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Advanced Cardiovascular Intervention 2009. Timings in PPCI: Have we learnt the lessons from our European Colleagues? Peter F Ludman. Europe. Denmark. DANAMI. Denmark Netherlands. Zwolle. Amsterdam. Denmark Netherlands Germany. Schomig Kastrati. Denmark Netherlands Germany Czech.

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advanced cardiovascular intervention 2009

Advanced Cardiovascular Intervention2009

Timings in PPCI:

Have we learnt the lessons from our European Colleagues?

Peter F Ludman

slide3

Denmark

DANAMI

slide4

Denmark

Netherlands

Zwolle

Amsterdam

slide5

Denmark

Netherlands

Germany

Schomig

Kastrati

slide6

Denmark

Netherlands

Germany

Czech

PRAGUE 1 and 2

slide7

Denmark

Netherlands

Germany

Czech

Poland

slide8

Denmark

Netherlands

Germany

Czech

Poland

France

CAPTIM

slide9

Denmark

Netherlands

Germany

Czech

Poland

France

Italy

slide10

Denmark

Netherlands

Germany

Czech

Poland

France

Italy

Spain

slide11

Sweden

Denmark

Netherlands

Germany

Czech

Poland

France

Italy

Spain

slide12

Sweden

Denmark

Netherlands

Germany

Czech

Poland

France

Italy

Spain

Austria (Vienna)

timings in ppci
Timings in PPCI

Onset of

STEMI

Reperfusion

FMC

Patient delay

EMS delay

15 min

Transport to PCI centre

DTB

timings in ppci14
Timings in PPCI

Onset of

STEMI

Reperfusion

FMC

Patient delay

EMS delay

EMS arrival

to needle (30 min)

PCI Related Delay

Patient delay

EMS delay

15 min

Transport to PCI centre

DTB

timings in ppci15
Timings in PPCI

Onset of

STEMI

Reperfusion

FMC

Patient delay

EMS delay

EMS arrival

to needle (30 min)

PCI Related Delay

Patient delay

EMS delay

15 min

Transport to PCI centre

DTB

timings in ppci17
Timings in PPCI

Onset of

STEMI

Reperfusion

FMC

Patient delay

EMS delay

EMS arrival

to needle (30 min)

PCI Related Delay

Patient delay

EMS delay

15 min

Transport to PCI centre

DTB

pci related delay
PCI Related Delay

Nallamothu AJC 2003;92:824–826

62 min

slide24

PCI Related Delay

  • Errors

Nallamothu AJC 2003;92:824–826

Nallamothu Am J Cardiol 2004;94:772–4

Betriu A, Masotti M Am J Cardiol 2005;95:100

Asseburg Heart 2007;93:1244–50

Terkelsen Heart 2009 95 362

slide25

Prague-1

Garcia

Prague-2

Danami-2

Ribicini

Veermer

Gibbons

slide26

Garcia

Prague-1

Prague-2

Ribicini

Danami-2

Veermer

Gibbons

slide27

Garcia

Prague-1

Prague-2

Ribicini

Danami-2

Veermer

Gibbons

Terkelsen

slide28

PCI Related Delay

Terkelsen Heart 2009 95 362

p=0.6

slide29

PCI Related Delay

Terkelsen Heart 2009 95 362

p=0.6

t = 171 min

slide30

PCI Related Delay

Terkelsen Heart 2009 95 362

FS

FS, Danami split

All

All, Danami split

74

86

119

171

pci related delay34
PCI Related Delay

Boersma EHJ 2006 27 779

pci related delay35
PCI Related Delay

on scene delay

Patient delay

EMS delay

EMS arrival

to needle (30 min)

PCI Related Delay

120

15

Patient delay

EMS delay

15 min

Maximum acceptable transport time

(105 min)

DTB

(30 min)

105

15

135

pci related delay36
PCI Related Delay

on scene delay

Patient delay

EMS delay

EMS arrival

to needle (30 min)

PCI Related Delay

120

15

Patient delay

EMS delay

15 min

Maximum acceptable transport time

(105 min)

DTB

(30 min)

105

15

135

slide37
But.....
  • PCI
    • 40% stents
    • <30% GP IIb/IIIa blockers
    • Clopidogrel dosing
    • No Prasugrel
  • Lytic
    • No mandated cath / PCI
    • Little rescue
timings in ppci38
Timings in PPCI

Onset of

STEMI

Reperfusion

FMC

Patient delay

EMS delay

EMS arrival

to needle (30 min)

PCI Related Delay

Patient delay

EMS delay

15 min

Transport to PCI centre

DTB

time delays v observed mortality
Time Delays v Observed Mortality

Zijlstra EHJ 2002:23;550

Lysis

% Mortality

PPCI

time delays v observed mortality40
Time Delays v Observed Mortality

Zijlstra EHJ 2002:23;550

Lysis

% Mortality

PPCI

No rush if doing PPCI?

slide43

Randomise to delay of:

0 to 120 min

Start PPCI / Lytic

slide44

PCI Related Delay

Mortality %

Time delay to presentation / Rx

slide45

PCI Related Delay

PPCI relatively time independent

ONLY

If all patients present with same pre Rx risk

Mortality %

Time delay to presentation / Rx

slide46

PCI Related Delay

Mortality %

Time delay to presentation / Rx

slide47

PCI Related Delay

Early presenters

High risk

Late presenters

Low risk

Mortality %

Time delay to presentation / Rx

slide48

PCI Related Delay

Terkelsen Heart 2009 95 362

Benefit from PPCI

Mortality %

Time delay to presentation / Rx

what are the lessons
What are the lessons?
  • PPCI preferred to lysis in almost all settings
  • Time matters
    • Rx a quick as possible
    • Networks of care required
    • Paramedic diagnosis + drive to PPCI
      • (? 100 min drive time)
  • Significant uncertainty about details!
have we learnt the lessons
Have we learnt the lessons?
  • PPCI is becoming the dominant strategy
iht causes delay
IHT causes delay

NIAP and Provisional analysis of BCIS data

iht causes delay52
IHT causes delay

NIAP and Provisional analysis of BCIS data

ppci for stemi admission route
PPCI for STEMIAdmission route
  • % of patients admitted direct to PCI centre
conclusions
Conclusions
  • lessons
    • PPCI dominant strategy
    • Speed matters
      • Suggested  delay dependency of PPCI misleading
      • Public awareness campaigns
      • Networks
        • Pre hospital diagnosis
        • Avoid IHT if possible
    • ‘PCI related delay’
      • Uncertain
      • Varies with clinical presentation
esc guidelines
ESC Guidelines

EHJ 2008;29:2909