1887
Volume 2012, Issue 2
  • ISSN: 2305-7823
  • E-ISSN:

Abstract

Abstract

In this article, we outline the plans, protocols and strategies to set up the first nationwide primary Percutaneous Coronary Intervention (PCI) program for ST-elevation myocardial Infarction (STEMI) in Qatar, as well as the difficulties and the multi-disciplinary solutions that we adopted in preparation. We will also report some of the landmark literature that guided our plans. The guidelines underscore the need for adequate number of procedures to justify establishing a primary-PCI service and maintain competency. The number of both diagnostic and interventional procedures in our centre has increased substantially over the years. The number of diagnostic procedures has increased from 1470 in 2007, to 2200 in 2009 and is projected to exceed 3000 by the end of 2012. The total number of PCIs has also increased from 443 in 2007, to 646 in 2009 and 1176 in 2011 and is expected to exceed 1400 by the end of 2012. These figures qualify our centre to be classified as ‘high volume’, both for the institution and for the individual interventional operators. The initial number of expected primary PCI procedures will be in excess of 600 procedures per year. Guidelines also emphasize the door to balloon time (DBT), which should not exceed 90 minutes. This interval mainly represents in-hospital delay and reflects the efficiency of the hospital system in the rapid recognition and transfer of the STEMI patient to the catheterization laboratory for primary-PCI. Although DBT is clearly important and is in the forefront of planning for the wide primary PCI program, it is not the only important time interval. Myocardial necrosis begins before the patient arrives to the hospital and even before first medical contact, so time is of the essence. Therefore, our primary PCI program includes a nationwide awareness program for both the population and health care professionals to reduce the pre-hospital delay. We have also taken steps to improve the pre-hospital diagnosis of STEMI. In addition to equipping all ambulances to perform 12-lead electrocardiograms (ECGs) we will establish advanced wireless transmission of the ECG to our Heart Centre and to the smart phone of the consultant on-call for the primary-PCI service. This will ensure that the patient is transferred directly to the cath lab without unnecessary delay in the emergency rooms. A single phone-call system will allow the first medic making the diagnosis to activate the primary PCI team. The emergency medical system is acquiring capability to track the exact position of each ambulance using GPS technology to give an accurate estimate of the time needed to arrive to the patient and/or to the hospital. We also plan for medical helicopter evacuation from remote or inaccessible areas. A comprehensive research database is being established to enable specific pioneering research projects and clinical trials, either as a single centre or in collaboration with other regional or international centers. The primary-PCI program is a collaborative effort between the Heart Hospital, Hamada Medical Corporation and the Qatar Cardiovascular Research Centre, a member of Qatar Foundation. Qatar will be first country to have a unified nationwide primary-PCI program. This clinical and research program could be a model that may be adopted in other countries to improve outcomes of patients with STEMI.

Loading

Article metrics loading...

/content/journals/10.5339/gcsp.2012.23
2013-12-01
2019-10-22
Loading full text...

Full text loading...

/deliver/fulltext/gcsp/2012/2/gcsp.2012.23.html?itemId=/content/journals/10.5339/gcsp.2012.23&mimeType=html&fmt=ahah

References

  1. [1]. P Libby. . Current concepts of the pathogenesis of the acute coronary syndromes. . Circulation . 2001; ; 104: : 365– 372
    [Google Scholar]
  2. [2]. . , Fibrinolytic Therapy Trialists' (FTT) Collaborative Group . Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. . Lancet . 1994; ; 343: : 311– 322
    [Google Scholar]
  3. [3]. . , The GUSTO Angiographic Investigators . The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. . N Engl J Med . 1993; ; 329: : 1615– 1622
    [Google Scholar]
  4. [4]. RJ Simes,, , EJ Topol, , Holmes DR Jr, , et al. for the GUSTO-I Investigators . . Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion: importance of early and complete infarct artery reperfusion. . Circulation . 1995; ; 91: : 1923– 1928
    [Google Scholar]
  5. [5]. RH Mehta,, , KJ Harjai,, , D Cox, , et al. Primary Angioplasty in Myocardial Infarction (PAMI) Investigators . . Clinical and angiographic correlates and outcomes of suboptimal coronary flow inpatients with acute myocardial infarction undergoing primary percutaneous coronary intervention. . J Am Coll Cardiol . 2003; ; 42: : 1739– 1746
    [Google Scholar]
  6. [6]. CL Grines,, , KF Browne,, , J Marco, , et al. for the Primary Angioplasty in Myocardial Infarction Study Group . . A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. . N Engl J Med . 1993; ; 328: : 673– 679
    [Google Scholar]
  7. [7]. AM Ross, , KS Coyne, , E Moreyra , et al. . Extended mortality benefit of early postinfarction reperfusion. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Trial. . Circulation . 1998; ; 97: : 1549– 1556
    [Google Scholar]
  8. [8]. F Zijlstra., , MJ de Boer., , JC Hoorntje., , S Reiffers., , JH Reiber., , H Suryapranata. . A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. . N Engl J Med . 1993; ; 328: : 680– 684
    [Google Scholar]
  9. [9]. JM Mayer., , W Merx., , R Dörr., , H Lanbertz., , C Bethge., , S Effert. . Successful treatment of acute myocardial infarction shock by combined percutaneous transluminal coronary recanalization (PTCR) and percutaneous transluminal coronary angioplasty (PTCA). . Am Heart J . 1982; ; 103: : 132– 138
    [Google Scholar]
  10. [10]. R Zahn, , R Schiele, , S Schneider , et al. . Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry. . J Am Coll Cardiol . 2001; ; 37: : 1827– 1835
    [Google Scholar]
  11. [11]. PB Berger,, , SG Ellis, , Holmes DR Jr , et al. . Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) Trial. . Circulation . 1999; ; 100: : 14– 20
    [Google Scholar]
  12. [12]. CP Cannon., , EM Antman., , R Walls., , E Braunwald. . Time as an adjunctive agent to thrombolytic therapy. . J Thromb Thrombolys . 1994; ; 1: : 27– 34
    [Google Scholar]
  13. [13]. G De Luca., , G Biondi-Zoccai., , P Marino. . Transferring patients with ST-segment elevation myocardial infarction for mechanical reperfusion: a meta-regression analysis of randomized trials. . Ann Emerg Med . 2008; ; 52: : 665– 676
    [Google Scholar]
  14. [14]. M Busk,, , M Maeng,, , K Rasmussen, , et al., DANAMI-2 Investigators . . The Danish multicentre randomized study of fibrinolytic therapy vs. primary angioplasty in acute myocardial infarction (the DANAMI-2 trial): outcome after 3 years follow-up. . Eur Heart J . 2008; ; 29: : 1259– 1266
    [Google Scholar]
  15. [15]. P Widimsky,, , D Bilkova,, , M Penicka, , et al., PRAGUE Study Group Investigators . . Long-term outcomes of patients with acute myocardial infarction presenting to hospitals without catheterization laboratory and randomized to immediate thrombolysis or interhospital transport for primary percutaneous coronary intervention: five years' follow-up of the PRAGUE-2 Trial. . Eur Heart J . 2007; ; 28: : 679– 684
    [Google Scholar]
  16. [16]. PG Steg, , SK James, , D Atar , et al. . ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). . Eur Heart J . 2012; ; 33: : 2569– 2619
    [Google Scholar]
  17. [17]. JR Timmer,, , JP Ottervanger,, , MJ de Boer, , et al., Primary Coronary Angioplasty vs Thrombolysis-2 Trialists Collaborators Group . . Primary percutaneous coronary intervention compared with fibrinolysis for myocardial infarction in diabetes mellitus: results from the Primary Coronary Angioplasty vs Thrombolysis-2 trial. . Arch Intern Med . 2007; ; 167: : 1353– 1359
    [Google Scholar]
  18. [18]. E Boersma., , AC Maas., , JW Deckers., , ML Simoons. . Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. . Lancet . 1996; ; 348: : 771– 775
    [Google Scholar]
  19. [19]. EC Keeley., , JA Boura., , CL Grines. . Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. . Lancet . 2003; ; 361: : 13– 20
    [Google Scholar]
  20. [20]. F Van de Werf, , J Bax, , A Betriu , et al. . Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation. . Eur Heart J . 2008; ; 29: : 2909– 2945
    [Google Scholar]
  21. [21]. FG Kushner, , M Hand, , SC Smith , et al. . 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update). . J Am Coll Cardiol . 2009; ; 54: : 2205– 2241
    [Google Scholar]
  22. [22]. JH Gurwitz, , TJ McLaughlin, , DJ Willison , et al. . Delayed hospital presentation in patients who have had acute myocardial infarction. . Ann Intern Med . 1997; ; 126: : 593– 599
    [Google Scholar]
  23. [23]. AP McGinn,, , WD Rosamond,, , Goff DC Jr., , HA Taylor., , JS Miles., , L Chambless. . Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987–2000. . Am Heart J . 2005; ; 150: : 392– 400
    [Google Scholar]
  24. [24]. CP Cannon, , CM Gibson, , CT Lambrew , et al. . Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. . JAMA . 2000; ; 283: : 2941– 2947
    [Google Scholar]
  25. [25]. CJ Terkelsen, , EH Christiansen, , JT Sørensen , et al. . Primary PCI as the preferred reperfusion therapy in STEMI: it is a matter of time. . Heart . 2009; ; 95: : 362– 369
    [Google Scholar]
  26. [26]. L Lambert., , K Brown., , E Segal., , J Brophy., , J Rodes-Cabau., , P Bogaty. . Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial infarction. . JAMA . 2010; ; 303: : 2148– 2155
    [Google Scholar]
  27. [27]. BR Brodie, , GW Stone, , MC Morice , et al. . Importance of time to reperfusion on outcomes with primary coronary angioplasty for acute myocardial infarction:results from the Stent Primary Angioplasty in Myocardial Infarction Trial. . Am J Cardiol . 2001; ; 88: : 1085– 1090
    [Google Scholar]
  28. [28]. BR Brodie, , BJ Gersh, , T Stuckey , et al. . When Is door-to-balloon time critical? Analysis from the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trials. . J Am Coll Cardiol . 2010; ; 56: : 407– 413
    [Google Scholar]
  29. [29]. BR Brodie, , C Hansen, , TD Stuckey , et al. . Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms. . J Am Coll Cardiol . 2006; ; 47: : 289– 295
    [Google Scholar]
  30. [30]. G De Luca,, , H Suryapranata,, , F Zijlstra, , et al., ZWOLLE Myocardial Infarction Study Group . . Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty. . J Am Coll Cardiol . 2003; ; 42: : 991– 997
    [Google Scholar]
  31. [31]. G De Luca., , H Suryapranata., , JP Ottervanger., , EM Antman. . Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. . Circulation . 2004; ; 109: : 1223– 1225
    [Google Scholar]
  32. [32]. MR Le May, , DY So, , R Dionne , et al. . A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. . N Engl J Med . 2008; ; 358: : 231– 240
    [Google Scholar]
  33. [33]. A Carter, , S Wood, , S Goodacre , et al. . Evaluation of workforce and organizational issues in establishing primary angioplasty in England. . J Health Serv Res Policy . 2010; ; 1: : 6– 13
    [Google Scholar]
  34. [34]. HM Krumholz, , EH Bradley, , BK Nallamothu , et al. . A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: an alliance for quality. . J Am Coll Cardiol Interv . 2008; ; 1: : 97– 104
    [Google Scholar]
  35. [35]. Smith SC Jr, , EJ Benjamin, , RO Bonow , et al. . AHA/ACC secondary prevention and risk reduction therapy for patients with coronary and other vascular disease: update. . Circulation . 2011; ; 124: : 2458– 2473
    [Google Scholar]
  36. [36]. RN Piana, , GY Paik, , M Moscucci , et al. . Incidence and treatment of ‘no-reflow’ after percutaneous coronary intervention. . Circulation . 1994; ; 89: : 2514– 2518
    [Google Scholar]
  37. [37]. G Tarantini, , L Cacciavillani, , F Corbetti , et al. . Duration of ischemia is a major determinant of transmurality and severe microvascular obstruction after primary angioplasty: a study performed with contrast-enhanced magnetic resonance. . J Am Coll Cardiol . 2005; ; 46: : 1229– 1235
    [Google Scholar]
  38. [38]. GJ Dehmer, , D Weaver, , MT Roe , et al. . A contemporary view of diagnostic cardiac catheterization and percutaneous coronary intervention in the United States: a report from the CathPCI Registry of the National Cardiovascular Data Registry, 2010 Through June 2011. . J Am Coll Cardiol ;: 2012 Oct 5. [Epub ahead of print] doi: 10.1016/j.jacc.2012.08.966
    [Google Scholar]
  39. [39]. C Di Mario., , D Syrseloudis., , S James., , N Viceconte., , W Wijns. . STEMI guidelines: from formulation to implementation. . Eurointervention . 2012; ; 8: Supplement P : 11– 17
    [Google Scholar]
  40. [40]. DD McManus., , J Gore., , J Yarzebski., , F Spencer., , D Lessard., , RJ Goldberg. . Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. . Am J Med . 2011; ; 1: : 40– 47
    [Google Scholar]
  41. [41]. A Wailoo, , S Goodacre, , F Sampson , et al. . Primary angioplasty versus thrombolysis for acute ST-elevation myocardial infarction: an economic analysis of the National Infarct Angioplasty project. . Heart . 2010; ; 96: : 668– 672
    [Google Scholar]
  42. [42]. KP Morgan., , MG Leahy., , JN Butts., , KJ Beatt. . The cost effectiveness of primary angioplasty compared to thrombolysis in the real world: one year results from West London. . EuroIntervention . 2010; ; 6: : 596– 603
    [Google Scholar]
  43. [43]. J Al Suwaidi, , K Al Habib, , N Asaad , et al. . Immediate and one-year outcome of patients presenting with acute coronary syndrome complicated by stroke: findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2). . BMC Cardiovasc Dis . 2012; ; 12: : 64 http://www.biomedcentral.com/1471-2261/12/64
    [Google Scholar]
  44. [44]. R Jirmár., , P Widimský., , J Capek., , O Hlinomaz., , L Groch. . Next day discharge after successful primary angioplasty for acute ST elevation myocardial infarction. An open randomized study “Prague-5”. . Int Heart J . 2008; ; 6: : 653– 659
    [Google Scholar]
  45. [45]. G Veen., , MJ de Boer., , F Zijlstra., , FW Verheugt. . Improvement in three-month angiographic outcome suggested after primary angioplasty or acute myocardial infarction (Zwolle trial) compared with successful thrombolysis (APRICOT trial). Antithrombotics in the Prevention of Reocclusion In COronary Thrombolysis. . Am J Cardiol . 1999; ; 84: : 763– 767
    [Google Scholar]
http://instance.metastore.ingenta.com/content/journals/10.5339/gcsp.2012.23
Loading
/content/journals/10.5339/gcsp.2012.23
Loading

Data & Media loading...

  • Article Type: Review Article
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error