Approaches to Shortening Door-to-Balloon Time: The Poland Experience by Dariusz Dudek MD, PhD Institute of Cardiology, Krakow, Poland

Dariusz Dudek, MD, PhD DISCLOSURES I have no real or apparent conflicts of interest to disclose.

Stent for Life Deliverables To increase the use of primary PCI towards >70% use among all STEMI patients To achieve primary PCI rates >600 / million per year in most European countries Empower PCI centers to offer 24/7 services for primary PCI

2001 - 2003 Int J Cardiol. 2008 Nov 24. [Epub ahead of print]

Stent 4 Life Malopolska region – Primary PCI Networks for STEMI & NSTEMI treatment p. limanowski 120,2 tys. p. gorlicki 106,4 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. 2001-2003 STEMI: 340 PPCIs / 1 mln 2009 ↑STEMI & ↑↑↑ NSTEMI PPCIs/1 mln ↑ increased availability, ↓ of delays p. limanowski 120,2 tys. p. gorlicki 106,4 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. p. limanowski 120,2 tys. p. gorlicki 106,4 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. 2008 STEMI:737 PPCIs / 1 mln NSTEMI:347 PPCIs / 1 mln 5

Malopolska Networks Decentralization Networks for 300 000 – 500 000 population with: shorter time since first medical contact to balloon time predefined patients transfer rules Consultations, quality control, training programs by University Center Targets: reduce time delay to reperfusion, increase reperfusion rate 6

NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT OF ACUTE CORONARY SYNDROMES 7

p. nowotarski 179,9 tys. p. limanowski 120,2 tys. Nowy Sącz + p. nowosądecki 279,4 tys. p. gorlicki 106,4 tys. p. suski 81,5 tys. p. wadowicki 153,4 tys. p. oświęcimski 153,1 tys. p. chrzanowski 128,7 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. p. tatrzański 65,3 tys. p. myślenicki 114,9 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. NEWORK OF CATHLABS FOR DIAGNOSIS AND TREATMENT OF HIGH-RISK PATIENTS: LMCA, MVD, SURGERY, HYBRID PROCEDURES, ADVANCED IMAGING, STRUCTURAL HEART DISEASES

Primary PCI for STEMI/ 1 milion population in 2009 Malopolska Registry. Primary PCI for STEMI/ 1 milion population in 2009 p. limanowski 120,2 tys. p. gorlicki 106,4 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. STEMI 660/milion STEMI 911/milion 24/7 service since 14 of July STEMI 224/milion STEMI 692/milion STEMI 750/milion 9 9

In-hospital mortality in 2009year for STEMI patients. Malopolska Registry. In-hospital mortality in 2009year for STEMI patients. p. miechowski 51,5 tys. p. olkuski 114,7 tys. 5.0 % p. dąbrowski 58,6 tys. Kraków + p. krakowski 998,8 tys. 5.4% 9.6% p. bocheński 99,7 tys. p. wielicki 102,5 tys. Tarnów + p. tarnowski 310,5 tys. p. brzeski 89,7 tys. p. limanowski 120,2 tys. 6.6% p. gorlicki 106,4 tys. 5.9% 10 10

Eur Heart J. 2009 Nov 19 [epub ahead of print]

Eur Heart J. 2009 Nov 19 [epub ahead of print]

Malopolska Registry of Acute Coronary Syndromes Treatment strategies in small Network 0.5 million population Nowy Sacz p. limanowski 120,2 tys. p. gorlicki 106,4 tys. Nowy Sącz + p. nowosądecki 279,4 tys. 506 tys. STEMI < 12 godz. PRIMARY PCI THROMBOLYSIS NO REPERFUSION Dudek D. et al. Kardiol. Pol. 2008;66:1224-32.

FROM NON-PCI HOSPITALS Stent as fast as possible & We need fast acting antiplatelet and antithrombotic drugs Prehospital management DRIP & SHIP FAST TRANSFER NO MORE SELF TRANSPORTATION NO MORE TRANSFERS FROM NON-PCI HOSPITALS

Percentage of STEMI patients arriving at cathlab directly via EMS in Krakow Region p. limanowski 120,2 tys. p. gorlicki 106,4 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. 2009/2010 20% 35% 20% 40% 50% 15

Comparison of time delays in between August – December 2009

Acute Coronary Syndrome Phase 4 of Krakow Region Programme for Interventional Treatment of MI 2009-2011 Acute Coronary Syndrome No ST elevation in ECG Direct phone contact with cathlab on duty Consent of interventional cardiologist to transfer patient Direct transfer to the closest cathlab on duty Krakowski Szpital Specjalistyczny im. Jana Pawła II w Krakowie Szpital Uniwersytecki w Krakowie Podhalański Szpital Specjalistyczny w Nowym Targu Szpital Specjalistyczny im. J. Śniadeckiego w Nowym Sączu Specjalistycznego Szpitala im. E. Szczeklika w Tarnowie Szpital Powiatowy im. T. Chałbińskiego w Zakopanem Szpital Powiatowy im. św. Maksymiliana w Oświęcimiu Transfer to the ER of nonPCI hospital Hospitalization at nonPCI hospital Our aims for NSTEMI: = shortening time delay from the diagnosis to invasive treatment = avoiding duplicate hospital stays (avoiding additional costs) YES Direct transfer <24h! One of the criteria: hemodynamic compromise VF/VT recurrent angina with ST depression over 2mm resting angina with no reaction to antiischemic drugs positive troponin, dynamic ST-T changes Diabetes mellitus EF<40, prior PCI, prior CABG, GFR <60ml/min/1.73m2, postinfarction angina, GRACE score>140 NO Elective coronary angio Non-invasive assessment in nonPCI hospital Other diagnosis If the delay is to be substantial ,one should take air transport into account

Current data on the situation in 9 cathlabs on duty: availibility of cathlab staff availibility of operating tables number of CCU beds anticipated transfer delays Phase 4 of Krakow Region Programme for Interventionaal Treatment of MI Phase 4c - 2011 Phase 4 of Krakow Region Programme for Interventional Treatment of MI 2009-2011 Coordinating Center for MI treatment Local government institutions / University Hospital EMS center Transfer of ECG signal to one of 9 cathlabs on duty in Krakow region Transport decision Tele - ECG transmission Direct transfer to cathlab

Phase 4 of Krakow Region Programme for Interventional Treatment of MI 2009-2011 Projected transport model: ECG transmission to Coordinating Center in Krakow transfer of ECG to local STEMI-network cathlab EMS → cathlab Current transport model EMS → ER ER → cathlab p. miechowski 51,5 tys. p. olkuski 114,7 tys. p. dąbrowski 58,6 tys. Kraków + p. krakowski 998,8 tys. Aim for STEMI: = shortening time delays from the diagnosis to invasive reperfusion = mortality reduction p. bocheński 99,7 tys. p. wielicki 102,5 tys. Tarnów + p. tarnowski 310,5 tys. p. brzeski 89,7 tys. p. limanowski 120,2 tys. p. gorlicki 106,4 tys. cathlab nonPCI hospital/ER EMS (ambulances) 19 19

Triage and transfer for PCI ACC/AHA focused updates 2009 (2) Current ESC STEMI & PCI Guidelines vs. 2009 Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) The implementation of network of hospitals connected by an efficient ambulance (helicopter) service and using a common protocol is key an optimal management of patients with STEMI. With such a network in place, target delay times should be: <10 min for ECG transmission; ≤5 min for tele-consultation; <30 min for ambulance arrival to start fibrynolytic therapy; and ≤120 min for ambulance arrival to first balloon inflation. Quality of care, appropriateness of reperfusion therapy, delay times and patients outcomes should be measured and compared at regular times and appropriate measures for improvement should be taken. (discussed but no exact recommendations) Each community should develop a STEMI system of care that follows standards at least as stringent as those developed for the AHA’s national initiative, Mission: Lifeline, to include the following: ongoing multidisciplinary team meetings that include emergency medical services, non–PCI-capable hospitals/STEMI referral centers, and PCI-capable hospitals/STEMI receiving centers to evaluate outcomes and quality improvement data; a process for prehospital identification and activation; destination protocols for STEMI receiving centers; transfer protocols for patients who arrive at STEMI referral centers who are primary PCI candidates, are ineligible for fibrinolytic drugs, and/or are in cardiogenic shock. (IC) Triage and transfer for PCI should be based on STEMI-networks 1 Eur Heart J. 2008;29(23):2909-45. 2 Circulation. 2009;120:2271-2306.

Triage and transfer for PCI ACC/AHA focused updates 2009 (2) Current ESC STEMI & PCI Guidelines vs. 2009 Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) Angiography during hospital stay after fibrynolytic therapy: Evidence of failed fibrynolysis or uncertainty about success: immediate (IIa B) Recurrent ischemia, reocclusion after initial successful fibrynolysis: immediate (I B) Evidence of successful fibrynolysis: within 3-24h after start of fibrynolytic therapy (IIa A) It is reasonable for high-risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non–PCI-capable facility to be transferred as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory (IIa B) Patients who are not at high risk who receive fibrinolytic therapy as primary reperfusion therapy at a non–PCI-capable facility may be considered for transfer as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory (IIb C). KRAKOW Network Experience 1 Eur Heart J. 2008;29(23):2909-45. 2 Circulation. 2009;120:2271-2306.