Primary PCI in the United States
• Minority of US Hospitals Achieve a median Door to Balloon Time of 90 minutes or less
• Majority of MI occur during “Off Hours” (nights and weekends)
Is Time as Critical in Primary PCI?
14 12.1
12
30-day 10 mortality 8
6
4
5 3.9
6.3 4.4
lytic
4.7
PCI
2
0 <2 hrs
2-4 hrs
>4 hrs
Time from onset of CP to randomization
Zijlstra, Eur Heart J 2002;23:550
ACC/AHA Recommendations for Direct PCI in AMI 2004
Class I • General:
– Patients presenting within 12 hours; if performed in a timely focedure and supported by experienced personnel in high volume centers
• To achieve results similar to randomized trials the following has to be met:
– PTCA within 90 minutes of presentation – Skilled operator (>75 cases/year) – Skilled lab (>200 cases/year) – Surgical back up necessary
• TIMI-3 flow rates 75-95% in infarct artery • Low incidence of hemorrhagic stroke • Can be done in patients with
contraindications for thrombolysis • Results superior to thrombolytics in
Overview
• Introduction
– The Argument for Primary PCI
• Overview of the Henry Ford Program • Program Specifics
– Process Dictates Outcomes
• Alternative Opportunities
is <75 years and revascularization can be done within 18 hours of shock onset. – <12 hours of symptoms and severe CHF or pulmonary edema
(2004) /clinical/guidelines
AMI Strategy
How to Achieve Door-to-Balloon Times of 90 Minutes and What to Do Next?
Aaron Kugelmass, MD
Director, Cardiac Cath Lab Associate Division Chief Henry Ford Hospital Detroit, Michigan, USA
*AHA: 2001 Heart and stroke statistics
Acute MI: Early Management Reperfusion
• Pharmacological (Thrombolysis)
– Fibrinolytics – Antithrombins – Platelet Inhibitors
• Mechanical (Direct/Primary PCI)
• Angioplasty • Stent • Thrombectomy
• Combined
– ? Facilitated PCI
Acute MI: Direct PCI Advantages
• Rapid assessment of anatomy and hemodynamics
Acute MI: Introduction
• 1.1 million people yearly in the US* • About 500,000 have STEMI • 220,000 die from their AMI • 50% of deaths in the first hour • Outlook of hospitalized patients better
randomized trials
PCI vs Lysis Meta Analysis
Keeley E, Lancet 2003; 361: 13–20
Lytics vs Transfer for PCI: DANAMI
Acute MI: Direct PCI Limitations
• Only 20% of US hospitals have cath labs and fewer have PTCA facilities
• Specific:
– Door To Balloon Time <90 min – < 3hours symptom, PCI if treatment <1 hour, lytics if >1 hour – Symptom >3 hours, PCI preferred <90min – Within 36 hours of MI when patient develops cardiogenic shock,