This House believes that experience and size is not relevant

Transcription

1 This House believes that experience and size is not relevant

2 Providing a primary angioplasty service

3 Hotly debated topics Treatment of MI Stewed prunes vs warmed milk Treatment of MI early mobilisation vs 6 week bed rest Treatment of MI Home vs CCU? Treatment of MI - Thrombolysis vs peace and quiet on medical ward? Management of MI Physician or specialist? Should all patients with MI have a cardiac catheter prior to discharge? Should angioplasty be performed without onsite surgical cover? Thrombolysis or angioplasty for acute myocardial infarction?

4 Carey JA, Davies SW, Balcon R, Layton C, Magee P, Rothman MT, Timmis AD, Wright JE, Walesby RK. Emergency surgical revascularisation for coronary angioplasty complications. Br Heart J Nov;72(5): Department of Cardiac Surgery and Cardiology, London Chest Hospital.

5 London Chest Hospital Between January 1980 and December 1990 No Mortality % total Resuscitation to surgery Resuscitation to delayed surgery Delays in operating on stable patients in centres which operate a "next available theatre" backup policy may not differ from some units performing PTCA with offsite cover for PTCA complications

6 Westminster Hospital

7 St Thomas Hospital

8 Westminster Hospital Consultant operators Perfusion to surgery Surgical theatre always available Shorter time to bypass Total 9 12 Mortality % Jan 1999 to Jan 2003

9 Delays in operating on stable patients in centres which operate a "next available theatre" backup policy may not differ from some units performing PTCA with offsite cover for PTCA complications

10 What determines outcome? Experience of individual operator Experience of unit Volume of individual Volume of unit Expertise of individual operator Expertise of unit

11 The rise and fall of expertise st Qtr 2nd Qtr 3rd Qtr 4th Qtr

12 Relation between hospital primary angioplasty volume and mortality for patients treated with acute MI treated with primary angioplasty vs thrombolytic therapy Primary PCI Thrombolysis High volume centres 3.4% 5.4% Intermediate volume 4.5% 5.9% Low volume 3.2% 4.3% Magid et al. JAMA

13 Paris Registry French Society of Cardiology recommendations for PTCA (2000) : < 250 PTCA/year : volume deemed insufficient > PTCA/year : volume considered insufficient, but if individual activity level of operators high : acceptable PTCA/year : adequate > 600 PTCA/year : optimal

14 Paris registry Stable ischaemia AMI <24 hrs <400 PTCAs/year >400 PTCAs/year <0.001 Spaulding et al. ESC 2006

15 Primary PCI Specialisation 1 Q 2Q 3Q 4Q 1-34% 35-62% 63 88% % Door to balloon <0.001 Relative risk of death <0.001 Nallamothu et al. Circulation 2006

16 Advanced angioplasty 1999 Interventional resources should be concentrated based on need Expensive procedures demand efficient services Critical volumes to accomidate costs and development of expertese

17 Leeuwarden (100 km) Heerenveen (70 km) Meppel Emmeloord (20 km) (36 km) Kampen (13 km) Harderwijk (40 km) Lelystad (75 km) Assen (70 km) Emmen (75 km) Hoogeveen (40 km) Hardenberg (35 km) Zwolle WL / Sophia ZH (2 km) Hengelo (65 km) Deventer (40 km) Zutphen (55 km) Apeldoorn (45 km) FZ 5/2000

18 NO Volume Expertise

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20 What is the best model? Upgrade local centres or expand large tertiary centres?

21 Principles for AMI-PCI OCT /7 service Sustainable in the long term Networked system Reduced Mortality Reduced costs Single centre: 7-12 operators

22 % Mortality 30 Day Mortality P= PCI Thrombolysis Thrombolysis mortality 18% at 1 year UK PACES

23 Pounds Sterling ( ) 8000 UK-PACES In-hospital Costs 400 consecutive patients 6000 p<0.001 p<0.001 p= Thrombolysis Procedures Hospital Stay Total PPCI Thrombolysis

24 Multivariate analysis : independent predictors of mortality Mortality rate according to age p < 0.001

25 The Benefit of Primary Angioplasty in the Elderly < NS < < Day Mortality <75 years 1 Year Mortality <75 years 30 Day Mortality >75 years 1Year Mortality >75 years PPCI Thrombolysis

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28 Volume vs outcome Primary PCI Surgical cover off site vs on site Equity of access Staffing What BCIS can do for you!

29 Institutional Volume vs Outcome 362,748 PCI s in in USA; ~ 80% stents Crude mortality (%) Low Medium High Very High > <0.001 Adjusted OR Low vs high: 1.21 ( ) Medium vs high: 1.02 ( ) Very high vs high: 0.94 ( ) Epstein et al. JACC 2004; 43: p

30 Primary PCI - how, where and when? Better than pre-hospital thrombolysis? Volume affects outcome Ambulance triage? Rescue and thrombolysis-ineligible cases only or all? Is it really cost-effective? How does it rank with other priorities?

31 Most trials examining the efficacy of Primary Angioplasty (PPCI) exclude the elderly leading to debate regarding its effectiveness in this population. This study demonstrates the short and long term benefits of PPCI in the elderly compared to thrombolysis and determines whether this differs from a younger cohort. Detailed demographic, procedural, 30 day and 1 year mortality data were collected on 400 consecutive patients treated for ST segment elevation myocardial infarction from 1 hub and 2 spoke sites in west London between July 2002 and February The first 200 patients received thrombolysis while the subsequent 200 patients underwent PPCI.

32 Table 2 Clinical ParametersAnd >75 years <75 years p value Killip Class 4 on arrival to Catheter Laboratory (%) Anterior Infarction (%) ns Peak CK (%) ns Mean Time from onset of symptoms to reperfusion (mins) ns Mean Pulse (bpm) ns Mean Systolic Blood Pressure (mmhg) ns Mean Diastolic Blood Pressure (mmhg) ns

33 >75 years <75 years Mean number of diseased vessels ns Multivessel disease (%) ns p value Significant Left Main Stem Stenosis (%) Proximal Left Anterior Descending culprit lesion (%) ns Mean number of lesions treated ns Multi-lesion intervention (%) ns Mean number of vessels treated ns Multi-vessel intervention (%) ns Mean bare metal stent use ns Mean drug eluting stent use ns Drug Eluting Stent Use (%) ns Intra-aortic balloon pump use(%) Temporary Pacing Wire use (%) 5 3 ns Adjuvant Clopidogrel use (%) ns Adjuvant Glycoprotein IIb/ IIIa inhibitor use (%) ns Duration of procedure (mins)

34 Operator Volume vs Outcome ~50% stents Adjusted Rates of 30-Day Mortality and CABG Following PCI Among 167,208 Medicare Beneficiaries During Adjusted for age, sex, race, AMI as primary diagnosis, comorbidity score, urgency of admission, and multivessel PCI. McGrath et al. JAMA, 2000; 284:

35 Operator Volume vs Outcome Beaumont Hospital ,293 PCI s 28 operators Annual operator volume <92, , >140 Career experience <8, 9-14, >14 End points: Mortality, MACE Stent rate ~ 80%

36 MI < 14 days: 7 Creat>1.5mg/dl: 4 MVD: 4 Age>65: 4 Relation of BRS to study outcomes. p < for death, MACE, MI after PCI, CVA, or CABG. p = 0.04 for MI after PCI. AJC 2004; 94:

37 Operator Volume vs Outcome BRS Mortality MACE Annual operator volume < % 2.52% % 2.93% > % 2.41% p value Career experience < % 2.79% % 2.54% > % 2.54% p value AJC 2004; 94:

38 No of Centres Operator volume in the UK (NHS Centres) 2003 data from 54 of 56 centres >250 No PCIs/Consultant

39 Higher mortality after PCI in hospitals without onsite surgery October 27, 2004 theheart.org 29% excess mortality among patients undergoing PCI at hospitals without onsite surgical backup.

40 Wennberg et al. JAMA 2004; 292:

41 Wennberg et al. JAMA 2004; 292:

42 Surgical cover in the UK On site Off site No of centres (% of total) No. of PCI (% of total) Procedures per centre (mean) Operator volume* (mean) (76%) (24%) (87%) (13%) * NHS Centres only

43 PCI volumes at centres with off 4 site surgical cover 3 No. of Centres >701 No. Procedures per Centre

44 Coronary Angiography in DGH NO diagnostic only sites with no potential to develop PCI should be closed no ability to bail-out no ability to follow-on All patients should be investigated at the local PCI centre

45 Institutional Volume vs Outcome in Primary PCI Low: n=112 ( 16 PPCI s/yr) Intermediate: n=223 (17-48 PPCI s/yr) High: n=111 ( 49 PPCI s/yr) In-hospital mortality for patients with AMI treated with thrombolysis vs PCI; interaction between reperfusion strategy and primary PCI volume was significant (p<.001). Magid et al: JAMA, 2000; 284:

46 Institutional PCI volume in the UK <200 <400 <600 <800 <1000 <1200 <1400 <1600 <1800 <2000 <2200 <2400 >2400

47 Prior Clopidogrel Therapy (%) 7 2 ns 5 2 ns ns PPCI >75 years (n=43) Thromboly sis >75 years (n=47) p value PPCI <75 years (n=153) Thromboly sis <75 years (n=157) p value p value (PPCI >75 years compared to PPCI <75 years) Age (years) ns ns <0.001 Male (%) ns ns <0.001 South Asian (%) 2 11 ns ns Chronic Obstructive Airways Disease (%) ns 4 5 ns Previous Myocardial Infarction (%) ns ns ns Previous Coronary Bypass Surgery (%) 0 4 ns 3 3 ns ns Previous Coronary Intervention (%) 12 2 ns 10 6 ns ns Diabetes Mellitus (%) ns ns ns Smoker (%) ns ns <0.001 Family history of coronary disease (%) ns ns ns Hypertension (%) ns <0.001 Treated Hypertension (%) ns <0.001 Hyperlipidaemia (%) ns ns Treated Hyperlipidaemia (%) ns ns Peripheral Vascular Disease (%) 2 4 ns 4 7 ns ns Cerebrovascular Disease (%) 9 21 ns 8 5 ns ns Prior Aspirin Therapy (%) ns ns ns Prior Beta blocker Therapy (%) ns ns ns Prior ACE Inhibitor Therapy (%) ns ns ns Prior Statin Therapy (%) ns ns ns

48 Multivariate analysis : independent predictors of mortality Female gender : 3.3 vs 1.8% High risk patients AMI : 5.6 vs 0.8 % Cardiac arrest : 40% Annual volume PTCA/ year > 600 PTCA/year : 2.17% < 250 PTCA/year : 2.7% P = 0.051

49 Statistical Analysis Interaction for mortality in logistic regression model : Age/highest risk patients (p=0.0001) Annual procedure volume/highest risk patients (p= 0.056) Case control analysis : two study groups of equal size with similar clinical characteristics (9,244 X 2) : Group 1 : centers < 400 PTCA/year Group 2: centers > 400 PTCA/year

50 In-hospital Mortality Rate Overall pop < 400 procedures/year > 400 procedures/year Mortality rate Adjusted Odds ratios P= High-risk subgroup P= Low risk subgroup P= 0.62

51 In-hospital Complication Rates < 400 procedures/year > 400 procedures/year 4.01 P= P= P=

52 Discussion Clear relationship between volume and in-hospital mortality in high-risk patients No data on operator volume. However, emergency procedures require an experienced interventional cardiologist, but also a multi-disciplinary team Quality of pre, per and post-ptca procedure management by medical and nursing staff is increased by regular exposure to emergency procedures Results similar to other registries Vogt A et al, Eur Heart J 1997;18: Williams DO et al, Circulation 2000;102: Kimmel SE et al J Am Coll Cardiol 2001;37:

53 In-hospital Mortality Rate < 400 procedures/year > 400 procedures/year Overall population Mortality rate Adjusted Odds ratios P= High-risk subgroup P= Low risk subgroup P= 0.62

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