1. Regional AMI Care: Bridging the Rural Health Care Gap Darren B. Bean, MD University of Wisconsin Emergency Medicine/Medflight Director UW Level 1 Heart Attack Program

2. Historical Perspective 1960’s Bedrest for 3 to 4 weeks Morphine sulfate 1970’s Coronary care units Intra-aortic balloon pump CABG surgery In-hospital mortality: 15% In-hospital mortality: 30%

3. 1980’s Concept of Coronary thrombosis

4. Frequency of Arterial Occlusion in Acute MI 1268257 57 * ** N N 0-4 4-6 6-12 12-24 100 80 60 40 20 100 80 60 40 20 Hours of Chest Pain Percent Total Occlusion *p<0.05 **p<0.01 DeWood, et al. N Engl J Med 1980;303:897

5. 1980’s The Revolution Begins: Thrombolytics Race for the ‘holy grail’

6. 1988: ISIS-2 Cumulative Vascular Mortality 0714212835 0 100 200 300 400500Days Lancet 1988;2:342 SK and Aspirin SK Aspirin Placebo N=17,187 13.2% 10.7% 10.4% 8.0%

7. Complication of Thrombolytics

8. 0.5 0.9 0.6 0.9 0.6 0.7 0.9 1.1 0.9 0.6 0 1 2 3 4 5 ICH in Major AMI Trials GUSTO III % of Patients ASSENT II GUSTO V t-PAr-PAt-PATNKr-PA Abx +  r-PA SKt-PA p = NS n-PAt-PA InTIME II p = 0.004p = 0.03 GUSTO I 1997-19991999-2001 1995-1997 1997-1998 1990-1993 Fibrinolytic Trial Experience

9. Thrombolytic Therapy: Benefit 30 % relative risk reduction in short term mortality (7-10%) 30 % relative risk reduction in short term mortality (7-10%) Benefit persists >10 years Benefit persists >10 years Despite benefit, up to 1/3 of STEMI patients receive no reperfusion therapy Despite benefit, up to 1/3 of STEMI patients receive no reperfusion therapy Fear of bleeding complication Fear of bleeding complication

10. Thrombolytic Therapy: Limitations 20% fail to restore vessel patency 20% fail to restore vessel patency 40-50% fail to restore TIMI 3 flow 40-50% fail to restore TIMI 3 flow 10-15% re-occlusion rate 10-15% re-occlusion rate 0.5-1% rate of intracranial hemorrhage 0.5-1% rate of intracranial hemorrhage

11. Angioplasty (PCI) Andreas Gruentzig 1977 Andreas Gruentzig 1977 >1,000,000 PCI procedures in US annually >1,000,000 PCI procedures in US annually >2,000,000 performed worldwide annually >2,000,000 performed worldwide annually

12. PTCA in Acute MI Definitions Primary (Immediate) - Initial strategy Primary (Transfer) Salvage (Rescue) - Thrombolytic failure Elective - Recurrent ischemia post-MI

13. Is primary angioplasty superior to thrombolysis? YES - if the right conditions exist: 1) Performed quickly 2) Experienced operator 3) High volume cardiac center

15. Thrombolytics: Clot age predicts reperfusion rate Very effective in fresh clot Very effective in fresh clot Up to 25% may fully abort if administered <1hr symptom onset Up to 25% may fully abort if administered <1hr symptom onset After 120 minutes dramatic fall in reperfusion rates After 120 minutes dramatic fall in reperfusion rates Mortality benefit dependent on TIMI 3 flow!! Mortality benefit dependent on TIMI 3 flow!!

17. Transfer for PCI: European Experience

18. High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs 5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs 5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs Lytic therapy Front-loaded tPA 100 mg (n=782) Lytic therapy Front-loaded tPA 100 mg (n=782) Death / MI / Stroke at 30 Days DANAMI-2: Study Design Primary PCI with transfer (n=567) Primary PCI with transfer (n=567) Primary PCI without transfer (n=223) Primary PCI without transfer (n=223) Stopped early by safety and efficacy committee

19. Lytic Primary PCI P=0.35 Death DANAMI-2: Results Lytic Primary PCI P=0.15 Stroke Lytic Primary PCI P<0.0001 Recurrent MI

21. Mean time to treatment delayed 44minMean time to treatment delayed 44min

22. Risk associated with helicopter transfer?

24. Have we been able to reproduce the European experience?

25. US Performance 2002: NRMI 4 NRMI 4 Transfer-In Annual Data Report 2002 Door to ECG. Door to ECG. ECG to Cath Lab Arrival ECG to Cath Lab Arrival Cath Lab to Balloon. Cath Lab to Balloon. 8 8 137 39 Door to Balloon: 198 minutes (25 th : 137; 75 th : 281) Gibson CM, 2002 1,292 patients Percent < 90 Min.: 4.8%

26. Re-examining the door to balloon inflation window How long is too long for primary PCI assuming door to needle (lytic) of 30 min? How long is too long for primary PCI assuming door to needle (lytic) of 30 min? Recent ACC/AHA guidelines reduce door to balloon inflation time to 90 min (including transferred patients) Recent ACC/AHA guidelines reduce door to balloon inflation time to 90 min (including transferred patients)

27. Nallamothu et al, Am J Cardiol 2003 Absolute Difference Risk of Death (%) 5 -5 10 304050607080 Time in Minutes Favors PCI Favors Lytic - 13 RCT’s - 5495 patients - P=0.04

28. Transfer for Primary PCI Mortality benefit of primary PCI exists when treatment is delayed no more than 60min Mortality benefit of primary PCI exists when treatment is delayed no more than 60min Relative risk of death increase 1.08 for every delay in 30 min from symptom onset to restoration of TIMI 3 flow Relative risk of death increase 1.08 for every delay in 30 min from symptom onset to restoration of TIMI 3 flow

29. ‘Let’s go get a Starbucks’

30. Regionalized Cardiac Care “Golden Hour” “Ultra-Aggressive” Trauma Model “Ultra-Aggressive” Trauma Model Alliance between regional EMS, referral centers, air-medical services, and tertiary cardiac centers. Alliance between regional EMS, referral centers, air-medical services, and tertiary cardiac centers.

31. Regionalized Cardiac System Mayo Clinic 236 patients from 28 community ED’s 236 patients from 28 community ED’s Lytics for symptoms <3 hours: Lytics for symptoms <3 hours: PPCI symptoms >3 hours PPCI symptoms >3 hours Primary Angioplasty: D2B 116 min (12% <90min) Lytics: 36% required rescue PCI No deaths in transfer

32. Regionalized Cardiac System Minneapolis 1345 patients from 30 Referral centers 1345 patients from 30 Referral centers Mileage determined treatment: Mileage determined treatment: <60miles: PPCI <60miles: PPCI >60miles: Facilitated PCI (1/2 dose lytics) >60miles: Facilitated PCI (1/2 dose lytics) A Regional System to Provide Timely Access to Percutaneous Coronary Intervention; Henry et al; Circulation, Aug 2007: 116 (7)

33. Regionalized Cardiac System Minneapolis <60 miles <60 miles D2B 95min (25 th 82min, 75 th 116min) D2B 95min (25 th 82min, 75 th 116min) >60 miles >60 miles D2B 120min (25 th 100min, 75 th 145min) D2B 120min (25 th 100min, 75 th 145min) A Regional System to Provide Timely Access to Percutaneous Coronary Intervention; Henry et al; Circulation, Aug 2007: 116 (7)

34. 20 40 0 ED to UW Call Received

35. Transfer Process

36. Cath lab Helicopter

37. Symptom onset 911 EMS Arrival EMS Departure Community ED Arrival ECG Call UW Medflight Activation Cath lab Activation Skids up Medflight Arrival Medflight Departure UW Arrival Cath lab Arrival Balloon Inflation Variable target intervals Variable non-target intervals Fixed intervals

38. Focus on ‘Variable’ Time Intervals Community ED arrival to call received Community ED arrival to call received Call received to system activation Call received to system activation Helicopter response time Helicopter response time Helicopter ground time Helicopter ground time Arrival to balloon inflation Arrival to balloon inflation

39. Focus on ‘Variable’ Time Intervals Community ED arrival to call received Community ED arrival to call received Call received to system activation Call received to system activation Helicopter response time Helicopter response time Helicopter ground time Helicopter ground time Arrival to balloon inflation Arrival to balloon inflation Education Education Goal ECG <10 min Goal ECG <10 min UW call < 15 min UW call < 15 min

40. Focus on ‘Variable’ Time Intervals Community ED arrival to call received Community ED arrival to call received Call received to system activation Call received to system activation Helicopter response time Helicopter response time Helicopter ground time Helicopter ground time Arrival to balloon inflation Arrival to balloon inflation “Accept always” policy “Accept always” policy Community ED Physician Activates System (no filters) Community ED Physician Activates System (no filters)

41. Focus on ‘Variable’ Time Intervals Community ED arrival to call received Community ED arrival to call received Call received to system activation Call received to system activation Helicopter response time Helicopter response time Helicopter ground time Helicopter ground time Arrival to balloon inflation Arrival to balloon inflation ‘Priority dispatch’ ‘Priority dispatch’ Lift first – patient info en route Lift first – patient info en route

42. Focus on ‘Variable’ Time Intervals Community ED arrival to call received Community ED arrival to call received Call received to system activation Call received to system activation Helicopter response time Helicopter response time Helicopter ground time Helicopter ground time Arrival to balloon inflation Arrival to balloon inflation Standard medications Standard medications No IV infusions No IV infusions ED – Medflight nurse coordination ED – Medflight nurse coordination

43. Focus on ‘Variable’ Time Intervals Community ED arrival to call received Community ED arrival to call received Call received to system activation Call received to system activation Helicopter response time Helicopter response time Helicopter ground time Helicopter ground time Arrival to balloon inflation Arrival to balloon inflation Early activation Early activation

44. Build Your Team

45. Build Your Tools

46. PCI vs ‘Lyse n Load’: Mileage

47. PCI vs ‘Lyse n Load’: Symptom Duration

48. PCI vs ‘Lyse n Load’: Time Prediction Model

49. The Transfer Cocktail: What do we really need? ASA ASA Metoprolol Metoprolol Clopridogel Clopridogel Nitroglycerine Nitroglycerine Heparin/LMWH Heparin/LMWH IIb-IIIa inhibitors IIb-IIIa inhibitors Lytics Lytics

50. The Transfer Cocktail: What do we really need? ASA ASA Metoprolol Metoprolol Clopridogel Clopridogel Nitroglycerine Nitroglycerine Heparin/LMWH Heparin/LMWH IIb-IIIa inhibitors IIb-IIIa inhibitors Lytics Lytics Standard Standard

51. The Transfer Cocktail: What do we really need? ASA ASA Metoprolol Metoprolol Clopridogel Clopridogel Nitroglycerine Nitroglycerine Heparin/LMWH Heparin/LMWH IIb-IIIa inhibitors IIb-IIIa inhibitors Lytics Lytics AHA class 1 AHA class 1 No morbidity/mortality benefit in STEMI No morbidity/mortality benefit in STEMI No difference in IV/Sublingual No difference in IV/Sublingual 1” paste = 20 mcg/min 1” paste = 20 mcg/min 20-30min steady-state

52. The Transfer Cocktail: What do we really need? ASA ASA Metoprolol Metoprolol Clopridogel Clopridogel Nitroglycerine Nitroglycerine Heparin/LMWH Heparin/LMWH IIb-IIIa inhibitors IIb-IIIa inhibitors 1-2” nitro paste 1-2” nitro paste Sublingual bridge Sublingual bridge

53. The Transfer Cocktail: What do we really need? ASA ASA Metoprolol Metoprolol Clopridogel Clopridogel Nitroglycerine Nitroglycerine Heparin/LMWH Heparin/LMWH IIb-IIIa inhibitors IIb-IIIa inhibitors

54. The Transfer Cocktail: What do we really need? ASA ASA Metoprolol Metoprolol Clopridogel Clopridogel Nitroglycerine Nitroglycerine Heparin/LMWH Heparin/LMWH IIb-IIIa inhibitors IIb-IIIa inhibitors Block platelet plug Block platelet plug Increased TIMI 2-3 flow upon cath lab arrival Increased TIMI 2-3 flow upon cath lab arrival No mortality with early vs cath lab initiation No mortality with early vs cath lab initiation

55. Bottom Line Standard STEMI ‘Cocktail’ Standard STEMI ‘Cocktail’ Eliminate infusions Eliminate infusions

56. Feedback Immediate feedback to all team members: Immediate feedback to all team members: Call to community ED Call to community ED Email summary <24 hours Email summary <24 hours Monthly case reviews Monthly case reviews Quarterly reports to community hospitals Quarterly reports to community hospitals

57. Conclusion Conventional transfer system fail in STEMI patients Conventional transfer system fail in STEMI patients Helicopter transfer services are central to regional system development Helicopter transfer services are central to regional system development Assemble your team, build your ‘tool box’ Assemble your team, build your ‘tool box’

58. Conclusion Primary angioplasty: improves survival Primary angioplasty: improves survival - Particular benefit in shock/CHF/”big one” - Particular benefit in shock/CHF/”big one” Cardiac regionalization critical Cardiac regionalization critical - Maximizing cantidacy primary angioplasty - Maximizing cantidacy primary angioplasty - Rescue angioplasty (20-40% lytic failure) - Rescue angioplasty (20-40% lytic failure)

59. Cutting Edge Rural EMS integration: ‘Scene STEMI’ Rural EMS integration: ‘Scene STEMI’ ECG telemetry systems ECG telemetry systems Rural volunteer basic EMT Rural volunteer basic EMT Better PCI vs Lytic decision tool Better PCI vs Lytic decision tool Ground contingency models Ground contingency models