S A H E A R T E A R L Y R E P E R F U S I O N P I L O T P R O J E C T

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2 S A H e a r t Ea r l y Re p e r f u s i o n P i l o t P ro j e c t

3 Early Reperfusion Project History Research demonstrates that the optimal time to treatment for an acute myocardial infarction (AMI) is <120 mins. Small scale survey run in Pretoria demonstrated that South Africa is far behind the ideal. SA Heart therefore decided to implement the Early Reperfusion Project to improve the situation. Early Reperfusion Project objectives: Improve quality of AMI care Improve the network of care to give more patients access to reperfusion therapy Decrease in AMI mortality

4 Cardiovascular disease Still the biggest killer in the world Acute ST elevation Myocardial Infarction (STEMI) represents c.40% of all MI

5 Symptoms of a heart attack Most typical discomfort/pain zones Other possible discomfort/pain zones Heavy pressure, tightness, crushing pain or unusual discomfort in the centre of the chest Sweating, sickness, faintness or shortness of breath may be experienced This may feel like indigestion, spread to shoulders, arms, neck or jaw and/or last for more than 15 minutes. It may stop or weaken and then return There may be a rapid, weak pulse Sharp stabbing pain in the left side of the chest is usually NOT heart pain (accessed on 7 Feb 2013

6 Ischemic Symptoms - Explained Discomfort or Pain in the Center of the Chest that lasts >20 minutes (MI), or that goes away and comes back (Crescendo Angina/UAP). Feels like an Uncomfortable Pressure, Squeezing or Burning. It often spreads to the neck/jaw, arms or the abdomen and is not respiratory dependant. Chest pain may also include back pain. Sublingual (oral) Nitroglycerine has minimal or no effect. Common accompanying symptoms are Nausea, Dizziness, Vomiting, Cold sweat, Anxiety and possibly Dyspnea. Symptoms in women are often different than in men. Women are more likely to experience nausea, dizziness, and anxiety.

7 STEMI: ECG Diagnosis Clot within the main lumen of the coronary artery Ruptured plaque with hemorrhage Q* vs. Non-Q MI * lack of blood supply leads to permanent myocardial infarction STEMI vs. NSTE-ACSI Adapted from J Davies (pathological specimen)

8 STEMI ECG

9 Reperfusion Therapy Options Need to open the blocked vessel as soon as possible either via thrombolysis or PCI PPCI recommended over fibrinolysis if performed by an experienced team within 120 minutes of first medical contact Longer PCI-delay (DB DN time) are associated with higher mortality rates and reduced PPCI survival advantage (Pinto D S et al. Circulation 2006;114: ) Often not a 24 hour service! Stone, Circulation, 2008

10 Relationship Between Mortality Reduction and Extent of Salvage % Mortality reduction (%) Impact of time delay - Time is critical! Modifying factors Collaterals Ischemic preconditioning MVO 2 Stuttering infarction 0 Hours Extent of salvage (% of area at risk) Time to treatment is critical Opening the IRA (PCI > lysis) Gersh: JAMA, 2005

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12 TIME TO REPERFUSION IS CRITICAL

13 Benefits of Early Reperfusion Saved myocardium Reduction in morbidity Improved quality of life Reduction in downstream healthcare costs

14 What Do I Do? Reperfuse now! Immediate PCI (< 120 mins) OR Thrombolysis (> 120 mins) Reperfuse how? Ship immediately to closest cathlab (< 120 mins) OR Drip and then ship to closest cathlab (> 120 mins) Reperfuse where? Closest cathlab location

15 Reperfusion choice depends on time to treatment If < 120 min PPCI Multivariable analysis estimating the treatment effect of reperfusion therapy with PCI or fibrinolysis based on increasing PCI-related delay. If > 120 min Thrombolysis MUST BE followed by PCI Pinto D S et al. Circulation 2006;114: N= pts from 645 National Registry of Myocardial Infarction Hospitals

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17 What Do I Do? Reperfuse now! Immediate PCI (< 120 mins) OR Thrombolysis (> 120 mins) Reperfuse how? Ship immediately to closest cathlab (< 120 mins) OR Drip and then ship to closest cathlab (> 120 mins) Reperfuse where? Closest cathlab location 1 st 1 st

18 What is PPCI? PPCI is a mechanical technique used to open up blocked coronary blood vessels that may or may not use stent(s) or other devices Procedure is performed under x-ray guidance and requires specialised skills and team-members More effective in reopening occluded arteries than thrombolysis For both AHA and ESC Primary PCI is a class 1A indication for Acute STEMI if it can be performed within 120min of first medical contact (90 minutes if presenting early with a large infarct and low risk of bleeding complications)

19 Benefits of PPCI vs Thrombolysis Lower in-hospital mortality Less complications Fewer ambulance journeys Reduced unscheduled revascularisation Shorter length of stay More cost-effective for the healthcare economy

20 Immediate PCI ( < 120 mins) Anti-Platelet Agents and Fibrinolytic Therapy How and what do I administer (primary care)? Starting dose Aspirin mg orally or 250mg IV Clopidogrel GP IIb/IIIa inhibitors such as Aggrastat (tirofiban) or Integrilin (eptifibatide) should not be used Ship the patient to the nearest cathlab

21 A Patient With The Following Criteria Is Suitable For Direct Transfer To A PPCI Cathlab History of symptoms compatible with MI (<12hrs) Clear ST segment elevation in 2 consecutive leads (2 small squares anterior, 1 small square non anterior) Left Bundle Branch Block (either new or presumed new) Alert, orientated and conscious

22 Two Different STEMI Subgroups Undergoing Ppci After Pre-hospital Resuscitation Initial neurological presentation in 135 consecutive patients with resuscitated cardiac arrest and STEMI ( ) Conscious on admission 49 (36%) Comatose on admission 86 (64%) Mortality 0% Mortality 43% Gorjup et al. Resuscitation 2007;72:

23 Where Is My Nearest Cathlab In Pretoria & Centurion? Dr George Mukhari Nelspruit Mediclinic Montana Eugene Marais Steve Biko Academic Pretoria Heart 1 Military Zuid Afrikaans Wilgers Unitas

24 What Do I Do? Reperfuse now! Immediate PCI (< 120 mins) OR Thrombolysis (> 120 mins) Reperfuse how? Ship immediately to closest cathlab (< 120 mins) OR Drip and then ship to closest cathlab (> 120 mins) Reperfuse where? Closest cathlab location 2 nd 2 nd

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26 20 15 Does Early Thrombolytic Therapy Affect Rate Of Survival? Mortality Time to treatment <70 min 70 min % Infarct Size LV (%) % 40 Ejection Fraction Weaver: JAMA, MITI trial,

27 But What About The Risks Associated With Thrombolysis? Thrombolysis is highly effective but there is 1% chance of intracranial bleeding

28 Thrombolysis Absolute Contraindications Previous intracranial haemorrhage or stroke of unknown origin at any time Ischaemic stroke in the preceding 6 months Central nervous system damage or neoplasms or atrioventricular malformation Recent major trauma/surgery/head injury (within the preceding 3 weeks) Gastrointestinal bleeding within the past month Known bleeding disorder (excluding menses) Aortic dissection Non-compressible punctures in the past 24 h (e.g. liver biopsy, lumbar puncture) ESC Guidelines for the management of AMI in patients presenting with ST segment elevation, European Heart Journal (2012), 33:

29 Tenectaplase Has A Lower Rate Of Non Cerebral Bleeding And Easy Administration Tenectaplase Tenectaplase

30 How Does Success Of Thrombolysis Affect Survival Rates? Blocked vessel has been opened Blocked vessel has only been partially opened

31 So Do I Wait To Check On The Success Of Thrombolysis? Routine transfer and PCI within 6 hours after lysis OR Transfer after 24 hours and elective cath within 2 weeks or urgent transfer for failed lysis (rescue PCI) (Cantor et al., STREAM study, NEJM 2009)

32 STREAM Study Conclusions Fibrinolysis with bolus tenecteplase and contemporary antithrombotic therapy given before transport to a PCI-capable hospital: Circumvents the need for urgent PCI in about two thirds of fibrinolytic treated STEMI patients Is associated with small increased risk of intracranial bleeding Is as effective as PPCI in STEMI patients within 3 hours symptom onset who cannot undergo PCI within 1 hour of first medical contact (Cantor et al., STREAM study, NEJM 2009)

33 What Do I Do? Reperfuse now! Immediate PCI (< 120 mins) OR Thrombolysis (> 120 mins) Reperfuse how? Ship immediately to closest cathlab (< 120 mins) OR Drip and then ship to closest cathlab (> 120 mins) Reperfuse where? Closest cathlab location 2 nd 2 nd

34 Thrombolysis Common Agents (Delayed PCI >120mins)

35 Thrombolysis (Delayed PCI >120mins) What do I administer? European Society of Cardiology recommends: Tenecteplase (fibrinolytic therapy) within 12h of symptom onset if PCI cannot be performed within 120 mins of first medical contact PLUS Oral/IV aspirin must be administered Clopidogrel Ship the patient to nearest cathlab ESC Guidelines for the management of AMI in patients presenting with ST segment elevation, European Heart Journal (2012), 33:

36 Where Is My Nearest Cathlab In Pretoria & Centurion? Dr George Mukhari Nelspruit Mediclinic Montana Eugene Marais Steve Biko Academic Pretoria Heart 1 Military Zuid Afrikaans Wilgers Unitas

37 Impact TIMI Flow of Rates PCI with Associated Fibrinolytic With Thrombolysis Therapy Following PCI (confirms the value of thrombolysis) Blocked vessel has been opened (Cantor et al., STREAM study, NEJM 2009)

38 Impact of PCI with Fibrinolytic Therapy White, H.D. Circulation (2008): 118:

39 Treatment Choice Conclusions During first 2-3 hours after symptom-onset, time to treatment is critical After 3 hours, PPCI is preferred if it can be done within 2 hours of first medical contact. If not, then a pharmacoinvasive strategy with thrombolysis followed by immediate transfer for PCI within next 3-24 hours may improve myocardial salvage and survival. Immediate or rescue PCI for failed thrombolysis

40 Summary of Common Challenges Not obtaining a history of cardiac chest pain Not performing immediate ECG on all patients triaged as possible cardiac chest pain Not performing serial ECG when appropriate Repeated ECGs when diagnosis is clear Lack of knowledge regarding closest cathlab Administering drugs before activating EMS Rotating and temporary staff unaware of protocol Thrombolytics not being carried on board ambulance Lack of beds available at hospital with a cathlab (call to check!) Possible medical aid authorisation delays

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42 What Can You Do To Help? Know where all your local cathlabs are Find out who the cardiologists are and their contact numbers If you think the patient might have had an MI, perform an ECG Take a picture of the ECG with your mobile phone and send it ahead to the cardiologist Carry and administer thrombolysis according to the guidelines Ask questions if you are unsure Do not delay getting your patient to a cathlab

43 Your Nearest Cardiologist Hospital Name Contact Number 1 Military Dr Mpe Dr George Mukhari Dr Mutati Eugene Marais Dr Dannheimer Dr Benson Montana Dr Bushidi Dr Zeelie Nelspruit Mediclinic Dr Fourie Dr Maree

44 Your Nearest Cardiologist Hospital Name Contact Number Dr Adeyemo Dr Bushidi Dr Makotoko Pretoria Heart Dr Mpe Dr Milela Dr Motaung Dr van der Spuy Steve Biko Academic Prof Sarkin Dr Badenhorst Dr Blomerus Unitas Dr Jacobs Dr Vorster Dr Ebrahim

45 Your Nearest Cardiologist Hospital Name Contact Number Dr Bennett Wilgers Dr Guerra Dr Mwangi Dr Snyders Dr Swanepoel Dr da Silva Dr Benson Zuid Afrikaans Dr Lester Dr Osrin Dr van Niekerk Dr van Wyk

46 Where Is My Nearest Cathlab In Pretoria & Centurion? Dr George Mukhari Nelspruit Mediclinic Montana Eugene Marais Steve Biko Academic Pretoria Heart 1 Military Zuid Afrikaans Wilgers Unitas

47 Questions? Thank you!

48 This project was made possible by an educational grant by the following companies