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AA 2008 Session III: STEMI The UK data

AA 2008 Session III: STEMI The UK data. Mark de Belder The James Cook University Hospital Middlesbrough. Disclosures/Conflicts of interest. Research Grants Cordis/Abbott Advisory Boards Cordis/Boehringer Ingelheim. We do not have accurate data!.

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AA 2008 Session III: STEMI The UK data

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  1. AA 2008Session III: STEMIThe UK data Mark de Belder The James Cook University Hospital Middlesbrough

  2. Disclosures/Conflicts of interest • Research Grants • Cordis/Abbott • Advisory Boards • Cordis/Boehringer Ingelheim

  3. We do not have accurate data! • We do not have precise figures for UK or for England & Wales on: • Numbers of MIs (in total), STEMIs and non-STEMIs • Numbers receiving lysis • Numbers of these referred for rescue • Numbers receiving interval PPCI • Numbers receiving PPCI • Numbers receiving no reperfusion therapy • Possible sources of data: • Office for National Statistics • DoH HES data • CCAD: MINAP and BCIS datasets • National and International Registries

  4. Trends in mortality from AMI 1993-2002from: Griffiths C, Brock A, Rooney C. Impact of introducing ICD-10 on trends in mortality from circulatory diseases in England & Wales. www.statistics.gov.uk/articles/hsq/hsq22ICD-10 A matter of coding? Better primary prevention? Better management of AMI? Better secondary prevention? Something in the air? All of the above? (adjusted from ICD-9 to ICD-10)

  5. GRACE RegistryThe Global Registry of Acute Coronary EventsST elevation audit 1999-2002 - reperfusionCarruthers KF et al, Heart 2005;91:290-8

  6. MINAP Report 2005/06Drug Therapy

  7. Trends since 2001Patients receiving Pre-Hospital Thrombolysis and PPCI

  8. MINAP 2006 3.3% ? Lysis patients: 54% IHL and 68% PHL undergo subsequent angiography John Birkhead, personal communication

  9. 6.6% of total, 13.5% of ACS 2.3% of total, 4.6% of ACS BCIS CCAD data 2006 48.7% 0.2%

  10. 2004 data: Ludman Primary PCI – the experience UK population 60 million, at 500 pmp = 30,000 procedures pa

  11. 2006 data: Ludman Primary PCIRoutine Rx for STEMI Working Hours 24/7 Number of centres NHS Centres only Working Hrs includes all 24/7 sites

  12. 2006 data: Ludman Primary PCI for STEMI2006 data from NHS Centres Total 3930 procedures 0 or No data CCAD E&W + Scot

  13. UK Centres - 2006 Angiography (90) PCI (91)

  14. Distance from hub andexpected distribution of STEMI cases

  15. London results: Time to nearest hospital: drivetime zones

  16. UK Centres - 2006 PCI (91) NIAP sites

  17. NIAP ProjectMain points from initial analysisBCS ASC, Glasgow, 2007 • Compared with the patients treated with thrombolysis identified by these networks, the PPCI treated cohort: • Had a low in-hospital mortality • Involved fewer ambulance journeys • Had fewer complications (re-infarction, major and minor bleeds [inc. i-c bleeds]) • Were less likely to require additional angiography and revascularisation (PCI/CABG) during the index hospitalisation • Had a shorter length of stay

  18. Median Door-to-Balloon times (minutes) BCS, Glasgow June 7, 2007

  19. 6 4 3 1399 467 378 Median LOS [days] BCS, Glasgow June 7, 2007

  20. NIAP: Indications for PCI in lysis group

  21. In-hospital Mortality (all patients)[Index hospitalisation PLUS “convalescent” hospital, includes shock] 62/1399 31/467 64/378

  22. 2006 data: Ludman Outcome 2006CCAD data only

  23. p<0.0001 (Unadjusted data)

  24. p=0.06 (Unadjusted data)

  25. p=0.017 (Unadjusted data)

  26. p=0.004 (Unadjusted data)

  27. Cardiac re-admissions and re-infarction

  28. Readmission days

  29. Additional procedures Given as procedures per pt as some patients had more than one procedure

  30. Conclusions • Need for more accurate data • Whether you are a believer in PPCI or lysis + rescue, current activity is insufficient • We will get better outcomes if we change our strategies • Current data support a change to PPCI • Regional organisation of “Heart Attack Centres” is essential • Triage in the field, and direct transfer to labs is the only viable way to deliver PPCI, and is the best way to deliver PHL and timely rescue PCI • STREAM will perhaps tell us what the options are for early presenters

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