Disease ManagementDisease Management Acute Myocardial InfarctionAcute Myocardial Infarction

University Hospital Bern University Hospital Bern

Background:Background:

1995/96 1997 1998 1999/2000

Department of Internal Medicine

Med.Klinik

Cardio- vascularDepartment

Emergency Department

Reperfusion Therapy 1995/96Reperfusion Therapy 1995/96

36

27

64

1511

53

0

10

20

30

40

50

60

70

1995 1996

PTCA

Lyse

No Reperf.

% p

at

Reperfusion Therapy 1995/96Reperfusion Therapy 1995/96%

pat

56

44 44

912

35

0

10

20

30

40

50

60

1995 1996

PTCALyseNo Reperf.

Prehospital delay < 6hPrehospital delay < 6h

Background:Background:

1995/96 1997 1998 1999/2000

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 02 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 A

ufnahme D

iagnose

Diagnose Akuter Myokardinfarkt

UAP/NQWMI Hochrisiko

UAP/NQWMI Hochrisiko

UAP/NQWMI Mittleres Risiko

UAP/NQWMI Niedriges Risiko

Symptome anhaltender Thoraxschmerz plus vegetative Symptome

Prolongierte AP (>20 min) AP + Links-herzinsuffizienz

Ruhe-AP Nächtliche AP

Ruhe-AP Nächtliche AP

Erstmalige AP Erhöhte AP- Frequenz

EKG Persistierende ST-Hebung Neuer LSB

Dynamische ST-Hebung Dynamische ST-Senkung

ST-Senkung (<1mm) T-inversion

ST-Senkung (<1mm) T-inversion

Normal Unverändert

Kardiale Marker

Troponin + CK +

Troponin + (CK (+))

Troponin + CK -

Troponin - (initial und nach 4 h) CK -

Troponin - (initial und nach 4 h) CK -

Mindestzahl pos. Kriterien

2 von 3 1 von 3 2 von 3 2 von 3 2 von 3

Akuter Myokardinfarkt

UAP/NQWMI hohes Risiko

UAP/NQWMI mittleres Risiko

UAP/NQWMI niedriges Risiko

- Direkt PTCAInselspital: 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 minUFH 1000E/h iv (TZ II: 20-40 sec), oder LMWH s.c.

- Rescue PTCA Bei erfolgloser Thrombolyse (Persistierende ST-, Schmerz) nach 60-90 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 Hochrisikokriterium2) Wiederauftreten von Ischämie 3) nach Ischämienachweis

Abkürzungen: LSB: LinksschenkelblockUFH= unfraktioniertes Heparin/LMWH=niedermolekulares HeparinAP=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: 031/632 21 11Tagesarzt Kardiologie: 181 62 48Invasiver Oberarzt: 181 76 30Tages-Oberarzt: 181 71 84

Implementation of Disease Implementation of Disease ManagementManagement

1995/96 1997 1998 1999/2000

Disease Management Acute Myocardial Infarction

Primary PTCA

Patient Flow Sheet for Data Collection and Quality Control

First EvaluationFirst Evaluation Disease Management for the Treatment Disease Management for the Treatment

of Acute Myocardial Infarctionof Acute Myocardial Infarction

G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch, G.M. Kuster, F. Noti, D. Pfiffner, M. Fleisch, S. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. EberliS. Windecker, E. Lipp, B. Meyer, B. Meier, F.R. Eberli

Patients and MethodsPatients 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

19981998 19991999 20002000(first half)

Number of pat. 67 91 58

Age (mean±SD) 64±12 61±13 63±13

Female (%) 22 16 24

Pre-hospital delay 206±194 199±157 235±173(min., mean±SD)

Patient CharacteristicsPatient Characteristics

Measure of Quality of Care for Successful Reperfusion Therapy

0.6

1.6

1.4

1.2

1.0

0.8

1.8

2.0

2.2

0-60 61-90 91-120 121-150 151-180 >180

Time, min

Mul

tiva

ria t

e ad

just

e d

Od d

s f o

r I n

- Hos

p ita

l Mo r

tali

ty

No. of Patients 2230 5734 6616 4461 2627 5412

*

* *

C. Cannon et al. JAMA 2000;283:2941-2947

D.M.: Improvement of Patient Flow in the Hospital

0 1 2 3 40

30

60

90

120

150

180

210

240

270

300

min

utes

1999 2000

82 74

100

1998

Door to Balloon Time = Time from Hospital Admission to Restoration of Normal Flow

Time from Hospital Admission to Cath. Lab.Time from Hospital Admission to Cath. Lab.

49(15-245)

43(5-165)

35(5-150)

0

20

40

1998 1999 2000

min

utes

median (range)

D. M.: Improved Pre-Cath. Lab. Steps

0

2

4

6

8

10

12

14

16

1998 1999 2000

Mortality

Re-MI

In-Hospital OutcomeIn-Hospital Outcome%

pat

ient

s

p<0.003 (Mortality)

In-Hospital Mortality and Re-Infarction

0

5

10

15

20

25

1998 1999 2000

All-Cause

Cardiovascular

Outcome: 6 Mt. Follow-upOutcome: 6 Mt. Follow-up%

pat

ient

s

p<0.003

Mortality (all-cause and cardiovascular)

0

2

4

6

8

10

12

14

1998 1999 2000

MI

UAP

Outcome: 6 Mt. Follow-upOutcome: 6 Mt. Follow-up%

pat

ient

s

Rehospitalisation for Acute Myocardial Infarction or Unstable Angina

Outcome: 6 Mt. Follow-upOutcome: 6 Mt. Follow-up

0

10

20

30

40

1998 1999 2000

% p

atie

nts

p<0.0003

Target Vessel Revascularisation (CABG and/or PTCA)

Comparison of Treatment for Acute Myocardial Infarction

Before and After Introduction of Disease Management

PatientsPatients

1995/96 19981998 1999 1999 2000 2000 (first half)

Number of pat. 56/55 67 91 58

Age (mean±SD) 65±13 64±12 61±13 63±13

Female 29% 22% 16% 24%

Known CAD 32% 27% 23% 13%

S/P CABG 5% 6% 10% 2%

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

1998 1999

2000

85 85.5 106

0 1 2 3 4 5 60

90

180

270

360

450

540

630

720

1995 1996 1998 1999 2000

120

220

160 180180

min

ute

s

Cardiogenic ShockCardiogenic Shock (% patients) (% patients)

1316

31

8

4

0

5

10

15

20

25

30

35

1995 1996 1998 1999 2000

% p

at

p<0.02

Length of Hospital StayLength of Hospital Stay (Insel;days)(Insel;days)

day

s

0

5

10

15

20

25

30

35

40

1995 1998 1996 1999 2000

14 13

7 5.5 5

0 1 2 3 4 5 6

day

s

0

5

10

15

20

25

30

35

40

1995 1998 1996 1999 2000

14 13

10

7 7

Length of Hospital StayLength of Hospital Stay (total;days)(total;days)

Patient Outcome: 6 Mt MortalityPatient Outcome: 6 Mt Mortality

79.3

11.5

20.4

3.53.5

18.5

0

5

10

15

20

25

1995 1996 1998 1999 2000

all cause

cardiovascular% p

at

p<0.003

SummarySummary

• 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

ConclusionsConclusions (I) (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)Conclusion (II)

• Disease Management is a helpful tool for improving treatment of patients with acute myocardial infarction.