Regional STEMI Transfer Systems: the Mayo and NC RACE Experiences

Regional STEMI Transfer Systems: the Mayo and NC RACE Experiences Dr. Henry H. Ting, Mayo Clinic College of Medicine Dr. James G. Jollis,, Duke University Medical Center

Mayo Clinic STEMI System for Transferred Patients FAST TRACK Henry H. Ting, MD MBA Mayo Clinic Rochester, Minnesota Jan. 28, 2010

No financial disclosures No conflicts of interest No off-label use Disclosures

D2B Sustain The Gain Nestler DM. Circ Cardiovasc Qual Outcomes. 2009;2:508-513.

PH ECG and Door-to-Balloon 30 min 64 min Ting HH. Presented at AHA November 2009

Patients Transferred for Primary PCI 60 Patients (%) 40 26.4 36.3 20 0 1.3 8.6 <1 <90 min 17.6 8.2 1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 7 to <12 4.3 Total door-to to-balloon time (hours) 2.2 3.7 Chakrabarti A, J Am Coll Cardiol 2008;51:2442-2443.

Reperfusion Strategies for Transferred STEMI Patients 1. Interhospital transfer for primary PCI 2. Pharmaco-invasive approach with lytics and early PCI 3. Lytic facilitated PCI 4. Prehospital triage for primary PCI

Reperfusion Strategies for Transferred STEMI Patients 1. Interhospital transfer for primary PCI 2. Pharmaco-invasive approach with lytics and early PCI 3. Lytic facilitated PCI 4. Prehospital triage for primary PCI

Minnesota Duluth St. Cloud Minneapolis/ St. Paul Wisconsin Rochester 0 100 200 Iowa Ting HH, et al. Circulation 2007;116:729-736

Regional STEMI Patients Treated with Primary PCI or Fibrinolytic Therapy 1.00 Cumulative probability 0.75 0.50 0.25 0.00 25 min 110 min Regional Hospital Primary PCI Regional Hospital Fibrinolysis 0 60 120 180 240 Door-to-balloon/door-to-needle time (minutes) Ting HH, et al. Circulation 2007;116:729-736

Mortality and Door-to-Needle / Door-to-Balloon 20 In-hospital Mortality (%) 16 12 8 4 0 P=0.01 1.1 3.5 5.6 6.6 11.5 13.5 <30 30-60 60-90 90-120 120-180 >180 Door-to-balloon / Door-to-needle time (minutes)

Door-in Door-out (DIDO) at 1 st Hospital and 1 st Door-to-balloon Time Median 1st Door-to-balloon (min) 250 200 150 100 50 0 143 DIDO >30 min P < 0.0001 87 DIDO <=30 min Ting HH, et al. AHA November 2009

Pharmaco-Invasive Strategy Definition: Broad use of rescue PCI after failed fibrinolysis, as well as an early PCI within 3-243 hours of successful fibrinolysis

30-day 1 1 Endpoint and Components Endpoint Standard N=498 (%) Pharmaco-Invasive N=512 (%) P value 1 end point 16.6 10.6 0.0013 Death 3.6 3.7 0.94 Re-infarction 6.0 3.3 0.044 Recurrent ischemia 2.2 0.2 0.019 Death/MI/ischemia 11.7 6.5 0.004 New/worsening CHF 5.2 2.9 0.069 Cardiogenic shock 2.6 4.5 0.11 Cantor WJ. N Engl J Med 2009;360:2705

30-day 1 1 Endpoint and Components Endpoint Standard N=498 (%) Pharmaco-Invasive N=512 (%) P value 1 end point 16.6 10.6 0.0013 Median time from lytics to PCI was 3.9 hours Death 3.6 3.7 0.94 Re-infarction 6.0 3.3 0.044 Recurrent ischemia 2.2 0.2 0.019 Death/MI/ischemia 11.7 6.5 0.004 New/worsening CHF 5.2 2.9 0.069 Cardiogenic shock 2.6 4.5 0.11 Cantor WJ. N Engl J Med 2009;360:2705

Pharmaco-Invasive Strategy: NORDISTEMI Bohmer E. JACC 2010; 55:102-110

Pharmaco-Invasive Strategy: NORDISTEMI Median time from lytics to PCI was 2.7 hours Bohmer E. JACC 2010; 55:102-110

ASSENT-4 Trial Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI 8 6 % 4 2 0 P =0.01 6 3 In-hospital Death DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI Primary PCI P <0.0001 P =0.0037 1.8 0 0 Total Stroke 1 Hemorrhagic Stroke Facilitated PCI Van de Verf, Lancet 2006;367:569-578

ASSENT-4 Trial Primary vs. Full-dose TNK Fibrinolytic-Facilitated PCI 8 6 Median time from lytics to PCI was 1.9 hours P =0.01 6 DSMB terminated study after 1667 / 4000 enrolled because of higher in-hospital mortality observed for facilitated PCI Primary PCI Facilitated PCI % 4 2 0 3 In-hospital Death P <0.0001 P =0.0037 1.8 1 0 0 Total Stroke Hemorrhagic Stroke Van de Verf, Lancet 2006;367:569-578

Prehospital Triage Model

Proximal LAD

Prehospital Triage Model 1. Paramedics acquire and interpret PH ECG 2. If Definite STEMI,, then 1-call 1 activation of cath lab and helicopter auto-launch to intercept patient at regional hospital (or intercept enroute) 3. Bypass ED evaluation at regional hospital & PCI hospital 4. Patient transported directly to cath lab 5. Explicit diversion criteria to deviate from #2-4

Description Time Time Interval (minutes) Symptom Onset 05:30 0 9-1-1 Call 06:05 35 EMS On-Scene 06:09 4 PH ECG Acquired 06:16 7 STEMI Protocol Activation 06:17 1 Transport to Local Community Hospital 06:22 5 Arrival at Door 1 06:26 4 Departure from Door 1 06:37 11 Arrival at Door2 07:10 33 First PCI Device 07:27 17 Time Intervals Duration (minutes) *Door 1 In-to-Door 1 Out 11 *Door 2-to-First PCI Device 17 *Door 1-to-First PCI Device 61 *First EMS Contact-to-First PCI Device 82 *Symptom Onset-to-First PCI Device 117 Pitta SR. Circ Cardiovasc Qual Outcomes. 2010;3:93-97

North Carolina's Statewide STEMI System James G. Jollis, MD, FACC Duke University

RACE Reperfusion in AMI in Carolina Emergency Departments

How patients present Call 911 EMS (~50%) Walk-in (~50%) Hospital transfer - Walk in or EMS to 1 st hospital (~60% of PCI hospital)

How patients present EMS Walk-in Hosp. transfer Current 90 90 180 Potential <60 <90 <120

21 primary PCI labs 500 EMS systems 5,240 paramedics 18,000 EMTs 121 emergency departments

Integrated, Integrated, Systematic Systematic AMI AMI Care Care

RACE Process 1) Develop leadership, funding, data structure 2) Establish REGIONAL PCI CENTERS (primary, lytic ineligible, rescue) 4) Improve system Measurement & Feedback 3b) EMS by EMS establishment of STEMI plan (review, consensus, training) 3a) HOSPITAL by hospital establishment of STEMI plan (review, consensus, training)

Establish a plan

RACE Interventions Regional coordinators

RACE Interventions Available at www.race-er.org OPERATIONS MANUAL Optimal system specifications by point of care EMS ED Transfer Receiving hospital Cath. Lab Other system issues payers, regulations

RACE Interventions Emergency Department Coordination and training of entire staff Registration (nurse first) Designated area for immediate Standing STEMI protocol agreed upon by entire emergency and cardiology staff Emergency physician leads team

RACE Interventions PCI Hospitals Single number cath lab activation Accept all STEMI patients regardless of bed availability Ongoing QI and data feedback NRMI database RACE Regional Coordinator Responsible for improving process in every hospital - EMS system in the region

EMS RACE Interventions 1) In the field ECG for all chest pain patients 2) 15 minute scene time 3) Hospital pre-notification 4) Standing STEMI plan / destination protocols

JAMA Nov. 2007

RACE results PCI hospitals: Door to device median times in minutes 180 150 120 90 60 30 0 P<0.001* 108 90 P<0.001 Pre 85 Post 74 149 P=0.01 106 All patients Direct presenters Transfer for PCI hospitals

RACE results Non-PCI hospitals: Reperfusion times median times in minutes 180 150 120 90 60 30 0 P<0.001* 120 71 Door-in door-out, all hospitals P<0.001 97 45 Door-in door-out, transfer hosps P=0.002 35 Pre Post 29 Fibrinolysis, doorto-needle * Remained significant in analysis accounting for clustering

RACE Centers and Regions 65 hospitals (10 PCI, 55 non PCI) Winston-Salem Durham-Chapel Hill- Greensboro Asheville 10 PCI centers 16 Transfer for PCI 28 Lytics 11 Mixed Charlotte East Carolina Each non-pci center was assessed for reperfusion designation based on resources, transfer ability, and transfer time to PCI center