nick curzen wessex cardiac unit southampton university hospital primary pci is the gold standard:...
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Nick Curzen Nick Curzen Wessex Cardiac UnitWessex Cardiac Unit
Southampton University HospitalSouthampton University Hospital
Primary PCI is the gold standard: period!Primary PCI is the gold standard: period!Primary PCI is the gold standard: period!Primary PCI is the gold standard: period!
Components of My Argument
Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
Mr PMr PPreviously fit 75 yr oldPreviously fit 75 yr old
Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………
0100 0100 Rx: aspirin + StreptokinaseRx: aspirin + Streptokinase 03150315 Call to Soton… continued pain; no ST resolutionCall to Soton… continued pain; no ST resolution
05300530 On cath lab table……. Systolic 95, pulmonary oedema getting worseOn cath lab table……. Systolic 95, pulmonary oedema getting worse
Mr PMr PPreviously fit 75 yr oldPreviously fit 75 yr old
Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………
0100 0100 Rx: aspirin + StreptokinaseRx: aspirin + Streptokinase 03150315 Call to Soton… continued pain; no ST resolutionCall to Soton… continued pain; no ST resolution
05300530 On cath lab table……. Systolic 95, pulmonary oedema getting worseOn cath lab table……. Systolic 95, pulmonary oedema getting worse
Can a single case ever make a bullet proof argument?Can a single case ever make a bullet proof argument?
Mr PMr PPreviously fit 75 yr oldPreviously fit 75 yr old
Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………
0100 0100 Rx: aspirin + StreptokinaseRx: aspirin + Streptokinase 315315Call to Soton… continued pain; no ST resolutionCall to Soton… continued pain; no ST resolution
05300530 On cath lab table……. Systolic 95, pulmonary oedema getting worseOn cath lab table……. Systolic 95, pulmonary oedema getting worse
Mr PMr PPreviously fit 75 yr oldPreviously fit 75 yr old
Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………Presented with 3 hr h/o chest pain to local A&E: ST elevation anteriorly………
0100 0100 Rx: aspirin + StreptokinaseRx: aspirin + Streptokinase 315315Call to Soton… continued pain; no ST resolutionCall to Soton… continued pain; no ST resolution
05300530 On cath lab table……. Systolic 95, pulmonary oedema getting worseOn cath lab table……. Systolic 95, pulmonary oedema getting worse
Can a single case ever make a bullet proof argument?Can a single case ever make a bullet proof argument?
oDid the diagnosis of failed reperfusion depend Did the diagnosis of failed reperfusion depend upon who was on call?upon who was on call?
oDid the diagnosis of failed reperfusion depend Did the diagnosis of failed reperfusion depend upon who was on call?upon who was on call?
oDid the diagnosis of failed reperfusion depend Did the diagnosis of failed reperfusion depend upon the hospital?upon the hospital?
oDid the diagnosis of failed reperfusion depend Did the diagnosis of failed reperfusion depend upon the hospital?upon the hospital?
oDid the transfer for rescue PCI depend upon the Did the transfer for rescue PCI depend upon the Interventionalist on call? Or the SpR?Interventionalist on call? Or the SpR?
oDid the transfer for rescue PCI depend upon the Did the transfer for rescue PCI depend upon the Interventionalist on call? Or the SpR?Interventionalist on call? Or the SpR?
oDid the transfer for rescue PCI depend upon the Did the transfer for rescue PCI depend upon the centre approached?centre approached?
oDid the transfer for rescue PCI depend upon the Did the transfer for rescue PCI depend upon the centre approached?centre approached?
oDid the PCI itself depend upon the operator?Did the PCI itself depend upon the operator?ie 3 vessel because of cardiogenic shockie 3 vessel because of cardiogenic shock
oDid the PCI itself depend upon the operator?Did the PCI itself depend upon the operator?ie 3 vessel because of cardiogenic shockie 3 vessel because of cardiogenic shock
This man had an inferior, 2This man had an inferior, 2ndnd rate treatment – rate treatment –
A treatment that none of us, let’s face it, would want for our own relatives!A treatment that none of us, let’s face it, would want for our own relatives!
There is considerable heterogeneity of interventional practice……There is considerable heterogeneity of interventional practice…… some will do rescue: some won’t – despite REACTsome will do rescue: some won’t – despite REACT
UK treatment for STEMI is suboptimal, badly organised, and unacceptableUK treatment for STEMI is suboptimal, badly organised, and unacceptable
for individuals we really care about for individuals we really care about
It’s time we delivered PPCI to the majority of the populationIt’s time we delivered PPCI to the majority of the population
This is just one case….. What does it tell us?This is just one case….. What does it tell us?
Components of My Argument
Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
We’ve got a good thrombolysis service going- isn’t that good enough?We’ve got a good thrombolysis service going- isn’t that good enough?
Why do we need these expensive high-tech treatments?Why do we need these expensive high-tech treatments?
The Case For Primary PCI in SouthamptonThe Case For Primary PCI in SouthamptonThe Case For Primary PCI in SouthamptonThe Case For Primary PCI in Southampton
AIMS OF OUR THERAPYAIMS OF OUR THERAPY
1.1. To re-establish NORMAL flow in the coronaryTo re-establish NORMAL flow in the coronary2.2. To reduce the tendency for clot formationTo reduce the tendency for clot formation
3.3. To reduce mechanical obstructionTo reduce mechanical obstruction
Infarct vessel patency status at 90 Infarct vessel patency status at 90 minutes related to mortality at 30 days minutes related to mortality at 30 days
in the GUSTO-I angiographic trialin the GUSTO-I angiographic trial
Infarct vessel patency status at 90 Infarct vessel patency status at 90 minutes related to mortality at 30 days minutes related to mortality at 30 days
in the GUSTO-I angiographic trialin the GUSTO-I angiographic trial
0
2
4
6
8
10
12
Mortality (%) at 30 daysMortality (%) at 30 days
Infarct vessel patency at 90 minutesInfarct vessel patency at 90 minutes
TIMI-0TIMI-0 TIMI-1TIMI-1 TIMI-2TIMI-2 TIMI-3TIMI-3
So what’s wrong with thrombolysis?So what’s wrong with thrombolysis?So what’s wrong with thrombolysis?So what’s wrong with thrombolysis?
Patency of infarct-related arteries in Patency of infarct-related arteries in patients treated with thrombolysispatients treated with thrombolysis
Patency of infarct-related arteries in Patency of infarct-related arteries in patients treated with thrombolysispatients treated with thrombolysis
0
20
40
60
80
100TIMI II flowTIMI III flow
Rate of vessel patency (%)Rate of vessel patency (%)
Strep (sc)HeparinStrep (sc)Heparin
Strep (iv)HeparinStrep (iv)Heparin
Acc t-PAAcc t-PA Acc t-PAStrep
Acc t-PAStrep
SUBOPTIMAL
SUBOPTIMAL (o
h, and
(oh, a
nd CRAPCRAP!)!) T
REATMENT
TREATMENT????????
Target of AMI therapy = TIMI 3 flowTIMI 3 flow
GUSTO-1GUSTO-1 90 min TIMI IIISK 29%tPA 54%
30 day mortalityTIMI 0/1 8.9%TIMI 2 7.2%TIMI 3 4.4%
Prehospital discharge reocclusion Prehospital discharge reocclusion of IRA 12-32% in patients successfully treated of IRA 12-32% in patients successfully treated with thrombolysiswith thrombolysis Am J Cardiol 1998;82:554-8Am J Cardiol 1998;82:554-8
12.3% IRA reocclusion rate in 733 patients after12.3% IRA reocclusion rate in 733 patients aftersuccessful thrombolysis………………….successful thrombolysis………………….Reocclusion “silent” in almost 50% Reocclusion “silent” in almost 50% Circulation 1990;82:781-91Circulation 1990;82:781-91
SUBOPTIMAL
SUBOPTIMAL (o
h, and CRAP!)
(oh, a
nd CRAP!) TREATMENT
TREATMENT????????
Thrombolysis addresses only the clot……..Thrombolysis addresses only the clot……..NOT the Ruptured plaque-fissureNOT the Ruptured plaque-fissureThrombolysis addresses only the clot……..Thrombolysis addresses only the clot……..NOT the Ruptured plaque-fissureNOT the Ruptured plaque-fissure
That’s why so many patients need …….That’s why so many patients need …….1)1) ““Rescue PCI” Rescue PCI” 2)2) Subsequent revascularisation on the admission or laterSubsequent revascularisation on the admission or later
That’s why current ESC guidelines recommend routine PCIThat’s why current ESC guidelines recommend routine PCIwithin 24 hours of “successful” thrombolysiswithin 24 hours of “successful” thrombolysisEur Heart Journal 2005;26:804-847Eur Heart Journal 2005;26:804-847SUBOPTIM
AL
SUBOPTIMAL (o
h, and CRAP!)
(oh, a
nd CRAP!) TREATMENT
TREATMENT????????
Thrombolysis is the dominant reperfusion strategy in UKTIMI 3 flow only achieved in 30-70% of patients30% reocclusion of the IRA in first 30 days after thrombolysisIn “real life” registries, 30% of STEMI patients ineligible for thrombolysis and total of 48% NOT thrombolysed!!
For every 50 STEMI patients treated with PPCI vs. thrombolysis:….1 life is saved and 2 other major complications (stroke or reinfarction)prevented
Requirement for revasc in group Rxed by thrombolysis is 70% at 1 year!!!
The Bottom Line About Thrombolysis
SUBOPTIMAL
SUBOPTIMAL (o
h, and CRAP!)
(oh, a
nd CRAP!) TREATMENT
TREATMENT????????
Components of My Argument
Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
Curzen 05
Strategies in Treatment of STEMIStrategies in Treatment of STEMIStrategies in Treatment of STEMIStrategies in Treatment of STEMI
Dissolve the ClotDissolve the Clot
Reduce the Inflammatory Response
Reduce the Inflammatory Response
Stent the MechanicalObstruction (stenosis)
Stent the MechanicalObstruction (stenosis)
Primary Coronary Angioplasty versus Primary Coronary Angioplasty versus Thrombolysis for Acute Myocardial Thrombolysis for Acute Myocardial
InfarctionInfarction Keeley EC, Boura JA, Grines CLKeeley EC, Boura JA, Grines CL
Primary Coronary Angioplasty versus Primary Coronary Angioplasty versus Thrombolysis for Acute Myocardial Thrombolysis for Acute Myocardial
InfarctionInfarction Keeley EC, Boura JA, Grines CLKeeley EC, Boura JA, Grines CL
Lancet 2003:361;1304-1305Lancet 2003:361;1304-1305Lancet 2003:361;1304-1305Lancet 2003:361;1304-1305
Streptokinase (n=1837)Streptokinase (n=1837)
ZijlstraZijlstra RiberioRiberio
GrinfeldGrinfeldZijlstraZijlstraAkhrasAkhrasWidimskyWidimskyde Boerde BoerWidimskyWidimsky
Fibrin Specific (n=5902)Fibrin Specific (n=5902)
DeWoodDeWood VermeerVermeerGrinesGrines AndersonAndersonGibbonsGibbons KastratiKastratiRibichiniRibichini AversanoAversanoGarciaGarcia GrinesGrinesGUSTO IIbGUSTO IIb HochmanHochmanLe MayLe MayBonnefoyBonnefoySchomigSchomig
Streptokinase (n=1837)Streptokinase (n=1837)
ZijlstraZijlstra RiberioRiberio
GrinfeldGrinfeldZijlstraZijlstraAkhrasAkhrasWidimskyWidimskyde Boerde BoerWidimskyWidimsky
Fibrin Specific (n=5902)Fibrin Specific (n=5902)
DeWoodDeWood VermeerVermeerGrinesGrines AndersonAndersonGibbonsGibbons KastratiKastratiRibichiniRibichini AversanoAversanoGarciaGarcia GrinesGrinesGUSTO IIbGUSTO IIb HochmanHochmanLe MayLe MayBonnefoyBonnefoySchomigSchomig
Primary angioplasty Primary angioplasty vs.vs. ThrombolysisThrombolysisTrials 1993 - 2002Trials 1993 - 2002
Primary angioplasty Primary angioplasty vs.vs. ThrombolysisThrombolysisTrials 1993 - 2002Trials 1993 - 2002
Primary PCI Primary PCI vs.vs. Thrombolysis ThrombolysisMMortalityortality
Primary PCI Primary PCI vs.vs. Thrombolysis ThrombolysisMMortalityortality
7.0
5.4
7.4
9.3
0
2
4
6
8
10
Perc
ent
p=0.002p=0.00295% CI 0.73 [0.06,0.86]
p=0.002p=0.00295% CI 0.73 [0.06,0.86]
PCI Lytic
p=0.003p=0.00395% CI 0.70 [0.58,0.85]
p=0.003p=0.00395% CI 0.70 [0.58,0.85]
All PatientsAll Patients No SHOCK PatientsNo SHOCK Patients
PCI Lytic
Lancet 2003;361:13-20Lancet 2003;361:13-20Lancet 2003;361:13-20Lancet 2003;361:13-20
Primary PCI Primary PCI vs.vs. Thrombolysis Thrombolysis Short Term Complications Short Term Complications
Primary PCI Primary PCI vs.vs. Thrombolysis Thrombolysis Short Term Complications Short Term Complications
8.2
0.05
2.5
1.0
14.3
1.12.0
6.8
0
4
8
12
16
Perc
ent
Lancet 2003;361:13-20Lancet 2003;361:13-20
ReinfarctionReinfarction TotalStrokeTotal
StrokeHaemorrhagic
StrokeHaemorrhagic
StrokeDeath,
reinfarction, strokeDeath,
reinfarction, stroke
p<0.0001p<0.0001
p=0.0004p=0.0004 p<0.0001p<0.0001
p<0.0001p<0.0001
Death Streptokinase Fibrin Specific
Non-fatal reinfarction Streptokinase Fibrin Specific
Stroke Streptokinase Fibrin Specific
All complications Streptokinase Fibrin Specific
Death Streptokinase Fibrin Specific
Non-fatal reinfarction Streptokinase Fibrin Specific
Stroke Streptokinase Fibrin Specific
All complications Streptokinase Fibrin Specific
Primary angioplasty Primary angioplasty vs.vs. Thrombolysis ThrombolysisType of Thrombolytic UsedType of Thrombolytic Used
Primary angioplasty Primary angioplasty vs.vs. Thrombolysis ThrombolysisType of Thrombolytic UsedType of Thrombolytic Used
0 0.5 0 1.5 2.00 0.5 0 1.5 2.0
Favours PCI Favours LyticFavours PCI Favours Lytic
Streptokinase Akhras Zwollet-PA Gibbons PAMIAccelerated t-PA RibichiniStreptokinase/t-PA AirPAMI
Streptokinase Akhras Zwollet-PA Gibbons PAMIAccelerated t-PA RibichiniStreptokinase/t-PA AirPAMI
Primary angioplasty Primary angioplasty vs.vs. Thrombolysis ThrombolysisLength of StayLength of Stay
Primary angioplasty Primary angioplasty vs.vs. Thrombolysis ThrombolysisLength of StayLength of Stay
-10 -5 0 +5 +10-10 -5 0 +5 +10
p=0.000295% CI -2.42 [-3.59,-1.25]
p=0.000295% CI -2.42 [-3.59,-1.25]
Favours PCI Favours LyticFavours PCI Favours Lytic
DaysDays
Early mortality in relation to the proportion Early mortality in relation to the proportion of patients with TIMI Grade III Flow after of patients with TIMI Grade III Flow after thrombolysis ( ) or primary PTCA ( )thrombolysis ( ) or primary PTCA ( )
Early mortality in relation to the proportion Early mortality in relation to the proportion of patients with TIMI Grade III Flow after of patients with TIMI Grade III Flow after thrombolysis ( ) or primary PTCA ( )thrombolysis ( ) or primary PTCA ( )
0
2
4
6
8
10
0 20 40 60 80 100
Patients with TIMI Grade III Flow (%)Patients with TIMI Grade III Flow (%)Grines 1996Grines 1996
11
22
33
44
5566
77
88
99
Death
(%
)D
eath
(%
)
This really This really doesdoes make a difference!! make a difference!!
Components of My Argument
Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
““Everyone is entitled to
their o
wn opinion,
Everyone is entitled to
their o
wn opinion,
but not th
eir own fa
ct”
but not th
eir own fa
ct”
Why can’t we provide a primary PCI Why can’t we provide a primary PCI service?service?
Why can’t we provide a primary PCI Why can’t we provide a primary PCI service?service?
Too few interventional cardiologistsToo few interventional cardiologistsToo little time in the cath labToo little time in the cath labGeneral medical commitmentGeneral medical commitmentPoorly developed Clinical NetworkPoorly developed Clinical NetworkDifficult geographyDifficult geographyToo few cath labsToo few cath labsInadequate ambulance serviceInadequate ambulance serviceNo ‘target’ (vis-à-vis thrombolysis)No ‘target’ (vis-à-vis thrombolysis)No money…No money…
Too few interventional cardiologistsToo few interventional cardiologistsToo little time in the cath labToo little time in the cath labGeneral medical commitmentGeneral medical commitmentPoorly developed Clinical NetworkPoorly developed Clinical NetworkDifficult geographyDifficult geographyToo few cath labsToo few cath labsInadequate ambulance serviceInadequate ambulance serviceNo ‘target’ (vis-à-vis thrombolysis)No ‘target’ (vis-à-vis thrombolysis)No money…No money…Load of B
ollocks
Load of Bollocks
Too few interventional cardiologistsToo few interventional cardiologistsToo little time in the cath labToo little time in the cath labGeneral medical commitmentGeneral medical commitmentPoorly developed Clinical NetworkPoorly developed Clinical NetworkDifficult geographyDifficult geographyToo few cath labsToo few cath labsInadequate ambulance serviceInadequate ambulance serviceNo ‘target’ (vis-à-vis thrombolysis)No ‘target’ (vis-à-vis thrombolysis)No money…No money…
If we can contort ourselves into deliveringIf we can contort ourselves into deliveringthrombolysis and then rescue PCI, I’mthrombolysis and then rescue PCI, I’msure we can manage to provide PPCIsure we can manage to provide PPCI
to the majority………. to the majority………. If If we can bewe can bebotheredbothered to plan it properly!! to plan it properly!!
If we can contort ourselves into deliveringIf we can contort ourselves into deliveringthrombolysis and then rescue PCI, I’mthrombolysis and then rescue PCI, I’msure we can manage to provide PPCIsure we can manage to provide PPCI
to the majority………. to the majority………. If If we can bewe can bebotheredbothered to plan it properly!! to plan it properly!!
Why can’t we provide a primary PCI Why can’t we provide a primary PCI service?service?
Why can’t we provide a primary PCI Why can’t we provide a primary PCI service?service?
And by the way - the old chestnut about thrombolysis for all & And by the way - the old chestnut about thrombolysis for all & then PCI isn’t looking too good at the moment, either!!!!...........then PCI isn’t looking too good at the moment, either!!!!...........
van de Werf F. European Society of Cardiology Congress 2005; September 4-7, 2005; Stockholm, Sweden.
ASSENT-4: 30-day mortality results
Outcome TNK+PCI (n=828)
PCI alone (n=838)
p
Number (%) of deaths
50 (6.0) 32 (3.8) 0.04
OOPSOOPS!!!!OOPSOOPS!!!!
ASSENT-4: In-hospital cardiac events
van de Werf F. European Society of Cardiology Congress 2005; September 4-7, 2005; Stockholm, Sweden.
Event TNK+PCI (%)
PCI alone (%)
p
Re-MI 4.1 1.9 0.01
Abrupt vessel closure 1.9 0.1 <0.001
Repeat TVR 4.4 1.0 <0.001
Pericarditis 0.7 0.1 0.07
Tamponade 0.6 0.4 0.50
Cardiac rupture 0.9 0.2 0.11
EM dissociation 1.7 1.0 0.20
Pulmonary edema 3.4 3.1 0.78
Ventricular fibrillation 5.6 3.7 0.08
OOPS!!
ASSENT-4: In-hospital stroke rates
van de Werf F. European Society of Cardiology Congress 2005; September 4-7, 2005; Stockholm, Sweden.
Outcome TNK+PCI (%)
PCI alone (%)
p
Total stroke 1.81 0 <0.001
Intracranial hemorrhage
0.97 0 0.004
Ischemic stroke 0.60 0 0.03
Hemorrhagic conversion
0.12 0 0.50
Unclassified 0.24 0 0.25
OOPS!!
ASSENT-4: Bleeding complications
van de Werf F. European Society of Cardiology Congress 2005; September 4-7, 2005; Stockholm, Sweden.
Outcome TNK+PCI (%)
PCI alone (%)
p
Any bleeding (%) 31.3 23.4 <0.001
Major bleeding (%) 5.7 4.4 0.26
OOPS!!
Why don’t we give thrombolysis & then PCI?Why don’t we give thrombolysis & then PCI?
OOPS!!
Components of My Argument
Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority Thrombolysis is a suboptimal treatment in the majorityThrombolysis is a suboptimal treatment in the majority
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
PPCI is a more effective, efficient treatment for the majority PPCI is a more effective, efficient treatment for the majority according to the evidence base according to the evidence base andand is the one that we would is the one that we would choose for ourselves or relativeschoose for ourselves or relatives
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
The arguments for not achieving PPCI in the majority in the UK areThe arguments for not achieving PPCI in the majority in the UK area reflection of a combination of complacency, apathy, ignorance, sloth anda reflection of a combination of complacency, apathy, ignorance, sloth andintellectual bankruptcy!intellectual bankruptcy!
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
It is high time we got off our arses and made this therapy availableIt is high time we got off our arses and made this therapy availableto the majority of STEMI patients in the UKto the majority of STEMI patients in the UK
European Society of Cardiology PCI GuidelinesEuropean Society of Cardiology PCI Guidelines
““PPCI should be the treatment of choice in patients presenting withPPCI should be the treatment of choice in patients presenting withPCI facility”PCI facility”
““After successful thrombolysis, the use of routine coronary After successful thrombolysis, the use of routine coronary angiography within 24 hrs and PCI, if applicable, is recommendedangiography within 24 hrs and PCI, if applicable, is recommendedeven in asymptomatic patients without demonstrable ischaemiaeven in asymptomatic patients without demonstrable ischaemiato improve outcomes.”to improve outcomes.”
European Heart Journal 2005;26:804-847
Facts About SouthamptonFacts About Southampton
2004 data: 66% of eligible STEMI patients actually thrombolysed2004 data: 66% of eligible STEMI patients actually thrombolysed
Estimated number needed to treat: 200 cases per yearEstimated number needed to treat: 200 cases per year
BUT…. These are not extra cases……….BUT…. These are not extra cases……….58% of STEMI patients underwent angiography & revasc during 58% of STEMI patients underwent angiography & revasc during index admission in 2004index admission in 2004
Current evidence shows benefit for early PCI even after thrombolysisCurrent evidence shows benefit for early PCI even after thrombolysisIf we do all of them it would only mean 1 extra case per 3 days in If we do all of them it would only mean 1 extra case per 3 days in working hrsworking hrs
Robust data support home after uncomplicated PPCI in 3 daysRobust data support home after uncomplicated PPCI in 3 daysie saves 2 bed days per patient!!ie saves 2 bed days per patient!!
If 60% of our STEMI patients have angiography & PCI already…If 60% of our STEMI patients have angiography & PCI already…Regardless of thrombolysisRegardless of thrombolysis
If ESC guidelines now recommend PPCI for If ESC guidelines now recommend PPCI for ALLALL our STEMI pts our STEMI pts
If ESC guidelines recommend angiography & PCI for even the If ESC guidelines recommend angiography & PCI for even the successfully thrombolysis treated STEMI patients within 24 hrssuccessfully thrombolysis treated STEMI patients within 24 hrs
If 70% of patients treated with thrombolysis If 70% of patients treated with thrombolysis (who don’t get in patient PCI) need angio & PCI within 1 year, (who don’t get in patient PCI) need angio & PCI within 1 year, having had further outpatient tests first………………having had further outpatient tests first………………
If PPCI patients can go home 2 days earlier than thrombolysed…If PPCI patients can go home 2 days earlier than thrombolysed…
Then to provide PCI at the time of STEMI presentation, when most Then to provide PCI at the time of STEMI presentation, when most heart muscle is saved and mortality reduced, is merely to deliver it heart muscle is saved and mortality reduced, is merely to deliver it at t=0, rather than t=HOURS, MINS and Months!!!!at t=0, rather than t=HOURS, MINS and Months!!!!
Then to provide PCI at the time of STEMI presentation, when most Then to provide PCI at the time of STEMI presentation, when most heart muscle is saved and mortality reduced, is merely to deliver it heart muscle is saved and mortality reduced, is merely to deliver it at t=0, rather than t=HOURS, MINS and Months!!!!at t=0, rather than t=HOURS, MINS and Months!!!!
What about Cost???????
STEMI with ThrombolysisSTEMI with ThrombolysisSTEMI with PPCISTEMI with PPCI
Thrombolysis:Thrombolysis:SuccessfulSuccessful
Thrombolysis:Thrombolysis:UnsuccessfulUnsuccessful
PCIPCI
STEMI
Rescue PCIRescue PCIOutpatientAngio/PCI
5 day stay 5 day stay
?100%70% 100%
*3 day stay*BETTER clinical
outcome
PPCI reduces mortality, reinfarction & heart failureThrombolysis does not address the stenosisMost patients who are thrombolysed now have angio+
PCI during their current admissionESC Guidelines suggest that almost all should70% of thrombolysed patients who go home have angio/PCI
within a year of discharge
PPCI reduces mortality, reinfarction & heart failureThrombolysis does not address the stenosisMost patients who are thrombolysed now have angio+
PCI during their current admissionESC Guidelines suggest that almost all should70% of thrombolysed patients who go home have angio/PCI
within a year of discharge
LET’S DELIVER THE BEST TREATMENT AT THE RIGHT LET’S DELIVER THE BEST TREATMENT AT THE RIGHT TIME……………….. TIME……………….. # LET US ENGAGE PROPERLY WITH COMMISSIONERS!!# LET US ENGAGE PROPERLY WITH COMMISSIONERS!!# TAKE THE CLINICAL ISSUES & OUR TRACK RECORD# TAKE THE CLINICAL ISSUES & OUR TRACK RECORDSERIOUSLY!!SERIOUSLY!!
SUMMARY
Don’t stand still in Don’t stand still in the NHS……………..the NHS……………..
And don’t be blind!And don’t be blind!
VOTE for the GOLD VOTE for the GOLD STANDARDSTANDARD
WeWe determine change! determine change!
* Not commissioners!* Not commissioners!
Don’t stand still in Don’t stand still in the NHS……………..the NHS……………..
And don’t be blind!And don’t be blind!
VOTE for the GOLD VOTE for the GOLD STANDARDSTANDARD
WeWe determine change! determine change!
* Not commissioners!* Not commissioners!
The real truth is, this is just not funny