Heart Attack Centres:

Every Network Should Have (at least) One

Dr Rod Stables

The Liverpool Heart and Chest Hospital

The Key Role of the Network

• Local problems - unique circumstances

PCI in Acute Coronary Syndromes

• Growing proportion of the PCI caseload

• Most positive clinical impact - prognosis / cost

• Non-ST elevation ACS - high risk

• More prevalent - 3 x

• Adverse prognosis

• Possible shift to earlier PCI intervention

• The provision of Primary PCI in ST MI

Lessons From NIAPP

• Recognition and appreciation of the pioneersSouth Tees Primary Angioplasty Service

(Middlesbrough & Durham) West Yorkshire Primary PCI Service

(Leeds)Primary PCI for Greater Manchester

(Manchester Royal Infirmary & Wythenshawe Hospitals)Royal Devon and Exeter Primary Angioplasty Project

(Exeter) West London Primary Angioplasty Service

(Hammersmith, St Mary’s & Harefield Hospitals) BAL Direct AMI service

(Barts and the London) South East London Primary Angioplasty Pilot

(Kings)

Lessons From NIAPP

• Performance requires ‘system change’ approach

• Performance determines ‘quality’

• Quality determines patient outcome

• High quality PPCI is VERY hard to deliver

• Creation of the optimum service will be demanding

PCI Advantage May be Time Dependent

00

-5-5

55

1010

1515

00 2020 4040 6060 8080 100100

PCI related time delay (mins)

Absolute difference in 4 – 6 week mortality %

Circles reflect trial sample sizeBlue line: weighted meta-regression

Nallamothu & Bates, Am J Cardiol 2003;92:824

Door to Balloon Time and Outcome in NIAPP

Mortality with increasing Door to Balloon times

0

2

4

6

8

10

12

14

16

18

20

Under 30mins

30-60mins

60-90mins

90-120mins

120-150mins

150-180mins

Over 180mins

Per

cen

tag

e m

ort

alit

y

In hospitalmortality

30 daymortality

1 yearmortality

Performance Reality ?

• NIAPP - not universal 24/7 service

• PPCI rates per million below expectation

• Reduced ‘out of hours’ activations

• Median door to balloon times variable

• Acceptable only in minority

• Leeds 24/7 service - first year experience

• Median door to balloon time = 98 minutes

Clin Med 2008;8:259-263

The Complete 24/7 Service

• Meeting the door to balloon standard

• >95 % within 90 minutes Median 45 minutes

• Direct to lab 24/7

• Resident on call ?

• Substantial human resource implications

• Non-medical workforce

• Migration to ‘routine hours only’ services

• Rotas with lots of bodies - big centres

Heart Attack Centres

• Critical mass - human and material resource

• Single catheter lab ?

• Two in-house operators ?

• Support for the sickest patients

• On site - shift - cardiology SpR and SHO

• Cardiothoracic anaesthetists and ICU

• Cardiothoracic surgery

• Case volume - The activity / outcome relationship

Volume and Outcome in Infarct PCI: ALKK Registry

4.41

3.97

3.182.78

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Mo

rtality (%)

4-166 196-323 327-520 521-2204

Zahn R et al, Heart 2008;94:329-35Zahn R et al, Heart 2008;94:329-35

Conclusions

• Acute coronary syndromes -

• Next growth area in PCI

• Substantial improvement in outcomes

• Magnitude of gain is quality dependent

• Optimum quality is very difficult to achieve

• Challenge convention ways of working

• Resource intensive

• Best performed in dedicated Heart Attack centres

Questions and Discussion