Myocardial Infarction Angioplasty The Middlesbrough Experience

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Myocardial Infarction AngioplastyThe
Middlesbrough Experience

• Rob Wright
• James Cook University Hospital

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Acknowledgements

• Mark de Belder
• Jim Hall
• Alun Harcombe
• Andrew Sutton
• Bob Morley and the Audit Team
• Cath Lab Team
• CCU

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SCH Original AMI PCI Protocol

• Contraindication to thrombolysis
• Presentation in, or early shock
• (if within 12 hours of onset of symptoms)
• Rescue at 2 hours post onset of thrombolysis
• Re-infarction
• Age not a contra-indication but comorbidity is

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James Cook Referring HospitalsThrombolysis
2002-2003

• Bishop Auckland 92
• Darlington Memorial 99
• Friarage Northallerton 47
• Hartlepool 98
• James Cook 159
• North Durham 161
• North Tees 129
• Scarborough 96
• West Cumberland 98

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South Cleveland HospitalInfarct Angioplasty 1998
- 2002
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MERLIN Sutton AGC JACC 200444287-96

• What to do when thrombolysis fails
• 307 patients with ECG failure to reperfuse
• Randomised to immediate angiogram or usual care

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A randomised trial of rescue angioplasty versus
a conservative approach for failed fibrinolysis
in ST elevation myocardial infarctionMiddlesbro
ugh Early Revascularisation to Limit
INfarction(MERLIN) trial

•  
• AGC Sutton MA MB MRCP, PG Campbell MB MRCP, R
  Graham MB MRCP,
• DJA Price MB MRCP, JC Gray1 BSc PhD, ED Grech MD
  MRCP FACC,
• JA Hall MA MD FRCP, AA Harcombe MD MRCP, RA
  Wright MD FRCP,
• RH Smith2 Bsc MB FRCP, JJ Murphy3 MB BS DM FRCP,
• A Shyam-Sundar2 MB BS MD DM FRCP, MJ Stewart MD
  FRCP,
• A Davies BSc MB BS FRCP, NJ Linker BSc MD FRCP
  FESC,
• MA de Belder MA MD FRCP
•  
• The James Cook University Hospital,
  Middlesbrough, UK.
• 1University of Newcastle-upon-Tyne, UK.
• 2University Hospital of North Tees,
  Stockton-on-Tees, UK.
• 3Darlington Memorial Hospital, Darlington, UK . 
• No conflicts of interest

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METHODS

• Inclusion Criteria
• Patients with STEMI and evidence of failure to
  respond to the administration of fibrinolytic
  therapy
• Presentation to hospital within ten hours of the
  onset of major symptoms was required.
• Failure to reperfuse was defined by a second
  12-lead ECG performed 60 minutes after the onset
  of fibrinolytic therapy showing
• Failure of the ST segment elevation in the worst
  lead (the lead with maximum ST elevation) to have
  resolved by 50 and the absence of an
  accelerated idioventricular rhythm (AIVR) at the
  time of the 60-minute ECG1
• Any fibrinolytic agent was allowed for trial
  entry 
• ST segment measured 80ms after the J point
• 1Sutton et al. Heart 200084(2)149-56.

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METHODS

• Exclusion criteria
• Cardiogenic shock, defined by hypotension
  (systolic BP ? 90mmHg), oliguria and poor
  peripheral perfusion with or without pulmonary
  oedema.
• Patients with confounding features on the
  pre-treatment ECG, e.g. the presence of bundle
  branch block configuration or a paced rhythm
• Patients with reinfarction in the same ECG
  territory within 2 months of an original
  infarction
• Patients without femoral arterial access
• Pregnancy
• Patients with significant co-existing pathology
  (eg. disseminated malignancy, end-stage
  respiratory failure) likely to affect prognosis
  during the follow-up period.

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Trial Flow Chart
Early crossover for shock only
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MERLIN Results 30 days
p0.02
p0.7
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MERLIN Conclusions

• No mortality benefit
• Increased risk of stroke and bleeding
• Reductions in
• Unplanned revascularisation 6.5 v 20.1 plt0.01
• Reinfarction 7.2 v 10.4 ns
• REACT

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JCUH Shock Survival (n113)Sutton AGC et al,
Heart in press
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SHOCK Trial - 1 year survival Hochman JS JAMA
2001
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Post-MERLIN Strategy

• August 2002 Operator Discretion
• August 2003 Czech Protocol
• February 2004 Open Primary PCI
• Participation in Finesse and Assent 4 studies
  affects some patients

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Prague-2 30 day Mortality Eur Heart J
20032494
Plt0.02
P0.12
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JCUH Czech AMI PCI Protocol

• Contraindication to thrombolysis
• Presentation in, or early shock (if within 12
  hours of onset of symptoms)
• Patients with onset of chest pain gt3 hours
• Patients with previous STEMI
• Rescue cases to be discussed individually
• Re-infarction

Age not a contra-indication but comorbidity is
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JCUH Open AMI PCI Protocol

• Patients with chest pain ST elevation lt 12hr
• Rescue cases to be discussed individually
• Re-infarction

Age not a contra-indication but comorbidity is
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Post-MERLIN September 2002 August 2004
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6/12 Czech Protocol 6/12 Open
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Patient Characteristics
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Culprit Vessel
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Procedure Details
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Complications
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TIMI Flows
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Procedure Timing
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JCUH AMI PCI Sep 03 Aug 04 (n ())
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JCUH AMI PCI Sep 03 Feb 04 In-Hospital
Mortality (n ())
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JCUH AMI PCI Sep 03 Aug 04 In-Hospital
Mortality (n ())
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Czech Protocol In-Hospital Deaths

• 62yr M, OOHA, Shock o/a
• 73yr F, Shock, IABP, Temp p/m
• 62yr M, Rescue shock, IABP, prev CABG
• 72yr F, Rescue shock, IABP, Temp p/m
• 70yr F, Rescue shock, IABP
• 76yr F, ReMI, shock, IABP
• 83yr M, PEA arrest day 6
• 76yr M, PEA arrest in CCU ?rupture

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Open Protocol In-Hospital Deaths

• 65yr M ReMI PCI (prev MI) on w/l for IHU CABG.
  16/5/04 LAD stent successful. 19/5/04 Cx
  dissection, perforation, IABP, CABG. Died 21/5/04
• 56yr M OOHA Transfer occ LAD, Shock, Ventilated
  IABP pre-PCI
• 61yr M Rescue Shock LAD (CTO RCA) IABP,
  ventilated
• 75yr M Facilitated RCA (3VD) VT arrest day 3 ?
  Rupture
• 77yr F ReMI RCA (3VD), shock, IABP, VSD

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JCUH AMI PCI Sep 03 Aug 04 (n176)
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AMI PCI Sep 03 Aug 04 (n176)In-Hospital
Mortality ()
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Conclusions

• Primary PCI is feasible for local population
• In-hospital results are encouraging
• Post-Merlin practice has changed significantly
• Tertiary service offered for
• Shock
• Reinfarction
• Contraindications to thrombolysis
• Rescue in selected cases

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Angiographically Guided Therapy for AMI

• Requirements
• Motivated Team
• Cooperation of Ambulance Service
• Telemetered ECG
• Anaesthetic Support
• Surgical Support

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Questions

• Widening the net
• Facilitation
• Thrombus extraction Distal protection
• Shock - ? LNMMA ? Pexelizumab ?Metabolic support
• Slow flow / No flow
• IABP
• Age What is optimal care for the over 80s?
• Audit
• Times, ST resolution, Stroke, Follow Up Revasc
  etc