William J. Phillips, MD, FACC Director of Cardiology November 10, 2011

Transcription

1 Code STEMI at CMMC William J. Phillips, MD, FACC Director of Cardiology November 10, 2011

2 Faculty Disclosure Information William J. Phillips, MD, FACC, FSCAI FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USES DISCLOSURE: None POTENTIAL CONFLICTS OF INTEREST: Employed by CMMC as an Interventional Cardiologist

3 CMHVI: PCI and Heart surgery close to home since May, 2003

4 Heart Disease Facts Cardiovascular disease (CVD) #1 killer since ,500 Americans die of CVD each day Estimated Costs: $403.1 billion dollars in 2006 Heart Attack is a major form of CVD 1.2 million coronary attacks estimated per year Nearly half of these people will die 330,000 coronary heart disease deaths occur out-of-hospital, or in the Emergency Department each year

5 Begin with the end in mind! CMHVI began amidst some controversy! Commitment to evidenced based medicine Expectation that our earliest patients would likely be emergent or urgent cases, where travel to a more established center was not an option Therefore, Primary PCI was an early emphasis. We knew we had to do a great job with our Acute MI patients!

6 What is Primary PCI? Primary PCI is when the initial treatment for an Acute MI is the use of balloon angioplasty and/or a stent, to open a completely closed coronary artery that is responsible for the heart attack.

7 Why do it? How do you do it? Primary PCI How do you do it faster? How do you decide between thrombolytic or primary PCI, especially at a non-pci center? like most community hospitals in Maine?

8 Why Do We Do PPCI? Fibrinolytic Rx for STEMI limited by inadequate reperfusion and/or reocclusion in ~25% of pts. An occluded infarct-related artery is associated with a doubling of long-term 20 mortality. Evidence for the open artery hypothesis: TIMI 1 Dalen, Gore, Braunwald et al. Am J Cardiol 1988; 62:179. Mortality (%) Occluded Patent Weeks

9 PPCI vs. Thrombolysis Lower mortality Lower reinfarction Fewer complications Fewer strokes But. Many more variables may be at work in achieving clinical trial-like results. And it was controversial, because it challenged community practice and referral bias.

10 Nallamothu/Bates: minutes

11 NRMI 2: Primary PCI Door-to to-balloon Time vs. Mortality MV Adjusted Odds of Death P=0.01 P= P= n = 2,230 5,734 6,616 4,461 2,627 5,412 Door-to-Balloon Time (minutes)

12 Importance of Door-to to-balloon Time: 30-Day Mortality in the GUSTO-IIb Cohort Mortali ity (%) P= TIME DEPENDENT OUTCOME DIFFERENCES ARE MUCH GREATER IN THE FIRST HOUR! Berger PB, et al. Circulation. 1999;100: CM Gibson 2006 < > PTCA not performed Door-to-Balloon Time (minutes)

13 I IIa IIb III Primary PCI: AHA/ACC Guidelines STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal. I IIa IIb III STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated. 9803mo01, 13

14 Trends in Prehospital Delay in Patients with AMI 5967 pts with AMI from 1986 to 2005 Mean and median delays unchanged in 20 years 4.6 and 2.0 hours in 2005 (1/2 patients are more than 2 hours) Longer delays in older patients with DM or prior MI (higher risk patients) Thrombolysis may be less effective and higher risk in these patients AJC, Dec. 15, 2008, p1589ff, Worcester Heart Attack Study

15 Treatment Delayed is Treatment Denied Symptom Recognition Call to Medical System PreHospital ED Cath Lab Increasing Loss of Myocytes Delay in Initiation of Reperfusion Therapy

16 Primary Angioplasty was starting to hit the public eye.

17 What was optimal therapy, given the multiple issues?

18 CHOICE: Selection of the Optimal Reperfusion Options for the STEMI Patient Full Dose Fibrinolytic Monotherapy if Door to balloon (D-B) > 90 min (?how much greater) Lack of access to skilled PCI center (D (D-B) (D-N) > 1 h < < 3 h from symptom onset (TNK (TNK 62% TIMI 3 flow) Primary PCI if Cardiogenic shock (age < 75) Bleeding risk Diagnosis in doubt (pericarditis/aneurysm) Door to balloon < 90 min Symptoms > 2-3 h Lytic failure or post lysis Skilled PCI center available, defined by: Operator experience > 75 cases/yr Team experience > 36 primary PCI/yr Age > 75 (90+% TIMI 3 flow)

19 Mortality in relation to therapy and delay 7-day mortality 30-day mortality Prehospital thrombolysis (PHT) Any time Primary PCI (PCI) 1-year mortality Adjusted outcome by Cox regression analysis including 23 variables plus propensity score. 30-day mortality Reperfusion started <=2 h 1-year mortality 30-day mortality 1-year mortality Reperfusion started >2 h 0,1 0,4 0,6 0,8 1 1,2 1, PCI or PHT better in-hospital thrombolysis better JAMA 2006;296:1749

20 Primary PCI vs thrombolysis age-adjusted adjusted 1 year mortality in relation to delay time tality 1-year mort Tlys PCI Thrombolysis PCI Deaths / Patients Tlys PCI Time for reperfusion (h) JAMA 2006;296:1749

21 Door to Balloon Time! There was convincing evidence that PCI was better, if it could be done promptly National attention began to focus on achieving the best D2B s! Centers of excellence began to establish protocols that would speed diagnosis and care. We felt that if we could treat trauma rapidly, we could treat STEMI as well.

22 Recognition of ST elevation by paramedics. Whitbread, M. Emerg Med J 2002; 19(1):66-7. Objective: To define the ability of paramedics to recognize ST-elevation using prehospital 12-lead EKG Results: 95% accuracy 91% specificity 97% sensitivity No difference from ER physician results

23 Recognition by paramedics Conclusions: Paramedics can recognize ST elevation using a 12 lead EKG. Radio transmission of an EKG may not be necessary to pre-alert hospital, is more expensive to implement, and in Maine, may not always be possible. (what about cell phone photos?)

24 Policy Support AHA 2004 Guidelines ACEP Policy Statement June 1999 Out-of-hospital 12-lead EKG National Association of EMS Physicians Position Paper: Prehospital Triage of Chest Pain Patients

25 The Plan 12 lead EKG Course & Repeat every 3 years All patients with chest pain or possible cardiac symptoms receive a prehospital 12-lead EKG 100% EKG review from March 1, 2004 July 1, 2005

26 Prehospital Activation of CMHVI Cath Lab United first service in state to activate cath lab Started 7/05 Improved morale Decreased door to balloon time Other services immediately wanted to join

27 Activation Inclusion Criteria ST elevation > 1mm in 2+ contiguous leads Ongoing symptoms i.e. chest pain, SOB. Palpable lower extremity pulses Ability to give informed consent (usually)

28 Service Area Now there are approx. 17 ambulance services trained

29 Extending Activation Training All services perform 12 lead EKG s on potential cardiac patients 100% 12 lead EKG review All services take a 20 EKG test and have to achieve 90% to pass

30 Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction Bradley, E.H., et al. NEJM 2006; 355: Six strategies to a faster door-to-balloon time: ER physicians activate cath lab (without waiting for cardiology confirmation) 8.2 min Single call to central page operator 13.8 min Prehospital cath lab activation (depending upon distance to hospital) 15.4 min Cath staff arrival < 30 min 19.3 min Having a cardiologist on site 14.6 min Real time data feedback to ED/Cath Lab 8.6 min

31 Profile Case 53 yo wm collapses at fire scene 30 min by ground from CMMC-Vfib arrest United ambulance CPR-Defib-IV-O2 12 lead EKG Ant/Lat MI

32 Profile Case Cath Lab and LifeFlight activated 3 min flight 20 min D2B Patient leaves hospital 3 days later Neuro intact

33 Early Results Prehospital Activation Benchmark Times 80 min or less 100% 70 min or less 89% 60 min or less 78% 40 min or less 44% 30 min or less 15%

34 In A Heartbeat As many of you are aware, in April 2006, the Dirigo Health Agency's Maine Quality Forum launched In a Heartbeat, a comprehensive initiative that creates an evidence-based treatment map for patients suspected of having a heart attack in Maine. In a Heartbeat seeks to reduce death and disability that result from acute myocardial infarction (AMI) or heart attack, and involves partners from across the state, (Emergency Medical Services, medical providers, Maine Center for Disease Control and Prevention, community outreach groups, and health advocacy organizations, such as the American Heart Association), working to ensure that Mainers who have heart attacks receive timely, quality care, regardless of where they live or work, and where they are treated.

35 ER admit!

36 In A Heartbeat program Agreed upon need for public education Ongoing review of emergency services Could not agree on a statewide priority for transporting STEMI patients to the closest PCI center!!! (unlike the Trauma protocol) Data collection unfunded Poster never produced or distributed

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38 Go in an Ambulance Person having a heart attack will be seen more quickly EMTs communicate with ER doctors ER can prepare for arrival EMTs can monitor condition and begin treatment Time saved is muscle saved

39 ACC database As reported in the 2007 Cath/PCI Registry Outcomes Report, the average Door to Balloon time was 118 minutes for the 767 hospitals reporting. Central Maine Medical Center s average time then was 60 minutes which beat the average by 58 minutes! National D2B Goal is 90 minutes or less. Most recent data reporting showed CMMC D2B time averaged 51 minutes!

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41 What has happened since 2005? Whereas most PCI centers in 2005 could not reach D2B goals, 90% are now doing so. We have engaged more community hospitals in our regular D2B meetings to enhance Door In Door Out strategies to facilitate transfers. Goal is 30 mins or less. EMS continues to monitor protocols and improve them. For example, we recently found that doing the field ECG in the patient s house, saved nearly 10 minutes compared to doing it in the vehicle.

42 What next? Engage more regional hospitals to participate. Local physician or nurse champions are indispensible. Protocol development can be collaborative through our D2B team meetings.

43 Maintaining Quality Monthly D2B meetings Interventional Cardiology Nursing ED physicians Cath lab staff EMS representatives Transfer hospital representatives from St Mary s, Rumford, Farmington, Bridgton, Parkview, others invited in person or conference call

44 D2B meeting format Review any case outside the 90 minute goal, regardless of transfer status Metrics reviewed: Chest pain onset to 1 st med contact Hospital arrival time Mode of arrival Diagnostic EKG time Cath lab activation time Depart mode and time Arrival from transfer site Cath lab arrival Balloon or device deployment time. Modifiers delaying treatment: VF, respiratory, CPR, etc.

45 Ongoing challenges New pharmacology Alternative and competing strategies Treatment of the post-cpr patient in coma Hypothermia protocols and training Additional community hospital support and involvement in QI process Cost effectiveness in a changing environment Drug eluting stents in AMI? Expensive transfers??declining need? : Incidence of AMI declining and survival improving!

46 There is still no general agreement in Maine that every STEMI patient should go to the nearest PCI center! Why not? Can EMS play a role here?

47 Achieving Rapid Treatment

48 Diversion to the PCI center? Happening today, though unusual. Challenges local resources. Not appropriate for unstable patients or those with a questionable diagnosis. May save ½ hour or more!

49 Think about this In 2005, the CMMC Heart team recognized the competence, professionalism, and responsibilities of our regions EMS teams and empowered them to directly activate our cardiac teams while bringing patients rapidly to our PCI center in order to save precious minutes that we call MINUTES OF MYOCARDIUM..

50 Now Isn t it time for our EMS services to extend to our Heart Team, the commensurate rights and responsibilities of displaying emergency flashing lights on our vehicles as attempt to get to the hospital promptly in order to definitively treat the patients you are transporting?

51 IS THIS AN EMERGENCY VEHICLE?

52 Special Thanks to the entire D2B team! The CMMC Cardiac Cath Lab staff! Their on call duties are incredibly demanding. They are the best! Our ED staff, physicians, nurses (especially!) and all their support staff. CMMC Connect for their invaluable help in facilitating transfers, communication, and quality reviews (everything is recorded!) All the EMS teams who are dedicated to helping their patients get the best care! The Lifeflight crews whose commitment to excellent and rapid care is second to none. Our referring hospitals and their STEMI teams. We have seen them shine! Our Administrators who support the ongoing Quality Assurance. Our Database Team!

53 Prehospital Cath Lab Activation The Central Maine Experience Kevin M. Kendall, M.D., FACEP EMS and LifeFlight Director

54 The End.