How to do Primary PCI

The basics and adjunctive pharmacology

Dr Andrew Sutton MA MD FRCP FESCConsultant Cardiologist

The James Cook University Hospital

NO CONFLICT OF INTEREST TO DECLARE

Before the cath lab..

• Discussion, formulation and agreement of a clear regional protocol is key

• Essential stakeholders: ambulance services, regional cardiologists, General Practitioners; walk-in centres; A&E staff

Before the cath lab..

• Aim for one pre-hospital patient pathway for each geographical region – irrespective of the day of the week, time of day, start/end of shifts.

• Familiarity with and repetition of a single pathway breed slickness and efficiency

• Continuous review, audit and feedback essential

Monthly median door to balloon times (minutes) JCUH October 2006 to October 2008

50

5754

49

5350

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08

Oct 06 to Oct 07=52.3 minutes

Nov 07 to Jun 08=42.4 minutes

Jun 08 to Oct 08 32.8 minutes

mean

ucl

Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008

Monthly median door to balloon times (minutes) JCUH October 2006 to October 2008

50

5754

49

5350

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08

Oct 06 to Oct 07=52.3 minutes

Nov 07 to Jun 08=42.4 minutes

Jun 08 to Oct 08 32.8 minutes

mean

ucl

Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008

CCU coordinator receives call from paramedic crew and copy of initial ECG

Monthly median door to balloon times (minutes) JCUH October 2006 to October 2008

50

5754

49

5350

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08

Oct 06 to Oct 07=52.3 minutes

Nov 07 to Jun 08=42.4 minutes

Jun 08 to Oct 08 32.8 minutes

mean

ucl

Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008

CCU coordinator receives call from paramedic crew and copy of initial ECG

Patient admitted directly to cath lab

Monthly median door to balloon times (minutes) JCUH October 2006 to October 2008

50

5754

49

5350

40 41 40

34.5

30.53234

48.5

39

44.544

35

4744

52

49

69

60.5

63

0

10

20

30

40

50

60

70

80

Oct

06

Nov

06

Dec

06

Jan

07

Feb

07

Mar

07

Apr

07

May

07

Jun

07

Jul

07

Aug

07

Sep

07

Oct

07

Nov

07

Dec

07

Jan

08

Feb

08

Mar

08

Apr

08

May

08

Jun

08

Jul

08

Aug

08

Sep

08

Oct

08

Oct 06 to Oct 07=52.3 minutes

Nov 07 to Jun 08=42.4 minutes

Jun 08 to Oct 08 32.8 minutes

mean

ucl

Influence of PPCI pathway policy changes on median door to balloon times The James Cook University Hospital October 2006 to October 2008

CCU coordinator receives call from paramedic crew and copy of initial ECG

Patient admitted directly to cath lab

Cath lab opened byresident member of staff

Aways room for improvement..

Help your out of area ambulance colleagues...

DTB direct Q3 2009 2010

Door to Balloon (direct) October 2009 to December 2009

46

43

40

39

38

36

0

50

100

150

200

250

300

350

400

450

Oct09 Oct09 Oct09 Nov09 Nov09 Nov09 Nov09 Nov09 Dec09 Dec09 Dec09 Dec09 Dec09 Dec09

DTB median 33.5 ucl 93

In the cath lab..• Brief assessment (history, ECG , examination)• Exclude aortic dissection, PE• Look for acute MR, VSD; determine access• Previous angio available?• Determine history of allergy• Record usual medication (esp. anticoagulants)

and medication already administered (aspirin, opiate analgesia)

• Obtain witnessed verbal consent

In the cath lab..• Slick patient preparation (iv access; ECG

monitoring; remote pads for defibrillation; monitoring of O2; removal of jewellery)

• Access – “normal” route is radial (82% radial last 1000 sequential cases in JCUH)

• Preferable to have easy access to femoral artery, even if not used

In the cath lab..• Common practice to administer a

“radial cocktail” (GNT/verapamil +/- UFH) after sheath insertion

• Advisable to avoid verapamil for STEMI• Diagnostic angio followed by choice of

guide catheter or whole procedure with Kiemeneij guide catheter

In the cath lab..• Do the case• Use of a thrombus extraction device is normal

practice• Clarify any pending non cardiac surgery prior

to choice of stent• Ask yourself if the stent big enough• TR band for radial access (increasingly use of

a closure device for femoral access)• Do the next case

In the cath lab – particular considerations

• Inferior STEMI– Bezold-Jarisch reaction: liberal use of iv fluids,

atropine; may require phenylephrine

• Culprit vessel or MV PCI?– Our default strategy is culprit vessel PCI (MV

PCI performed in context of cardiogenic shock and lack of haemodynamic response to culprit vessel PCI)

“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.”

JCUH drugs

Aspirin loading 300mg (paramedic).

Weight adjusted UFH (60U per kg) assuming patient will also receive ReoPro (89% of last 1000 sequential cases).

ReoPro is only administered in the cath lab.

“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.”

JCUH drugs

Clopidogrel loading 600mg

(not by paramedics)

For self-presenters to local or regional A&E, load with aspirin 300mg and clopidogrel 600mg prior to urgent transfer

“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.”

JCUH drugs

Prasugrel is used instead of clopidogrel on a patient by patient basis at operator discretion.

“A word of advice, Durk: it’s the Mesolithic, we’ve domesticated the dog, we’re using stone tools and no one’s naked anymore.”

Alternatively…

Aspirin loading 300mg (paramedic).

Prasugrel 60mg loading dose as routine (well recognised exceptions); potential for administration by ambulance crew.

Bivalirudin + bail out GpIIb/IIIa inhibitor.

In the cath lab.. escalation of care

• Not all PPCI is simple

83F

Inferior STEMI

TIMI 2 flow

Critical prox RCA

Lesion uncrossablewith whole range of CTO balloons

Lesion successfully crossed with 2.1F Tornus device

Subsequent rotablation and stenting

Final result

In the cath lab.. escalation of care

• Not all PPCI is simple

• Not all MI (or PPCI) is without complication

62M

Posterolateral STEMI

Severe pulmonary oedema requiring NIV and anaesthetic support

Severe MR noted pre-lab

Sub-total occlusion of Cx

Cx ballooned for ongoing pain

IABP

Urgent mechanical mitral valve replacement 90 minutes later

Complete recovery

77F

Inferior STEMI with CHB

Ostial LMS disease and calcified, severe LAD and Cx disease

Occluded RCA in calcified vessel

Vessel opened

Serial balloon inflations

TIMI 3 flow

Delivery of kit very difficult

No stent; planned urgent CABG

Vessel repeatedly re-occluded after wire removal

Haemodynamic compromise

IABP, TPW

Cardiothoracic anaesthetic input

Emergency CABG from lab

In the cath lab.. escalation of care

• Not all PPCI is simple

• Not all MI (or PPCI) is without complication

• ...which means you get some very sick patients

In the cath lab.. escalation of care• Infrastructure for the sickest group

must be in place

In the cath lab.. escalation of care• Infrastructure for the sickest group

must be in place– Input from experienced cardiothoracic

anaesthetists vital for some

In the cath lab.. escalation of care• Infrastructure for the sickest group

must be in place– Input from experienced cardiothoracic

anaesthetists vital for some– Provision for invasive ventilation– Provision for IABP

General ITU do not take these patients

In the cath lab.. escalation of care• Infrastructure for the sickest group

must be in place– Input from experienced cardiothoracic

anaesthetists vital for some– Provision for invasive ventilation– Provision for IABP– Provision for cooling

General ITU do not take these patients

In the cath lab.. escalation of care• Infrastructure for the sickest group

must be in place– Input from experienced cardiothoracic

anaesthetists vital for some– Provision for invasive ventilation– Provision for IABP– Provision for cooling– Provision for cardiothoracic surgical input

General ITU do not take these patients

The basics.... conclusion

Agreed regional protocol for delivery of PPCI

Mechanism in place for wherever the patient presents

Mechanism of continuous monitoring, audit and feedback

The basics.... conclusion

Agreed regional protocol on drugsStrategy for the PPCI which is not

simpleInfrastructure for those patients

requiring urgent anaesthetic and surgical input