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“Saving Time, Saving Lives” Paul M. Murray, MD, FACC March 10, 2009

“Saving Time, Saving Lives” Paul M. Murray, MD, FACC March 10, 2009. Outline. STEMI (ST Elevation Myocardial Infraction) Primary PCI (Door to Balloon -D2B- time) National Overview Case Review TRMC Experience Primary Elective. Outline. I. STEMI (ST Elevation Myocardial Infraction)

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“Saving Time, Saving Lives” Paul M. Murray, MD, FACC March 10, 2009

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  1. “Saving Time,Saving Lives”Paul M. Murray, MD, FACCMarch 10, 2009

  2. Outline • STEMI (ST Elevation Myocardial Infraction) • Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review • TRMC Experience • Primary • Elective

  3. Outline I. STEMI (ST Elevation Myocardial Infraction) II. Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III. TRMC Experience • Primary • Elective

  4. STEMIST Elevation Myocardial Infarction

  5. Emergency Management of Complicated STEMI (2004)

  6. Initial 12 lead ECG; if not diagnostic repeat at 5 to 10 minute intervals ST elevation or new or presumably new LBBB • Beta blocker • IV nitroglycerin if persistent chest pain • IV Heparin or Angiomax • Clopidogrel (Plavix) • GP IIb/IIIa inhibitor if primary PCI Primary PCI, if available, with goal less than 90 minutes OR thrombolysis with goal of 30 minutes Chest pain pattern suggesting an STEMI

  7. Triage Aspirin (chewed) SL nitroglycerin (3 doses) Establish IV Morphine Continuous ECG monitoring Oxygen therapy Obtain History & Physical Draw blood for labwork Goal = 10 minutes

  8. Cardiac biomarkers (cTnI or cTnT preferred) CBC with platelet count PT and INR aPTT Electrolytes Magnesium BUN Creatinine Blood glucose Lipid profile Initial labwork should include:

  9. Conditions other than MI that can elevate Troponin

  10. Thrombolysis In Myocardial Infarction (TIMI) Score for STEMI • DM, history or HTN or history of Angina (1 point) • Systolic blood pressure less than 100 mm Hg (3 points) • Heart rate greater than 100 BPM (2 points) • Killip class II-IV (2 points) • Body weight less than 150 lb or 67 kg (1 point) • Anterior lead ST elevation or left BBB (1 point) • Time to treat more than 4 hours (1 point) Age • >=75 years old (3 points) • 65 – 74 years old (2 points) • Less than 65 (0 points)

  11. TIMI Risk Score Predicts 30 Day Mortality 0 points = 0.8% 1 point = 1.6% 2 points = 2.2% 3 points = 4.4% 4 points = 7.3% 5 points = 12% 6 points = 16% 7 points = 23% 8 points = 27% 9 to 14 points = 36%

  12. Outline • STEMI (ST Elevation Myocardial Infraction) II. Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III. TRMC Experience • Primary • Elective

  13. Outline • STEMI (ST Elevation Myocardial Infraction) II.Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III. TRMC Experience • Primary • Elective

  14. “Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction” N ENGL J MED 2006; 355:2308-20

  15. 100 150 200 50 Door-to-Balloon Time (min) 362 Hospitals Figure 1. Frequency Distribution for Median Door-to-Balloon Times among Study Hospitals.The mean (±SD) of these median times was 100.4±23.5 minutes, which is considerably longer than the 90-minute interval recommended in the 2004 guidelines of the American Heart Association and the American College of Cardiology.4

  16. D2B: An Alliance for Quality • ED activation of Cath Lab • One call activation (Group page) • Pre-hospital ECG • Cath Team ready in 20-30 minutes • In-hospital cardiologist • Prompt data feedback

  17. D2B Time According to the Number of Key Strategies Used

  18. Outline • STEMI (ST Elevation Myocardial Infraction) II.Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III. TRMC Experience • Primary • Elective

  19. CASE STUDY 60 year-old Caucasian male History & Risk Factors include: ♥Hypertension ♥Hyperlipidemia ♥Hyperglycemia ♥ETOH abuse

  20. CASE STUDY ♥Onset of “indigestion” just after McDonald’s double cheeseburger ♥Indigestion progressed to severe discomfort within minutes ♥Associated SOB and profound diaphoresis ♥Took 2 Aspirin and called 911 ♥ECG at scene revealed acute changes

  21. 12 lead ECG from EMS

  22. Timeline

  23. CASE STUDY SUMMARY Day 1 PTCA & DES in 100% prox RCA (D2B = 24 minutes) Day 2 Nutrition consult and Cardiac Rehab consult Day 3 Discharged home on Aspirin, Plavix, Lopressor, Lipitor

  24. Outline • STEMI (ST Elevation Myocardial Infraction) • Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III. TRMC Experience • Primary • Elective

  25. Outline • STEMI (ST Elevation Myocardial Infraction) II.Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III. TRMC Experience • Primary • Elective

  26. Trends in Bypass and PCI Procedures United States: 1990-2002 CABG PCI Source: CDC/NCHS.

  27. PCI With or Without Onsite Surgery StandbyACC-NCDR 2001-2004 In-hospital Mortality : Offsite vs Onsite CVSx MortalityP-value No Acute MI(n=482,018)0.54% vs 0.41% 0.87 STEMI(n= 90,050)4.65% vs 4.83%0.75 NSTEMI(n=94,347)1.94% vs 2.09%0.12

  28. Primary PCIwithout on-site cardiac surgery Risk Benefit

  29. PRIMARY PCI INCLUSION CRITERIA • Chest pain > 20 minutes AND • > 1 mm ST-segment elevation in two contiguous ECG lead • OR • New or presumed new LBBB • OR • >1 mm ST-segment depression in V1/V2 compatible with true posterior MI Patients with chest pain >12 hours were allowed in the registry but were considered thrombolytic-ineligible

  30. Average Monthly D2B Times July 2007-June 200840 total patients with a yearly average of 79 minutes

  31. Outline • STEMI (ST Elevation Myocardial Infraction) II.Primary PCI (Door to Balloon -D2B- time) • National Overview • Case Review III.TRMC Experience • Primary • Elective

  32. C-PORT Elective Trial 32 active sites • 7 states • NJ, GA, IL, OH, OR, AL, PA • 6 new sites in enrollment process 9500 randomized patients as of March 2009 Goal of 16,000–18,000 randomized patients

  33. C-PORT Elective • Non-inferiority trial • Primary Endpoints • Death at 6 weeks • MACE (death+MI+TVR) at 9 months • Secondary Endpoints at 6 weeks and 9 months • Emergency CABG • Myocardial Infarction • Stroke • TVR (Target Vessel Revascularization) • Subsequent PCI or CABG • Bleeding • Heart Failure/Angina • Direct Medical Costs

  34. Registry Refuse C-PORT Elective Patient for Diagnostic Cath Refuse Registry Informed consent Catheterization Exclusion criteria Meets inclusion criteria PCI with SOS PCI no SOS

  35. TRMC CPORT ENROLLMENTJune 2006 – February 2009 • Total Patients 2453 • Total Patients Consented 2287 (93.2%) • Elective 2087 • Primary 200 • No Consent Patients 166 • Not approached 147 • Refused 19 (0.8% of total) • Randomized Patients 387 • TRMC 290 (75%) • Tertiary 97 (25%) • Primary Patients 200 • PCI 159 • No PCI 41

  36. QUESTIONS??

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