Transcript AHA2006 Oral presentation Safety of transfer

Inter-Hospital Transfer of
High Risk STEMI Patients for
PCI is Safe and Feasible
David M. Larson , Katie M. Menssen, Scott W. Sharkey,
Marc C. Newell, Anil K. Poulose, Ivan J. Chavez, Yale L. Wang,
Barbara T. Unger, Timothy D. Henry
Minneapolis Heart Institute Foundation at Abbott
Northwestern Hospital, Minneapolis, MN
Presenter Disclosure Information
David M. Larson, MD
Inter-Hospital Transfer of High Risk ST-Segment
Elevation Myocardial Infarction Patients for Percutaneous
Coronary Intervention is Safe and Feasible
DISCLOSURE INFORMATION:
None
Background
• Primary PCI is superior to fibrinolysis for
treatment of STEMI if performed in a timely
manner at experienced centers
• Only 25% of US hospitals have PCI capability
• Recent ACC/AHA guideline recommends
transfer for PCI in high risk patients (cardiogenic
shock, Killip class ≥3), although the risk of
transfer of this group of patients has not been
well documented
ACC/AHA STEMI Guideline
Fibrinolysis generally preferred
•Invasive strategy not an option
Cath lab occupied/not available
Vascular access difficulties
No access to skilled PCI center
• Delay to invasive strategy
Prolonged transport
Door to balloon >90 minutes
>1 hour vs. lysis now
•Very early presentation
<1-2 hours from symptoms
Invasive Strategy generally preferred
• Skilled PCI center available/short delay
Operator experience 75 cases/yr
Team experience 36 PCI/yr
Door to balloon <90 minutes
• High risk from STEMI
Cardiogenic shock (age <75)
Killip  3
• Increased bleeding risk
Especially ICH
• Late presentation
>2-3 hours from symptoms
• Diagnosis in doubt
Complications During Transfer
Number of pts Exclusions
transferred
Deaths During
Transfer
V-fib During
Transfer
0
8
(n=559)
Cardiogenic shock
Mechanical ventilation
Prague 2
None
2
3
Terminal cardiogenic
shock
Problems with transport
0
2
0
2
(n=149)
Age ≥80
Cardiogenic shock
Air PAMI
Cardiogenic shock
0
0
2 (0.14%)
15 (1.1%)
Danami 2
(n=425)
Prague
(n=201)
Maastricht
(n=71)
Total
(n=1405)
Study Objective
• To assess the risk of inter-hospital transfer
of an unselected high risk cohort of STEMI
patients for primary or facilitated PCI
• With particular focus on high risk patients
including cardiogenic shock, out of
hospital cardiac arrest, advanced age,
long distance
2,500 PCI/year
Minneapolis Heart Institute/Abbott
Northwestern Hospital (ANW)
A tertiary Cardiovascular Center
in Minneapolis, MN
600 STEMI-PCI
46 Cardiologists
10 Interventional
Cardiologists
Methods
• A standardized protocol (“Level 1 MI
program”) for transfer of STEMI patients
for primary or facilitated PCI from 28 rural
and community hospitals was
implemented based on the Trauma system
concept in 2003
• Consecutive patients presenting with STelevation or new LBBB with symptoms
<24 hours were included
Methods
• No patients were excluded from transfer or
analysis including elderly, cardiogenic
shock and post cardiac arrest patients
• Extensive clinical and angiographic data
including time intervals, complications
during transfer and clinical outcomes were
entered in to a prospective registry
Results
• From 7/03 to 6/06, 861 consecutive
STEMI patients were transferred from the
emergency department for PCI from 28
non-PCI hospitals
• Transfer distances ranged from 17-210
miles
Mode of Transfer
Helicopter – 69%
Ground ALS – 31%
Zone 1 – 55 %
Zone 1 – 45 %
Zone 2 – 93%
Zone 2 – 7%
High Risk Patients
•
•
•
•
Age 80: 117 (13.5%)
Cardiogenic shock: 98 (11.4%)
Cardiac arrest (pre-transfer): 61 (7.1%)
Endotracheal intubation (pre-transfer): 44
(5.1%)
Time Intervals (median)
66
66
ANW
49
Zone 1
22
59
Zone 2
0
20
ED
33
40
Transport
60
95
21
80
ANW to Balloon
19
100
120
120
Complications During Transfer
• Cardiopulmonary arrest - 17 (2%)
• Intubation - 6 (0.7%)
• Death - 1 (0.1%)
Cardiopulmonary Arrest During
Transfer
• 15 patients transferred by helicopter
• 2 patients transferred by ground
ambulance
Cardiopulmonary Arrest
During Transfer – 17 (2%)
• Ventricular fibrillation - 12 (1.4%)
• Asystole – 4 (0.4%)
• Respiratory arrest – 1 (0.1%)
13/17 (76%) of the patients were Killip 4 pretransfer
Outcomes of Cardiac Arrest
During Transfer
• Of the 17 patients who arrested, all but 1
were resuscitated with return of
spontaneous circulation on arrival to cath
lab
• 3 died in the cath lab before PCI due to
refractory cardiogenic shock
• 2 died post PCI in hospital
• 11 discharged and alive at 30 days
Conclusion
• Transfer of STEMI patients including high risk,
unstable patients with cardiogenic shock and post
cardiac arrest from community hospitals for PCI
utilizing an established transfer protocol is safe
and effective.
• Death during transfer occurred in 0.1% similar to
previous clinical data of 0.14% despite the
inclusion of very high risk patients
• This data represents the largest reported series
to date of STEMI patients transferred for Primary
PCI