Alexandra Arias - Mendoza FACC, FESC - Professor of Cardiology - UNAM Head - Cardiovascular Critical Care & ER Instituto Nacional de Cardiología ...
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1 IMPROVING NETWORKS IN STEMI CARE: WHAT CAN WE DO MORE? Alexandra Arias – Mendoza FACC, FESC Professor of Cardiology - UNAM Head – Cardiovascular Critical Care & ER Instituto Nacional de Cardiología Ignacio Chávez Mexico City – Mexico
Alexandra Arias 2 Conflicts of interest • Research and Clinical Trials: Amgen, Boehringer Ingelheim, Novo Nordisk • Consulting Fees/Honoraria: ACC, Amgen, Bayer, Boehringer Ingelheim, Pfizer, Sanofi • Other: Instituto Nacional de Cardiología (Employee), Conacyt (National Investigator)
Alexandra Arias 3
Disclaimer
Please note some of the data presented herein may contain off-label dosages and use.
Please always refer to the current prescribing information as approved in your country.
The opinions expressed in this presentation are those of the presenter. They do not purport to reflect
the opinions and views of Boehringer Ingelheim.
Alexandra Arias 4
1. Historical perspective
2. Challenges of STEMI networks
3. Impact of developing a pharmaco-invasive
system and Mexican guidelines
Alexandra Arias 5 1. Historical perspective
Alexandra Arias 6
STEMI in Latin America: EPICOR registry
Most Latin American countries lack a universal STEMI system of care, and when a STEMI
network does exist, treatment is insufficient for the country’s needs.
Sept 2010 − March 2011
1066 STEMI patients
from 4 LA countries
Mexico, Argentina, Brazil, Venezuela
Rosselló X et al. Int J Cardiol 2017;245:27-34.
Alexandra Arias 7
STEMI in Latin America: EPICOR registry
Most Latin American countries lack a universal STEMI system of care, and when a STEMI
network does exist, treatment is insufficient for the country’s needs.
Sept 2010 − March 2011
1066 STEMI patients
from 4 LA countries
Mexico, Argentina, Brazil, Venezuela
Rosselló X et al. Int J Cardiol 2017;245:27-34.
Alexandra Arias 8
STEMI reperfusion and mortality in Mexico
Mexican National Registry of ACS 2013
PPCI
15%
No
reperfusion
Fibrinolysis 47.4%
37.6%
47.4% of STEMI patients in a national Mexican registry
received no form of reperfusion
n=8296 STEMI patients (2012 – 2013)
30-day mortality after a heart attack
is almost four times the OECD average (26.6%) 2013
OECD indicators -2015
ACS, acute coronary syndromes
OECD, Organisation for Economic Cooperation and Development
Martínez Sánchez et al. Arch Cardiol Mex. 2016 Jul-Sep;86(3):221-32.
Alexandra Arias 9
STEMI in Greater Mexico City*:
time to reperfusion is delayed in most cases
Time to reperfusion 10.8 hours; n=1365 patients; 2013-2016
90% walk-ins
ECG diagnosis
*As of 2020, 21,804,515 people live in the Greater Mexico City area
Covering an area of 7,866.1 km2
Araiza-Garaygordobil D et al. Arch Cardiol Mex 2019;86(3):221-232.
Alexandra Arias 10 2. Challenges of a STEMI Network in Greater Mexico City
Alexandra Arias 11 Challenges – Greater Mexico City Delays to reperfusion • Lack of awareness Araiza Garaygordobil & Arias Mendoza. Instituto Nacional de Cardiología “Ignacio Chávez”
Alexandra Arias 12
Challenges – Greater Mexico City
Delays to reperfusion
• Limited human resources
• Lack of awareness • Education (GP afraid to
use lytics due to bleeding)
• DIDO > 30 min
• No fibrinolytics during
first medical contact
• No communication
• No ECG in some
centres
Araiza Garaygordobil & Arias Mendoza. Instituto Nacional de Cardiología “Ignacio Chávez”Alexandra Arias 13
Challenges – Greater Mexico City
Delays to reperfusion
• Limited human resources
• Lack of awareness • Education (GP afraid to
use lytics due to bleeding)
• DIDO > 30 min • Lack of transfer facilities
• Ambulances
• Delayed > 60 min
• Distances
• No fibrinolytics during • Geography
first medical contact • Traffic
• No communication • Sometimes
• No ECG in some weather
centres
Araiza Garaygordobil & Arias Mendoza. Instituto Nacional de Cardiología “Ignacio Chávez”Alexandra Arias 14
Challenges – Greater Mexico City
Delays to reperfusion
• Limited human resources
• Lack of awareness • Education (GP afraid to
use lytics due to bleeding)
• DIDO > 30 min • Lack of transfer facilities
• Ambulances
• Delayed > 60 min Not enough 24/7 PPCI
• Distances
• No fibrinolytics during • Geography
first medical contact • Traffic
• No communication • Sometimes
• No ECG in some weather
centres
Araiza Garaygordobil & Arias Mendoza. Instituto Nacional de Cardiología “Ignacio Chávez”Alexandra Arias 15
Challenges – Greater Mexico City
Delays to reperfusion
• Limited human resources
• Lack of awareness • Education (GP afraid to
use lytics due to bleeding)
• DIDO > 30 min • Lack of transfer facilities
• Ambulances
• Delayed > 60 min Not enough 24/7 PPCI
• Distances
• No fibrinolytics during • Geography
first medical contact • Traffic
• No communication • Sometimes
STEMI remains a major health care problem
• No ECG in some weather and serves as target for a quality
centres improvement.
Araiza Garaygordobil & Arias Mendoza. Instituto Nacional de Cardiología “Ignacio Chávez”Alexandra Arias 16
Challenges
Primary challenge Other challenges
• Convince that the best option is pharmaco- • Standardised protocols
invasive strategy • Transportation - EMS
• Colleagues and health care authorities
• Communication
• Education
• Funding – lytics, ecg
• RegistryAlexandra Arias 17
Spoke and hub models and pharmaco-invasive strategy:
feasible option in Mexico city -2013
Level 3 facilities
24/7 PPC
Cath lab no 24/7 PPC
Level 2
Level 1
Martínez-Sánchez C, et al. Reperfusion therapy of myocardial infarction in Mexico: A challenge for modern cardiology. Arch Cardiol Mex. 2017 Apr -
Jun;87(2):144-150.
Level 1 Level 2 Level 3 facilitiesAlexandra Arias 18
What have we done to improve STEMI
care in Mexico?
Key lessons to be sharedAlexandra Arias 19
2016
Diagnosis reperfusion and mortality rates
Availability of human resources and material
resources
Secretary of Health and Interamerican Bank
2019
2017
Communication – App, real-time 2015 Pharmaco-invasive
ECG transmission Develop leadership, Regional STEMI
Data collection (Phase Mx) The best option for Mexico Networks
Feedback structure Health Secretary Establish Regional PCI Centres
Education - training
APP Communication National STEMI Protocol - Algorithm
2018
Hospital by hospital establishment of STEMI
plan (review, consensus, training)
EMS establishment of STEMI plan (review,
consensus, training)Alexandra Arias 20 3. Impact of developing a pharmaco- invasive system and Mexican guidelines
Alexandra Arias 21 PHASE-MX registry cohort (April 2018 – February 2020) CJC Open DOI: (10.1016/j.cjco.2020.11.012) Copyright © 2020 Terms and Conditions Araiza-Garaygordobil D et al. Pharmaco-invasive Strategy vs Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: A Study from Mexico City.
Alexandra Arias 22
Mexico City network
IAM – Mx STEMI network
60 hospitals
23.5% → First contact INC
55.2% CDMX
44% other states
(Morelos, Mexico, Hidalgo,
Large Mexico City)
Area: 7,866.1 km2
Population: 21 million
CJC Open DOI: (10.1016/j.cjco.2020.11.012)
Araiza-Garaygordobil D et al. Pharmacoinvasive Strategy vs. Primary Percutaneous Coronary Intervention in
ST-Elevation Myocardial Infarction: A Study from Mexico City.Alexandra Arias 23
PHASE-MX registry results Figure 3
Primary composite endpoint Primary endpoint: patients presenting to
non-PCI hospitals
Greater benefit in patients arriving at non-PCI hospitals when fibrinolytic therapy is given immediately at the ER
Mortality in pharmaco-invasive group: 4.8%
CJC Open DOI: (10.1016/j.cjco.2020.11.012)Alexandra Arias 24 Reduction in ischaemic time at non-PCI hospitals Previous ischaemic time: 648 min Actual ischaemic time: 325 min Araiza-Garaygordobil D et al. Arch Cardiol Mex 2019;86(3):221-232. CJC Open DOI: (10.1016/j.cjco.2020.11.012) Copyright © 2020 Terms and Conditions
Alexandra Arias 25
In-hospital mortality in patients with STEMI taken to PS
Gender differences in attention times for reperfusion, hospital stay, and LVEF in STEMI versus PCI
Time Total (n=340) Male (n=296) Female (n=44) p Variable ACP n (%) EFI n (%) Total n (%)
Total ischaemic time (min) 320 (205-599) 313.5 (205-589.5) 360 (214-658) 0.63 Survival 163 (93.7) 157 (94.6) 320 (94.1)
First medical contact (min) 120 (60-270) 120 (60-247.5) 180 (75-325) 0.08 Death 11 (6.3) 9 (5.4) 20 (5.9)
Door-to-needle time (min) 54 (30-103) 60 (30-110) 31 (20-85) 0.09 P = 0.82. PS: pharmaco-invasive strategy; PCI: percutaneous
coronary intervention; STEMI: ST-segment elevation
Door-to-device time (min) 72.5 (60-95) 71.5 (60-96) 73 (65-93) 0.56 myocardial infarction.
Mortality in women: 9.1%
Arch Cardio Mex -2020 Nov 11. doi: 10.24875/ACM.20000160.Alexandra Arias 26
Reperfusion trends at Instituto Nacional de Cardiología 2006-2021
Education improves lysis in non-PCI hospitals
Education
Education
Mortality
Non-reperfused: 10.5% (n= 2,750)
Fibrinolysis INC: 4.9% (n= 587)
Fibrinolysis FINC: 6.3% (n=1,353)
PPCI: 6.0% (n=2,511)
Global: 7.7% (n=7,201)Alexandra Arias 27
Reperfusion trends at Instituto Nacional de Cardiología 2006-2021
Education improves lysis in non-PCI hospitals
COVID-19
Education
Education
Mortality
Non-reperfused: 10.5% (n= 2,750)
Fibrinolysis INC: 4.9% (n= 587)
Fibrinolysis FINC: 6.3% (n=1,353)
PPCI: 6.0% (n=2,511)
Global: 7.7% (n=7,201)Alexandra Arias 28 Guidelines for early diagnosis and timely treatment STEMI Mexico Universal Reperfusion Algorithm Borrayo-Sánchez G, et al.GacMed Mex. 2020
Alexandra Arias 29 Can we do more?
Alexandra Arias 30
We can always do more!!!
2021
Improvement in
2020 – 2021 pre-hospital care –
EMS
Working on new
STEMI networks Pre-hospital
Close data
around the fibrinolysis
monitoring &
feedback Country and the
region
Education
Guatemala
Improving time to
treatment ParaguayAlexandra Arias 31 Conclusions • STEMI systems of care improve outcomes and allow patients to receive the appropriate therapy in time.
Alexandra Arias 32 Conclusions • STEMI systems of care improve outcomes and allow patients to receive the appropriate therapy in time. • Latin American countries need to develop STEMI systems of care adapted to their complex circumstances. The pharmaco-invasive strategy is the most feasible option in most cases.
Alexandra Arias 33 Conclusions • STEMI systems of care improve outcomes and allow patients to receive the appropriate therapy in time. • Latin American countries need to develop STEMI systems of care adapted to their complex circumstances. The pharmaco-invasive strategy is the most feasible option in most cases. • Pharmaco-invasive approach is safe and effective to improve reperfusion rates, decrease mortality/morbidity, and decrease total ischaemic time.
Alexandra Arias 34
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