Acute Myocardial Infarction: Results of the DHMC Regional

Acute Myocardial Infarction: Results of the DHMC Regional

Acute Myocardial Infarction: Results of the DHMC Regional Registry Nathaniel W. Niles, MD December 6, 2004 Dartmouth-Hitchcock Medical Center Non-DHMC Emergency Dept AMI diagnosed >30 min of CP and/or ECG with 1mmST elevation or LBBB Oxygen, ASA, low dose heparin, beta blocker, nitrates, Morphine, 2 IV lines, treat pain, CHF, shock, arrhythmias December 2001 Facilitated PCI Remote ER and Age < 75 Administer abciximab and Dose Thrombolytic Acute MI is Thrombolytic Therapy Primary PCI ST elevation Primary

Alice Peck Day or VA Hospital now on the DHMC ALWAYS TAKE list Contraindication for Thrombolytic therapy/ abciximab Full Dose Thrombolytic Administer abciximab Transport to DHMC Cath Lab ASAP Transport to DHMC for potential salvage PCI ASAP DHMC STEMI Registry Goals Assess safety and effectiveness of specific novel management strategies (facilitated PCI for transfer patients) Monitor regional outcomes over time in order to assess the impact of

overall quality improvement efforts STEMI Registry Case Report Form Emergency Room Presentation (Hx/PE), ECGs, Treatment, Timing of Treatment Cath Lab TIMI Flow,Timing of reperfusion, Intervention, Extent of CAD Follow-up Death, Stroke, Recurrent MI, CHF, Bleeding Complications, Repeat Revascularization Procedures Enrollment Initiated 12/01 Cath lab database query 1/01-12/01 retrospective chart review 1/02-3/04 prospective chart review 4/04-7/04 prospective cath lab data entry Safety and Effectiveness of

specific novel management strategies: Facilitated PCI in Moderate to High Risk Patients Requiring Hospital Transfer for PCI Presented at TCT 2004 Clinical history consistent with acute myocardial infarction and ST elevation, LBBB or anterior ST depression consistent with acute posterior MI N=564 Presenting to DHMC or Local Hospital N= 125 (22%) Primary Strategy No TTx GP 2b3a Inh Emergent cath N= 107 (19%) TIMI Score < 2 N = 22 (4%) TIMI Score 2 N = 85 (15%) Presenting to Remote Hospital N= 439 (78%)

Facilitated Strategy dose TTx GP 2b3a Inh Emergent transfer for cath N= 163 (29%) TIMI Score < 2 N = 51 (9%) TIMI Score 2 N = 112 (20%) Door-to-Balloon Time 300 p<0.0001 227 Time in minutes 250 200 154 150 100

Primary strategy Facilitated stretegy 50 0 Door-to-balloon time Reperfusion was delayed on average more than 70 minutes among facilitated PCI strategy patients Primary Strategy Pre-Cath Lab OutcomesFacilitated Strategy 80 p<0.0001 14 p<0.0003 70 % of Patients 66 64 40 30

20 32 38 % of Patients 12 60 50 p=ns 10 8 6 4 10 2 0 0 Ongoing CP on arrival to cath lab

Persistent ST on arrival to cath lab p=ns 10.5 8.9 7.1 5.3 Pre-cath Shock upon clinical arrival to cath deterioration lab to intubation or shock Facilitated PCI strategy patients arrived at the cath lab in more stable condition Cath Lab Findings and Outcomes Initial TIMI Flow in IRA 90

Cath Lab Intubation or IABP 25 p<0.0001 80 TIMI 2 25% 60 50 40 30 20 10 0 TIMI 2 23% TIMI 3 50% TIMI 3 p<0.0001 19% Primary Strategy Facilitated Strategy

20 % of Patients % of Patients 70 p=0.0056 15 17.6 10 5 5.4 0 Primary Strategy Facilitated Strategy Facilitated Strategy yielded more patent arteries and was associated with less complcated procedures In-hospital Outcomes 22

p=0.025 Primary strategy 20 18 18.8 Facilitated strategy ns % of Patients 16 14 12 14.1 p=0.098 10.6 10.6 9.8 10 ns

ns 8 ns 5.9 6 4 ns 4.7 4.4 2.7 ns 2.7 2 0 6.3 8 6.3 ns

5.7 5.7 3.5 2.3 0.9 Death Recurrent MI Clin. CHF Stroke ICH TIMI Major Hem. Repeat PCI/CABG Com posite* Length of Stay (days) *Composite = Death, Recurrent MI, ICH, Repeat Revascularization Conclusions: Transfer for Optimal

vs. facilitated PCI 1 PCI Longer delays before reperfusion (avg. >70 minutes) But No greater likelihood of deterioration pre-cath Less likely to have ischemia in lab and had less complicated procedures Better initial infarct artery flow and overall better clinical outcomes Tended to have more bleeding problems But no increase in ICH Monitoring Regional Outcomes Over Time DHMC STEMI Transfer Volumes Q1(01)-Q2(04) Number of STEMI Patients 60 50 40 30 20 10 0 Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04)

AMI Transfer Patients: 01 04 In-hospital Mortality p=0.0375 % Mortality 15 10 10.4 8.5 5.1 5 0 3.8 2001 2002 2003 Year 2004

AMI Transfer Patients: 01 04 In-hospital MACE* 16 % MACE 14 13.6 14.4 12 10.2 10 8 6.4 6 4 2 0 2001 2002

2003 2004 Year *Death, Recurrent MI, ICH, Repeat revascularization AMI Transfer Patients In-hospital Bleeding Complications 15 TIMI Major Hemorrhage ICH % 10 6.7 5 0 6.4 5.1 4 0

2001 0.8 2002 1.1 2003 Year 0 2004 Possible Explanations for Improving Outcomes Lower risk patients now transferred Reduction in delays to reperfusion Volume effect Improved outcomes with increased volume Effect of half dose lytic protocol DHMC STEMI: Mean TIMI Risk Score Q1(01)-Q2(04) 6 TIMI Risk Score

* 5 4 3 2 1 0 Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04) *Composite of advanced age, CV risk factors, hypotension, tachycardia, high Killip class, low body weight, anterior MI location, delay in Tx DHMC STEMI: Mean Door-to-Balloon time Q1(01)-Q2(04) 1200 Door-to-Balloon time (min) 1100 1000 900 800 700 600 500 400

300 200 100 0 Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04) Q3(04) Quarter DHMC STEMI Transfer Volumes Q1(01)-Q2(04) Number of STEMI Patients 60 50 No Lytic Given Full Dose Half Dose 40 30 20 10 0 Q1(01) Q2(01) Q3(01) Q4(01) Q1(02) Q2(02) Q3(02) Q4(02) Q1(03) Q2(03) Q3(03) Q4(03) Q1(04) Q2(04) AMI Transfer Patients: By Intended Dose In-hospital Mortality

% Mortality 20 18 16 14 12 10 8 6 4 2 0 p<0.0009 p=ns p<0.04 13.5 6 3 None Given Full Dose Lytic Dose Strategy

Half Dose AMI Transfer Patients: By Intended Dose TIMI Risk Score Average TIMI Risk Score 6 p=0.007 4 p=ns p<0.06 5 3.7 3.1 3 3 2 1 0

None Given Full Dose Lytic Dose Strategy Half Dose AMI Transfer Patients: By Intended Dose Reperfusion and Facilitated Course No lytic given 100 Persistant CP or ST elevation Full dose lytic Clinical Deterioration Pre-Cath 14 25 Half dose lytic

Cath Lab IABP or Intubation 60 TIMI 3 Flow on Initial Angio 22.8 80 12 12 50 20 75 44 10 60 40 40

61 53 15 8 6 36 14.7 30 6.2 5.4 10 20 4 15 5 20 2 0 0

0 4.8 10 0 Door-to-Balloon Time (min) AMI Transfer Patients: By Intended Dose Door-to-Balloon Time 500 450 400 350 300 250 200 150 100 50 0 p=0.0001 p=0.0164 p=0.0023 353 274

219 None Given Full Dose Lytic Dose Strategy Half Dose AMI Transfer Patients: 01 04 In-hospital Mortality by Treatment strategy % Mortality 15 13.5 Half dose All others 10 9.1 7.6 5

0 4.5 2001 2.3 2.6 2002 2003 Year 3 2004 Monitoring Outcomes Over Time Outcomes are improving Explanation of improvement is unclear: Half-dose lytic regimen Expidited care in half-dose group Hawthorne effect? Still Room for improvement

Faster transfers Better regimens (reduce bleeding) DHMC STEMI Registry Conclusions useful in assessing the safety and efficacy of novel management strategies for STEMI patients useful in assessing the impact of new protocols over time will likely be useful for providing benchmark data to individual institutions for QA/QCI DHMC STEMI Registry Limitations Enrollment bias - cath lab enrollment will miss patients who are not sent to the cath lab emergently Patients admitted to the initial hospital Patients in whom the decision is made not to cath Patients who die before they get to cath lab DHMC STEMI Registry Next Steps

ER enrollment of all STEMI patients in the region Web-based, secure, registry interface On-line decision support Risk assessment tools Guidelines Treatment protocols Regular feedback to participating ERs/hospitals STEMI patient outcomes overall and by treatment strategy Process metrics (e.g. time intervals) Partnership in process improvement Novel treatment regimens Transfer delay reduction Pre-hospital triage?? Questions?

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