Transfer For Primary PCI by dfgh4bnmu

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									     Transfer For Primary PCI


      Cindy L. Grines, M.D., FACC, FSCAI
        Department of Cardiovascular Disease
                     William Beaumont Hospital
                        Royal Oak, Michigan




Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.

Affiliation/Financial Relationship               Company

Grant/Research Support               Cardiovascular Research Foundation
                                     Portola Pharmaceuticals, Inc.
                                     Osiris Therapeutics, Inc.

Consulting Fees/Honoraria            Abbott Vascular, Inc.
                                     MEDRAD I
                                     MEDRAD, Inc.
                                     Daiichi/Sankyo-
                                     Daiichi/Sankyo-Lilly, Inc
                                     Medtronic, Inc.
                                     Nile Therapeutics
 Why Not Transfer All STEMI Patients
          for Primary PCI?

 Delay in reperfusion may increase

    mortality

 Transfer may not be safe

 P liti l and financial issues
  Political d fi     i li




                 Transfer for Primary Angioplasty
                  Versus Thrombolysis in STEMI
                                  g
                       Transferring      On-Site
       Study              for PCI     Thrombolysis       30 Day Death              OR (95% CI)

AIR-PAMI (18)                6/71         8/66                                   0.67   (0.22,   2.04)
CAPTIM (19)                 20/421       16/419                                  1 26
                                                                                 1.26   (0.64,
                                                                                        (0 64    2.46)
                                                                                                 2 46)
Caress (24)                  9/297       14/300                                  0.64   (0.27,   1.50)
DANAMI-2 (3)                37/567       48/562                                  0.75   (0.48,   1.17)
Dobrzycki et al (21)        12/201       18/200                                  0.64   (0.30,   1.37)
HIS (22)                     1/25         2/23                                   0 44
                                                                                 0.44   (0.30,
                                                                                        (0 30    5.18)
                                                                                                 5 18)
Massirichi (17)             11/149        5/75                                   1.12   (0.37,   3.34)
PRAGUE (12)                 19/201       14/99                                   0.63   (0.30,   1.32)
PRAGUE 2 (16)               29/429       42/421                                  0.65   (0.40,   1.07)
SWEDES (23)                  3/101        4/104                                  0.77
                                                                                 0 77   (0.17,
                                                                                        (0 17    3.51)
                                                                                                 3 51)
TRANSFER-AMI (25)           19/512       18/498                                  1.03   (0.53,   1.98)

Total (95% Cl)          166/2974        189/2767                                 0.77 (0.62, 0.96)


                                                      01 02 05 01 2 5 10

                                                        Favors       Favors
                                                     Transferring    on-site
                                                        for PCI   Thrombolysis
Ann Emerg Med 2008;52:665
                 Transfer for Primary Angioplasty
                  Versus Thrombolysis in STEMI
                                  g
                       Transferring      On-Site
       Study              for PCI     Thrombolysis       30 Day ReMI               OR (95% CI)

AIR-PAMI (18)                1/71         0/66                                   2.83   (0.11, 70.69)
CAPTIM (19)
         ( )                 7/421       15/419                                  0.46   (0.18, 1.13)
                                                                                        (    ,      )
Caress (24)                  4/297        6/300                                  0.67   (0.19, 2.40)
DANAMI-2 (3)                11/567       35/562                                  0.30   (0.15, 0.59)
Dobrzycki et al (21)         4/201       11/200                                  0.35   (0.11, 1.11)
HIS (22)
    ( )                      0/25         1/23                                   0.29   (    ,
                                                                                        (0.01, 7.59))
Massirichi (17)              5/149        7/75                                   0.34   (0.10, 1.10)
PRAGUE (12)                  8/201       10/99                                   0.37   (0.14, 0.97)
PRAGUE 2 (16)                6/429       13/421                                  0.45   (0.17, 1.18)
SWEDES (23)( )               0/101        2/104                                  0.20   (    ,
                                                                                        (0.01, 4.26))
TRANSFER-AMI (25)           17/512       30/498                                  0.54   (0.29, 0.98)

Total (95% Cl)              63/2974     136/2767                                 0.42 (0.31, 0.571)


                                                      01 02 05 01 2 5 10

                                                        Favors       Favors
                                                     Transferring    on-site
                                                        for PCI   Thrombolysis
Ann Emerg Med 2008;52:665




                 Transfer for Primary Angioplasty
                  Versus Thrombolysis in STEMI
                                  g
                       Transferring      On-Site
       Study              for PCI     Thrombolysis      30 Day Stroke              OR (95% CI)

AIR-PAMI (18)                0/71         3/66                                   0.13 (0.01, 2.50)
CAPTIM (19)                  0/421        4/419                                  1.11 (0.01, 2.04)
Caress (24)                  0/297        4/300                                  0.11 (0.01, 2.06)
DANAMI-2 (3)                 9/567       11/562                                  0.81 (0.33, 1.96)
Dobrzycki et al (21)         1/201        3/200                                  0.33 (0.03, 3.18)
  S
HIS (22)                      /
                             0/25          /
                                          0/23                                      Not estimable
Massirichi (17)              6/149        2/75                                   1.53 (0.30, 7.78)
PRAGUE (12)                  3/201        1/99                                   1.48 (0.15, 14.46)
PRAGUE 2 (16)                1/429        9/421                                  0.11 (0.01, 0.85)
SWEDES (23)                  0/101        3/104                                  0.14 (0.01, 2.80)
                                                                                 0 14 (0 01 2 80)
TRANSFER-AMI (25)            1/512        6/498                                  0.16 (0.02, 1.34)

Total (95% Cl)              21/2974      46/2767                                 0.40 (0.24,   0.67)


                                                      01 02 05 01 2 5 10
                                                        Favors      Favors
                                                     Transferring   on-site
                                                        for PCI Thrombolysis
Ann Emerg Med 2008;52:665
          Does Transfer Delay
             Increase Mortality?




              Pooled Prague I & II:
                      vs. 30-
Duration of Transport vs 30-day Mortality in PCI
       Subgroups (blue) vs. all TL (red).

12      < 30 min                       10.8
        31 60
        31-60
10
        > 60 min            8.7
 8      TL
                     5.8
 6

 4     3.5

 2   p<0.05 vs TL

 0
      n=114
      n=114         n=257
                    n=257   n=69       n=520
If There Is A Delay To The Cath Lab,

Should One Give Lytics to Facilitate

              Reperfusion Prior to PCI?




                   Meta-
                   Meta-analysis: Facilitated PCI vs
                             Pi
                             Primary PCI

                            M t lit
                            Mortality            Reinfarction
                                                 R i f   ti             Major Bl di
                                                                        M j Bleeding


Lytic alone                1 43
                           1.43                    1.81
N=2953
N=2953                 (1.01-2.02)             (1.19-2.77)


IIb/IIIa alone             1.03                1.40
                                               1 40
N=1148                 (0.49-2.17)         (0.49-3.98)

Lytic + IIb/IIIa           3.07                1.03
N 399
N=399                  (0.18-52.0)
                       (0 18 52 0)         (0 15 7 13)
                                           (0.15-7.13)



All                        1.38                1.71                       1.51
(N=4500)               (1.01-1.87)         (1.16 - 2.51)              (1.10 - 2.08 )

                         0.1      1       10     0.1      1        10    0.1      1        10
                         Fac. PCI     PPCI       Fac. PCI      PPCI      Fac. PCI      PPCI
                          Better      Better      Better       Better     Better       Better

                                                        Keeley E. & Grines C. Lancet 2006;367:579.
                                         ASSENT-
                                         ASSENT- 4 PCI:
                Pharmaco-
  No Benefit of Pharmaco-invasive Approach even
       when Anticipated DTB Time > 90 min.




                                                            Lancet 2006;367:569




                                         FINESSE Trial

                    2452 STEMI Pts < 6 Hrs
                    Anticipated DTB > 90 min
                           (Median 2.2 hrs)


     Half-
     Half-Dose                  Abciximab     Primary PCI
    Retaplace +                 Facilitated   (Abciximab
     Abciximab                     PCI           in lab)
   Facilitated PCI
                    43.
• ST resolution (%) 43.9*           33.1
                                    33 1         31 0
                                                 31.0
• Major bleed (%)     4 .8 *         4.1          2.6
• Transfusion (%)     5 .7 *         3.5          2.4

                               * p<.05




                                                            NEJM 2008;358:2205
              y
     Time Delays in FINESSE Trial




                                              Ellis S et al. NEJM 2008;358:2205




                     FINESSE Trial:
              Pharmaco-          pp
No Benefit of Pharmaco-invasive Approach in
    Patients with Prolonged DTB Times




                                               End-
Prespecified Subgroup Analysis for the Primary End-Point Comparison
                                               Ellis S et al. NEJM 2008;358:2205
          y
 PCI vs. Lysis: Even with long PCI-related
                               PCI-
delay, mortality is still better than thrombolysis




                           Boersma, E. et al. Eur Heart J 2006 27:779-788




        y
      Why Does Transfer in
          the United States
            Take So Long?
              Treatment Times Based on
                  Transfer Distance
                                  PCI           Zone 1           Zone 2
                                 Center         < 60 mi         60-
                                                                60-210 mi              p
                                (n=297)
                                (n=297)         (n=620)          (n=396)             Value
Sx to first door (min)        100 (58,226)      95 (50,205)      85 (44,185)         0.094
In door – out door (min)
                    ( )             NA           49 (36,66)
                                                    ( , )         60 (48,81)
                                                                     ( , )          <0.0001
Transport (min)                     NA           22 (15,31)       34 (26,49)        <0.0001
Helicopter (% pts)                  NA              55%              94%
ANW to balloon (min)           65 (47,84)        21 (16,28)       19 (15,25)        <0.0001
CV lab to balloon (min)         16 (11,22)       14 (10,20)        12 (9,18)        <0.0001
First door to balloon (min)        (47 84)
                               65 (47,84)       95 (82 116)
                                                   (82,116)         (100,145)
                                                                120 (100 145)       <0 0001
                                                                                    <0.0001
Total Sx to balloon (min)     171 (118,307)    203 (147,325)    214 (167,326)       <0.0001

Only 11 minutes difference in DTB times in short versus
long distance transfers
                                                               Henry TD et al. Circ 2007;116:721




              AIR PAMI Trial Time Delays
                                       Transfer for
                                                                    Lytic Therapy
                                          PTCA
Time Delays (minutes)                 Median    Mean    Median            Mean         P
                                                 + SD                     + SD        value
Emergency center arrival to
E             t     i lt                35      52 + 57   32             44 + 37      0 67
                                                                                      0.67
  randomization
Randomization to call for transfer       6      15 + 30
Call to transfer arrives at             20      23 + 18
   hospital #1
Transfer arrives to transfer leaves     12       14 + 9
   hospital #1
Transfer time                           26      33 + 29
Arrival t h    it l   t
A i l at hospital #2 to                 11      20 + 49
   catheterization laboratory
Catheterization laboratory arrival      14      18 + 14
   to treatment
   t t t       t
ER to treatment                        155     174 + 80        51        63 + 39     < 0.0001
                                                                    Grines JACC 2002;39:1713-9
         What Can be Done to Improve
              Transfer Delays?
 Pre hospital ECG
  Pre-hospital
    • Direct transfer to PCI center (bypassing closest
      hospital)
    • EMS authority to mobilize cath lab
 H   it l ith t           bilit
  Hospital without PCI capability
    • Ambulance remains at hospital, patient not taken off
       t t h
      stretcher
    • Avoid IV infusion pumps (delays in switching
      equipment)
    • Authority to transfer patient to tertiary care center
      without delay of speaking to a cardiologist




          Fix and Ship Back Strategy

Author      Region       Transfer      Transfer     Mortality
                            in           back
Chan         British       1154      937 (81.2%)       1.9%
(2009)      Columbia

Matteau     Montreal        246      166 (67.5%)       2.4%
(2007)
    Radial access or femoral closure device
    Transfer back immediately post PCI using same
     ambulance, nurse in attendance
    Trials of Primary PTCA at Hospitals
          without Surgical Backup
 Study           n            Design                  Result
Wharton        506            Single        Procedural success
             consec.          center             in-hosp.
                                             94% in hosp.
               pts                          Mortality 5% overall,
                                             3% without shock
PAMI           500         Prospective,     TIMI 3 flow 95%
No SOS         high         19 center        (core lab)
               risk          registry       6 mo mortality 5%
                                             6-mo.

C PORT
C-PORT         451         Randomized   LOS 4.5 vs 6 0
                           Randomized,             45      6.0
               high        tPA vs on-site   days, p=.02
               risk            PTCA         MACE at 6 mo.
                                            (12.4    19.9,     03)
                                            (12 4 vs 19 9 p=.03)




                     Transfer the Doctor

                              Physician       Patient
 Clinical outcomes         Transfer Group Transfer Group               P
                               (n=165)        (n=169)                Value

Door-2-balloon (min)           95 + 20         147 + 29           < 0.0001
30-day outcomes
 Death                            (3.6)
                                6 (3 6)           (5 9)
                                               10 (5.9)               0 33
                                                                      0.33
 Non-fatal
    re-infarction (n[%])
                  ( [ ])          ( )
                                7 (4.2)            ( )
                                               15 (8.9)               0.09
 TVR                            2 (1.2)          4 (2.4)              0.43
 Mace                          15 (8.9)        29 (17.2)              0.03

                                                        2008;121(6):485-
                                             Clin Med J 2008;121(6):485-491
 Which Patients Benefit from Transfer
      for Primary PCI vs Lysis?
 Mortality benefit greatest in highest risk pts
                                          early,
  • In low risk patients who present very early lytics
    could be acceptable

 Stroke benefit in elderly, hypertensive patients

 Reinfarction benefit appears to be independent
  of risk




                                US
              STEMI Care in the U.S.
  Primary PCI in most patients
  Delay in Reperfusion
    • Prehospital ECG and divert to PCI center
    • Integrated hospitals and systems of transfer
          g         p           y

    • Consider thrombolytics

  Lack of available beds at PCI Center
    • Transfer patient back to referring hospital
    • Perform PCI in hospitals without surgical backup
      (non PCI centers)
    • Transfer the cardiologist, not the patient
                    Conclusions

 Time required for transportation is a minor component of
  the overall delay.

 Reduction in death, reMI and stroke was observed in
  meta analysis of 6 000 patients randomized to transfer
  meta-analysis    6,000
  for PCI versus lysis, despite transfer delays

 Pharmaco-invasive approach (facilitated PCI) is inferior
  to primary PCI

 Therefore, transfer for primary PCI should be performed
  regardless of distance!




 Mortality for Patients Receiving Reperfusion via
 Pre-            In-
 Pre-hospital or In-hospital Lytics or Primary PCI:
                  Swedish Registry




                                   Stenestrand U et al. JAMA 2006;296:1749

								
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