I have no financial relationships to disclose

Transcription

1 I have no financial relationships to disclose

2 Networking decreases mortality Vasil Velchev,MD,PhD UH St. Anna Sofia

3 time = myocardium = life

4 Transfer for angioplasty vs. Immediate Thrombolysis (hospital presentation) Death Angio Th Nb of events / nb randomised Maastricht PRAGUE Air-Pami DANAMI 2 (all patients) PRAGUE 2 5/75 5/75 7/101 14/99 6/71 8/67 52/790 59/782 29/429 42/421 Total 0.76 p= / /1444 Relative Risk Dalby 4 et al. Circulation 2003; 108:18

5 ESC Guidelines: PCI for acute CAD Recommendations PPCI for STEMI (within 2 hours!) Class LOE I A Rescue PCI for failed fibrinolysis (within 12 hours) IIa A PCI for STEMI with shock and contraindications to fibrinolytic therapy irrespective of time delay I B Angiography and PCI after successful fibrinolysis (within 24 hours) IIa A Urgent PCI for hemodynamically unstable NSTE- ACS (within 2 hours) I C Early PCI for high-risk NSTE-ACS (within 72 hours) I A

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7 Reperfusion Therapy: Important Time Lines Onset of STEMI FMC Start lytic Reperfusion Onset of STEMI FMC PCI-related delay Reperfusion Balloon Sheath Patient-dependent (Organization-dependent) Organization-dependent FMC:First Medical Contact

8 % mortality Vienna STEMI registry Time to treatment vs. in-hospital mortality % Total 0 to 2 2 to 6 6 to 12 Hours from onset of pain No Reperfusion 5.9% of patients treated with pre-hospital TT arrived at the PCI-hospital in shock vs 12% in non-pre-treated patients (p<0.001) PPCI, primary percutaneous coronary intervention; TT, thrombolytic therapy Kalla K et al. Circulation 2006;113:

9 Cardiac Survival % Time to Reperfusion and Late Cardiac Survival Moses Cone Primary PCI Registry 2 hrs >2-4 hrs >6 hrs >4-6 hrs Years Brodie JACC 1998

10 Door-to-Balloon Time and Late Mortality In Patients with Early Presentation (< 2 hrs) Moses Cone Primary PCI Registry Brodie ACC 2004

11 If Networking brings more STEMI to PPCI in time decreases mortality Is it true for every country irrespective of infrastructure, budgeting and PCI center experience?

12 Annual mortality from ICD 2000 BG Reason of death IHD in or 243 per Men 271 Women 214 Грива 2011 Бюлетин на МЗ 12

13 Age-standardized mortality from ischaemic heart disease in European regions (men; age group years; year 2000). Müller-Nordhorn J et al. Eur Heart J 2008;29:

14 Age-standardized mortality from ischaemic heart disease in European regions (women; age group years; year 2000). Müller-Nordhorn J et al. Eur Heart J 2008;29:

15 Reperfusion therapy / STEMI P. Widimsky, EHJ, Nov 2009

16 P. Widimsky, EHJ, Nov 2009

17 PPCI / BG people Number of STEMI / p.a. PCIs PPCI 1180/ PPCI- 130/per mil. PPCI for 14% of all STEMI patients 27% of all STEMI get reperfusion RX (PPCI or FL)

18 BG cathlabs/5 in Sofia Workforce of 34 invasive cardiologist No transfer algorithms except private EC STEMI patient taken to the nearest hospital Irrespective to PCI abilities Dedicated PPCI program since 2001 in Sofia -1.4mln Long time delays even in Sofia

19 Stent for Life Initiative STEMI Guidelines Implementation Integrate SFL into National Cardiology Program Build Regional Network and Infrastructure (EMS) Cath Lab Staffing and Work Organization Allocate Budget (Procedure reimbursement & 24/7 staff remuneration) Establish National ACS/AMI Registry Increase Disease Awareness (Educational campaign to government, payers and lay public)

20 Declaration to support the Initiative at the national level was signed at the ESC/EAPCI General Assembly on Aug 31, 2009 by NS of Cardiology Presidents from: Turkey (78 p-pci / mil. / yr.) Greece (95 p-pci / mil. / yr.) Bulgaria (130 p-pci / mil. / yr.) Serbia (157 p-pci / mil. / yr.) France (231 p-pci / mil. / yr.) Spain (251 p-pci / mil. / yr.)

21 Stent for Life Initiative Objectives in BG Implement an action program to increase patient access to primary PCI where indicated: To increase the use of primary PCI to more than 70% among all ST segment elevation myocardial infarction patients, To achieve primary PCI rates of more than 600 per one million inhabitants per year, To offer 24/7 service for primary PCI procedures at all invasive facilities to cover the country STEMI population need.

22 How Can We Improve Networks and Infrastructure Regional network (EMS and PCI centers) should cover an area with population around 0,5 million (cca 0,3 1 million). SFL organized local meetings of interventional community, EC and general practitioners All PCI centers should provide non-stop (24/7) services for primary PCI. PCI hospitals, which are not able to provide non-stop (24/7) primary PCI services, should not be part of the network. J. Knot:How to set up an effective national primary angioplasty network: lessons learned from five European countries (EuroIntervention, August 2009).

23 How Can We Improve Transport & Time Delays Implement protocols and critical care pathways to achieve a door to balloon time <90 minutes. - Clear definition of geographical areas of interest - Shared protocols based on risk stratification - Transportation with appropriately equipped and trained staff Primary transport should bypass the nearest non- PCI hospital and the Emergency Room or Intensive Care Unit of the PCI center. - Admission to Emergency Room (or ICU) in the PCI center delays reperfusion by at least minutes. - Admission to non-pci hospital followed by the secondary transport to PCI center delays reperfusion by at least minutes. J. Knot: How to set up an effective national primary angioplasty network: lessons learned from five European countries(eurointervention, August 2009).

24 PAIN FMC EC ECU Non PPCI Hospital ICU Cath Lab

25 Pain to ECG time in 51 STEMI Rousse region Min 45min. Max 120 h Man 28±34 h

26 Budget Money needed for reaching the target PPCI number г г ПКИ 14% от ОМИ ~ ПКИ 75% от ОМИ

27 New Ministry of Health regulations Formal regulations for EC to transfer STEMI patients to nearest PPCI -capable hospital. 2. The cathlabs are only allowed to function if 24/service available. 3. Check list for EC physicians. 4. National registry of ACS interventions. 5. Reimbursement per procedure. 6. Quick transfer for angio after every FL / unstable coronary syndrome

28 2011 Money for service one payer NIC # of Cathlabs in BG 32(9 in Sofia) Round the clock Cathlabs: all by default Dedicated PPCI program since 2001(Sofia), SFL since 2008; registry since 2011 Transfer algorithms for ECP get the patient to the nearest PCI hospital Money goes with the patient - you can transfer immediately after lysis and get paid; Strong incentive for more procedures but low for quality control

29 Население ~ 260 хил. Разстояние 210 км Средно за 3 часа казанлък дупница сандански Транспорт

30 STEMI PPCI for all Ambulance ECD No Cath Lab Hospital ICU Cath Lab

31 PPCI growth trend Karmfiloff, Jorgova Euronitervention 2012

32 STEMI mortality/bg Karmfiloff, Jorgova Euronitervention 2012

33 STEMI and mortality/bg Karmfiloff, Jorgova Euronitervention 2012

34 BG data on PPCI 2011 Total # of PCIs p.a. Population 7.5 bill. ACS - nearly 50% of PCI s Total # of PPCIs- 4700/ PPCI per bill PPCI in 70% of all STEMI patients hospitalized in a first 24H in Sofia STEMI treated by reperfusion RX (Sofia) (PPCI+FT) - 80% Data from the National Insurance Company

35 Developments PCI readily available for acute patients National standards for cardiology. Unified certification of interventionalists. PPCI a basic part of interventional cardiology training (BSC, BSIC and MH) National registry for PCI all Cath Labs included by 2011(BSIC and NIC) Rapid adoption of new recommendations: new AA, TA, transfer times

36 Shortcomings Difficult quality control all data in the registry self reported Some operators in remote areas on the steep part of the learnig curve Obliteration for surgery options for acute patients

37 Real life PPCI program lead to nearly 30% drop in AMI in-hospital mortality mainly because of increased access of reperfusion TX Death rate AMI Грива 2011 Бюлетин на МЗ 84/ death vs 74/100000

38 БЛАГОДАРЯ!