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Myocardial Infarction Angioplasty The Middlesbrough Experience

Myocardial Infarction Angioplasty The Middlesbrough Experience. Rob Wright James Cook University Hospital. Acknowledgements. Mark de Belder Jim Hall Alun Harcombe Andrew Sutton Bob Morley and the Audit Team Cath Lab Team CCU. SCH Original AMI PCI Protocol.

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Myocardial Infarction Angioplasty The Middlesbrough Experience

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  1. Myocardial Infarction AngioplastyThe Middlesbrough Experience Rob Wright James Cook University Hospital

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

  3. 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

  4. 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

  5. South Cleveland HospitalInfarct Angioplasty 1998 - 2002

  6. MERLIN Sutton AGC JACC 2004;44:287-96 • What to do when thrombolysis fails • 307 patients with ECG failure to reperfuse • Randomised to immediate angiogram or usual care

  7. A randomised trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST elevation myocardial infarction:Middlesbrough 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

  8. 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 2000;84(2):149-56.

  9. 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.

  10. Trial Flow Chart Early crossover for shock only

  11. P=0.3 P=0.0004 P=0.7 P=0.3 P=0.03 MERLIN Results: 30 days p=0.02 p=0.7

  12. MERLIN Conclusions • No mortality benefit • Increased risk of stroke and bleeding • Reductions in • Unplanned revascularisation 6.5 v 20.1% p<0.01 • Reinfarction 7.2 v 10.4% ns • REACT

  13. JCUH Shock Survival (n=113)Sutton AGC et al, Heart in press

  14. SHOCK Trial - 1 year survival Hochman JS JAMA 2001

  15. 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

  16. Prague-2 30 day Mortality Eur Heart J 2003;24:94 P<0.02 P=0.12

  17. 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 >3 hours • Patients with previous STEMI • Rescue cases to be discussed individually • Re-infarction Age not a contra-indication but comorbidity is

  18. JCUH “Open” AMI PCI Protocol • Patients with chest pain + ST elevation < 12hr • Rescue cases to be discussed individually • Re-infarction Age not a contra-indication but comorbidity is

  19. Post-MERLIN September 2002 – August 2004

  20. 6/12 “Czech Protocol” – 6/12 Open

  21. Patient Characteristics

  22. Culprit Vessel

  23. Procedure Details

  24. Complications

  25. TIMI Flows

  26. Procedure Timing

  27. JCUH AMI PCI Sep 03 – Aug 04 (n (%))

  28. JCUH AMI PCI Sep 03 – Feb 04 In-Hospital Mortality (n (%))

  29. JCUH AMI PCI Sep 03 – Aug 04 In-Hospital Mortality (n (%))

  30. 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

  31. 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

  32. JCUH AMI PCI Sep 03 – Aug 04 (n=176)

  33. AMI PCI Sep 03 – Aug 04 (n=176)In-Hospital Mortality (%)

  34. 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

  35. Angiographically Guided Therapy for AMI Requirements • Motivated Team • Cooperation of Ambulance Service • Telemetered ECG • Anaesthetic Support • Surgical Support

  36. 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

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