ACUTE CORONARY SYNDROMES

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The Evolution of STEMI Care PCI in the State
of Jefferson ASSET(Acute ST Segment Elevation
Taskforce)
WA State STEMI Summit Oct 31, 2009
Brian W. Gross, MD, FACC The Heart Clinic of S.
Or N. Ca
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(No Transcript)
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(No Transcript)
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Primary PCI
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The Evolution of STEMI Care
1920
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The Evolution of STEMI Care
1929
Werner Forssmann
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The Evolution of STEMI Care
1960s
1958
Harold Dodge
Mason Sones
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The Evolution of STEMI Care
Defibrillation
CCU 1967
Claude Beck 1947 (Case Western) 1st Human (14
y.o.) Bernard Lown 1959 (Boston) DC Frank
Pantridge 1960 (Belfast) Portable BiPhasic
-1980s Michael Mirowski 1980 Johns Hopkins
Implantable
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The Evolution of STEMI Care
1969

• The Mobile CCU Seattles Medic 1

Leonard Cobb
Michael Copass
Mickey Eisenberg
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The Evolution of STEMI Care
Infarct preservation techniques
GIK
1970s
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The Evolution of STEMI Care
1979
Peter Rentrop
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The Evolution of STEMI Care
1979
Andreas Gruntzig
Geoffrey Hartzler
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The Evolution of STEMI Care
1980
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The Process
Plaque
3 mm
3 mm
Plaque Rupture
n
Plaque Rupture Vessel Thrombosis
STEMI
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The Evolution of STEMI Care
Intra-Coronary SK
1983
J. Ward Kennedy Jim Ritchie Jim Fritz Kathryn
Davis
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The Evolution of STEMI Care
IC IV Thrombolysis
1990s
Cath Lab ED Field
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The Evolution of STEMI Care
1993
GUSTO
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Clot BustersDoor to NeedleDoor to Balloon
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The Evolution of STEMI Care
2003
DANAMI 2
Pts 1572 tPA vs PCI Ref Hosp (24)PCI
(5) EndPts Death, CVA, rc-MI tPA
PCI 14.2 8.5 _at_30 days
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Lytics
vs
PCI
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Short-Term STEMI Mortality Rates
in Randomized Controlled Trials
Huynh, T. et al. Circulation 2009 1193101-3109
Favors PCI Favors Lytic
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The Evolution of STEMI Care
1999 2004 2005 2007
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The Evolution of STEMI Care
2006

• ED Physician Activates Cath Lab
• while EMS is enroute with Pt
• Single Call Activation
• ED Activates Cath Lab
• 4) Cath Lab Response lt20 min
• 5) Cardiologist on site 24/7
• 6) Real Time Data FeedBack

False Activations Rare !Really?
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Heart Attacks Time
6 hrs
2 hrs
4 hrs
Time is Muscle
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Beyond a D2B Time of 90 Minutes Every 15 minutes
of Delay leads to Increased Mortality
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The Evolution of STEMI Care
2006
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The Evolution of STEMI Care
2007
2008
D2N D2D D2B
EMS D2B 69 min InterHosp D2B 123 min
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Emergent STEMI PCI

• Primary Percutaneous Coronary
• Intervention (PCI) is the most
• complex, multi-disciplinary, and
• time-sensitive therapeutic intervention
• in the world of medicine today.

The Process is measured in Minutes The Outcomes
are measured in Mortality Teamwork and smooth
Transitions are essential !
Dr. Ivan Rokos,STEMI Systems, May 2007
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The Challenge is to Synchronize all the
Individual Components
and seamlessly move STEMI patients safely
rapidly from any location to the PCI cath lab
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Intracoronary(or Intravenous)Thrombolysis - RCA
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Acute RCA MI
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Acute RCA MI
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Acute RCA MI
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Acute RCA MI
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The Mortality History of ST Elevation Heart
Attacks
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(No Transcript)
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STEMI in the State of Jefferson
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ASSET Mission Statement (Acute ST Segment
Elevation Taskforce)
To facilitate the accurate and rapid diagnosis,
treatment, transport of patients with Acute ST
Segment Elevation Myocardial Infarction (STEMI)
from throughout the region to the Rogue Valley
Hospital Cath Lab for Emergent Percutaneous
Coronary Intervention (PCI).
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How Often ?
7-10
gt95
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ASSET Protocol

• Hx of Heart Equivalent Discomfort lt12 hrs
• Ptlt86, No LBBB (if Positive nearest hospital)
• ECG 2mm ST elevation at J Pt in 2 contiguous
  leads V1-3
• or ECG 1mm ST Elevation at J Pt in 2 contiguous
  leads I, aVL, II, III, aVF, V4-6
• or VF/VT converting to a perfusing rhythm with
  stable VSs ECG as above gt 5 min after shock

EMS Dx by LifePak 12 or Paramedic 182 mg ASA
chewed PreAlert STEMI Activation (name, dob,
cardiologist, ETA) Triage direct to Cath
Lab Avoid IV Tubing
Hospital ASA 182 mg 4000 U IV
Heparin Triage direct to Cath Lab
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ASSET In-Hospital STEMI Mortality
NRMI(2001) Like Hosp
233 consecutive STEMI Patients
June 03-Dec 04
PCI Hosp
American Journal of Cardiology 2007991360-1363
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The History of STEMI PCI
2007
American Journal of Cardiology 2007991360-1363
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ASSET Clinical Case bjm
BJM 35 y.o. male married 3 children
PMH Smoker
Dyslipidemia ECG Anteroseptal STEMI
35 VFs in ED Cath Lab CATH prox LAD ---
Taxus DES CK 26,031 Hosp 3 days
Full Recovery
kl,dw,kd
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ASSET Clinical Case - bjm
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ASSET Clinical Case - bjm
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ASSET Clinical Case - bjm
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The most stabilizing of STEMI therapys is the
swift safe opening of the infarct artery !
STEMI Therapy Paradigm
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STEMI PCI Perfect Storm

• PCI intuitively appeals to so many as a perfect
  solution
• Prime example of rapid translation of research
  results to practice
• EMS is excited about a pivotal activation role
• ER Physicians are happy to hand off complex,
  hi-risk patients
• Non-Interventional Cardiologists happy to be out
  of drama loop
• Interventional Cardiologists love being embroiled
  in the ACTION
• Patients reap the benefit of rapid pain relief
  and stabilization
• Families appreciate the swift response and
  positive outcomes
• ACC/AHA Guidelines encourage performance
• JCAHO and CMS measure and publish standards of
  performance
• NCDR / ACTION Registry record performance
• GWTG rewards performance
• Hospitals promote their performance

Blankenship JC, Williams SH. Rapid Transferfor
STEMI PCIIts just not that hard! J Inv Card
200921434-5
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STEMI Primary PCI Results - DTB Benchmarks for
Transfer-In Pts
ACTION Registry
1st Door to Balloon lt 90 Minutes

1st Door to Balloon lt 120 Minutes

33 of the primary PCI patients are transferred in
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ASSET vs. ACTION Registry D2B July 07 June 08
(Last reported Qtr from ACTION Registry)
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ASSET Paramedic Transfer Complications
Or.Why did I ever sign on to do this
??? 6/03-12/04 (3/233 Pts)
3 Cardioversions
2 Intubations
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ASSET Mortality by 1st Hospital D2B Time June 03
December 08 (n18/609)
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Jackson/Josephine County EMS STEMI Response
Time-Contact to Open Artery
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Paramedic Triaged STEMI PCI Hospital D2B
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ASSET- Initial Medical Contact Median D2B
ComponentsJune 03-Dec 04 vs. 2008
Referring Hospitals
STEMI Receiving Hospital
Paramedics
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All STEMI Patients 2008 (n116) STEMI Receiving
Hospital D2B
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STEMI Mortality by Initial Medical Contact June
2003 December 2008
3.8
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ASSET In-Hospital Mortality by Age June 2003
July 2008 (n652)
If patient lt50 0.0 (0 of 75) If patient lt60
0.4 (1 of 242) If patient lt70 1.2
(5/420) If patient lt86 3.5 (23/652)
Circ Cardiovasc Qual Outcomes 20092e1-e66
DOI 10.1161/CIRCOUTCOMES.109.191960
Abstract 148
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ASSET Management/Mortality June 2003 December
2008 (n720)
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(No Transcript)
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The History of STEMI PCI JACC CV Interventions -
April 2009
2009
The Pre-Alert with field ECG is Key!
2712 pts with Pre Hosp-ECG STEMI Dx to 10
SRCs 86 D2B lt 90 min 50 D2B lt 60 min 25
D2B lt 45 min
68 E2B lt 90 min
J. Am. Coll. Cardiol. Intv., April 2009 2 339 -
346
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ASSET
A closer look at ASSET
40 min
RVMC
20 min
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Pain in the ASSET Program
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In-Hospital Outcomes - STEMI vs. NSTEMI
Unadjusted mortality Transfusion among
non-CABG patients
ACTION Registry-GWTG DATA July 1, 2007 June
30, 2008
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My initial recommendations were lt6 hrs D2W -
reject

• A real challenge will be to develop consistent
  definitions because there will be an attempt to
  dramatize false positives in the press
• WE need to make sure people dont game the system
  like Dr Brindis pointed out in is editorial ie
  balloon inflated in aorta