Advanced Angioplasty 2005

1. Advanced Angioplasty 2005 Primary PCI making it happen Data collection and Timings Peter Ludman University Hospital Birmingham

5. Motto ‘Time is Muscle’

6. Lysis - Treatment Delay Boersma E Lancet 1996;348:771-75 • 35/7 mortality reduction v delay Trials included in FTT analysis

7. PPCI v Lysis Keeley Lancet 2003; 361: 13–20 • PPCI (n=3872) v Lysis (n=3867) % Frequency

8. However beautiful the strategy, you should occasionally look at the results. Winston Churchill

9. Time to PPCIdelays after admission GUSTO IIb Berger P 1999;100:14-201

10. Time to Reperfusion Brodie BR et al JACC 1998;32:1312 • 1,352 patients treated by primary PTCA n=164 n=581 n=332 n=275

11. Time to Reperfusion Brodie BR et al JACC 1998;32:1312 • 1,352 patients treated by primary PTCA

12. Time to PPCI Zijlstra F EHJ 2002;23:550-557 • 2635 patients (10 trials) n=325 n=414 n=218

13. NRMI-2: Time to PTCA Cannon CP JAMA 2000;283:2941-2947

14. Time to Rx – myocardial salvage Schomig A Circ 2003;108:1084 • 264 PPCI patients • 3 tertiles • Tc-99m Sestamibi SPECT

15. Prague 2Mortality benefit by time to randomisation Widimsky P. EHJ 2003;24: 94–104 • Transfer for PPCI v on site SK • n=850 Time from Sx to Randomisation

16. Prague 2Mortality benefit by time to randomisation Widimsky P. EHJ 2003;24: 94–104 • Transfer for PPCI v on site SK • n=850 Time from Sx to Randomisation

17. Time to PPCI – the early times Steg PG for CAPTIM Circ 2003;108:2851 • n = 840 (planned 1200) • prehospital tPA + rescue v PPCI Mortality

18. Time to PPCI – the early times Steg PG for CAPTIM Circ 2003;108:2851 ‘Loosing an hour’ to implement a strategy for transfer has a differential impact on those seen early rather than late

19. Early v late presentersDoor to Balloon time Brodie Moses Cone registry Data ACC 2004 Early Presenters (≤ 2hrs) Late Presenters (>2hrs)

20. Time to PPCI in Shock Brodie BR JACC 2003;145:708-15 • LeBauer Cardiovascular Research Foundation Registry of consecutive PPCI • n = 1843, shock in 138

21. Very early Rx (1 to 3 hours) • Excellent results with PCI or lysis • Door to balloon • Keep as short as possible • Particularly important in early presenters • ? also in high risk late presenters • Late presenters • PPCI >> Lysis

22. Acceptable Time Delay for Transfer? Dalby M Circulation 2003;108:1809-1814 • Randomised trials of lysis v transfer • Maastricht trial • Prague • Air PAMI • Captim • Danami 2 • Prague 2

23. Transfer Time Delays Difference 48 90 69 60 111 92 61

24. Time delays PPCI v Lysis Nallamothu BK AJC 2003;92:824 • Meta analysis of 23 trials • Door to balloon v door to needle Risk reduction of PCI over lysis

26. Circadian Variation Henriques JPS JACC 2003;41:2138–42 • 1702 consecutive PPCI (Zwolle 1994 to 2000) * * # # P<0.01 * P=0.02

27. Circadian Variation Henriques JPS JACC 2003;41:2138–42 • 1702 consecutive PPCI (Zwolle 1994 to 2000) # * * # P=0.03 * P<0.01

28. Circadian Variation • Patient characteristics • Risk profile • Delayed conscious awareness of pain • Pathophysiology • Platelet aggregation • Coronary flow • Viscosity • Cortisol • Epinephrine • APTT • Endogenous tPA • Fibrinogen • Fibrinolytic factors Performance of the Healthcare team

29. Lady Astor 'Sir, you're drunk!‘ Winston Churchill Yes, madam, I am drunk. But in the morning I will be sober and you will still be ugly.

30. Circadian Variation Dawson D. Nature 1997;388:235 Cognitive psychomotor performance of hand–eye coordination

31. Circadian Variation Dawson D. Nature 1997;388:235

32. Guidelines and Data Collection • Circulation. 2004;110:588-636 • Eur Heart J. 2003; 24: 28–66

33. ACC/AHA Guidelines Goal: ‘ischaemic time’ < 120 mins (Sx to lysis or PCI) EMS Prehosp lysis < 30 min of arrival at scene Non PCI centre Door to needle < 30 min If < 90 min (total) to balloon or if transport will not add more than 60 to time to balloon v local lysis PCI centre Door to balloon <90 min

34. ACC/AHA Guidelines Circulation. 2004;110:588-636 • Fibrinolysis preferred if • Early presentation < 3hr (and delay to PPCI) • PPCI not an option • Lab busy • No lab / inappropriate lab • Delay to invasive strategy • > extra 1 hr over lysis time • > 90 min medical contact to balloon

35. ACC/AHA Guidelines Circulation. 2004;110:588-636 • PPCI Preferred if • Skilled PCI service with surgical backup • Operator > 75 Primary PCI pa • Team > 36 Primary PCI pa • Timings as before • High risk for STEMI • Shock • Killip ≥ 3 • Contraindication to lysis • Late presentation (> 3 hours) • STEMI diagnosis in doubt

36. ESC Guidelines Eur Heart J. 2003; 24: 28–66 • Fast Track patients (clear indication for reperfusion) • Door to needle < 20 min • Door to Balloon < 60 min

37. BCIS – CCADVersion 5.1.3 MINAPVersion 6.1 Date and Time Symptom onset Arrival in first hospital Admission route (Arrival in PCI hospital) Start of procedure First balloon inflation Flow in IRA Symptom onset Call for help Arrival of first professional help Arrival of emergency services Arrival at hospital First balloon inflation Date only angio (local) 1st intervention or surgery (local)

38. UK data collectionThe future BCIS dataset 2003 data: Ludman MINAP dataset Cardiothoracic surgical dataset EP dataset NHS Number Office of National Statistics Mortality register Event free survival

39. Swedish Coronary Angiography and Angioplasty Registry - SCAAR SCAAR Swedish Population Register Date of Death Swedish Patient Administration Register Readmissions (all events) Data from year 2001 Survival data to end 2002 9,496 of 9,535 patients

40. Swedish Coronary Angiography and Angioplasty Registry - SCAAR Nilsson T http://www.sos.se/ 6% 1yr 9% 2yr

41. Mottos ‘Time is Muscle’

42. ‘Mind the Gap’ David Beckam’s Brain surgeon

43. ‘Always knowingly undersold’ Joe’s Shoe Company

44. Alf’s Garage ‘Piston Broke?’ We can help

45. The Literal Society We are the literal society

46. British Rail This motto has been withdrawn Due to it being the wrong kind of motto

47. Primary PCI ‘………………………..’ Suggestions ?

48. The End