Primary PCI

National Audit Day28 Nov 2012 ‐Wrexham

Dr Stephen Dormanp

Consultant Cardiologist, MCC

Mid & West Cardiac Network lead

Primary PCI in WalesPrimary PCI in Wales

• Data period Apr 2011‐Mar 2012

• ActivityActivity

• Timings

• Procedural technique

• OutcomesOutcomes

• Length of stay

A brief history of Primary PCI

20031995 + 

A brief history of Primary PCI.....

Jan 2003Meta analysesKeeley et al 

Early European adoptersMajor

2005MCC/UH

2009/10Extende1983+

2012PPCI now availabl

24/7PPCI superior to lysis

Major European  centres begin PPCI

MCC/UHWDaytime PPCI for local popn

d to 24/7 PPCI for local popn

Case seriesSafety & efficacy of PPCI proposed

e 24/7 to most of SWales

1990 2000 2010

popn

2003 20081993+ 20112003BCS/DOH

PPCI PilotLondon Chest, 

2008UK NIAP report “PPCI is d i bl

1993+RCT’sPAMI / Zwolle“Reduced mortality & re infarction and

2011WHSCC Commissions PPCI

,RD&E, Leeds etc..

desirable, faesible & cost effective”

lower stroke rate with PTCA vs Lysis”

MIINAP 2012Reperfusion treatment for patients with a final diagnosis of STEMI

Primary PCI now makes up moremakes up more

than 95% of reperfusion treatment intreatment in

England (51% in Wales)

BCIS Audit report 2012BCIS Audit report 2012

ACTIVITYACTIVITY

STEMI in Wales – Population estimatesSTEMI in Wales – Population estimates

Population STEMI rate p.a*

N Wales 700,000 350

Mid &WestMid & West Wales 933,000 466

S th E tSouth East Wales 1300,000 650

WALES 2.93 million 1466

* Predicted hospitalised STEMI rate per annum based on 2010 BCIS audit data of 500 hospitalised STEMI’s per annum – ESC 2012 guidelines assume a predicted STEMI incidence of 660pmp

Regional Heart attack centre PPCI activityRegional Heart attack centre PPCI activity

350

250

300

214

200

250 214

2010/11

100

150 115

0

50

MCC UHW

Regional Heart attack centre PPCI activityRegional Heart attack centre PPCI activity

350337

250

300

214 220

200

250 214

2010/11

2011/12

100

150 115 2011/12

0

50

MCC UHW

Primary & Rescue PCI activity for Wales 2011/12

400

337350

400Primary PCI

Rescue PCI

220250

300

s 220

150

200

No. of case

100

150

204

1839 31

9 217

0

50

MCC UHW Glan Clywd Royal Gwent Liverpool H&C

Primary PCI per million population (pmp) by network

361

400

361

350

250

300

169200

Mid & West Wales

SE Wales

North Wales

100

150 BCIS

5450

Population sssumptions:•M&W Wales 933,000•SE Wales 1300,000 •N Wales 700,000

0Mid & West Wales SE Wales North Wales BCIS

Primary PCI per million population (pmp) by network

361

400

361341350

BCIS overall UK PPCI

250

300 BCIS overall UK PPCI rate pmp 2011 data

169200

Mid & West Wales

SE Wales

North Wales

100

150 BCIS

5450

Population sssumptions:•M&W Wales 933,000•SE Wales 1300,000 •N Wales 700,000

0Mid & West Wales SE Wales North Wales BCIS

BCIS 2011 dataBCIS 2011 data

MINAP 2011/12Reperfusion by Network

Patients having Primary PCI

n %

England: Overall 19139 95%g

Wales: Overall 528 51%

North Wales Cardiac network

16

South Wales Cardiac network

512 64%

Expansion of regional heart attack programme 2011/2012

50

35

40

45

onth MCC extend to M&W Wales regional service

25

30

35

I's per m

o

UHW extend to SE Wales regional service

15

20

o. of P

PCI

MCC

UHW

0

5

10No

0

Month

TIMINGSTIMINGS

% of PPCI cases which are Inter Hospital Transfers

77 80%90.0%

% of PPCI cases which are IHT

77.80%

60 0%

70.0%

80.0%

40.0%

50.0%

60.0%

MCC

UHW

19.8% 22.5%20.0%

30.0% Liverpool H&C

BCIS

4.1%0.0%

10.0%

MCC UHW Li l BCISMCC UHW Liverpool H&C

BCIS

DIRECT admission to PPCI centreDIRECT admission to PPCI centre

Timings DTB/CTB Direct to PPCI centreTimings – DTB/CTB Direct to PPCI centreExcluding all patients with cardiogenic Shock & ventilated patients

MCC UHW LHC BCIS 2011 data

Median Door to Balloon 46 50 30time (DTB)

% of DTB < 90 minutes 84% 88% 100% Mean 91%90 minutesMedian Call to Balloon 106 116 107

(CTB)% of CTB < 150 mins 84% 89% 50% Mean 81%150 mins

Direct & Interhospital transfersDirect & Interhospital transfers

Timings Direct & IHT DTB/CTBTimings ‐ Direct & IHT  DTB/CTBExcluding all patients with cardiogenic Shock & ventilated patients

MCC UHW LHC BCIS 2011 datadata

Median Door to Balloon 43 mins - 30 minstime (DTB)

% of DTB < 90 i t 85.9% - 89.50% Mean

91 9%90 minutes 85.9% 89.50% 91.9%Median Call to Balloon 108 mins - 230 minsto Balloon (CTB)

108 mins - 230 mins

% of CTB < 80 5% 28 90% Mean 150 mins 80.5% - 28.90% 80.4%

MINAP 2012 – PPCI in hospitals in England & Wales

PROCEDURAL TECHNIQUEPROCEDURAL TECHNIQUE

Primary PCI as a % of total PCI centre activity

35%

PPCI as a % of total PCI activity

25%

30%

20%

25%

10%

15%

5%

0%

MCC UHW Glan Clywd Liverpool H&C BCIS

% of PPCI cases using DES% of PPCI cases using DES% of cases using DES

59.4 59.560 0

70.0

% of cases using DES

45.450.0

60.0

35

30.0

40.0

1120.0

30.0

11

0.0

10.0

MCC UHW Glan Clwyd LHC BCIS

% of PPCI cases using any GPIIbIIIa% of PPCI cases using any GPIIbIIIa% of cases using any GPIIbIIIa

60.0

% of cases using any GPIIbIIIa

40.0

50.0

30.0

40.0

20.0

0.0

10.0

0.0

MCC UHW Glan Clwyd LHC BCIS

% of PPCI cases using Bivalirudin% of PPCI cases using Bivalirudin100 0

80.0

90.0

100.0

60.0

70.0

40.0

50.0

10 0

20.0

30.0

0.0

10.0

MCC UHW Gl LHC BCISMCC UHW Glan Clwyd

LHC BCIS

% of PPCI cases using Prasugrel% of PPCI cases using Prasugrel90 0

70 0

80.0

90.0

50 0

60.0

70.0

30 0

40.0

50.0

20.0

30.0

0.0

10.0

MCC UHW Glan Clwyd LHC BCIS

% of PPCI cases using Radial access% of PPCI cases using Radial access% of cases using Radial access

90.0

100.0

% of cases using Radial access

60.0

70.0

80.0

40.0

50.0

60.0

10 0

20.0

30.0

0.0

10.0

MCC UHW Glan Clwyd LHC BCIS

BCIS figure applies to all PCI’s as no PPCI specific data available

y

OUTCOMESOUTCOMES

MINAP 2012 OutcomesMINAP 2012 ‐ Outcomes

Procedural success – TIMI3 flow (% of all cases)

92.1 92.3 94.4 91.290.0

100.0

75

60 0

70.0

80.0

40 0

50.0

60.0

20.0

30.0

40.0

0.0

10.0

n.b Procedural success not recorded for 20% of Glan Clwyd cases

MCC UHW Glan Clwyd LHC BCIS

PPCI 30 day mortality including shock & ventilated cases

7.0%

30 day mortality

5.0%

5.8%

5.0%

6.0%

4.2%

3.5%

3 0%

4.0%

5 0%

2.0%

3.0%

0%0.0%

1.0%

MCC UHW Glan Clwyd LHC BCIS

PPCI 30 day mortality ‐ Excluding Cardiogenic shock & Ventilated patients

2.80%3.00%

30 day mortality

2.40%

2.00%

2.50%

1.50%

2.00%

0.50%0 50%

1.00%

0%0.00%

0.50%

MCC UHW LHC BCIS

Length of stayLength of stay

Median length of stay in PCI centreg y(Excludes shock & ventilated patients)

44

4.5

Median Length of stay (days)

2.83

3.5

4

2

2.5

2

2.5

3

1

1.5

0

0.5

UHW data includes CABG/ICD etc but excludes repatriated patients

MCC UHW LHC BCIS

AcknowledgmentsAcknowledgments

• Andrea Beniamous / Stephen Morris – MCC

• Tim Kinnaird – UHWTim Kinnaird  UHW

• Paul Das / Richard Cowell – N Wales

ConclusionsConclusions

• Regional expansion of Morriston & UHW PPCI programmes has led to a substantial increase in the PPCI activity in the S Wales cardiac network

• N Wales network continues to rely predominantly on a lysis based reperfusion service which is at odds a ys s based epe us o se ce c s a oddswith the UK trend

• Quality & Outcome data for both Welsh Regional PPCI programmes is in line with published nationalPPCI programmes is in line with published national standards