primary pci national audit day presentation2.ppt pci - wales.pdf · primary pci national audit day...
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Primary PCI
National Audit Day28 Nov 2012 ‐Wrexham
Dr Stephen Dormanp
Consultant Cardiologist, MCC
Mid & West Cardiac Network lead
Primary PCI in WalesPrimary PCI in Wales
• Data period Apr 2011‐Mar 2012
• ActivityActivity
• Timings
• Procedural technique
• OutcomesOutcomes
• Length of stay
A brief history of Primary PCI
20031995 +
A brief history of Primary PCI.....
Jan 2003Meta analysesKeeley et al
Early European adoptersMajor
2005MCC/UH
2009/10Extende1983+
2012PPCI now availabl
24/7PPCI superior to lysis
Major European centres begin PPCI
MCC/UHWDaytime PPCI for local popn
d to 24/7 PPCI for local popn
Case seriesSafety & efficacy of PPCI proposed
e 24/7 to most of SWales
1990 2000 2010
popn
2003 20081993+ 20112003BCS/DOH
PPCI PilotLondon Chest,
2008UK NIAP report “PPCI is d i bl
1993+RCT’sPAMI / Zwolle“Reduced mortality & re infarction and
2011WHSCC Commissions PPCI
,RD&E, Leeds etc..
desirable, faesible & cost effective”
lower stroke rate with PTCA vs Lysis”
MIINAP 2012Reperfusion treatment for patients with a final diagnosis of STEMI
Primary PCI now makes up moremakes up more
than 95% of reperfusion treatment intreatment in
England (51% in Wales)
BCIS Audit report 2012BCIS Audit report 2012
ACTIVITYACTIVITY
STEMI in Wales – Population estimatesSTEMI in Wales – Population estimates
Population STEMI rate p.a*
N Wales 700,000 350
Mid &WestMid & West Wales 933,000 466
S th E tSouth East Wales 1300,000 650
WALES 2.93 million 1466
* Predicted hospitalised STEMI rate per annum based on 2010 BCIS audit data of 500 hospitalised STEMI’s per annum – ESC 2012 guidelines assume a predicted STEMI incidence of 660pmp
Regional Heart attack centre PPCI activityRegional Heart attack centre PPCI activity
350
250
300
214
200
250 214
2010/11
100
150 115
0
50
MCC UHW
Regional Heart attack centre PPCI activityRegional Heart attack centre PPCI activity
350337
250
300
214 220
200
250 214
2010/11
2011/12
100
150 115 2011/12
0
50
MCC UHW
Primary & Rescue PCI activity for Wales 2011/12
400
337350
400Primary PCI
Rescue PCI
220250
300
s 220
150
200
No. of case
100
150
204
1839 31
9 217
0
50
MCC UHW Glan Clywd Royal Gwent Liverpool H&C
Primary PCI per million population (pmp) by network
361
400
361
350
250
300
169200
Mid & West Wales
SE Wales
North Wales
100
150 BCIS
5450
Population sssumptions:•M&W Wales 933,000•SE Wales 1300,000 •N Wales 700,000
0Mid & West Wales SE Wales North Wales BCIS
Primary PCI per million population (pmp) by network
361
400
361341350
BCIS overall UK PPCI
250
300 BCIS overall UK PPCI rate pmp 2011 data
169200
Mid & West Wales
SE Wales
North Wales
100
150 BCIS
5450
Population sssumptions:•M&W Wales 933,000•SE Wales 1300,000 •N Wales 700,000
0Mid & West Wales SE Wales North Wales BCIS
BCIS 2011 dataBCIS 2011 data
MINAP 2011/12Reperfusion by Network
Patients having Primary PCI
n %
England: Overall 19139 95%g
Wales: Overall 528 51%
North Wales Cardiac network
16
South Wales Cardiac network
512 64%
Expansion of regional heart attack programme 2011/2012
50
35
40
45
onth MCC extend to M&W Wales regional service
25
30
35
I's per m
o
UHW extend to SE Wales regional service
15
20
o. of P
PCI
MCC
UHW
0
5
10No
0
Month
TIMINGSTIMINGS
% of PPCI cases which are Inter Hospital Transfers
77 80%90.0%
% of PPCI cases which are IHT
77.80%
60 0%
70.0%
80.0%
40.0%
50.0%
60.0%
MCC
UHW
19.8% 22.5%20.0%
30.0% Liverpool H&C
BCIS
4.1%0.0%
10.0%
MCC UHW Li l BCISMCC UHW Liverpool H&C
BCIS
DIRECT admission to PPCI centreDIRECT admission to PPCI centre
Timings DTB/CTB Direct to PPCI centreTimings – DTB/CTB Direct to PPCI centreExcluding all patients with cardiogenic Shock & ventilated patients
MCC UHW LHC BCIS 2011 data
Median Door to Balloon 46 50 30time (DTB)
% of DTB < 90 minutes 84% 88% 100% Mean 91%90 minutesMedian Call to Balloon 106 116 107
(CTB)% of CTB < 150 mins 84% 89% 50% Mean 81%150 mins
Direct & Interhospital transfersDirect & Interhospital transfers
Timings Direct & IHT DTB/CTBTimings ‐ Direct & IHT DTB/CTBExcluding all patients with cardiogenic Shock & ventilated patients
MCC UHW LHC BCIS 2011 datadata
Median Door to Balloon 43 mins - 30 minstime (DTB)
% of DTB < 90 i t 85.9% - 89.50% Mean
91 9%90 minutes 85.9% 89.50% 91.9%Median Call to Balloon 108 mins - 230 minsto Balloon (CTB)
108 mins - 230 mins
% of CTB < 80 5% 28 90% Mean 150 mins 80.5% - 28.90% 80.4%
MINAP 2012 – PPCI in hospitals in England & Wales
PROCEDURAL TECHNIQUEPROCEDURAL TECHNIQUE
Primary PCI as a % of total PCI centre activity
35%
PPCI as a % of total PCI activity
25%
30%
20%
25%
10%
15%
5%
0%
MCC UHW Glan Clywd Liverpool H&C BCIS
% of PPCI cases using DES% of PPCI cases using DES% of cases using DES
59.4 59.560 0
70.0
% of cases using DES
45.450.0
60.0
35
30.0
40.0
1120.0
30.0
11
0.0
10.0
MCC UHW Glan Clwyd LHC BCIS
% of PPCI cases using any GPIIbIIIa% of PPCI cases using any GPIIbIIIa% of cases using any GPIIbIIIa
60.0
% of cases using any GPIIbIIIa
40.0
50.0
30.0
40.0
20.0
0.0
10.0
0.0
MCC UHW Glan Clwyd LHC BCIS
% of PPCI cases using Bivalirudin% of PPCI cases using Bivalirudin100 0
80.0
90.0
100.0
60.0
70.0
40.0
50.0
10 0
20.0
30.0
0.0
10.0
MCC UHW Gl LHC BCISMCC UHW Glan Clwyd
LHC BCIS
% of PPCI cases using Prasugrel% of PPCI cases using Prasugrel90 0
70 0
80.0
90.0
50 0
60.0
70.0
30 0
40.0
50.0
20.0
30.0
0.0
10.0
MCC UHW Glan Clwyd LHC BCIS
% of PPCI cases using Radial access% of PPCI cases using Radial access% of cases using Radial access
90.0
100.0
% of cases using Radial access
60.0
70.0
80.0
40.0
50.0
60.0
10 0
20.0
30.0
0.0
10.0
MCC UHW Glan Clwyd LHC BCIS
BCIS figure applies to all PCI’s as no PPCI specific data available
y
OUTCOMESOUTCOMES
MINAP 2012 OutcomesMINAP 2012 ‐ Outcomes
Procedural success – TIMI3 flow (% of all cases)
92.1 92.3 94.4 91.290.0
100.0
75
60 0
70.0
80.0
40 0
50.0
60.0
20.0
30.0
40.0
0.0
10.0
n.b Procedural success not recorded for 20% of Glan Clwyd cases
MCC UHW Glan Clwyd LHC BCIS
PPCI 30 day mortality including shock & ventilated cases
7.0%
30 day mortality
5.0%
5.8%
5.0%
6.0%
4.2%
3.5%
3 0%
4.0%
5 0%
2.0%
3.0%
0%0.0%
1.0%
MCC UHW Glan Clwyd LHC BCIS
PPCI 30 day mortality ‐ Excluding Cardiogenic shock & Ventilated patients
2.80%3.00%
30 day mortality
2.40%
2.00%
2.50%
1.50%
2.00%
0.50%0 50%
1.00%
0%0.00%
0.50%
MCC UHW LHC BCIS
Length of stayLength of stay
Median length of stay in PCI centreg y(Excludes shock & ventilated patients)
44
4.5
Median Length of stay (days)
2.83
3.5
4
2
2.5
2
2.5
3
1
1.5
0
0.5
UHW data includes CABG/ICD etc but excludes repatriated patients
MCC UHW LHC BCIS
AcknowledgmentsAcknowledgments
• Andrea Beniamous / Stephen Morris – MCC
• Tim Kinnaird – UHWTim Kinnaird UHW
• Paul Das / Richard Cowell – N Wales
ConclusionsConclusions
• Regional expansion of Morriston & UHW PPCI programmes has led to a substantial increase in the PPCI activity in the S Wales cardiac network
• N Wales network continues to rely predominantly on a lysis based reperfusion service which is at odds a ys s based epe us o se ce c s a oddswith the UK trend
• Quality & Outcome data for both Welsh Regional PPCI programmes is in line with published nationalPPCI programmes is in line with published national standards