Treatment of ST-elevation myocardial infarction in China: Where are we?
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1 Treatment of ST-elevation myocardial infarction in China: Where are we? Associate Professor, Yihong Sun, MD Peking University People s Hospital Beijing, China
2 Disclosure conflict of Interest
3
4 The Challenges of Coronary Artery Disease in China Predicted annual total CHD deaths (CHD Policy Model-China) Circ Cardiovasc Qual Outcomes May;3(3):
5 Hospitalized STEMI Treatment in Europe Data from National Registries or Surveys ( ) In-hospital Mortality: % European Heart Journal (2010) 31,
6 Rapid increase in Percutaneous Coronary Interventions in China Over 300,000 PCI in 2011! Heart 2010;96:
7 Numbers of patients receiving PCI in China in 2010 Zhang et al. / J Zhejiang Univ-Sci B (Biomed & Biotechnol) (8):
8 Reperfusion Therapy of STEMI in China 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% GRACE China( ) CPACS( ) BRIG(2006) BEIJING(2006) NO TT PPCI Gao, et al. Heart 2008;94: Zhao, et al. Chin J Cardil, 2009;37: Hu, et al. Clin Invest Med 2008;31:e Lv,et al. Chin J Cardiol, 2005,33,789-82
9 Trend in patients with D to B <90mins in US Circulation. 2011;124:
10 European Heart Journal doi: /eurheartj/ehs215
11 Time Delay of Reperfusion Therapy of STEMI in China BEIJING(L3*) BRIG(L3) BRIG(L2) CAPACS(L3) prehospital dalay D2B D2N CAPACS(L2) Median time (minutes) Gao, et al. Heart 2008;94: Zhao, et al. Chin J Cardil, 2009;37: Hu, et al. Clin Invest Med 2008;31:e Lv,et al. Chin J Cardiol, 2005,33,789-82
12 The Registry of Reperfusion Therapy in Patients with STEMI in Beijing 18 million residents 19 hospitals with capability of primary PCI 16 centers in urban 3 centers in rural area From Nov 2005 to Dec 2006 Clin Invest Med. 2008,31(4):E189-97
13 Clin Invest Med. 2008,31(4):E Patient Characteristics by Reperfusion Strategy Data of Beijing Registry 2006 Total N=809 PPCI n=521 TT n=133 No n=155 Age (years) 60.9± ± ± ±13.6 <0.001 Age >75 135(16.9) 74(14.2) 9(7.2) 52(33.5) <0.001 Female 178(22.3) 105(20.2) 26(20.8) 47(30.5) 0.02 Smoking 446(56.5) 304 (59.5) 81(65.9) 61(39.45) <0.001 Diabetes 158(19.9) 92(17.9) 25(20.2) 41(26.5) 0.18 Hypertension 414(51.9) 226(51.3) 60(48.0) 88(57.1) 0.04 hypercholestoremia 162(20.4) 102(19.8) 26(20.8) 34(22.4) 0.63 Prior MI 74(9.3) 31(6.0) 19(15.2) 24(15.6) <0.001 CKD 14(1.8) 8(1.5) 0(0) 6(3.9) Prior stroke 81(10.2) 50 (9.7) 9 (7.3) 22 (14.2) 0.10 Prior HF 10(1.3) 4(0.8) 2(1.6) 4(2.6) 0.09 p
14 Patient Characteristics by Reperfusion Strategy Data of Beijing Registry 2006 Off-hour presentation Total N=809 PPCI n=521 TT n=133 No n= (64.9) 333(63.9) 86(68.8) 101(65.2) 0.59 p Pre-hospital ECG 291(35.9) 205(41.5) 42(34.4) 44(30.3) 0.03 EMS transport 310(38.7) 221(42.4) 43 (34.4) 46(29.7) 0.01 Pre-hospital delay >3h 351(44.2) 223(43.1) 41(33.3) 87(56.1) <0.001 Clin Invest Med. 2008,31(4):E189-97
15 Evidence Based Medication in Hospital Data of Beijing Registry 2006 Total N=809 PPCI n=521 TT n=133 No n=155 p Aspirin 774(98.1) 503(97.7) 121(99.2) 150(98.7) 0.46 Clopidogrel 701(90.0) 496(96.9) 96(81.4) 109(73.2) <0.001 UFH 211(27.5) 127(25.4) 63(52.9) 21(14.3) <0.001 LMWH 717(91.8) 481(94.5) 103(85.1) 133(88.1) B-blocker 593(76.1) 397(77.7) 85(71.4) 111(74.5) 0.31 ACEI 559(72.5) 368(73.3) 88(72.2) 103(69.6) 0.67 Statin 716(91.6) 484(94.7) 102(85.0) 130(86.1) <0.001 Clin Invest Med. 2008,31(4):E189-97
16 In Hospital Outcomes by Reperfusion Strategy Data of Beijing Registry 2006 Total N=809 PPCI n=521 TT n=133 No n=155 p Death 37(4.6) 16(3.1) 7(5.6) 14(9.0) Re-infarction 13(1.7) 8(1.6) 3(2.7) 2(1.4) 0.71 Stroke 3(0.4) 1(0.2) 1(0.9) 1(0.7) 0.47 New Heart failure 114(15.0) 68(13.5) 22(19.3) 24(16.9) 0.22 Severe Bleeding 17(2.3) 12(2.4) 2(1.8) 3(2.2) 0.91 Clin Invest Med. 2008,31(4):E189-97
17 Time from onset of symptoms to Treatment Data of Beijing Registry 2006 Onset of symptom On scene departure In hospital treatment In hospital fibrinolysis 130 min 30 min D to N 87.5mins Primary PCI 137 min 25 min D to B 137mins Hospital arrival Clin Invest Med. 2008,31(4):E189-97
18 Pre-hospital Delay (symptom onset to hospital arrival) Data of Beijing Registry 2006 >6hours 2-6 hours <2 hours % Clin Invest Med. 2008,31(4):E189-97
19 The social-economic factors associated with Pre-hospital Delay Data of Beijing Registry 2006 Variable Pre-hospital delay 2h N=364 Pre-hospital delay >2h N=445 P Age (mean, y) ± ± Age 65 y 128 (35.16) 189 (42.47) Female 74 (20.73) 108 (25.35) Health insurance 224(61.5) 294(66.1) Education 167(45.9) 245(55.1) Income >2000RMB/M 73(20.1) 123(27.6) Clin Invest Med. 2008,31(4):E189-97
20 The risk factors associated with Pre-hospital Delay Data of Beijing Registry 2006 Variable OR 95% CI P Nitrate on symptom onset , No severe symptom , Symptom persist <30mins , Self transport , Clin Invest Med. 2008,31(4):E189-97
21 The Delay of Door to reperfusion Time Data of Beijing Registry 2006 >240 mins >180 min mins min mins min mins min 60-<90 min <60 min 20% min <30 min D to B D to N Clin Invest Med. 2008,31(4):E189-97
22 The Delay of Door to reperfusion Time Data of Beijing Registry 2006 D to B >90 mins p value D to n >30 mins p value Low volume PCI center Age > Off hour presentation Referral HF(kiliip 4) Prehospital delay >2 h Odds ratio(95%ci) Odds ratio(95%ci) Clin Invest Med. 2008,31(4):E189-97
23 In-hospital Pathway of Thrombolysis Data of Beijing Registry 2006 Arrival at the local hospital ECG Decision making Risk of thrombolysis, Biomarker Informed consent ED(64%) CCU(36%) PCI(18%) EM (71min) CCU (112min) 6 mins 40 mins 15 mins 7 mins 20 mins 50mins Total (83min) 6 mins 43 mins 17 mins Clin Invest Med. 2008,31(4):E189-97
24 The Chinese Consensus on Reperfusion Therapy for STEMI
25 Triage of Reperfusion strategy in hospital (Chinese Consensus) Suspected STEMI Time and risk Time of onset Risk of STEMI Risk of thrombolysis Delay of PCI PCI capable Non-PCI-capable 3-12 hours Transfer within 90 min Yes No < 3 hours In hospital fibrinolysis Primary PCI failed Successful Chin J Intern Med, 2009; 48:885 Rescue PCI angiography
26 Ongoing registry of ACS in China Web based registry Initiated in Centers STEMI and NSTEMI ACS 1500 patients before 7th Agu, STEMI analysed
27 Reperfusion Treatment by Gender Preliminary analysis of Beijing ACS Registry 2012 No reperfusion Percentage of STMI (%) % 16.4% 64.4% 36.1% 5.1% 70.2% Thrombolysis PPCI 2006 (n=809) 2011 (n=567)
28 Pre-hospital Delay (symptom onset to hospital arrival) Preliminary analysis of Beijing ACS Registry 2012 >6hours hours 28,6 <2 hours 42, Data not published
29 Delay of D to B in PPCI Preliminary analysis of Beijing ACS Registry 2012 Percentage of STMI (%) 40% Data not published
30 Trends of time delay in PPCI and Thrombolysis min Symptom to D D to N 137 Symptom to D D to B 2012 Data not published
31 The rate of Pre-hospital ECG and EMS transport Preliminary analysis of Beijing ACS Registry 2012 Percentage of STMI (%) Pre-hospital ECG EMS transport PPCI Thrombolysis No reperfusion
32 Reperfusion Treatment by Gender Preliminary analysis of Beijing ACS Registry 2012 No reperfusion Percentage of STMI (%) % 4.9% 74.8% 36.1% 5.8% 58.1% Thrombolysis PPCI Male (n=412) Female (n=155)
33 Door-to-reperfusion Time: Key Steps In Process Improvement Patients education Pre-hospital ECG STEMI Alert activated by ED physician Physician and Nurse Champions in the ED and Cath Lab Prompt and detailed data feedback report
34 Int J Cardiol Nov 17;153(1):81-2.
35 Improvement of D to B in single PCI center in Beijing Int J Cardiol Nov 17;153(1):81-2.
36 Transfer for primary percutaneous coronary intervention in STEMI in Single PCI center in Shanghai Chinese Medical Journal 2008; 121(6):
37 Summary The use of reperfusion therapy for STEMI varied across the country. Prehospital delay is still a big challenge. Primary PCI is the preferred treatment for STEMI in China. However, PPCI were not performed within the recommended time (90mins). Fibrinolytic therapy is still the choice of reperfusion and the in-hospital delay of fibrinolytic therapy needs to be improved. National network and regional programs is warranted to improve the optimal treatment and should be evaluated in the future.
38 THANK YOU!
39 The 23rd GWICC Oct, 2012 Beijing WELCOME!
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