interventional study in a single Australian metropolitan health care network. • 560 patients • MonAMI group • All patients (n=186) who underwent PPCI following field ECG • Non-MonAMI group • Patients (n=254) who underwent PPCI following standard triage during the time of field ECG capability • Pre-MonAMI group. • The D2BT of 120 consecutive patients who underwent PPCI prior to initiation of field triage

  9. 12 Lead ECG Project Traditional AMI Communication Strategy: MICA Transports Patient to ED Patient with CP MICA 12 Lead ECG Performed by ED Staff Patient Triaged in ED Diagnosis Made ED Resident/Registrar or Consultant Calls Cardiology Registrar Cardiology Registrar sights ECG & calls Interventional Cardiologist Contact CCU Ward Service Consultant Infarct Team Activated

  10. 12 Lead ECG Project New lines of Communication: MICA Attends & Performs 12 Lead ECG On Site MICA Transports Patient to Monash Heart Cath Labs Patient with CP 12 Lead ECG Electronically Transmitted to ED Page Diagnosis Made by ED Consultant Interventional Cardiologist Contact Infarct Team Ready & Waiting in Cath Labs

  11. Patient Demographics

  12. Field ECG faxed to MMC 204 ED stand down N = 85 (41%) Taken to Cath Lab N = 119 (59%) STEMI N = 0 ACS (excluding STEMI) N = 35 No ACS N = 52 Primary PCI N = 107 CAD no PCI N = 3* No overt CAD N = 9 MonAMI Pilot Study December 2007 – July 2008 * Severe Triple Vessel Disease (CABG)

  13. P < 0.001 Median D2B Times December 2007 – July 2009

  14. Median Times

  15. Ambulance times (minutes) P = 0.31

  16. Proportion of cases achieving D2B time under 90 minutes 75%* *AHA /ACC/SCAI guidelines

  17. Conclusion The performance of field 12 lead ECG to triage and pre hospital activation of the infarct team significantly improves door to balloon times and results in a greater proportion of patients achieving guideline recommendations.

  18. MonAMI Pilot Study Ambulance Victoria Greg Cooper Ambulance Victoria Group Manager Danny McGennisken Operations Manager Paramedic Education & Training Eddy Watkins Clinical support Officer Bill Barger Manager Clinical Standards & Audits Ian Jarvie Ambulance Victoria Clinical Support Officer Monash Heart Prof Ian Meredith Director MonashHeart Dr Yuvi Malaiapan Head Interventional Services SH Emergency Dept Prof George Braitberg Professor and Director SH Emergency Medicine Dr Tony Kambourakis Director Emergency Monash Clayton Mr Damien Gibney NUM Emergency Monash Clayton Strategy Planning & Performance Ms Fiona Webster Executive Director SPP Ms Ruth Smith Director Access, Innovation & Service Improvement Ms Karen Barker Project Officer Southern Health Information Technology Mr Charles Burgess Executive Director IT Mr Peter Kinsman Director IT Monash Sector Executive Mr Adam Horsburgh Director Monash sector

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