Quality assessment in STEMI patients: the Belgian STEMI registry...
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Quality assessment in STEMI patients: the Belgian STEMI registry : 2007-2014 Belgian Interdisciplinary Working Group on Acute Cardiology (BIWAC) College of Cardiology
Transcript of Quality assessment in STEMI patients: the Belgian STEMI registry...
Quality assessment in STEMI patients:
the Belgian STEMI registry : 2007-2014
Belgian Interdisciplinary Working Group on
Acute Cardiology (BIWAC)
College of Cardiology
Lethality of AMI 2000-2003: MKG data
From dr W Aelvoet, RIZIV/ENAMI
N= 44782 AMI in hospital lethality: 15.9%
STEMI registry : Organisation
•Belgian Interdisciplinary working group of acute cardiology
Ministry of Public Health
College of Cardiology
BIWAC *
Steering committee: 16 members
regional representation
Local Investigators:
one (two) responsibles / hospital
Minimal Data Base
Patient characteristics (TIMI risk score) Reperfusion strategy In Hospital Outcome
Electronic CRF
TIMI risk score (automatically calculated)
Circulation: 2000;102:2031
Presenter
Presentation Notes
Circul 2000: 102; 2031 Op basis van 14000 patienten uit INTIME 2 + validatie in TIMI 9 trial
Enrolment STEMI patients 1/1/2007 – 31/12/2013
3733
798
800
136
1289
3469
968
1683 2262
n= 15816 110 hospitals
60 hospitals with >10 pts/y
0
1000
2000
3000
AUDIT STEMI REGISTRY:2007-2013
Centre Source doc. Correct item
2007-2008 (16) 2008-2009 (15) 2009-2010 (14) 2010-2011 (14) 2011-2012 (10) 2012-2013 (10) 2013-2014 (10)
2468/3255= 76% 2541/2877= 88% 2445/2793= 88% 2427/2877= 84% 1763/2100= 84% 1733/2058= 84%
2356/2468=95% 2460/2541=97% 2349/2445=96% 2348/2427=97% 1714/1763=97% 1683/1733=97%
* prize: ESC textbook of Intensive and Acute cardiac care
Publications – abstracts/reports • 2008:
– ACC (Versaille): STEMI in PCI vs non-PCI – Activity report: focus on time
• 2009: – BSC: PCI vs TT – ESC (Barcelona): PCI vs TT – ESC (Barcelona): DM vs non-DM – ESC (Barcelona): STEMI and gender – Activity report: focus on cardiogenic shock
• 2010: – BSC: no reperfusion vs reperfusion – ACC (USA): STEMI and gender – ESC (Stockholm); STEMI and elderly – ACC (Kopenhagen): STEMI and no reperfusion – Activity report: focus on gender
Publications – abstracts/reports
• 2011: – BSC: STEMI and no reperfusion STEMI and young patients Door to balloon time revisited? - ESC: STEMI and octogenerians door to balloon time revisited? – Activity report: focus on elderly patients
• 2012: - BSC : interhospital variation in length of hospital stay - Activity report: focus on PCI vs no-PCI centres
Publications – abstracts/reports
• 2013: - ESC: Impact of transition of thrombolysis to primary PCI on
door-to-balloon and mortality -ACC: Impact of transition of thrombolysis to primary PCI on door-to-
balloon time and mortality - Activity report: evolution of reperfusion therapy in Belgium
• 2014: – ESC: impact of mode of arrival on reperfusion therapy – Activity report: quality indicators for STEMI
Publications 1. Claeys et al, Contemporary mortality differences between primary PCI and
thrombolysis ina community-based STEMI population. Arch Intern Med. 2011;171(6):544-549
2. Claeys et al, STEMI mortality in community hospitals versus PCI-capable hospitals: results from a nationwide STEMI network programme. EHJ: Acute Cardiovascular Care 2012;1(1) 40–47
3. Claeys et al; Inter-hospital variation in length of hospital stay after STEMI patients: results from the Belgian STEMI registry, Acta Cardiologica 2013: 68(3); 235-239
4. Gevaert et al. Renal dysfunction in STEMI-patients undergoing primary angioplasty : higher prevalence but equal prognostic impact in female patients; an observational cohort study from the Belgian STEMI registry BMC nephrology 2013-14; 62
5. Gevaert et al.: Gender, TIMI-risk score and in-hospital mortality in STEMI patients undergoing primary PCI, results from the Belgian STEMI registry Euro-intervention 2014;9: 1095-1101
6. VandeCastele et al : Reperfusion therapy and mortality in octogenarian STEMI patients: Results from the Belgian STEMI registry, Clinical Research in Cardiology 2013; 102; 837-45
Mortality versus Reperfusion strategy
Claeys et al, Arch of Intern Med 2011
Presenter
Presentation Notes
16% prehosp TT in de groep van TT (mortaliteit 8% bij preTT vs inhosp TT) Highly different risk profile, TT are selected for low risk patients: smaller difference than ex
Mortality versus Reperfusion strategy
Claeys et al, Arch of Intern Med 2011
Presenter
Presentation Notes
16% prehosp TT in de groep van TT (mortaliteit 8% bij preTT vs inhosp TT) Highly different risk profile, TT are selected for low risk patients: smaller difference than ex
Mortality versus Reperfusion strategy
Claeys et al, Arch of Intern Med 2011
Presenter
Presentation Notes
16% prehosp TT in de groep van TT (mortaliteit 8% bij preTT vs inhosp TT) Highly different risk profile, TT are selected for low risk patients: smaller difference than ex
Mortality versus Reperfusion strategy
Claeys et al, Arch of Intern Med 2011
Early PCI: < 60 min
Interm PCI: 60-120
Late PCI: > 120 min
Early TT: <30 min
Interm T: 30-60 min
Late T: > 60 min
Door-t- balloon time should be less than 60 min to obtain lowest mortality rates !!
Presenter
Presentation Notes
16% prehosp TT in de groep van TT (mortaliteit 8% bij preTT vs inhosp TT) Highly different risk profile, TT are selected for low risk patients: smaller difference than ex
Mortality versus Reperfusion strategy
0
5
10
15
20
25
30
Perc
ent
0 1 2 3 4 5 6 7 8 9 >9TIMI risk score
N= 11467
Trombolysis N=665
Rescue PCI N=299
PCI N= 9617
Faciliated PCI N=250
No Reperfus. 636
0
2
4
6
8
10
12
14
16
18
Perc
ent
0 1 2 3 4 5 6 7 8 9 >9TIMI risk score
0
2
4
6
8
10
12
14
16
Perc
ent
0 1 2 3 4 5 6 7 8 9 >9TIMI risk score
3.9
N = 954 ( 8%)* N=9867(86%) N= 636 (6%)
4.1 5.9
MORTALITY
6.0 % 6,7% 19%
*Elective Invasive evaluation:502+299=801( 84%)
Presenter
Presentation Notes
16% prehosp TT in de groep van TT (mortaliteit 8% bij preTT vs inhosp TT) Highly different risk profile, TT are selected for low risk patients: smaller difference than ex
Attenuation of mortality benefit PCI over TT
0 5
10 15 20 25 30 35 40 45 50
0 1 2 3 4 5 6 7 8 >8
PCI thrombolysis
PCI vs TT : P=0.02
InTIME II
Claeys et al, Arch of Intern Med 2011
Presenter
Presentation Notes
We compared TT versus PCI for the different risk score. Absolute benefit is highly P value? TT: 6.8% vs PCI: 5.6% (p=0.26) Logist regressie p=0.01
mortality in octogenarian STEMI
Vandecasteele et al, Clinical Research in Cardiology 2013
Presenter
Presentation Notes
We compared TT versus PCI for the different risk score. Absolute benefit is highly P value? TT: 6.8% vs PCI: 5.6% (p=0.26) Logist regressie p=0.01
Mortality in octogenarian STEMI
Vandecasteele et al, Clinical Research in
Cardiology 2013
Presenter
Presentation Notes
We compared TT versus PCI for the different risk score. Absolute benefit is highly P value? TT: 6.8% vs PCI: 5.6% (p=0.26) Logist regressie p=0.01
Mortality versus Acute cardiac care program
Claeys et al, EHJ-ACC 2012
Presenter
Presentation Notes
P=0.07 P=0.16 Indien reperfusie eruit: verschil 6.3 vs 6.5 First admission in Admitted in PCI centr versus first admission. 70% versus 32% (no PCI centres are definitely still under represented in this registry, we will encourage.;) Risk profile of the is identical Obviously the reperfusion strategy is different with initial invasive approach in almost The we are dealing with a more tailored invasive approach it How does this translate into outcome.
Mortality versus Acute cardiac care program
Claeys et al, EHJ-ACC 2012
Presenter
Presentation Notes
P=0.07 P=0.16 Indien reperfusie eruit: verschil 6.3 vs 6.5 First admission in Admitted in PCI centr versus first admission. 70% versus 32% (no PCI centres are definitely still under represented in this registry, we will encourage.;) Risk profile of the is identical Obviously the reperfusion strategy is different with initial invasive approach in almost The we are dealing with a more tailored invasive approach it How does this translate into outcome.
0
2
4
6
8
10
12
14
16
18
Perc
ent
0 1 2 3 4 5 6 7 8 9 >9TIMI risk score
0
2
4
6
8
10
12
14
16
18
20
Perc
ent
0 1 2 3 4 5 6 7 8 9 >9TIMI risk score
Mortality versus Acute cardiac care program
4.2 4.1 MORTALITY
6.7%
PCI centre N=7024(60%)
trombolysis: 2%
Rescue PCI: 1%
Prim –facilat PCI: 93%
No reperfusion: 4 %
No-PCI centre
N=4443 (40%)
trombolysis: 15%
Rescue PCI: 5%
Prim –facilat PCI:75%
No reperfusion: 8 %
6.9%
Claeys et al, EHJ-ACC 2012
Presenter
Presentation Notes
P=0.07 P=0.16 Indien reperfusie eruit: verschil 6.3 vs 6.5 First admission in Admitted in PCI centr versus first admission. 70% versus 32% (no PCI centres are definitely still under represented in this registry, we will encourage.;) Risk profile of the is identical Obviously the reperfusion strategy is different with initial invasive approach in almost The we are dealing with a more tailored invasive approach it How does this translate into outcome.
Regional data on Reperfusion therapy
87
90
94
40 84
91
70
85 87
Primary PCI
4,6
86
2,2 1,7 5,4 0
20
40
60
80
100
thromb. PPCI ResPCI facPCI no rep
reperfusion therapy
77,4 81,2 86,6 89,8 92,7 92,8 93,3
0
50
100
2007 2008 2009 2010 2011 2012 2013
Presenter
Presentation Notes
P<0.001
Evolution reperfusion therapy
5 4 4 4 3 4 3 6 4 2 2 1 1 1
89 92 94 94 96 95 96
0 20 40 60 80
100
2007 2008 2009 2010 2011 2012 2013
no reperf TT PCI
PCI center
11 11 8 6 6 6 7
33 23 15 11 6 5 3
56 66
77 83 88 89 90
0 20 40 60 80
100
2007 2008 2009 2010 2011 2012 2013
no reperf TT PCI
No-PCI center
Reperfusion time: diagnosis to balloon time
16
34 22
11 13 3
-10
10
30
50
<30 30-60 60-90 90-120 >120 NA
DTB (min)
14
36
22 12 15 12
35 24
13 15
-10
10
30
50
<30 30-60 60-90 90-120 >120
DTB (min) DAY vs NIGHT (20-7)
P=0.04
Reperfusion time: diagnosis to balloon time
7,1 7,6 9,6 8,5
10,5 12,2 10
2,7 2,8 5,5 5,8 6
8 7
0
5
10
15
20
2007 2008 2009 2010 2011 2012 2013
DTN 90-120 DTN>120
P<0.001
P<0.001
9 10 11 10 11 13
11 11 11 14
12 13 16 15
0
5
10
15
20
2007 2008 2009 2010 2011 2012 2013
DTN 90-120 DTN>120
P<0.001
Early infarction (<3h)
Presenter
Presentation Notes
Early TT: 4.1% doch RR is identiek , niet significant
Quality indicator: DTB>120 in PCI centres
0
,05
,1
,15
,2
,25
,3
e
d
e
r
l)
e
e
e
)
c
t
h
n
s
e
t
t
m
Mean=10%
% DTB>120 in non-PCI centres: 20%
Regional data on in hospital mortality
8.8
5.4
5.5
5.9 4.5
7.2
4.9
6.2 7.6
Average:6,9%
In nonCPR pt: 3.9%
Mortality
30d mortility (n=7031)
5.4 % (vs 4.8% in hospital)
6,4 7,6 7,6 5,9 6,3 7,3 7
0 2 4 6 8
Presenter
Presentation Notes
The mean in hosptial mortality rate is 6.8% , evolutie p=0.03 In almost 1500 patient we have also data on 30 d mortality and this show a mortality of 6.8 % a difference of 1.3% which is concordant with international data.
Indepedent predictors of mortality
P value 0R (95%CI)
Killip > 1 <.0001 5 (4 - 7)
CPR <.0001 5 ( 4-6)
age <.0001 1.04 (1.03-1.05)
PCI vs TT No reperf
0.02 <0,0001
1.5 ( 1.1 – 2.7) 2,3 (1,7-3,1)
Ischemia>4h 0.0001 1.5 (1.3-2.0)
PAD <0.0001 1,8 (1.4-2.4) female 0.01 1.3 (1. 1-2.0)
Presenter
Presentation Notes
Region and PCI centres are no independent predictors Individual components of the TIMI risk score
Conclusions
• The present study demonstrates that thanks to the promotion and implementation of the concept of STEMI network in Belgium, PCI rate increased significantly, particularly in the community hospitals, and reached a penetration rate of >90% which is in line with European recommendations.
• The transition of thrombolysis to transfer for pPCI in the setting of a STEMI network was, however, associated with almost 50% increase of the proportion of patients with prolonged diagnosis-to-balloon time.
Presenter
Presentation Notes
the emergency medical system (EMS) capacity was not adapted to the increased need for transferring patient to PCI capable hospitals
European guidelines on STEMI, from Steg et al. , Eur Heart J 201 2;33:2569- 261 9
ESC guidelines
European guidelines on revascularisation, from Windecker et al. , Eur Heart J 201 4
EMS = SMUR
Project 2014-2015
• Quality indicators in STEMI patient – Diagnosis to-balloon time (system time) – Door-to-balloon time – Reperfusion therapy – Discharge medications
