Title: Acute Myocardial Infarction: Results of the DHMC Regional Registry Nathaniel W. Niles, MD December 6
1Acute Myocardial Infarction Results of the DHMC
Regional Registry Nathaniel W. Niles, MD
December 6, 2004Dartmouth-Hitchcock Medical
Center
2December 2001
Acute ST elevation MI is now on the DHMC ALWAYS
TAKE list
For Age75 increased risk of ICH, consider
Primary PCI if Call-to-table time Primary thrombolytic therapy with TNK plus
enoxaparin
3DHMC STEMI Registry
- Goals
- Assess safety and effectiveness of specific novel
management strategies (facilitated PCI for
transfer patients) - Monitor regional outcomes over time in order to
assess the impact of overall quality improvement
efforts
4STEMI Registry
- Case Report Form
- Emergency Room
- Presentation (Hx/PE), ECGs, Treatment, Timing of
Treatment - Cath Lab
- TIMI Flow,Timing of reperfusion, Intervention,
Extent of CAD - Follow-up
- Death, Stroke, Recurrent MI, CHF, Bleeding
Complications, Repeat Revascularization
Procedures - Enrollment
- Initiated 12/01
- Cath lab database query
- 1/01-12/01 retrospective chart review
- 1/02-3/04 prospective chart review
- 4/04-7/04 prospective cath lab data entry
5Safety and Effectiveness of specific novel
management strategies Facilitated PCI in
Moderate to High Risk Patients Requiring Hospital
Transfer for PCIPresented at TCT 2004
6Clinical history consistent with acute myocardial
infarction and ST elevation, LBBB or anterior ST
depression consistent with acute posterior
MI N564
Presenting to DHMC or Local Hospital N 125 (22)
Presenting to Remote Hospital N 439 (78)
7Door-to-Balloon Time
Time in minutes
- Reperfusion was delayed on average more than 70
minutes among facilitated PCI strategy patients
8Pre-Cath Lab Outcomes
- Facilitated PCI strategy patients arrived at
the cath lab in more stable condition
9Cath Lab Findings and Outcomes
Initial TIMI Flow in IRA
Cath Lab Intubation or IABP
of Patients
of Patients
- Facilitated Strategy yielded more patent
arteries and was associated with less complcated
procedures
10In-hospital Outcomes
p0.025
ns
p0.098
ns
of Patients
ns
ns
ns
ns
ns
11Conclusions
Transfer for facilitated PCI
Optimal 1 PCI
vs.
- Longer delays before reperfusion (avg. 70
minutes) - But
- No greater likelihood of deterioration pre-cath
- Less likely to have ischemia in lab and had less
complicated procedures - Better initial infarct artery flow and overall
better clinical outcomes - Tended to have more bleeding problems
- But
- no increase in ICH
12Monitoring Regional Outcomes Over Time
13DHMC STEMI Transfer Volumes Q1(01)-Q2(04)
Number of STEMI Patients
14AMI Transfer Patients 01? 04 In-hospital
Mortality
Mortality
Year
15AMI Transfer Patients 01? 04In-hospital MACE
MACE
Year
Death, Recurrent MI, ICH, Repeat
revascularization
16AMI Transfer Patients In-hospital Bleeding
Complications
Year
17Possible Explanations for Improving Outcomes
- Lower risk patients now transferred
- Reduction in delays to reperfusion
- Volume effect Improved outcomes with increased
volume - Effect of half dose lytic protocol
18DHMC STEMI Mean TIMI Risk Score Q1(01)-Q2(04)
TIMI Risk Score
Composite of advanced age, CV risk factors,
hypotension, tachycardia, high Killip class, low
body weight, anterior MI location, delay in Tx
19DHMC STEMI Mean Door-to-Balloon time
Q1(01)-Q2(04)
Door-to-Balloon time (min)
Quarter
20DHMC STEMI Transfer Volumes Q1(01)-Q2(04)
Number of STEMI Patients
21AMI Transfer Patients By Intended
DoseIn-hospital Mortality
ppns
p Mortality
Lytic Dose Strategy
22AMI Transfer Patients By Intended DoseTIMI Risk
Score
p0.007
pns
pAverage TIMI Risk Score
Lytic Dose Strategy
23AMI Transfer Patients By Intended
DoseReperfusion and Facilitated Course
No lytic given
Half dose lytic
Full dose lytic
TIMI 3 Flow on Initial Angio
Persistant CP or ST elevation
Cath Lab IABP or Intubation
Clinical Deterioration Pre-Cath
24AMI Transfer Patients By Intended
DoseDoor-to-Balloon Time
p0.0001
p0.0023
p0.0164
Door-to-Balloon Time (min)
Lytic Dose Strategy
25AMI Transfer Patients 01? 04In-hospital
Mortality by Treatment strategy
Mortality
Year
26Monitoring Outcomes Over Time
- Outcomes are improving
- Explanation of improvement is unclear
- Half-dose lytic regimen
- Expidited care in half-dose group
- Hawthorne effect?
- Still Room for improvement
- Faster transfers
- Better regimens (reduce bleeding)
27DHMC STEMI RegistryConclusions
- useful in assessing the safety and efficacy of
novel management strategies for STEMI patients - useful in assessing the impact of new protocols
over time - will likely be useful for providing benchmark
data to individual institutions for QA/QCI
28DHMC STEMI RegistryLimitations
- Enrollment bias - cath lab enrollment will miss
patients who are not sent to the cath lab
emergently - Patients admitted to the initial hospital
- Patients in whom the decision is made not to cath
- Patients who die before they get to cath lab
29DHMC STEMI Registry
- Next Steps
- ER enrollment of all STEMI patients in the region
- Web-based, secure, registry interface
- On-line decision support
- Risk assessment tools
- Guidelines
- Treatment protocols
- Regular feedback to participating ERs/hospitals
- STEMI patient outcomes overall and by treatment
strategy - Process metrics (e.g. time intervals)
- Partnership in process improvement
- Novel treatment regimens
- Transfer delay reduction
- Pre-hospital triage??
30