Disease Management Acute Myocardial Infarction University Hospital Bern

Background: 1995/ /2000 Department of Internal Medicine Med.Klinik Cardio- vascular Department Emergency Department

Reperfusion Therapy 1995/96 % pat

Reperfusion Therapy 1995/96 % pat Prehospital delay < 6h

Background: 1995/ /2000 Disease Management Acute Myocardial Infarction Primary PTCA

Disease Management: Acute Myocardial Infarction (I). Objectives: Analysis and graphic visualization of patient flow from admission – discharge Development and implementation of updatable guidelines for the treatment of patients with AMI Quality control

Disease Management: Acute Myocardial Infarction (II). Objectives: Improvement of patient flow Reduction of time to reperfusion Shortening of hospital stay Improvement of clinical outcome Contain costs

Simplified Patient Flow of Patients With Acute Myocardial Infarction ER Cath.Lab. Int.C ICU WARD Rehab.

Disease Management: Participants Emergency Department Cardiology Intensive Care Unit Rehabilitation Administration, Cost accounting, Controlling Health insurance total 15 persons 4 days (half time) 1 fellow (cardiology) - 100% three months 1 attending (cardiology) - 50% three months

Behandlungsgrundsätze Akutes Koronarsyndrom Diagnostik: Anamnese, klin. Status, EKG, (Troponinschnelltest) BE (Hämatologie, Elektroyte, Gerinnung, Kreatinin, Lipidstatus, CK + CK-MB, Troponin I, LDH, ASAT, Röhrchen für Testblut) Therapie: - 2 l 0 2 nasal - Nitroglycerinkapsel s.l. 2x - ASS (Aspégic®) 500 mg iv - Morphin iv bei persist. Schmerzen - Heparin 5000 E im Bolus I.v., dann 1000 E/h i.v. - Betablocker i.v. (z. B. Lopresor® 5 mg i.v. max. 3x in 15 min, dann p.o. 3x25 mg/d). Vorsicht: Hypotonie vermeiden, insbes. unmittelbar vor Koronarografie - Bei persist. Symptomen Perlinganit i.v. Bei Aufnahme Diagnose

Akuter Myokardinfarkt UAP/NQWMI hohes Risiko UAP/NQWMI mittleres Risiko UAP/NQWMI niedriges Risiko - Direkt PTCA Inselspital: alle Patienten falls keine KI Andere Spitäler: bei KI für Thrombolyse oder Hochrisikopatienten (ausgedehnte Ischämie, nach Kammerflimmern, hämodyn. Instabilität, etc.) Begleitherapie: Heparin, GP IIb/IIIa (laut Verordnung Kardiologie) - Syst. Thrombolyse Reteplase (Rapilysin®) 2x10 Ei.v. im Abstand von 30 min.,oder Alteplase (Actilyse ) bei > 65kg: 15 mg Bolus iv. über 1 min, 50 mg iv über 30 min, 35 mg iv als Infusion über 60 min UFH 1000E/h iv (TZ II: sec), oder LMWH s.c. - Rescue PTCA Bei erfolgloser Thrombolyse (Persistierende ST-, Schmerz) nach min., v.a. bei Vorderwandinfarkt oder hämodyn. Verschlechterung - Schnelle Koronarografie und Revaskularisation (< 12 h) - Fortfahren mit UFH/LMWH und antianginöser Therapie - GP IIb/IIIa: Andere Spitäler: Beginn mit Tirofiban (Aggrastat ) oder Abciximab (Reopro ), Verlegung zur Revaskularisation. Inselspital: Entscheid nach diagn. Koronarografie. Ausnahme: Wartezeit auf Koronarografie > 1 h - LMWH (z.B. Enoxaparine (Clexane ) 1 mg/kg 2x/d s.c. oder Nadroparin (Fraxiparine ) 120 IU/kg s.c. 2x/d) - Mobilisation - Ischämienachweis - Koronarografie bei 1) Auftreten eines Hochrisikokriterium 2) Wiederauftreten von Ischämie 3) nach Ischämienachweis Abkürzungen: LSB: Linksschenkelblock UFH= unfraktioniertes Heparin/ LMWH=niedermolekulares Heparin AP=Angina pectoris/ TZ=Thrombinzeit /KI=Kontraindikationen - Absetzen des Heparins - Antianginöse Therapie (Betablocker per os) - Mobilisation - Ischämienachweis mittels Belastungstest - Koronarografie bei Ischämienachweis, sonst Spitalentlassung Anmeldung und Information: Von extern: 031/ Tagesarzt Kardiologie: Invasiver Oberarzt: Tages-Oberarzt:

Implementation of Disease Management 1995/ /2000 Disease Management Acute Myocardial Infarction Primary PTCA

Patient Flow Sheet for Data Collection and Quality Control

First Evaluation Disease Management for the Treatment of Acute Myocardial Infarction G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch, S. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. Eberli First Evaluation Disease Management for the Treatment of Acute Myocardial Infarction G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch, S. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. Eberli

Patients and Methods Patients with ST-elevation myocardial infarction admitted within 12 hours after onset of chest pain (excl.: Rescue-PTCA). Analysis of patient flow: –Door to balloon time, Hospital stay Analysis of patient outcome: –In hospital cardiac adverse events –6 month clinical follow-up Comparison of the years before (1998) with the years after (1999, 2000) introduction of DM

(first half) Number of pat Age (mean±SD)64±1261±1363±13 Female (%) Pre-hospital delay 206±194199±157235±173 (min., mean±SD) Patient Characteristics

Measure of Quality of Care for Successful Reperfusion Therapy >180 Time, min Multivariate adjusted Odds for In-Hospital Mortality No. of Patients * * * C. Cannon et al. JAMA 2000;283:

D.M.: Improvement of Patient Flow in the Hospital minutes Door to Balloon Time = Time from Hospital Admission to Restoration of Normal Flow

Time from Hospital Admission to Cath. Lab. minutes median (range) D. M.: Improved Pre-Cath. Lab. Steps

In-Hospital Outcome % patients p<0.003 (Mortality) In-Hospital Mortality and Re-Infarction

Outcome: 6 Mt. Follow-up % patients p<0.003 Mortality (all-cause and cardiovascular)

Outcome: 6 Mt. Follow-up % patients Rehospitalisation for Acute Myocardial Infarction or Unstable Angina

Outcome: 6 Mt. Follow-up % patients p< Target Vessel Revascularisation (CABG and/or PTCA)

Comparison of Treatment for Acute Myocardial Infarction Before and After Introduction of Disease Management

Patients / (first half) Number of pat. 56/ Age (mean±SD)65±13 64±12 61±13 63±13 Female 29% 22% 16% 24% Known CAD32% 27% 23% 13% S/P CABG 5% 6% 10% 2%

Time from Onset of Symptoms to Hospital Admission in Patients with AMI minutes

Cardiogenic Shock (% patients) % pat p<0.02

Length of Hospital Stay (Insel;days)

Length of Hospital Stay (total;days)

Patient Outcome: 6 Mt Mortality % pat p<0.003

Summary The project Disease Management –had no influence on prehospital delay –improved patient flow within the hospital, as assessed by door to balloon time –shortened length of hospital stay –had a favorable effect on patient outcome, as assessed by a trend towards decreased MACE (death, MI, UAP) and decreased need for target vessel revascularization

Conclusions (I) The project Disease Management –improved interdisciplinary patient management –resulted in a uniform treatment according to evidence based medicine Surprisingly, Disease Management changed referral patterns. Patients were also referred for primary PTCA to the tertiary center, when they presented with uncomplicated myocardial infarction in an outside hospital

Conclusion (II) Disease Management is a helpful tool for improving treatment of patients with acute myocardial infarction.