Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: - PowerPoint PPT Presentation

Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: Regional STEMI Transfer Systems: the Mayo and NC RACE the Mayo and NC RACE the Mayo and NC RACE Experiences Experiences Experiences Dr. Henry H. Ting, Mayo Clinic College of Medicine Dr. Henry H. Ting, Mayo Clinic College of Medicine Dr. Henry H. Ting, Mayo Clinic College of Medicine Dr. James G. Jollis Jollis, Duke University Medical Center , Duke University Medical Center Dr. James G. Dr. James G. Jollis, Duke University Medical Center

Mayo Clinic STEMI System Mayo Clinic STEMI System for Transferred Patients for Transferred Patients “FAST TRACK FAST TRACK” ” “ Henry H. Ting, MD MBA Henry H. Ting, MD MBA Henry H. Ting, MD MBA Mayo Clinic Mayo Clinic Mayo Clinic Rochester, Minnesota Rochester, Minnesota Rochester, Minnesota Jan. 28, 2010 Jan. 28, 2010 Jan. 28, 2010

Disclosures Disclosures Disclosures • • • No financial disclosures No financial disclosures No financial disclosures • • • No conflicts of interest No conflicts of interest No conflicts of interest • • • No off- -label use label use No off No off-label use

D2B – – “Sustain The Gain Sustain The Gain” ” D2B “ D2B – “Sustain The Gain” Nestler DM. Circ Cardiovasc Qual Outcomes. 2009;2:508-513.

PH ECG and Door- -to to- -Balloon Balloon PH ECG and Door PH ECG and Door-to-Balloon 64 min 30 min Ting HH. Presented at AHA November 2009

Patients Transferred for Primary PCI Patients Transferred for Primary PCI Patients Transferred for Primary PCI 60 40 36.3 Patients Patients (%) (%) 26.4 17.6 20 8.6 8.2 4.3 3.7 2.2 1.3 0 <1 <90 1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to min <12 Total door Total door- -to to- -balloon time (hours) balloon time (hours) Chakrabarti A, J Am Coll Cardiol 2008;51:2442-2443.

Reperfusion Strategies for Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI Patients Transferred STEMI Patients Transferred STEMI Patients 1. 1. 1. Interhospital transfer for primary PCI Interhospital transfer for primary PCI Interhospital transfer for primary PCI 2. 2. 2. Pharmaco- -invasive approach with lytics and early PCI invasive approach with lytics and early PCI Pharmaco Pharmaco-invasive approach with lytics and early PCI 3. 3. 3. Lytic facilitated PCI Lytic facilitated PCI Lytic facilitated PCI 4. 4. 4. Prehospital triage for primary PCI Prehospital triage for primary PCI Prehospital triage for primary PCI

Reperfusion Strategies for Reperfusion Strategies for Reperfusion Strategies for Transferred STEMI Patients Transferred STEMI Patients Transferred STEMI Patients 1. 1. 1. Interhospital transfer for primary PCI Interhospital transfer for primary PCI Interhospital transfer for primary PCI 2. 2. 2. Pharmaco- -invasive approach with lytics and early PCI invasive approach with lytics and early PCI Pharmaco Pharmaco-invasive approach with lytics and early PCI 3. 3. 3. Lytic facilitated PCI Lytic facilitated PCI Lytic facilitated PCI 4. 4. 4. Prehospital triage for primary PCI Prehospital triage for primary PCI Prehospital triage for primary PCI

Minnesota Duluth St. Cloud Wisconsin Minneapolis/ St. Paul Rochester 0 100 200 Iowa Ting HH, et al. Circulation 2007;116:729-736

Regional STEMI Patients Treated with Primary Regional STEMI Patients Treated with Primary Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy PCI or Fibrinolytic Therapy PCI or Fibrinolytic Therapy 1.00 Cumulative probability Cumulative probability 0.75 25 min 110 min 0.50 0.25 Regional Hospital Primary PCI Regional Hospital Primary PCI Regional Hospital Fibrinolysis Regional Hospital Fibrinolysis 0.00 0 60 120 180 240 Door-to-balloon/door-to-needle time (minutes) Door-to-balloon/door-to-needle time (minutes) Ting HH, et al. Circulation 2007;116:729-736

Mortality and Mortality and Mortality and Door- -to to- -Needle / Door Needle / Door- -to to- -Balloon Balloon Door Door-to-Needle / Door-to-Balloon 20 In-hospital Mortality (%) In-hospital Mortality (%) P=0.01 P=0.01 16 13.5 11.5 12 8 6.6 5.6 3.5 4 1.1 0 <30 30-60 60-90 90-120 120-180 >180 Door-to-balloon / Door-to-needle time (minutes) Door-to-balloon / Door-to-needle time (minutes)

Door-in Door-out (DIDO) at 1 st Hospital and 1 st Door-to-balloon Time Median 1st Door-to-balloon (min) 250 P < 0.0001 200 150 143 100 87 50 0 DIDO >30 min DIDO <=30 min Ting HH, et al. AHA November 2009

Pharmaco- -Invasive Strategy Invasive Strategy Pharmaco Pharmaco-Invasive Strategy • • • Definition: Broad use of rescue PCI after failed Definition: Broad use of rescue PCI after failed Definition: Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3- -24 hours 24 hours fibrinolysis, as well as an early PCI within 3 fibrinolysis, as well as an early PCI within 3-24 hours of successful fibrinolysis of successful fibrinolysis of successful fibrinolysis

30- -day 1 day 1° ° Endpoint and Components 30-day 1° 30 Endpoint and Components Endpoint and Components Standard Pharmaco- -Invasive Invasive Standard Pharmaco Endpoint P value Endpoint P value N=498 (%) N=512 (%) N=498 (%) N=512 (%)  1  16.6 10.6 0.0013 1 end point end point 16.6 10.6 0.0013 Death 3.6 3.7 0.94 Death 3.6 3.7 0.94 Re- -infarction infarction 6.0 3.3 0.044 Re 6.0 3.3 0.044 Recurrent ischemia 2.2 0.2 0.019 Recurrent ischemia 2.2 0.2 0.019 Death/MI/ischemia Death/MI/ischemia 11.7 11.7 6.5 6.5 0.004 0.004 New/worsening CHF New/worsening CHF 5.2 5.2 2.9 2.9 0.069 0.069 Cardiogenic shock 2.6 4.5 0.11 Cardiogenic shock 2.6 4.5 0.11 Cantor WJ. N Engl J Med 2009;360:2705

30- -day 1 day 1° ° Endpoint and Components 30-day 1° 30 Endpoint and Components Endpoint and Components Standard Pharmaco- -Invasive Invasive Standard Pharmaco Endpoint P value Endpoint P value N=498 (%) N=512 (%) N=498 (%) N=512 (%)  1  16.6 10.6 0.0013 1 end point end point 16.6 10.6 0.0013 Death 3.6 3.7 0.94 Death Median time from lytics to PCI was 3.9 hours 3.6 3.7 0.94 Re- -infarction infarction 6.0 3.3 0.044 Re 6.0 3.3 0.044 Recurrent ischemia 2.2 0.2 0.019 Recurrent ischemia 2.2 0.2 0.019 Death/MI/ischemia Death/MI/ischemia 11.7 11.7 6.5 6.5 0.004 0.004 New/worsening CHF New/worsening CHF 5.2 5.2 2.9 2.9 0.069 0.069 Cardiogenic shock 2.6 4.5 0.11 Cardiogenic shock 2.6 4.5 0.11 Cantor WJ. N Engl J Med 2009;360:2705

Pharmaco- -Invasive Strategy: Invasive Strategy: Pharmaco Pharmaco-Invasive Strategy: NORDISTEMI NORDISTEMI NORDISTEMI Bohmer E. JACC 2010; 55:102-110

Pharmaco- -Invasive Strategy: Invasive Strategy: Pharmaco Pharmaco-Invasive Strategy: NORDISTEMI NORDISTEMI NORDISTEMI Median time from lytics to PCI was 2.7 hours Bohmer E. JACC 2010; 55:102-110

ASSENT-4 Trial ASSENT-4 Trial Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital 8 8 mortality observed for facilitated PCI P =0.01 6 6 6 6 Primary PCI Facilitated PCI Primary PCI Facilitated PCI % 4 % 4 3 3 P <0.0001 P =0.0037 1.8 1.8 2 2 1 1 0 0 0 0 0 0 In-hospital Total Stroke Hemorrhagic In-hospital Total Stroke Hemorrhagic Death Stroke Death Stroke Van de Verf, Lancet 2006;367:569-578

ASSENT-4 Trial ASSENT-4 Trial Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI Median time from lytics to PCI was 1.9 hours DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital 8 8 mortality observed for facilitated PCI P =0.01 6 6 6 6 Primary PCI Facilitated PCI Primary PCI Facilitated PCI % 4 % 4 3 3 P <0.0001 P =0.0037 1.8 1.8 2 2 1 1 0 0 0 0 0 0 In-hospital Total Stroke Hemorrhagic In-hospital Total Stroke Hemorrhagic Death Stroke Death Stroke Van de Verf, Lancet 2006;367:569-578

Prehospital Triage Model Prehospital Triage Model Prehospital Triage Model

Proximal LAD