management of ami does time matter?? what is the best strategy: ppci vs tt

Management Of AMIManagement Of AMI

• Does time matter??• What is the best strategy:

• PPCI• Vs• TT

Advise & Guidance &Advise & Guidance &Lessons from NERMI Lessons from NERMI

and other MI Registriesand other MI RegistriesRaouf Mahran,, Prof.NHI.Imbaba.Prof.NHI.Imbaba.

MRCP,DCM,DGM,LRCPSMRCP,DCM,DGM,LRCPS

Optimizing reperfusionOptimizing reperfusion

• Rapid delivery of reperfusion therapy is essential whether PPCI or thrombolytics

• Each of these reperfusion methods has its merits and shortcomings.

• The ideal reperfusion strategy would deliver rapid, complete and sustained reperfusion with normalization of micro-vascular flow.

Importance of EarlyImportance of EarlyReperfusion Therapy in STEMIReperfusion Therapy in STEMI

Outcomes Dependent Upon:• Time to treatment-TIME IS STILL MUSCLE

• Early and full restoration in coronary blood flow

• Sustained restoration of flow

Prehospital IssuesPrehospital Issues• EMS

– Emphasis on early defibrillation; AEDs; 911 dispatchers training & use of national protocols

• Chest Pain Evaluation & Treatment– Emphasis on giving chewable ASA, unless

contraindicated & prehospital ECG & checklist

• Prehospital Fibrinolysis– Upgraded to a Class IIa (Level B) Recommendation

• Prehospital Destination Protocols– Where to transport STEMI patients-Have a plan in

place– Special considerations

• Cardiogenic Shock Cardiogenic Shock • Fibrinolytic contraindicatedFibrinolytic contraindicated

Antman et al. JACC 2004;44:675-7.Antman et al. JACC 2004;44:675-7.

Achieve Coronary PatencyAchieve Coronary Patency

• Initial Reperfusion Therapy – Defined as the initial strategy employed to

restore blood flow to the occluded coronary artery

• 4 Major Options:• Pharmacological Reperfusion Pharmacological Reperfusion • PCI PCI • Acute Surgical Reperfusion Acute Surgical Reperfusion • Facilitated PCIFacilitated PCI

Antman et al. JACC 2004;44:680.Antman et al. JACC 2004;44:680.

Trials/Consensus???

PPCI

Vs

TT

Which is best for our patients?

Limitations of current Limitations of current reperfusion therapyreperfusion therapy

Thrombolytics

• Drug failure (30%)• Re-infarction• Bleeding

Primary PCI

• Inevitable delay• Availability• Operator dependent

Should we combine therapies?Should we combine therapies?

Primary PCI vs Primary PCI vs Thrombolysis in STEMI: Thrombolysis in STEMI:

Meta-analysis (23 RCTs, N=7739)Meta-analysis (23 RCTs, N=7739)

Adapted with permission from Keeley EC, et al. Adapted with permission from Keeley EC, et al. LancetLancet. 2003;361:13-20. 2003;361:13-20..

PCIPCI

ThrombolyticThrombolytictherapytherapy

00

55

1010

2525

1515

2020

Fre

qu

ency

(%

)F

req

uen

cy (

%)

Short-term Short-term OutcomesOutcomes(4-6 weeks)(4-6 weeks)

DeathDeath

PP=.0002=.0002

NonfatalNonfatalMIMI

PP<.0001<.0001

RecurrentRecurrentIschemiaIschemia

PP<.0001<.0001

Hemor-Hemor-rhagicrhagicStrokeStroke

PP<.0001<.0001

MajorMajorBleedBleed

PP=.032=.032

Death, Death, Nonfatal Nonfatal

Reinfarction,Reinfarction,or Strokeor Stroke

PP<.0001<.0001

Bonferroni correctionBonferroni correction6 variables: p <0.00836 variables: p <0.0083

•Analysis:Analysis:Of 6763 pts,3383 randomised to FL,and 3380 to Of 6763 pts,3383 randomised to FL,and 3380 to PCI.PCI. Median presentation time delay ,was not different.140 Median presentation time delay ,was not different.140 m,in PCI&m,in PCI&143m for FL.11% . 143m for FL.11% . Result:Result:1)PCI was associated with: 1)PCI was associated with: 37%37% reduction in 30 days reduction in 30 days mortality.mortality.2)2)ReinfarctionReinfarction occurred in occurred in 6.7 % of FL pts6.7 % of FL pts, and in only , and in only 2.42.4% % of PCIof PCI patients. patients.**European heart journal(2006)27,**European heart journal(2006)27,779-788779-788.Author:Eric Boersma,et al..Author:Eric Boersma,et al.

PPCI versus in-hospital fibrinolysis(FL),PPCI versus in-hospital fibrinolysis(FL),

in AMI.in AMI.

•

AnalysisAnalysis::7084 underwent primary PCI;3078 PHT,and 7084 underwent primary PCI;3078 PHT,and 16043 IHT.16043 IHT.Result;primary PCI was associated with Result;primary PCI was associated with lower mortalitylower mortality than IHT at 30 days than IHT at 30 days (4.9%)(4.9%) Vs Vs (11.4%),(11.4%),plus reduced plus reduced duration of hospital stay,readmission,and reinfarction.duration of hospital stay,readmission,and reinfarction.

**JAMA,October 11-2006-vol 296,No 14 **JAMA,October 11-2006-vol 296,No 14 17491749.Author:U.Author:U

Long term outcome of Long term outcome of Primary PCIPrimary PCI VS VS Prehospital(PHT)Prehospital(PHT) and In hospital and In hospital thrombolysis thrombolysis (IHT)(IHT) ,for patients with ,for patients with STST MI.MI.

Methods:225 pts were assigned to recive PPCI& 226 pts to accelerated TPA:(15 mg bolus,then infusion of 0.75mg/kg for 30m,then 0.5 mg/kg for 60 minutes.)Results:composite end points were reduced in PPCI 10.7% when compared to17.7%(TT) At 6 weeks.At 6 month it was 12.4%(PPCI) Vs 19.9%(T.T)**JAMA,April 17.2002-volume 287,No.15 1943.

thrombolytic therapy (TT) Vs primary PCI for AMI,To hospitals without on site Cardiac surgery.

Way of NatureWay of NatureEventful ProgressEventful Progressfrom Drip To Shipfrom Drip To Ship

Type of Reperfusion Therapy for Type of Reperfusion Therapy for STEMI PatientsSTEMI Patients

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

IV LyticIV Lytic

PPCIPPCI

Year of DischargeYear of Discharge

NRMI 2NRMI 2 NRMI 3NRMI 3 NRMI 4NRMI 4 NRMI 5NRMI 5

Pat

ien

ts,

%P

atie

nts

, %

6.96.9

38.838.8

47.047.0

22.722.7

NSTEMI and STEMI: FindingsNSTEMI and STEMI: Findingsin 2,072,715 Patientsin 2,072,715 Patients

20

40

60

80

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

STEMISTEMI

NSTEMINSTEMI



Pat

ien

ts,

%P

atie

nts

, %

n=938,675n=938,675

n=1,134,040n=1,134,040

missing 354,435 patients from NRMI 1

59.159.1

37.337.340.940.9

62.762.7

STEMI : Absence of Initial STEMI : Absence of Initial Reperfusion TherapyReperfusion Therapy

0

10

20

30

40

50

60

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005



Pa

tie

nts

, %P

ati

en

ts, %

Immediate CABG

–

Range 0.9 % - 1.7

%

37.037.045.345.3

Absence of Reperfusion: Influence of AgeAbsence of Reperfusion: Influence of Age

15

25

35

45

55

65

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005


≤ 65 Yrs

> 65 Yrs


Pat

ien

ts,

%P

atie

nts

, %

58.858.853.253.2

30.930.922.922.9

Absence of Reperfusion: Influence of Absence of Reperfusion: Influence of Gender Gender

30

40

50

60

70

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005


Males

Females


Pat

ien

ts,

%P

atie

nts

, % 54.454.4

46.846.8

40.140.1

32.032.0

1.5

2.0

2.5

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Ho

urs

(M

ed

ian

)H

ou

rs (

Me

dia

n)

2.02.0

1.61.6

Symptom to Door Times: STEMISymptom to Door Times: STEMI



Door to Balloon Times Among Patients Door to Balloon Times Among Patients Transferred in NRMI 4Transferred in NRMI 4

Door toDoor to

Data:Data:

5050thth: 9 Min. : 9 Min.

2525thth: 4 Min.: 4 Min.

7575thth: 16 Min.: 16 Min.

Data to Data to

Cath Lab Arrival:Cath Lab Arrival:

5050thth: 132 Min.: 132 Min.

2525thth: 88 Min.: 88 Min.

7575thth: 219 Min.: 219 Min.

Cath Lab toCath Lab to

Balloon:Balloon:

5050thth: 37 Min.: 37 Min.

2525thth: 28 Min: 28 Min

7575thth: 50 Min.: 50 Min.

99 132132 3737

Total Door 1 to Balloon Time: Total Door 1 to Balloon Time: 185 minutes185 minutes (25 (25thth: 137; 75: 137; 75thth: 276): 276)

Percent of Patients with Door to Balloon Time < 90 MinPercent of Patients with Door to Balloon Time < 90 Min = = 3.0%3.0%

Sample Size: 1,346; Time Period: January 2002 – December 2002Sample Size: 1,346; Time Period: January 2002 – December 2002

4.2%

16.2%

0%2%

4%6%

8%10%

12%14%

16%18%

90 minutes <2 hours

4.2%

16.2%

0%2%

4%6%

8%10%

12%14%

16%18%

90 minutes <2 hours

Times to Treatment in Transfer Patients Times to Treatment in Transfer Patients Undergoing PPCI for AMI: NRMI 3/4 AnalysisUndergoing PPCI for AMI: NRMI 3/4 Analysis

Nallamothu, Circulation. 2005; 111:761-767Nallamothu, Circulation. 2005; 111:761-767

• Analysis of 4278 pts transferred for PPCIAnalysis of 4278 pts transferred for PPCI

Initial Door to Balloon InflationTimeInitial Door to Balloon InflationTime

Door to Drug Times - Median ValuesDoor to Drug Times - Median Values

25.0

30.0

35.0

40.0

45.0

50.0

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

40

30

46

33

Year of Discharge

NRMI 2 NRMI 3 NRMI 4 NRMI 5

Min

ute

s (M

ed

ian

)

Transfer

Non-transfer

Door to Balloon Times According to Door to Balloon Times According to WorkdayWorkday

70

80

90

100

110

120

130

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

125125

7575

100100 9898

On-HoursOn-Hours

Off-HoursOff-Hours



Min

ute

s (M

edia

n)

Min

ute

s (M

edia

n)

No Transfers

Pe

rce

nt

of

Pa

tien

tsP

erc

en

t o

f P

ati

ents

Door-to-Door-to-BalloonBalloon Time < Time < 9090 MinutesMinutes

25

30

35

40

45

50

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

29.8%

44.8%



NRMI Survey 2004 (1994-2003), Door to Balloon Times are in NRMI Survey 2004 (1994-2003), Door to Balloon Times are in excess of guidelines: (often for patients presenting directly to PCI excess of guidelines: (often for patients presenting directly to PCI

hospitals and almost invariable when a transfer is required)hospitals and almost invariable when a transfer is required)

STEMI: Transfer Status PTCASTEMI: Transfer Status PTCADoor-to-balloon times for primary PTCA patients, Door-to-balloon times for primary PTCA patients, by primary transfer statusby primary transfer status..Gibson, CM Gibson, CM Am Heart JAm Heart J 2004;148:S29–33. 2004;148:S29–33.

NRMI 1NRMI 1 NRMI 2NRMI 2 NRMI 3NRMI 3NRMI 4NRMI 4

75

105

135

165

195

225

255

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2001 2002 2003

Min

ute

s (m

edia

n)

NRMI transfer-in patientsNRMI transfer-in patients

NRMI non-transfer-in patientsNRMI non-transfer-in patients

180180

9090

Dea

ths

in h

osp

ital

, %

Dea

ths

in h

osp

ital

, %

PPCIPPCI

IV LyticIV Lytic

MortalityMortality During Hospitalization During Hospitalization by Reperfusion Therapyby Reperfusion Therapy

3

4

5

6

7

8

9

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

3.8 %

3.7 %

5.5 %

8.6 %


NRMI 1NRMI 1 NRMI 2NRMI 2 NRMI 3NRMI 3 NRMI 4NRMI 4 NRMI 5NRMI 5

““TimeTime is Muscle”: PTCA is Muscle”: PTCA GUSTO-IIb and NRMI-2 registry 27.000 ptGUSTO-IIb and NRMI-2 registry 27.000 pt

• Strong relationship between the “door to balloon” time and mortality.

Cannon et al, JAMA 2000; 283: 2941Cannon et al, JAMA 2000; 283: 2941

NERMI: ConclusionsNERMI: Conclusions

• STEMI patients represent a decreasing proportion of those presenting with AMI (37%)

• There has been little improvement in increasing the proportion of patients who receive some form of early reperfusion therapy (37%). Women and the elderly are less likely to receive early reperfusion therapy.

• Primary PCI now exceeds lytic therapy as the mode of early reperfusion.

NERMI: ConclusionsNERMI: Conclusions• Symptom to door times are declining but still

remain too long (1.6 hrs)• Door to drug times have declined over time

from 40-46 minutes to 30-33 minutes and are not affected by inter-hospital transfer.

• Door to balloon times have decreased from a median of 120 to 96 minutes and are profoundly affected by transfer and time of day.

• Less than half of patients achieve a door to balloon time of < 90 minutes and even for non-transfers the rates is only 53%.

management of ami does time matter?? what is the best strategy: ppci vs tt

Documents

pci patients

reperfusion methods

primary pci vs thrombolysis

sustained reperfusion

resultprimary pci

ideal reperfusion strategy

ppci vs ttwhich

recive ppci