AA 2008Session 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!
• 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
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
(adjusted from ICD-9 to ICD-10)
A matter of coding?A matter of coding?Better primary prevention?Better primary prevention?Better management of AMI?Better management of AMI?Better secondary prevention?Better secondary prevention?Something in the air?Something in the air?All of the above?All of the above?
GRACE RegistryThe Global Registry of Acute Coronary Events
ST elevation audit 1999-2002 - reperfusion
Carruthers KF et al, Heart 2005;91:290-8
0
10
20
30
40
50
60
70
80
%
Any Lysis PPCI
UKEurMultinat
MINAP Report 2005/06Drug Therapy
0102030405060708090
100
%
D-to-N<30min
C-to-N<60min
ASA BB Statins
TargetObserved
Trends since 2001Patients receiving Pre-Hospital Thrombolysis and PPCI
0
100
200
300
400
500
600
700
No.PHTPPCI
MINAP 2006
18289
597
3349
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
Lysis Referred forRescue
Interval PCI PPCI
3.3%3.3%
John Birkhead, personal communication
Lysis patients: 54% IHL and 68% PHL undergo subsequent angiography
??
BCIS CCAD data 2006
55823
27169
36791258 222 249 114
0
10000
20000
30000
40000
50000
60000
All
All ACS
PPCI
Rescue
ReMI
ReMI rescue
AT/SAT2.3% of total, 4.6% of ACS2.3% of total, 4.6% of ACS
6.6% of total, 13.5% of ACS6.6% of total, 13.5% of ACS
48.7%48.7%
0.2%0.2%
Primary PCI – the experience
0
200
400
600
800
Primary PCI pmp
UK population 60 million, at 500 pmp = 30,000 procedures pa
2004 data: Ludman
Primary PCIRoutine Rx for STEMI
13
28 32 37
0%
20%
40%
60%
80%
100%
2004 2005 2006 2007
513 18 23
0%
20%
40%
60%
80%
100%
2004 2005 2006 2007
2006 data: Ludman
NHS Centres only
Working Hours 24/7
Number of centres
Working Hrs includes all 24/7 sites
0
50
100
150
200
250
300
350
Number of procedures
Hospitals
Primary PCI for STEMI2006 data from NHS Centres
Total 3930 procedures
0 or No data
CCAD E&W + Scot
2006 data: Ludman
UK Centres - 2006Angiography (90) PCI (91)
A 1(M )
A 1(M )
A 1(M )
A 1(M )
A 57(M)
A 64 (M )
M 1
M 1
M 18
M 180
M 6
M 602
M 62
M 62
M 62
M 63
M 65
M 66
M 67
Barnsley
Batley
Bebington
Birkenhead
Bootle
Burnley
Bury
Cheadle and Gatley
Chester
Crosby
Darlington
Dewsbury
Doncaster
Ellesmere Port Grimsby
Halifax
Harrogate
Hartlepool
Huyton-with-Roby
Macclesfield
Morecambe
Morley
Rochdale
Runcorn
Sale
Salford
Scunthorpe
Southport
Stockton-on-Tees
Wakefield
Wallasey
Warrington
Widnes
Wigan
Blackburn
Blackpool
Bolton
Bradford
Huddersfield
Kingston upon Hull
Leeds
Liverpool Manchester
Middlesbrough
Oldham
Preston
Rotherham
Sheffield
St. Helens
Stockport
York
.
15-30 min
30-45 min
45-60 min
60+ min
below 15 min
Distance from hub andexpected distribution of STEMI cases
A 1
A 102A 329(M)
M 1
M 1
M 11
M 20
M 23
M 25
M 25
M 26
M 3
M 4
M 40
Havering
Kingstonupon Thames
Bromley
Greenwich
Barnet
Hillingdon
Bexley
Enfield
Barking and Dagenham
Hackney
Tower Hamlets
Newham
Waltham Forest S
Waltham Forest N
Redbridge
Haringey
Hammersmithand Fulham
Ealing
Hounslow
Brent
Harrow
Camden
Islington
Croydon
Kensington and Chelsea
Westminster
Lambeth
Southwark
Lewisham
Wandsworth
Richmond upon Thames
Sutton
Merton
City of London
Chest
Royal Free
St Thomas'
Kings College
St George's
HarefieldHospital
Hammersmith HeartHospital
St Mary's
10 km
A: <=5 min
B: <=10 min
C: <= 15 min
D: <= 20 min
E: <= 30 min
F: > 30 min
London results: Time to nearest hospital: drivetime zones
UK Centres - 2006PCI (91)
NIAP sites
NIAP ProjectMain points from initial analysis
BCS 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
Median Door-to-Balloon times (minutes)
31
85
97
74
34
70
36
130
0 20 40 60 80 100 120 140
Direct Lab
Direct CCU
Direct A&E
Direct all
Transfer D2tB Lab
Transfer D2tB A&E
Transfer D2tB
Transfer D1tB
mins
BCS, Glasgow June 7, 2007BCS, Glasgow June 7, 2007
Median LOS [days]
BCS, Glasgow June 7, 2007BCS, Glasgow June 7, 2007
0
1
2
3
4
5
6
PPCI Lysis None
PPCILysisNone
1399 467 378
33
66
44
NIAP: Indications for PCI in lysis group
12
0.4 1.9 2.1
18
1.3
64
0
10
20
30
40
50
60
70
%
Rescue AT/SAT ReMI ReMIRescue
Post-MI Unlisted None
In-hospital Mortality (all patients)
[Index hospitalisation PLUS “convalescent” hospital, includes shock]
4.4
6.6
16.9
0
2
4
6
8
10
12
14
16
18
%
PPCI Lysis Nil62/1399 31/467 64/378
All as % No. SuccessPartial
successFail no comp
Re-PCI
QMIEm
CABGDeath
NSTEMI / UA no shock 13667 93.5 2.7 3.0 0.3 0.2 0.09 0.62
All STEMI
no shock3656 93.0 2.0 2.4 0.6 0.14 2.5
Primary PCI 2549 90.4 2.2 2.7 0.5 0.2 4.6
Rescue PCI 1187 91.1 1.9 2.6 0.4 0 4.8
Shock 430 65.6 4.1 2.2 0.5 0.93 30.2
Outcome 2006CCAD data only
2006 data: Ludman
p<0.0001
(Unadjusted data)
p=0.06
(Unadjusted data)
p=0.017
(Unadjusted data)
p=0.004
(Unadjusted data)
Cardiac re-admissions and re-infarction
9.4
17.6
12.7
2.7
9.4
4.5
0
2
4
6
8
10
12
14
16
18
%
Cardiac readmissions All reinfarction
PPCILysisNil
Readmission days
Reperfusion strategy
Total readmissions
Readmissions per pt
Readmissions per hospital survivor
Total days Days per pt Days per hospital survivor
PPCI 548 0.39 0.41 2729 1.95 2.04
Lysis 260 0.56 0.60 1947 4.17 4.47
Nil 177 0.47 0.56 1464 3.87 4.67
Additional procedures
0.16
0.67
0.35
0.12
0.46
0.13
0.0290.0580.066
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
per patient
Angio PCI CABG
PPCILysisNil
Given as procedures per pt as some patients had more than one procedure
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