Cath Lab Digest - February 2008 - (Page 32)

32 STEMI INTERVENTIONS FEBRUARY 2008 Sameer Mehta, MD, FACC, MBA, is studying ST-elevation myocardial infarction interventions in his work with the Primary PCI and the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) Database at 5 community hospitals in Miami, Florida, now up to 270 patients. A past chief of interventional cardiology and director of the cardiovascular laboratory at Cedars Medical Center in Miami, Dr. Mehta is also president of the IndoAmerican Society of Interventional Cardiologists (ISIC) and a course director for the Lumen-Vascular Interventions Symposium. Dr. Mehta will be commenting on the important work going on around the world as societies and their hospitals struggle to educate patients about the importance of timely intervention in STelevation myocardial infarction, and work collaboratively to decrease the time from patient arrival to intervention. Excerpt from: Chapter 19. STEMI Interventions – Future Perspectives I This month, we share an excerpt from Dr. Mehta’s upcoming Textbook of STEMI Interventions. magine a patient involved in an automobile accident on the Florida turnpike while driving from Miami to Orlando, and sustaining a laceration and a thigh fracture. Within minutes, Emergency Medical Services (EMS) will rescue and transport the patient to the closest Level 1 Trauma Center, where an expert team of trauma surgeons rushes the patient to the operating room to treat the laceration and the fracture. If all goes well, discharge from the hospital occurs on day 3; a few weeks later after a short course of rehabilitation, the patient is discharged home, and six months later, resumes his regular singles tennis schedule. This is quality care provided within the American medical system. It is made possible by a superb national trauma system which works in a coordinated fashion to triage the patient to the appropriate institution for adequate care. In contrast, let us now assume our patient is having an ST-elevation myocardial infarction (STEMI) while making the same drive. We could imagine the pain beginning early in the morning, but it was intermittent and temporarily subsided; our patient may have attributed the discomfort to his gastro-esophageal reflux and decided to continue the drive. Six hours later, as he drives on the interstate, the pain returns and becomes unbearable, and he pulls over and calls 911. Once again, EMS responds urgently, the paramedics diagnose STEMI, stabilize the patient, and transport him to the nearest ER, just off the next exit on the turnpike. It is a small, community hospital without an available cath lab nearby. In consultation with a cardiologist, the emergency room physician administers a thrombolytic agent. The patient is admitted to the 2-bed CCU and continues to have lingering pain. Table 1. Integrated U.S. STEMI Triage Models Hartford, Connecticut Model Integrated STEMI model “Hub and spoke,” pharmaco-invasive model of considerable duration — 6 years. Comprised of: 5 spoke hospitals — (no PCI ability on site) 1 hub hospital — a single, high-volume tertiary center with highly experienced interventional cardiologists available for 24/7 PCI. 1,560 consecutive PCI patients triaged into the hub and spoke model, with 60% first coming into contact at the “spoke” hospital. First cohort of 808 patients (2000-2003) demonstrated inefficiencies of transfer system: Group A: Initial presentation at “spoke” and received bolus fibrinolytic and GP2B/3A — 30-day mortality 1.6%. Group B: Presentation at “hub” and proceeded to primary PCI, mortality 1.7%. Group C: Presentation at “spoke” with transfer without fibrinolytic to “hub” for primary PCI, ischemic time 241 min. and mortality 5.5%. Minneapolis Heart Institute Foundation The Mayo Clinic STEMI Protocol Experience Probably the most relevant model for future Integrative STEMI, pharmaco-invasive, systems: facilitative PCI, modified hub and spoke Pharmaco-invasive, hub and spoke model model program Exceptional efficiency with both the invasive Relevant for developing STEMI triage mod- (D2B times) strategy and fibrinolytic (doorels, particularly for providing coverage for to-needle times) strategy. large geographic areas. Complies completely with current AHA/ACC guidelines Modeled on the Trauma System Between May 2004 – Dec 2006: Excellent pilot project. Rapid transfer of 597 STEMI patients were treated at the STEMI patients from community hospitals hub (St. Mary’s Hospital) and 28 regional up to 210 miles from a PCI center using a hospitals. standardized protocol with an integrated Group A: 258 patients who presented to the transfer system. Hub and were treated with PPCI. Group B: 105 patients who presented to a Between March 2003 – Nov 2006: regional hospital with symptom onset >3 1345 consecutive STEMI patients were hours and were transferred for PPCI. treated, including 1048 transferred from Group C: 131 patients that presented to a non-PCI hospitals. regional hospital with onset <3 hours and Median door-to-balloon time for Zone 1 were treated with full-dose fibrinolytic (<60 miles) was 95 min and for Zone 2 (60- therapy. 120 miles) was 120 min. Despite high-risk population, the program D2B time: Group A, 71 min. had exceptional results: D2B time: Group B, 116 min. In-hospital mortality: 4.2% and length of Door-to-needle time: Group C, 25 min. stay of 3 days. 1. Henry TD, Sharkey SW. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation 2007;116:721–728. 2. Bradley EH, Herrin J, Wang Y, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med 2006;355:2308–2320. 3. Rathore SS, Epstein AJ, Volpp KG, Krumholz HM. Regionalization of care for acute coronary syndromes: more evidence is needed. JAMA 2005;293:1383–1387.

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Cath Lab Digest - February 2008 Bay Regional Medical Center ENDEAVOR IV: A Zotarolimus-Eluting Stent Versus a Paclitaxel-Eluting Stent in a Randomized Clinical Trial A 3D CT Vessel “Roadmap” Over Live Fluoroscopy for Chronic Total Occlusions Contents Clinical Editor’s Corner An Evaluation of Cath Lab Turnaround Time Commentary: An Evaluation of Cath Lab Turnaround Time Excerpts from Chapter 19. STEMI Interventions – Future Perspectives The Potential Clinical Utility of Intravascular Ultrasound Guidance in Patients Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents The Ten-Minute Interview with…Debbie Charlton, RN The Society of Invasive Cardiovascular Professionals (SICP) at Transcatheter Cardiovascular Therapeutics (TCT) 2007 The Cath Lab is a Business: Do You Have the Knowledge to Stay Afloat? Incidence and Predictors of Vascular Complications after Invasive Coronary Procedures: A Prospective Analysis Ask the Clinical Instructor: A Q&A Column for those New to the Cath Lab Volunteer Survey SICP* Section Meetings Calendar What Do You Think? CEU Education Center Clinical & Industry News Classifieds Advertisers Index

Cath Lab Digest - February 2008

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