Primary PCI: Is it worth it? Dr Miles Dalby Consultant Cardiologist Royal Brompton

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Primary PCIIs it worth it? Dr Miles
DalbyConsultant CardiologistRoyal Brompton
Harefield NHS TrustSenior Lecturer Imperial
College
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East of England Ambulance Service
South Central Ambulance Service
Harefield
Harefield
London Ambulance Service
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Changing paradigms in Percutaneous
revascularisation
Acute MI Care DGH Non-Acute PCI Centre
Yet the evidence indicates that the greatest
clinical benefit from PCI is in the acute setting
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A 55 year old woman was at Heathrow airport
leaving for a holiday. She developed crushing
chest pain at the departure gate and an ECG
performed by paramedics demonstrated an inferior
ST elevation heart attack. She was transferred by
the London Ambulance Service direct to the
catheter laboratory at Harefield for primary
angioplasty with a door-balloon time of lt 15
minutes and an excellent clinical recovery
Thrombolysis clot busting
Primary Angioplasty
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Direct Transfer Trials N 7,739
PCI (Death/CVA/ReMI) Lysis
PCI (Death) Lysis
Maastricht PRAGUE Air-Pami CAPTIM DANAMI
2 PRAGUE 2
Transfer Trials N3750
TOTAL
Keeley et al Lancet 200336113 Dalby et al
Circulation 20031081809
RR 0.81 p0.086
RR 0.58 plt0.001
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NIAP final report Department of Health October
20th 2008
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2am Harefield Heart Attack Centre 15 minutes
after primary call
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How much back up have you got at a DGH? How much
back up have you got at a centre? Can you have
an IABP immediately if you need one? Can you
have it 24/7 365?

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Teamwork and delivering rapid reperfusion..
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Getting the in hospital logistics right
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With respect to reperfusion times Means are
skewed by long waiters Medians dont quantify
the length of long waits SD and SIQR dont
quantify long waiters Ranges include but dont
quantify long waiters None of the above allow
fair comparison None of the above easily allow
proportion analysis
NUMBER PATIENTS
90 MINS
DOOR - BALLOON TIME
M Dalby, M Roughton, C Ilsley NEJM (letter)
20073561475
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Kaplan Meier analysis has the following
strengths Shows all the data Encompasses full
range, with quantification of long waiters Allows
proportion analysis of care quality Allows fair
comparison between services
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Door to Balloon Time
gt90 treated within 45 minutes
75 treated within 30 minutes
50 treated within 20 minutes
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Myocardial Ischaemia National Audit Program
(MINAP) In June 2008 the first hospital specific
door-balloon times were reported. Harefield
Hospital was the fastest unit in the UK with a
median door-balloon time of 23 minutes
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Program roll out
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PPCI as of all PCI at Harefield
6 14 19 22 29
2009 YTD PPCI 34 of all PCI