Jakarta Cardiovascular Care Unit Network System System
Surya Dharma, MD, PhD FIHA, FICA, FAPSIC, FESC, FSCAI Department of Cardiology and Vascular Medicine Faculty of Medicine, University of Indonesia National Cardiovascular Center Harapan Kita, Jakarta
Conflict of Interest •
Nothing to Declare
Conflict of Interest •
Nothing to Declare
Overview of the Network Network •
Background
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Pre-Hospital Care
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In-Hospital Care
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Future Concept
RISKESDAS (Indonesia): Top 10 cause of mortality •
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1. Cerebrovascular disease 2. Tuberculosis 3. Hypertension 4. Accident 5. Perinatal disease 6. DM 7. Cancer 8. Liver disease 9. Ischemic Heart Disease 10. Lower respiratory tract infection Source: Ministry of Health, Republic of Indonesia, 2007
ACS with persistent ST segment elevation
Fibrinolysis Earlier treatment
vs
Primary PCI improved prognosis
Boersma E, et al. Lancet 1996;348:771-5 De Luca, et al. Circulation 2004;109:1223-5
2013 ACCF/AHA Guideline for the Management of STElevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (JACC 2013;61:e78-e140)
STEMI networks emphasized !
Percentage of patient diagnosed with ACS admitted to emergency room
t n e i t a P
13000 12159 12000 11420 11000 10617 10188 10000 8661 9634 8306 9000 8060 8007 8000 7000 6000 5000 2332 24% (35%) 28% 22% 4000 1882 1678 1499 (30,4%)3402 3035 2911 2832 3000 2569 (18,6%)(20,2%) (23,5%) 2000 1000 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year Total patient admitted to ER
Number of ACS patient
Source: Jakarta Acute Coronary Syndrome Registry Data Base 2015, Emergency Unit National Cardiovascular Center Harapan Kita
ACS registry’s patient distribution Consecutive ACS N=2797
No reperfusion N= 510 (59%)
STEMI N= 869 (31,1%)
NSTEMI N= 789 (28,2%)
Fibrinolytic N= 96 (11%)
Primary PCI N= 263 (30%)
Source: JAC registry data base 2010, NCCHK (Dharma S, et al. Neth Heart J 2012;20:254-259)
UAP N= 1139 (40,7%)
Description of STEMI patient without reperfusion (N=510) Variables
Description
Source of referral, n (%) Walk in / ambulance Primary physician
145 (28%) 24 (5%)
Inter-hospital
294 (58%)
Intra-hospital
47 (9%)
Location of STEMI, n (%) Anterior
333 (65%)
Non anterior
177 (35%)
Onset of STEMI, n (%) ≤12 h
90 (18%)
>12 h
416 (82%) (Dharma S, et al. Neth Heart J 2012;20:254-259)
In-hospital mortality P<0.001 P<0.03 13,3
Percentage (%)
6,2 5,3
PPCI
Fibrinolytic
No reperfusion
(Dharma S, et al. Neth Heart J 2012;20:254-259)
Common cause of time delay in Jakarta
Other Time Delays: - patient delay: lack awareness of symptom of heart attack, fear of hospital, insurance problem - Diagnosis and treatment delay - Transportation delay: Traffic jam - Lack collaboration between hospitals and doctors - Ambulance organization
Jakarta Cardiovascular Care Unit Network System has been introduced in Jakarta as a system of care for AMI patients using a pharmaco-invasive approach since 2011
Therapeutic Strategies for AMI In-hospital
Pre-hospital
AED + BLS
Acute
Early Diagnostic
Primary PCI
Post-discharge
Chronic Secondary prevention CV continuum prevention
Pre-hospital Fibrinolytic
MISSION !
14
JAKARTA CCU NETWORK SYSTEM PASIEN DENGAN NYERI DADA Puskesmas, RSUD, RS swasta, klinik
Rekam EKG 12 lead
119
Transmisi EKG (Heart Line): - Direct line: 5682424
Ambulans, koordinasi Pemda DKI Jakarta
RS RUJUKAN YG MEMILIKI FASILITAS PCI (PCI CENTER)
-
Fax: 29414874
[email protected]
- (BBM): PIN:284BB6B1 - WA: 081934178177 e
Jakarta Map
RSUD CENGKARENG
RSUD TANGERANG PJNHK RS TARAKAN RSCM dan RSPAD
RS PERSAHABATAN
RS PASAR REBO
-11 million -15.000/km2
RS Fatmawati
Karakteristik pasien serangan jantung di DKI Jakarta sebelum dan setelah diberlakukannya sistem jejaring Variabel
2008 – 2010 Periode sebelum ada jejaring (N=869)
2011 Periode setelah adanya jejaring (N=636)
281 (32.3%)
221 (34.7%)
43 (4.9%)
13 (2.0%)
488 (56.2%)
390 (61.2%)
57 (6.6%)
13 (2.0%)
< 12 jam
422 (48.8%)
299 (46.9%)
≥ 12 jam
442 (51.2%)
338 (53.1%)
Fibrinolytic
96 (26.7%)
42 (16.9%)
Kateterisasi jtg + stent
263 (73.3%)
206 (83.1%)
Nilai P
Sumber rujukan Datang sendiri/amb Dokter primer RS/fasyankes lain Intra-hospital
<0.001*
Onset serangan jantung 0.466
Pilihan pengobatan
Dharma S, et al. Eur Heart J 2013;34:402 (Abstract).
0.005*
Karakteristik pasien serangan jantung di DKI Jakarta sebelum dan setelah diberlakukannya sistem jejaring Variable
2007 – 2010 Periode sebelum ada jejaring (N=869)
2011 Periode setelah adanya jejaring (N=636)
Nilai P
Anterior
530 (61.0%)
376 (59.1%)
Non anterior
339 (39.0%)
260 (40.9%)
Killip I
598 (69.2%)
429 (68.5%)
Killip II
223 (25.8%)
151 (24.1%)
Killip III
25 (2.9%)
17 (2.7%)
Killip IV
18 (2.1%)
29 (4.6%)
Door-to-needle time< 30 min
77 (80.2%)
120 (84.5%)
<0.001*
Door-to-balloon < 90 min
135 (51.3%)
105 (49.1%)
0.364
60 (6.9%)
53 (8.3%)
0.303
Lokasi STEMI NS
Killip class
Angka kematian di RS
Dharma S, et al. Eur Heart J 2013;34:402 (Abstract).
NS
Awareness Campaign for the community
Pelatihan di IGD RS Jantung dan Pembuluh Darah Harapan Kita
October 2013
Melihat tindakan Primary PCI secara langsung
Melihat terapi fibrinolitik secara langsung
FREE REFERENCES
References
In-Hospital care
IN-HOSPITAL SETTING (PCI CENTER): Pre-cath lab process ACTION registry (N= 12581) Benefit of By-passing ED for primary PCI: - 1316 pts (10.5% bypassing ED) - Lower heart failure and shock on presentation - More FMC-to-device time <90 min (80.7% vs. 53.7%, P<0.0001) - Lower Unadjusted in-hospital mortality (2.7% vs. 4.1%, p=0.01) Bagai A, et al. Circulation 2013;128:352-359
Off-hours vs. Regular working hours primary PCI (N=1126 patients, 857 (76%) off-hours)
Dharma S, et al. AsiaIntervention 2015;1:109-115
15 Minutes is all it takes…
Time (Min) Vascular access (3 min)
0 1
Xylocaine (2 min)
2
3
4
Guiding catheter (7 min)
5 6
7
Angiography (6 min)
8
10 9
Guidewire (9 min)
Thrombus aspiration (11 min)
11
12
NTG (14 min)
13
Stenting (13 min)
15 14
Final angiogram (15 min)
The importance of STEMI networking
Symptom to seek help
EMS activation
ED evaluation/R x strategy
Reperfusion therapy
Future Concept
PANGGILAN GAWAT DARURAT
Puskesmas, RSUD, RS swasta, klinik, pasien
119 (Call Center Pusat)
119 (Call Center Daerah) Dikelola DinKes setempat
FIRST MEDICAL CONTACT
Heart Line
Open Heart 2015.
STEMI Chain of Survival PRE-HOSPITAL
Door In Symptom to seek help
IN-HOSPITAL
Door Out
Primary hospital/ Referral center
Ambulance activation
Reperfusion therapy in PCI Center
Wang TY et al. JAMA 2011;305:2540-2547
Wang TY et al. JAMA 2011;305:2540-2547
Universal time metrics in STEMI care revisited! (N=520 STEMI calls, planned for Primary PCI, 279 IHT and 241 direct presenters (DP)): •
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Compared with IHT, DP patients presented to the PCI center earlier after symptom onset (5.3 ± 2.67 h vs. 6.4 ± 2.1 h, p<0.001). IHT patients had shorter door-to-device time (median 87 vs. 76 minutes, p<0.001), but had longer total ischemia time (median 400 vs. 457 minutes, P<0.001). median door-in to door-out (DI-DO) time was 173 minutes After multivariable logistic regression, a delay in DI-DO time for IHT patients was found to be the strongest predictor of longer total ischemia time (adjusted odds ratio 2.73, 95% confidence interval 1.58 to 4.71, p<0.001). Dharma S, et al. Submitted for publication
JAC Registry (56 centers, N=3015) 1024 STEMI patients, October 2014-July 2015
Multivariate predictor of prolonged DI-DO time (>180 minutes) in patients transferred for primary PCI, N=238 Dharma S et al. Submitted for publication
Changing the DTD to total ischemia time as the main metrics for measuring the performance of reperfusion therapy
TIM SPGDT KEM-KES RI
Call Center Dinkes DKI
AGD Dinkes DKI Jakarta
Heart Line (Jakarta Cardiovascular Care Unit Network System) in Emergency Unit of NCCHK
Temporal trends in mortality of STEMI patients: A half-decade experience after application of a STEMI network (Jakarta Cardiovascular Care Unit Network System)
9.6%
ARR= 3% RRR= 31% 6.6%
2008/2009
2014/2015
Overall in-hospital mortality of STEMI patients
Nama Rumah Sakit :
JAKARTA ACUTE CORONARY SYNDROME (JAC) REGISTRY Tanggal Masuk:
Jam Masuk :
Faktor Risiko PJK Hipertensi Diabetes Melitus Riwayat Keluarga Dislipidemia Merokok
Tanggal Keluar :
STEMI, Lokasi Onset: Killip: Non-STEMI UAP
Rujukan dari : Klinik : Puskesmas : Interhospital : Intrahospital : Datang sendiri : Door in – Door out :
ada
Grace :
Skor TIMI :
Pasien dirawat / dirujuk Rujuk Ke
TD :
mmHg
HR :
x/menit
TB :
cm
Jenis Kelamin : Laki / Perempuan
BB :
kg
Usia
Rescue PCI Urgent PCI Elective PCI Medical Management
Kematian Sebab (Jantung / Bukan Jantung)
:
Etnis
:
Aspirin Clopidogrel β-blocker
Statin Lain - lain : Obat Pulang : Aspirin
IABP - Tgl. Pemasangan : - Tgl. Pelepasan : - Ukuran Balon :
Pendarahan Tipe : (Mayor / Minor) : Urgent / Early PCI
Clopidogrel β-blocker
ACE inhibitor
mL
Statin Lain - lain :
Antikoagulan Unfractionated Heparin Dosis : Loading : Maintenance :
Stroke Tipe : Hemoragik / Iskemik Angina berulang dengan perubahan ST/T Komplikasi Mekanik Tipe : VSD MR
Heparin berat molekul rendah Enoxaparin / Fondaparinux Dosis :
Aritmia Tipe : Echo 1
Echo 2 )
(Tanggal :
tahun
Terapi dalam 24 jam :
CABG – Tanggal :
Infark Miokard Berulang
EDD ESD EF TAPSE E/A LA
Telepon
ACE inhibitor
tidak ada
Tgl. Kejadian :
(Tanggal :
:
menit
Primary PCI - Akses : Radial Femoral - Door to Device: menit - Trombektomi : Ya Tidak Tipe: Ukuran: F - TIMI Flow Pre : Post : - MBG Post : - Tipe Stent : DES / BMS
menit
No. Rekam Medis :
Tgl. Lahir : Pendidikan : Alamat :
Terapi Fibrinolitik Nama obat : Door to Needle :
Infarct Related Artery : Hasil Angiografi Koroner : - 1VD / 2VD / 3VD / LM Arteri Koroner yang terlibat : - RCA / LAD / LCX / LM Outcome :
TIMI:
Jam Keluar :
)
Laboratorium Hb Ht Leukosit Ureum Kreatinin Gula Darah Sewaktu Na Kalium Kolesterol HDL LDL Trigliserida Asam Urat CKMB 1 CKMB 2
Open Heart 2015.
Conclusions 1. STEMI patients should receive a timely reperfusion
2. Jakarta CCU Network System was build to improve the treatment of AMI patients in Jakarta 1. Improvement of Pre-hospital Care: a. DI-DO time b. Total ischemia time is the main metrics for performance measure c. Extensive use of pre-hospital care form (data sheet) d. Wide extension of JAC Registry (
[email protected])
4. Improvement of In-hospital care: a. By-passing ED may minimize reperfusion times b. Similar performance for primary PCI at off-hours and regular hours
5. STEMI networking plays a central role in AMI treatment
