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Advanced Cardiovascular Intervention 2009

Advanced Cardiovascular Intervention 2009. Timings in PPCI: Have we learnt the lessons from our European Colleagues? Peter F Ludman. Europe. Denmark. DANAMI. Denmark Netherlands. Zwolle. Amsterdam. Denmark Netherlands Germany. Schomig Kastrati. Denmark Netherlands Germany Czech.

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Advanced Cardiovascular Intervention 2009

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  1. Advanced Cardiovascular Intervention2009 Timings in PPCI: Have we learnt the lessons from our European Colleagues? Peter F Ludman

  2. Europe

  3. Denmark DANAMI

  4. Denmark Netherlands Zwolle Amsterdam

  5. Denmark Netherlands Germany Schomig Kastrati

  6. Denmark Netherlands Germany Czech PRAGUE 1 and 2

  7. Denmark Netherlands Germany Czech Poland

  8. Denmark Netherlands Germany Czech Poland France CAPTIM

  9. Denmark Netherlands Germany Czech Poland France Italy

  10. Denmark Netherlands Germany Czech Poland France Italy Spain

  11. Sweden Denmark Netherlands Germany Czech Poland France Italy Spain

  12. Sweden Denmark Netherlands Germany Czech Poland France Italy Spain Austria (Vienna)

  13. Timings in PPCI Onset of STEMI Reperfusion FMC Patient delay EMS delay 15 min Transport to PCI centre DTB

  14. Timings in PPCI Onset of STEMI Reperfusion FMC Patient delay EMS delay EMS arrival to needle (30 min) PCI Related Delay Patient delay EMS delay 15 min Transport to PCI centre DTB

  15. Timings in PPCI Onset of STEMI Reperfusion FMC Patient delay EMS delay EMS arrival to needle (30 min) PCI Related Delay Patient delay EMS delay 15 min Transport to PCI centre DTB

  16. Timings in PPCI Onset of STEMI Reperfusion FMC Patient delay EMS delay EMS arrival to needle (30 min) PCI Related Delay Patient delay EMS delay 15 min Transport to PCI centre DTB

  17. Published data point

  18. Meta analysis (published data)

  19. PCI Related Delay Nallamothu AJC 2003;92:824–826 62 min

  20. PCI Related Delay • Errors 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

  21. Prague-1 Garcia Prague-2 Danami-2 Ribicini Veermer Gibbons

  22. Garcia Prague-1 Prague-2 Ribicini Danami-2 Veermer Gibbons

  23. Garcia Prague-1 Prague-2 Ribicini Danami-2 Veermer Gibbons Terkelsen

  24. PCI Related Delay Terkelsen Heart 2009 95 362 p=0.6

  25. PCI Related Delay Terkelsen Heart 2009 95 362 p=0.6 t = 171 min

  26. PCI Related Delay Terkelsen Heart 2009 95 362 FS FS, Danami split All All, Danami split 74 86 119 171

  27. Meta analysis (published data)

  28. Meta analysis (published data)

  29. Patient level meta-analysis

  30. PCI Related Delay Boersma EHJ 2006 27 779

  31. PCI Related Delay on scene delay Patient delay EMS delay EMS arrival to needle (30 min) PCI Related Delay 120 15 Patient delay EMS delay 15 min Maximum acceptable transport time (105 min) DTB (30 min) 105 15 135

  32. PCI Related Delay on scene delay Patient delay EMS delay EMS arrival to needle (30 min) PCI Related Delay 120 15 Patient delay EMS delay 15 min Maximum acceptable transport time (105 min) DTB (30 min) 105 15 135

  33. But..... • PCI • 40% stents • <30% GP IIb/IIIa blockers • Clopidogrel dosing • No Prasugrel • Lytic • No mandated cath / PCI • Little rescue

  34. Timings in PPCI Onset of STEMI Reperfusion FMC Patient delay EMS delay EMS arrival to needle (30 min) PCI Related Delay Patient delay EMS delay 15 min Transport to PCI centre DTB

  35. Time Delays v Observed Mortality Zijlstra EHJ 2002:23;550 Lysis % Mortality PPCI

  36. Time Delays v Observed Mortality Zijlstra EHJ 2002:23;550 Lysis % Mortality PPCI No rush if doing PPCI?

  37. The Impossible Trial

  38. Randomise to delay of: 0 to 120 min

  39. Randomise to delay of: 0 to 120 min Start PPCI / Lytic

  40. PCI Related Delay Mortality % Time delay to presentation / Rx

  41. PCI Related Delay PPCI relatively time independent ONLY If all patients present with same pre Rx risk Mortality % Time delay to presentation / Rx

  42. PCI Related Delay Mortality % Time delay to presentation / Rx

  43. PCI Related Delay Early presenters High risk Late presenters Low risk Mortality % Time delay to presentation / Rx

  44. PCI Related Delay Terkelsen Heart 2009 95 362 Benefit from PPCI Mortality % Time delay to presentation / Rx

  45. 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!

  46. Have we learnt the lessons? • PPCI is becoming the dominant strategy

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