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Regional AMI Care:Bridging the Rural Health Care Gap Darren B. Bean, MD University of Wisconsin Emergency Medicine/Medflight Director UW Level 1 Heart Attack Program Historical Perspective 1960’s Bedrest for 3 to 4 weeks Morphine sulfate 1970’s Coronary care units Intra-aortic balloon pump CABG surgery 1980’sConcept of Coronary thrombosis Frequency of Arterial Occlusion in Acute MI 1980’s The Revolution Begins: Thrombolytics Race for the ‘holy grail’ 1988: ISIS-2 Complication of Thrombolytics ICH in Major AMI Trials Thrombolytic Therapy: Benefit 30 % relative risk reduction in short term mortality (7-10%) Benefit persists 10 years Despite benefit, up to 1/3 of STEMI patients receive no reperfusion therapy Fear of bleeding complication Thrombolytic Therapy: Limitations 20% fail to restore vessel patency 40-50% fail to restore TIMI 3 flow 10-15% re-occlusion rate 0.5-1% rate of intracranial hemorrhage Angioplasty (PCI) Andreas Gruentzig 1977 1,000,000 PCI procedures in US annually 2,000,000 performed worldwide annually PTCA in Acute MIDefinitions Primary (Immediate) - Initial strategy Primary (Transfer) Salvage (Rescue) - Thrombolytic failure Elective - Recurrent ischemia post-MI Is primary angioplasty superior to thrombolysis? YES - if the right conditions exist: Performed quickly Experienced operator High volume cardiac center Thrombolytics:Clot age predicts reperfusion rate Very effective in fresh clot Up to 25% may fully abort if administered 1hr symptom onset After 120 minutes dramatic fall in reperfusion rates Mortality benefit dependent on TIMI 3 flow!! Transfer for PCI:European Experience DANAMI-2: Results Risk associated with helicopter transfer? Have we been able to reproduce the European experience? US Performance 2002:NRMI 4 Re-examining the door to balloon inflation window How long is too long for primary PCI assuming door to needle (lytic) of 30 min? Recent ACC/AHA guidelines reduce door to