How to do Primary PCI The basics and adjunctive pharmacology

1. How to do Primary PCIThe basics and adjunctive pharmacology Dr Andrew Sutton MA MD FRCP FESC Consultant Cardiologist The James Cook University Hospital

2. NO CONFLICT OF INTEREST TO DECLARE

3. Before the cath lab.. • Discussion, formulation and agreement of a clear regional protocol is key • Essential stakeholders: ambulance services, regional cardiologists, General Practitioners; walk-in centres; A&E staff

4. Before the cath lab.. • Aim for one pre-hospital patient pathway for each geographical region – irrespective of the day of the week, time of day, start/end of shifts. • Familiarity with and repetition of a single pathway breed slickness and efficiency • Continuous review, audit and feedback essential

5. Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008

6. Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008 CCU coordinator receives call from paramedic crew and copy of initial ECG

7. Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008 Patient admitted directly to cath lab CCU coordinator receives call from paramedic crew and copy of initial ECG

8. Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008 Patient admitted directly to cath lab Cath lab opened by resident member of staff CCU coordinator receives call from paramedic crew and copy of initial ECG

9. Aways room for improvement..

10. Help your out of area ambulance colleagues...

13. DTB direct Q3 2009 2010

14. In the cath lab.. • Brief assessment (history, ECG , examination) • Exclude aortic dissection, PE • Look for acute MR, VSD; determine access • Previous angio available? • Determine history of allergy • Record usual medication (esp. anticoagulants) and medication already administered (aspirin, opiate analgesia) • Obtain witnessed verbal consent

15. In the cath lab.. • Slick patient preparation (iv access; ECG monitoring; remote pads for defibrillation; monitoring of O2; removal of jewellery) • Access – “normal” route is radial (82% radial last 1000 sequential cases in JCUH) • Preferable to have easy access to femoral artery, even if not used

16. In the cath lab.. • Common practice to administer a “radial cocktail” (GNT/verapamil +/- UFH) after sheath insertion • Advisable to avoid verapamil for STEMI • Diagnostic angio followed by choice of guide catheter or whole procedure with Kiemeneij guide catheter

17. In the cath lab.. • Do the case • Use of a thrombus extraction device is normal practice • Clarify any pending non cardiac surgery prior to choice of stent • Ask yourself if the stent big enough • TR band for radial access (increasingly use of a closure device for femoral access) • Do the next case

18. In the cath lab – particular considerations • Inferior STEMI • Bezold-Jarisch reaction: liberal use of iv fluids, atropine; may require phenylephrine • Culprit vessel or MV PCI? • Our default strategy is culprit vessel PCI (MV PCI performed in context of cardiogenic shock and lack of haemodynamic response to culprit vessel PCI)

19. “A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” JCUH drugs Aspirin loading 300mg (paramedic). Weight adjusted UFH (60U per kg) assuming patient will also receive ReoPro (89% of last 1000 sequential cases). ReoPro is only administered in the cath lab.

20. “A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” JCUH drugs Clopidogrel loading 600mg (not by paramedics) For self-presenters to local or regional A&E, load with aspirin 300mg and clopidogrel 600mg prior to urgent transfer

21. “A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” JCUH drugs Prasugrel is used instead of clopidogrel on a patient by patient basis at operator discretion.

22. “A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.” Alternatively… Aspirin loading 300mg (paramedic). Prasugrel 60mg loading dose as routine (well recognised exceptions); potential for administration by ambulance crew. Bivalirudin + bail out GpIIb/IIIa inhibitor.

23. In the cath lab.. escalation of care • Not all PPCI is simple

24. 83F Inferior STEMI TIMI 2 flow Critical prox RCA

25. Lesion uncrossablewith whole range of CTO balloons

26. Lesion successfully crossed with 2.1F Tornus device

27. Subsequent rotablation and stenting

28. Final result

29. In the cath lab.. escalation of care • Not all PPCI is simple • Not all MI (or PPCI) is without complication

30. 62M Posterolateral STEMI Severe pulmonary oedema requiring NIV and anaesthetic support

31. Severe MR noted pre-lab

32. Sub-total occlusion of Cx

33. Cx ballooned for ongoing pain IABP

34. Urgent mechanical mitral valve replacement 90 minutes later Complete recovery

35. 77F Inferior STEMI with CHB Ostial LMS disease and calcified, severe LAD and Cx disease

36. Occluded RCA in calcified vessel

37. Vessel opened Serial balloon inflations TIMI 3 flow Delivery of kit very difficult No stent; planned urgent CABG

38. Vessel repeatedly re-occluded after wire removal Haemodynamic compromise IABP, TPW Cardiothoracic anaesthetic input Emergency CABG from lab

39. In the cath lab.. escalation of care • Not all PPCI is simple • Not all MI (or PPCI) is without complication • ...which means you get some very sick patients

40. In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place

41. In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some

42. In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some • Provision for invasive ventilation • Provision for IABP General ITU do not take these patients

43. In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some • Provision for invasive ventilation • Provision for IABP • Provision for cooling General ITU do not take these patients

44. In the cath lab.. escalation of care • Infrastructure for the sickest group must be in place • Input from experienced cardiothoracic anaesthetists vital for some • Provision for invasive ventilation • Provision for IABP • Provision for cooling • Provision for cardiothoracic surgical input General ITU do not take these patients

45. The basics.... conclusion • Agreed regional protocol for delivery of PPCI • Mechanism in place for wherever the patient presents • Mechanism of continuous monitoring, audit and feedback

46. The basics.... conclusion • Agreed regional protocol on drugs • Strategy for the PPCI which is not simple • Infrastructure for those patients requiring urgent anaesthetic and surgical input