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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

Myocardial Infarction AngioplastyThe Middlesbrough Experience

Rob Wright

James Cook University Hospital

acknowledgements
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
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

james cook referring hospitals thrombolysis 2002 2003
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

merlin sutton agc jacc 2004 44 287 96
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
slide8

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

methods
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.

methods10
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.
trial flow chart
Trial Flow Chart

Early crossover for

shock only

merlin results 30 days

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

merlin conclusions
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
post merlin strategy
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
jcuh czech ami pci protocol
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

jcuh open ami pci protocol
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

czech protocol in hospital deaths
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
open protocol in hospital deaths
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
conclusions
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
angiographically guided therapy for ami
Angiographically Guided Therapy for AMI

Requirements

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