(During Working Hours
       07:30 – 14:30 hours

           Yahya kiwan
•   No delay. Time is muscle and muscle is life.
•   Applicable to: Cardiology 1st & 2nd on-call doctors,
    Interventional Cardiologists, cath lab nursing team, cath
    lab technicians, A/E doctors and nurses.
•   Hospital must:
•   Meet minimum requirements for program
•   Complete prescribed training and ongoing education
•   Adhere to a protocol including the selection of patients,
    data collection, in-service education and notification of
    any serious events involving a patient
•   Collect all data that is relevant
• Clinical indications:
  – As alternative to fibrinolyic therapy (see
    Attachment I).
  – Or in fibrinolytic – ineligible patient (See
    Attachment II))
                 Clinical protocol
•   Clinical Selection Criteria (Class 1A)
•   The following criteria must be met for the selection of patients for
    the performance of primary angioplasty:
•   The patient is 18 years or more with no terminal illness.
•   The patient has no childbearing potential or has a negative
    pregnancy test
•   The patient presents with:
•   1- > 30 minute ongoing ischemic cardiac pain
•   And
•   2- > 0.1 mv ST- segment elevation in 2 or more contiguous ECG
•   Or
•           New or suspected new LBBB
•   Or
•          >0.1 mv ST segment depression in V and V2 consistent with
    true posterior infarction
•   And
•   3- Who arrive in the ER < 12 hours after symptom onset
           Clinical Exclusion criteria

    Patients will be excluded from primary angioplasty procedures if any
      of the following conditions apply:

•     The patient’s symptoms of a myocardial infarction began > 12 hours
      prior to presentation at the Emergency Department

•     The patient has a sensitivity to contrast dyes, which cannot be
      adequately pre-treated with diphenhydramine and/or steroids.

•      The patient has severe peripheral vascular disease with inability of
      the operator to obtain vascular access.
•       Known terminal illness.

•     Known bleeding risk/ ongoing bleeding

•     Coronary anatomy not suitable for PCI
 3-(Class II A): Primary PCI should be performed
  for patients in cardiogenic shock within 36
  hours of the MI and within 18 hours of the
4-(Class II A): It is reasonable to do primary PCI
  with symptoms onset of 12-24 hours and one
  or more of the following:
  A)Severe CHF
  B)Hemodynamic or electrical instability
  C)Persistent ischemic symptoms
5- Primary angioplasty should not be performed if:
1.     The infarct related artery cannot be identified.
2. There is severe triple vessel disease best
      treated with CABG (only a bridge balloon
      angioplasty of infarct related artery, or if the
      patient still unstable, then other vessels can be
3. There is > 50% stenosis of the left main
      coronary artery.
6- When to transfer patient from A/E to cath lab: -
   as time is muscle and muscle is related to
   survival. Every effort should be made to transfer
   patient without any delay:
    a) The patient should be given 300 mg Aspirin,
               600 mg.Plavix
     b) I.V. cannula inserted.
    c) Consent form taken, then immediately transferred
      to cath lab without any other unnecessary paper
      work delay. The rest could be done in the cath lab.
7- Admission of patient from ED:
 A) Priority of admission for patients undergoing emergency PCI over
      all other admissions.

 B) Emergency admission shall be done for all cases transferred from
     the ED to the cath lab by the admission office regardless of the
     availability of beds in the hospital. This shall be done during
     transfer &/or during the PCI procedure. [N.B. If the bed is
     unavailable, a virtual ward can be created on SAM System for
     this reason through the I.T. Dept.)

 C) Bed management team & admission office in collaboration with
      cardiology department and nursing supervisor are responsible
      for finding a bed for these patients.

 D) If after the PCI beds are not at all available, then the patient is to be
       transferred to the CPU until the bed is made available (but the
       patient remains under cardiology care).
 All these efforts should not
compromise the patient transefer
to cath lab which is the most
important priority .
     B) Quality Assurance (QA)

•   All staff (including, at a minimum, all
    interventional cardiologists, cath lab
    nurses, and cath lab technicians) as well
    as representatives of the Emergency
    Department and CCU staff shall
    participate in educational/ awareness
    creating sessions, emphasis on pain →
    door → door → cath lab and door to
A) All Physicians performing primary angioplasty
 Continue to perform no fewer than 100 cardiac catheterization
    procedures/ year (total diagnostic and therapeutic) of which at
    least 75 are angioplasty procedures
B) In-service Education
   a) Training of all staff (including, at a minimum, all interventional
        cardiologists, cath lab nurses, and cath technicians) shall be
        performed on the intra-aortic balloon pump monthly.
   b) preferably staff including the interventional cardiologists, nurses, and
        technicians have a current ACLS certification.
   c) In-service programs will, at a minimum, be based upon needs identified
        through staff evaluation and the quality assurance process.
C) Regular ongoing quality assurance and improvement
   Weekly review of door-to-needle time and evaluate means of
   improving the same.

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