The Role of DHMC as an ST The Role of DHMC as an ST Elevation Myocardial Infarction Elevation Myocardial Infarction Receiving Center in a Regional Receiving Center in a Regional

STEMI Care Network:STEMI Care Network:

Nathaniel Niles, MDNathaniel Niles, MDCREST SymposiumCREST SymposiumNovember 7th, 2008November 7th, 2008

STEMI = Acute Coronary ThrombosisSTEMI = Acute Coronary Thrombosis

STEMI STEMI (ST elevation Myocardial Infarction)(ST elevation Myocardial Infarction)

•• Relatively commonRelatively common•• Multiple treatment Multiple treatment

strategy optionsstrategy options•• Requires coordinationRequires coordination

•• MultidisciplinaryMultidisciplinary•• EMSEMS•• Emergency MedicineEmergency Medicine•• CardiologyCardiology

•• InterhospitalInterhospital•• Must be managed Must be managed

quicklyquicklyTime Time ~ Muscle~ Muscle

Boersma E. et al. Lancet. 1996:348:771Boersma E. et al. Lancet. 1996:348:771

PrePre--Hospital DelayHospital Delay The Golden early hours:The Golden early hours:

MetaMeta--analysis on 50,246 patients in thrombolytic analysis on 50,246 patients in thrombolytic trialstrials

7

31

68

97

2

21

14

0

10

20

30

Death Non-fatalreinfarction

Total stroke Recurrentischemia

Death,reinfarction,

stroke

Primary PCI

ThrombolyticTherapy

p=0.0002p=0.0002

p=0.0003p=0.0003

p=0.0004p=0.0004

p=0.0001p=0.0001

p=0.0001p=0.0001

Freq

uenc

y (%

)Fr

eque

ncy

(%)

Thrombolytic Therapy is Inferior to PCI for Thrombolytic Therapy is Inferior to PCI for Treating STEMITreating STEMI

23 study systematic review: short23 study systematic review: short--term outcomesterm outcomes

Lancet 2003;361:13Lancet 2003;361:13--2020

7

21.3

0

89

6.9

2.5 2.45

15

0

5

10

15

20

Death Non-fatalreinfarction

Total stroke ICH Death,reinfarction,

stroke

1 PCI (n=1466) TTx (n=1443)

p=0.057p=0.057

p=0.0001p=0.0001

p=0.049p=0.049

p=0.0001p=0.0001

Freq

uenc

y (%

)Fr

eque

ncy

(%)

Transfer for PCI Transfer for PCI vsvs

OnOn--site Thrombolyticsite Thrombolytic5 study systematic review:5 study systematic review:

Lancet 2003;361:13Lancet 2003;361:13--2020

p=0.25p=0.25

Average Transfer Time Average Transfer Time 39 minutes39 minutes

oo

11oo

PCI Benefit also time dependentPCI Benefit also time dependent Mortality benefit with primary PCI as function of PCIMortality benefit with primary PCI as function of PCI--relatedrelated

time delaytime delay

P = 0.006

0 20 40 60 80 100PCI-Related Time Delay (door-to-balloon -

door-to-needle)

Abs

olut

e R

isk

Diff

eren

ce in

Dea

th (%

)A

bsol

ute

Ris

k D

iffer

ence

in D

eath

(%)

-50

510

15

Circle

sizes

=

sample size of the individual study.

Solid line

=

weighted meta-regression.

Nallamothu BK, Bates ER.

Am J Cardiol. 2003;92:824-6

62 min62 min Benefit

Favors PCI

Benefit

Favors PCI

Harm

Favors Lysis

Harm

Favors Lysis

II IIaIIa IIbIIb IIIIII

STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal (Level of Evidence: A)

STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center and undergo PCI within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless contraindicated. (Level of Evidence: B)

STEMI Guidelines (2007)STEMI Guidelines (2007)

Regional STEMI Care NetworkRegional STEMI Care Network RationaleRationale

•• PCI is > thrombolytic therapyPCI is > thrombolytic therapy•• Transfer for PCI > onTransfer for PCI > on--site site fibrinolyticfibrinolytic

therapytherapy•• Death during transfer rare Death during transfer rare

•• US Guidelines: D2B US Guidelines: D2B ≤≤90 minutes90 minutes•• Only ~ 25% acute care hospitals in the US are PCI capable and evOnly ~ 25% acute care hospitals in the US are PCI capable and even en

fewer have 24/7 fewer have 24/7 cathcath

labslabs•• Hospital Hospital ““specializationspecialization””

on primary PCI on primary PCI →→

faster treatment and lower faster treatment and lower mortalitymortality

SoSo……What once could be treated locally (What once could be treated locally (TtxTtx

can be given at any hospital) now can be given at any hospital) now requires a regional network around a PCI Center to diagnose STEMrequires a regional network around a PCI Center to diagnose STEMI I get the patient rapidly to PCIget the patient rapidly to PCI

MoreoverMoreover……•• Trauma center systems have been successfulTrauma center systems have been successful•• Formalization of regional networks will better enable payers to Formalization of regional networks will better enable payers to track track

quality (treatment times) and structure incentivesquality (treatment times) and structure incentives

DHMC Position in the SystemDHMC Position in the System

STEMISTEMIPatientPatient

STEMISTEMIPatientPatient

STEMISTEMIPatientPatient

STEMISTEMIPatientPatient

EMSEMS

Primary PCIPrimary PCI--Capable HospitalCapable HospitalDHMCDHMC

LocalLocal

Non PCINon PCI--Capable HospitalCapable HospitalSTEMI Referral HospitalSTEMI Referral Hospital

RemoteRemote

Non PCINon PCI--Capable HospitalCapable HospitalSTEMI Referral HospitalSTEMI Referral Hospital

Zone 1Zone 1 Zone 2Zone 2

EDED

16%16%

~4%~4% 80%80%

DHMC EDDHMC EDPrimary PCIPrimary PCI--Capable HospitalCapable Hospital

STEMISTEMIPatientPatient

11oo

PCIPCI

Zone 1Zone 1Non PCINon PCI--Capable HospitalCapable Hospital(STEMI Referral Hospital)(STEMI Referral Hospital)

PCI avail within 90PCI avail within 90’’

11oo

PCIPCI

Reperfusion StrategyReperfusion Strategy

Zone 2Zone 2Non PCINon PCI--Capable HospitalCapable Hospital(STEMI Referral Hospital)(STEMI Referral Hospital)

PCI not avail within 90PCI not avail within 90’’

11oo

LyticLytic

TxTx

or or ½½

dose dose LyticLytic

plus GP 2b3a plus GP 2b3a

InhInh

TrfTrf

for immediate for immediate PCIPCI

TrfTrf

PharmacoPharmaco--invasiveinvasive

OutcomeOutcome PharmacoPharmaco invasive invasive

strategystrategy((½½

dose dose LyticLytic++AbciximabAbciximab+PCI for all) +PCI for all)

(%)(%)

ThrombolysisThrombolysis alonealone

((½½

dose dose LyticLytic++AbciximabAbciximab

+rescue PCI only) +rescue PCI only) (%)(%)

pp

Death/reDeath/re--MI/ MI/ refractory ischemia refractory ischemia at 30 daysat 30 days 4.14.1 11.111.1 0.0010.001

Di Mario C. European Society of Cardiology Congress 2007; September 3, 2007; Vienna, Austria.

CARESS TrialCARESS Trial

How has DHMC really performed How has DHMC really performed as a STEMI Receiving Center?as a STEMI Receiving Center?

The RegionThe Region•• Upper CT Valley, Upper CT Valley,

~60 m N and 45 m ~60 m N and 45 m S on I91 and 30S on I91 and 30--40 40 m NW or SE on m NW or SE on I89.I89.

•• 20 Referral 20 Referral HospitalsHospitals

•• Zone 1 = the local Zone 1 = the local area, APD and area, APD and VAMCVAMC

•• Zone 2 = Zone 2 = everything elseeverything else

•• ~40 Ambulance ~40 Ambulance servicesservices

•• 2 Helicopters 2 Helicopters based at DHMCbased at DHMC

904 total registry patients from 2001904 total registry patients from 2001→→mid 2007mid 2007

891 STEMI patients891 STEMI patients

13 NSTEMI patients13 NSTEMI patients

742742Presented to regional referral hospitalsPresented to regional referral hospitals

3434Zone 1 Zone 1

(VAMC or APD)(VAMC or APD)11

Admitted to initial Admitted to initial hospital or hospital or

initially initially tfxdtfxd

elsewhereelsewhere

33 33 transferred transferred

emergently to emergently to DHMC with DHMC with

STEMISTEMI

1 1 Managed Managed

conservativelyconservatively

149149Presented Presented to DHMCto DHMC

44DHMC DHMC

inpatientsinpatients145 145 admitted with admitted with STEMI from STEMI from DHMC ERDHMC ER

9 9 Managed Managed

conservativelyconservatively

708708Zone 2Zone 2

(Other referral hospitals)(Other referral hospitals)5353

Admitted to Admitted to initial hospital initial hospital or initially or initially tfxdtfxd

elsewhereelsewhere

655 655 transferred transferred

emergently to emergently to DHMC with DHMC with

STEMISTEMI

12 12 Managed Managed

conservativelyconservatively

136 136 to to cathcath

lab lab emergentlyemergently

5 post 5 post lyticlytic131 no 131 no lyticlytic

0 0 to to cathcath

lab lab latelate

post post lyticlytic

32 32 to to cathcath

lab lab emergentlyemergently

3 post 3 post lyticlytic29 no 29 no lyticlytic

0 0 to to cathcath

lab lab latelate

post post lyticlytic

596 596 to to cathcath

lab lab emergentlyemergently

470 post 470 post lyticlytic124 no 124 no lyticlytic

47 47 to to cathcath

lab lab latelate

post post lyticlytic

DHMC STEMI RegistryDHMC STEMI Registry

Median Times Over TimeMedian Times Over Time DHMC ED STEMI PatientsDHMC ED STEMI Patients

1734

0

50

100

2001-2003 2004-2007

% o

f pat

ient

s %

of p

atie

nts ≤≤

90 m

inut

es90

min

utes

98

35

149

90

30

126

0

50

100

150

200

2001-2003 2004-2007

Door-to-tabletop

Tabletop-to-balloon

Door-to-balloon

min

utes

min

utes

Distribution among 365 hospitals studiedMedian 100.4 SD 23.5 -

April to September 2005

Bradley E et al. N Engl J Med 2006;355:2308-2320

MEDIAN DOORMEDIAN DOOR--TOTO--BALLOON TIMESBALLOON TIMES

DHMC ED STEMI PatientsDHMC ED STEMI Patients n=131n=131

10.0

3.9

0

5

10

15

2001-2003 2004-2007

ns

Years

7.9 8.2

0

5

10

15

2001-2003 2004-2007

ns

Actual 30 day Actual 30 day mortality (%)mortality (%)

TIMI score predicted TIMI score predicted 30 day mortality (%)30 day mortality (%)

DHMC ED & Zone 1 STEMI PatientsDHMC ED & Zone 1 STEMI Patients n=168n=168

10.6

4.7

0

5

10

15

2001-2003 2004-2007

ns

Years

8.0 8.4

0

5

10

15

2001-2003 2004-2007

ns

Actual 30 day Actual 30 day mortality (%)mortality (%)

TIMI score predicted TIMI score predicted 30 day mortality (%)30 day mortality (%)

Zone 2 PatientsZone 2 Patients

(STEMI Patients Transferred from (STEMI Patients Transferred from Remote Referral Hospitals)Remote Referral Hospitals)

Median Times Over TimeMedian Times Over Time Zone 2 STEMI PatientsZone 2 STEMI Patients

188

47

230176

38

231

0

50

100

150

200

250

300

2001-2003 2004-2007

Door-to-tabletopTabletop-to-balloonDoor-to-balloon)

203

47

260

179

40

223

0

50

100

150

200

250

300

2001-2003 2004-2007

Door-to-tabletop

Tabletop-to-balloon

Door-to-balloon

““IdealIdeal”” (Weekdays 7 AM to 5 PM)(Weekdays 7 AM to 5 PM)

““SuboptimalSuboptimal”” (After hours and Weekends)(After hours and Weekends)

Initial Door-to-balloon times in Transfer Patients Undergoing 1°

PCI in the US

NRMI-3/4 Analysis (1999-2002) n=4278

12%90-120 minutes

56%120-240 minutes

4% < 90 minutes 28%

>240 minutes

Circulation. 2005;111:761-767.

50% had door50% had door--toto--balloon time > 3 hoursballoon time > 3 hours

Zone 2 STEMI Emergent Transfers: Zone 2 STEMI Emergent Transfers: Median DoorMedian Door--toto--table time Q1(01)table time Q1(01)--Q2(07)Q2(07)

0

100

200

300

400

500

APDW

RJVA

Mt Ascu

tneyNew

London

VRHGiff

ordSprin

gfield

Cottage

Grace C

ottag

eNVRHRutla

ndCVHSpear

eBrat

tlebo

roLittl

eton

Cheshire

Wee

ksNCH

Andros

coggin

UCVH

2001-20032004-2007

Doo

rD

oor -- t

oto-- ta

ble

time

(min

)ta

ble

time

(min

)

HospitalHospital

Zone 2 Transfers: Helicopter Zone 2 Transfers: Helicopter vsvs

Ground Ground TransportTransport

Median DoorMedian Door--toto--table time Q1(01)table time Q1(01)--Q2(07)Q2(07)

0

100

200

300

400

500

APDW

RJVA

Mt Ascu

tneyNew

London

VRHGiff

ordSprin

gfield

Cottage

Grace C

ottag

eNVRHRutla

ndCVHSpear

eBrat

tlebo

roLittl

eton

Cheshire

Wee

ksNCH

Andros

coggin

UCVH

Helicopter (44%)Ground (56%)

Doo

rD

oor -- t

oto-- ta

ble

time

(min

)ta

ble

time

(min

)

HospitalHospital

Mean of Median differences = 69 minMean of Median differences = 69 min

STEMI Emergent Transfer Volumes STEMI Emergent Transfer Volumes Q1(01)Q1(01)--Q2(07)Q2(07)

0

10

20

30

40

50

60

70

80

90

100

Q1(01)

Q2(01)

Q3(01)

Q4(01)

Q1(02)

Q2(02)

Q3(02)

Q4(02)

Q1(03)

Q2(03)

Q3(03)

Q4(03)

Q1(04)

Q2(04)

Q3(04)

Q4(04)

Q1(05)

Q2(05)

Q3(05)

Q4(05)

Q1(06)

Q2(06)

Q3(06)

Q4(06)

Q1(07)

Q2(07)

Half Dose

Full Dose

No Lytic Given

Ukn

Per

cent

of S

TEM

I Pat

ient

sP

erce

nt o

f STE

MI P

atie

nts

Zone 2 STEMI Emergent Transfer Patients: Zone 2 STEMI Emergent Transfer Patients: By Intended DoseBy Intended Dose

30 Day Mortality30 Day Mortality

11.8

7

3.5

02468

101214161820

None Given Full Dose Half Dose

% M

orta

lity

Lytic Dose Strategy

nsp<0.0006

p=0.08

N=136N=136 N=171N=171 N=339N=339

Zone 2 STEMI Emergent Transfer Patients: Zone 2 STEMI Emergent Transfer Patients: By Intended DoseBy Intended Dose

NeuroNeuro

Complications (ICH, Total Stroke)Complications (ICH, Total Stroke)

0.74

1.5

0.59

1.21.5

2.4

0

0.5

1

1.5

2

2.5

3

3.5

4

None Given Full Dose Half Dose

ICHTotal Stroke

%

Lytic Dose Strategy

nsns

ns

Zone 2 Transfer PatientsZone 2 Transfer Patients n=641n=641

8.1

5.1

0

5

10

15

2001-2003 2004-2007

ns

Years

7.6 7.5

0

5

10

15

2001-2003 2004-2007

ns

Actual 30 day Actual 30 day mortality (%)mortality (%)

TIMI Score predicted TIMI Score predicted 30 day mortality (%)30 day mortality (%)

DoorDoor--toto--Balloon TimesBalloon TimesNonNon--

transferstransfers(PPCI)(PPCI)(min)(min)

TransfersTransfers

Zone 1Zone 1 Zone 2Zone 2No lyticNo lytic(PPCI)(PPCI)(min)(min)

No No LyticLytic(PPCI)(PPCI)(min)(min)

½½

Dose Dose LyticLytic(min)(min)

Full Dose Full Dose LyticLytic(min)(min)

DHMCDHMC 126126 151151 282282 210210 244244ANWANW 6565 9595 Not reportedNot reported 120120 --MayoMayo 7171 116116 -- Not reported

30 day Mortality30 day MortalityNonNon--

transferstransfers(PPCI)(PPCI)

TransfersTransfers OverallOverallNo lyticNo lytic(PPCI)(PPCI)

½½

Dose Dose LyticLytic

Full Full Dose Dose LyticLytic

DHMCDHMCn=395n=395

5.65.6 9.29.2 3.7*3.7* 5.65.6 5.15.1

ANWANWN=1345N=1345

4.44.4 4.64.6 5.7*5.7* -- 5.15.1

MayoMayoN=597N=597

7.27.2 7.17.1‡‡ -- 3.73.7††§§ 4.24.2

*Facilitated PCI *Facilitated PCI ††

Primary Ttx with rescue PCI if necessaryPrimary Ttx with rescue PCI if necessary‡‡

Late presenters onlyLate presenters only§§

Early presenters onlyEarly presenters only

DHMC ED & Zone 1 DHMC ED & Zone 1 --

11°°

PCI PatientsPCI Patients Early and Late DoorEarly and Late Door--toto--Balloon Times Balloon Times vsvs

::

1.7

7.2

0

5

10

15

20

0-2hours

>2hours

ns

Door-to-Balloon Time

5.6

8.8

0

5

10

15

20

0-2hours

>2 hours

0.02

30 Day Mortality 30 Day Mortality (%)(%)

TIMI Risk TIMI Risk Predicted 30 Day Predicted 30 Day

Mortality (%)Mortality (%)PrePre--CathCath

Shock or Shock or IntubationIntubation

6.3

11.8

0

5

10

15

20

0-2hours

>2hours

ns

Zone 2 PCI PatientsZone 2 PCI Patients DoorDoor--toto--Balloon TimeBalloon Time

01.8

8.6

0

5

10

15

20

0-2hours

2-4hours

>4hours

.0016

Door-to-Balloon Time

55.9

8.6

0

5

10

15

20

0-2hours

2-4 hours

>4hours

0.0001

30 Day Mortality 30 Day Mortality (%)(%)

TIMI Risk TIMI Risk Predicted 30 Day Predicted 30 Day

Mortality (%)Mortality (%)PrePre--CathCath

Shock or Shock or IntubationIntubation

0

10.5

13.5

0

5

10

15

20

0-2hours

2-4hours

> 4hours

ns

Can we be satisfiedCan we be satisfied…… No!No!

•• InIn--

house D2B times are too slowhouse D2B times are too slow•• We can see a relationship between D2B time and We can see a relationship between D2B time and

30 day outcome in our overall data30 day outcome in our overall data•• Less than 20% of our patients are offered 1Less than 20% of our patients are offered 1ºº

PCI PCI

•• ICH risk of ICH risk of ½½

dose dose lyticlytic

protocol (1.5%protocol (1.5%--

in our in our hands too high?)hands too high?)

•• A STEMI Center Certification Program is in the A STEMI Center Certification Program is in the works (Criteria for eligibility will likely be based on works (Criteria for eligibility will likely be based on treatment times and volumes as well as quality treatment times and volumes as well as quality outcomes)outcomes)

•• PayPay--forfor--performance reimbursement strategies performance reimbursement strategies are here or comingare here or coming

ST

Elevation MI Process UpgradeSTEP UP Project

Obtain commitment of DHMC Senior managementForm a multidisciplinary group with members from Cardiology, Emergency medicine, EMS, Communications, CCU, Cardiac Cath Lab, DHMC administration and Quality managementIdentify/develop and implement strategies which improve the process of care, treatment times and outcomes of STEMI patients within our hospital and within our region

STEP 1 STEP 1 --

Get OrganizedGet Organized

STEP UP

Project: Goals1.

Implement proven strategies for reducing Door-

to-balloon time to < 90 min in > 75% of STEMI patients

2.

Design a STEMI pre-hospital triage network for the purpose of providing timely primary angioplasty to STEMI patients from an enlarged geographic area around DHMC

3.

Critically assess our current inter-hospital transfer system including the current facilitated PCI program in order to identify process/protocol improvements

D2B: An Alliance for Quality D2B: An Alliance for Quality EvidenceEvidence--based Strategies based Strategies for reducing Door-

to-balloon time to < 90 min in > 75% of STEMI patients

1.1.

ED physician activates the cath labED physician activates the cath lab2.2.

One call activates the cath labOne call activates the cath lab

3.3.

CathCath

lab team ready in 20lab team ready in 20--30 minutes30 minutes4.4.

Prompt data feedbackPrompt data feedback

5.5.

TeamTeam--based approachbased approach6.6.

PrePre--hospital ECG to activate the hospital ECG to activate the cathcath

lab*lab*

STEP 2 STEP 2 --

Improve InImprove In--house D2Bhouse D2B

STEMI Patients Presenting to DHMC EDSTEMI Patients Presenting to DHMC ED QC Chart D2B Individual MeasurementsQC Chart D2B Individual Measurements 20012001--2008(Q3)2008(Q3)

0

50

100

150

200

250

300

350

400

450

141

64

May 1May 1stst

20082008

357

166

0

25

50

75

100

1stQtr'01

2ndQtr'01

3rdQtr'01

4thQtr'01

1stQtr'02

2ndQtr'02

3rdQtr'02

4thQtr'02

1stQtr'03

2ndQtr'03

3rdQtr'03

4thQtr'03

1stQtr'04

2ndQtr'04

3rdQtr'04

4thQtr'04

1stQtr'05

2ndQtr'05

3rdQtr'05

4thQtr'05

1stQtr'06

2ndQtr'06

3rdQtr'06

4thQtr'06

1stQtr'07

2ndQtr'07

3rdQtr'07

4thQtr'07

1stQtr'08

2ndQtr'08

3rdQtr'08

STEMI Patients Presenting to DHMC EDSTEMI Patients Presenting to DHMC ED % D2B % D2B ≤≤

90 min by Quarter90 min by Quarter

On line with D2B Strategies May 1On line with D2B Strategies May 1stst

20082008

>75% >75% ≤≤90 min Target!90 min Target!

%%

STEP 3 Expanding EMS STEP 3 Expanding EMS →→ DHMC systemDHMC system

•• ↑↑

EMS 12 lead ECG EMS 12 lead ECG capability (Medtronic capability (Medtronic grant)grant)

•• EMS checklist to EMS checklist to establish candidacy for establish candidacy for 11ºº

PCI and collect QI dataPCI and collect QI data

•• CathCath

Lab activation Lab activation based on ECG in the field based on ECG in the field (automated reading)(automated reading)

•• ““Destination protocolsDestination protocols””

for local ED bypass and for local ED bypass and transport directly to transport directly to DHMC DHMC CathCath

LabLab

Goal = 35 miles up and down I91 and I89

Strategies

•• ECG within 10 minutes of ECG within 10 minutes of arrival for all Suspected arrival for all Suspected STEMI patientsSTEMI patients

•• EMS transported patients EMS transported patients remain on stretcher for ECG remain on stretcher for ECG and transfer decisionand transfer decision

•• Doc, Nurse, Scribe Doc, Nurse, Scribe Checklists to allow parallel Checklists to allow parallel workflow and QI data workflow and QI data feedback systemfeedback system

•• Zone 1 ED Physician Zone 1 ED Physician activates activates cathcath

lab if lab if transport is immediately transport is immediately available. available.

•• Response to Response to interhospitalinterhospital

STEMI transfer based on 9STEMI transfer based on 9--11--

1 system rather than 1 system rather than ““next next available ambulanceavailable ambulance””

STEP 4 Expanding Zone 1STEP 4 Expanding Zone 1

Shorten Shorten ““inin--doordoor--outout--doordoor””

time at presenting hospitaltime at presenting hospital

Zone 1 Option Zone 1

Goal = 20Goal = 20--25 min.25 min.

Strategy

Rethink the Zone 2 StrategyRethink the Zone 2 Strategy

•• Continue the Facilitated PCI option?Continue the Facilitated PCI option?•• Selected patients only?Selected patients only?•• Change Change lyticlytic

regimen?regimen?

STEP 5STEP 5

√√

YesYes

√√

NoNo

√√

YesYes

The The PharmacoPharmaco--invasive Option for Zone 2 Patientsinvasive Option for Zone 2 Patients Alternative RegimensAlternative Regimens

½½

dose dose LyticLytic

plus GP plus GP 2b3a inhibitor plus low 2b3a inhibitor plus low dose heparin infusion dose heparin infusion followed by PCI ASAPfollowed by PCI ASAP

ProsPros ProsProsSuperior to Superior to ““StandStand--alonealone””

lyticlytic

TxTx

in in CARESS TrialCARESS Trial

Superior to Superior to ““StandStand--alonealone””

lyticlytic

TxTx

in in TRANSFER AMI and CAPITAL AMI TRANSFER AMI and CAPITAL AMI TrialsTrials

Benefits early presentersBenefits early presenters Benefits early presentersBenefits early presentersWe have good mortality track recordWe have good mortality track record Simpler / QuickerSimpler / Quicker

ConsCons ConsConsIncreased bleeding/ICH in our handsIncreased bleeding/ICH in our hands More Bleeding / ICH riskMore Bleeding / ICH risk

Not guideline compliantNot guideline compliantComplex and time consumingComplex and time consuming

Full dose Full dose lyticlytic

and and clopidogrelclopidogrel

plus low plus low

dose heparin bolus dose heparin bolus followed by PCI ASAPfollowed by PCI ASAP

Questions?Questions?