REPERFUSION TREATMENT

IN STEMI,
WHEN TIME IS MUSCLE,
LEARN FROM GOOD
NETWORKING
EVIT RUSPIONO, MD, FIHA
DISCLOSURE STATEMENT
OF FINANCIAL INTEREST
I, EVIT RUSPIONO, MD, FIHA DO NOT HAVE
A FINANCIAL INTEREST/ARRANGEMENT
OR AFFILIATION WITH ONE OR MORE
ORGANIZATIONS THAT COULD BE
PERCEIVED AS A REAL OR APPARENT
CONFLICT OF INTEREST IN THE CONTEXT
OF THE SUBJECT OF THIS
PRESENTATION.
 SCOPE OF PROBLEM IN ACUTE CORNARY
SYNDROME

• Acute coronary syndrome (ACS) is now a major cause of

death and disability in Asia- Pasific region.1
• Western world, shows improvement in in-hospital and
post discharge mortality due to timely and effective
reperfusion as well as standardized pharmacological
approaches.1
• Asia pacific ACS mortality ~ 5% during hospitalization
and double at 1 year after discharge.1

1. Mark Y. Chan et al. Int. Journal of Cardiology. 2016, Pages 861–869

Time-Dependent Benefit of Reperfusion
Therapy
2014 ESC recommendation for Organization of STEMI patient
disposal describing pre- and in-hospital management and
reperfusion strategies within 12 hours of first medical contact
with ideal time interval for interventions

ESC Guideline. European

Heart Journal (2014)
2014 ESC Indication for Primary PCI for
myocardial reperfusion in STEMI

ESC Guideline. European Heart Journal (2014)

2014 ESC Indication for Primary PCI for
myocardial reperfusion in STEMI

ESC Guideline. European Heart Journal (2014)

2014 ESC Logistic for Primary PCI for
myocardial reperfusion in STEMI

ESC Guideline. European Heart Journal (2014)

2014 ESC Logistic for Primary PCI for
myocardial reperfusion in STEMI

ESC Guideline. European Heart Journal (2014)

 Reperfusion in Asia-Pasific
• China registry based studies only 30% STEMI patient treated with
many patient are not reperfused within recommended times. (1)
• CREATE registry in India ~ primary PCI rate is much lower in India
compared with more developed countries.(1)
• Malaysia NCVD – ACS registry fibrinolysis use was relatively high
(70%) and use of invasive procedures low (13–17%) versus other
registries. (1)
• In Indonesia STEMI registry – National Heart Centre ~ only 40%
patient get reperfusion in 2008-2009(2) and 59% in 2014-2017 (3)
• At Dr. Iskak Tulungagung General Hospital, 71,5% patient get
reperfusion in 2016-2017
1. Mark Y. Chan et al. Int. Journal of Cardiology. 2016, Pages 861–869
2. S. Dharma et al. Neth Heart J. 2012 Jun; 20(6): 254–259.
3. Indonesian STEMI (iSTEMI) Netwok data online
STEMI NETWORK AT DR. ISKAK
TULUNGAGUNG
GENERAL HOSPITAL
History of ACS Care at Dr. Iskak Tulungagung
General Hospital
Intensive Cardiac Care Unit (2003)

Thrombolytic therapy at ICCU (2005)

Coronary Angiography (2011)

Thrombolytic therapy at ED (2016)

Creating ACS Team (January 2016)

Networking with Primary Health Care

(April 2016)

Primary PCI capable (June 2016)

ACS Management Enhancement

ACS Team was formed in January 2016

AIM : To measure Programme’s effectivity

The aim of Management Response Time of
Acute Coronary Syndrome in Community
 Organizational Structure of ACS TEAM
ADVISOR
Tulungagung Regent

GOVERNING BOARD
Director of dr. Iskak General
Hospital
CO-GOVERNING BOARD
Head of Public Health Service

CHAIRMAN
Vice Director of dr. Iskak General
Hospital CO-CHAIRMAN
Head of Health Care Division
of dr. Iskak General Hospital

SECRETARY 1 SECRETARY 2
Head of Emergency Departement Head of Health Care Division of
of dr. Iskak General Hospital Public Health Service

TEAM WORK 1 TEAM WORK 2 TEAM WORK 3

Pre-Hospital Management Intra Hospital Management Supervisory
ACS Team for STEMI at Tulungagung Regency
1. PREHOPITAL CARE
• PUBLIC HEALTH OFFICE
• PRIMARY HEALTH CARE
• PRIVATE HOSPITAL
2. HOSPITAL CARE
• HOSPITAL MANAGEMENT
• REPERFUSION TEAM :
- CARDIOLOGIST - EMERGENCY RESIDENT
- EMERGENCY PHYSICIAN - EMERGENCY NURSES
- CARDIOLOGIST RESIDENT - CATHLAB NURSES
 Flowchart of ACS Management at Dr. Iskak
General Hospital
-Community
- primary health care
-Private hospital

Call TEMS

COMMANDER
Emergency Physician

ECG test

ST Elevation Non ST Elevation

Call Reperfusion Team Transfer to Red Zone Further Investigation

Thrombolytic or Primary PCI

 Proposed ACS Pathway

Community
Early patient recognition and action

Call TEMS Primary Health Care Directly to ED Dr.

(0355) 320119 / general practice Iskak
Prahospital Tulungagung
management General Hospital
Rural/Teritorial Metropolitan
 Goes to nearest primary health Directly picked up to Call TEMS
care with 24 hours ECG 12 Dr. Iskak (0355) 320119
Lead Tulungagung
 Consultation with cardiologist General Hospital
& EM by phone/WhatsApp Risk Stratification

ST-Elevation Myocardial Infarction (STEMI) Non ST-Elevation Acute Coronary Syndrome

(NSTEACS)
Intrahospital High risk intermediate Low risk
management Transfer to Red Zone Dr. Iskak
Tulungagung General Hospital
Further investigation
Thrombolytic at Primary PCI at
ED Cathlab
ICCU Discharge
Check up and
treadmill
Enhanced Strategy Prahospital Management
of ACS with TEMS
- Education (brochure, Community
counseling, on air radio
Early patient recognition and action
counseling, PHC and
clinic propagation)
- Department of health and
hospital networking
Primary Health Directly to ED
Call TEMS
Care / general Dr. Iskak
(0355) 320119 practice Tulungagung
General
Hospital

Rural/Teritorial Metropolitan
 Goes to nearest primary Directly picked Call TEMS
1. Clinically coordinated health care with 24 hours up to Dr. Iskak
transfer of time critical (0355)
ECG 12 Lead Tulungagung 320119
patients with STEMI to
 Consultation with General Hospital
tertiary hospital with
cardiologist & EM by
cardiac catheter
phone/WhatsApp
laboratory.
2. Consultant cardiology
support for Risk Stratification
management and
transfer advice for
patients with NSTEACS ST-Elevation Acute Coronary Syndrome Non ST-Elevation Acute Coronary Syndrome
(NSTEMI) (NSTEACS)
Flowchart of Tulungagung Emergency
Medical Service (TEMS)

CALL CENTER TEMS

PHC
TEMS

Calling

Goes to
Scene
EMERGENCY
BUTTON

CALL FROM COMUNITY Definitive Patient

Close Case
Care Stabilization
What we have done …..
• Formed ACS
Management
Response Time
Team in
Tulungagung
• Socialization to
primary health care
and private hospital
about the ACS
program
• Build networking
system with all
primary and private
health care in
Tulungagung
• Monitoring and
evaluation
periodically.
 TIME IS MUSCLE, MUSCLE IS LIFE

Call Centre TEMS

(0355)320119

Prehospital provider
Vital link in the life line 24/7 PCI capable centre
play a critical role
Tulungagung Emergency Medical Service (TEMS)

CALL CENTER DISPATCHER

Tulungagung Emergency Medical Service (TEMS)

HEALTH FACILITY MAPPING

AMBULANCES
POSITIONING
 Tulungagung Emergency Medical Service (TEMS)

24/7 TEMS AMBULANCE

SERVICE

Coordination and Initial

treatment
 Prahospital Triage for Acute Myocardial Infarction
Patients
(Waktu) (tanggal,jam, min) : Keluhan utama : Riwayat Medis dan Pengobatan
Awal timbul gejala :
Meminta pertolongan medis :
Jam ambulans tiba/sampai di IGD :
Jam ambulans berangkat merujuk :
Jam berangkat sendiri ke RS :
Jam pasien tiba di RS : Pemeriksaan Fisik : Kesadaran : TD : / mmHg
Jam mentransmit EKG : Denyut jantung : x/menit Laju nafas : x/menit
Irama : SR/Sinus Tachycardia/SB/AF/SVT/VT/VF/AV Block

Seorang pasien dengan keluhan nyeri dada /

rasa tidak nyaman di dada Heart Line :
Fax :
Rekam EKG 12 sandapan Email :
BBM :
Transmit EKG ke Heart line WhatsApp :
di RSUD dr. Iskak Tulungagung Direct Line :

EKG normal atau
tanpa elevasi segmen ST
Konsultasikan ke Heart Line
Rujuk ke RS primer atau PCI
Center
Continued…
Dijumpai elevasi segmen ST ; Dijumpai LBBB, RBBB
inferior : II, III, aVF atau irama pacu jantung
lateral : I, aVL, V1-V6
anterior : V2-V4
anterior ekstensif : I, aVL,V1-V6
posterior : V7-V9 atau ST depresi di V1-
V2
Onset gejala </= 12 jam Onset gejala > 12 jam
O2 nasal 3-4 L/menit O2 nasal 3-4 L/menit
Tablet nitrat 5 mg SL Tablet nitrat 5 mg SL
Aspilet 160-320 mg dikunyah Aspilet 160-320 mg dikunyah
Clopidogrel 300-600 mg p.o Clopidogrel 300-600 mg p.o
Rujuk ke PCI center untuk Primary PCI,
jika Rujuk ke PCI center untuk evaluasi
estimasi waktu antara FMC sampai
tindakan
kateterisasi ( balonisasi ) < 120 menit.
Jika tidak, diberi terapi fibrinolitik
Type of Reperfusion Strategy:
24/7 Primary PCI Service
Type of Reperfusion Strategy:
Fibrinolytic Therapy at ED
ACS Management at Dr. Iskak General Hospital

Activation
Reperfusion Team

Call center system

Emergency button
24 hours ready
ambulances
Hospital-PHC networking
 The Number of Call to TEMS by Community,
January 2016 – June 2017
120 110 110
98 101
100
88
81
80 76 75
65 68
61 63
59
60 51
46 49
40 38
40

20 14
8 9 8 10 8 9 10
5 5 6 4 4 5 5 5 6
2
0

total call caused by heart disease

SOURCE OF REFFERAL

38%

62%

Walk in Via Network

OUTCOME
Profil STEMI Reperfusion at Dr. Iskak General
Hospital, January 2016 – July 2017
35 34

30
30

25
25 24
22 22
2121 21
20 20 20 20
20 19
18 18 18 18
17 17 17
16
15
15 14 1414 14 14
13
12 12
11
10 10
10 9 99
8 8 8
77 7
4 4 5 4 4
5 3 3 3 3 3
0 1
0 0
0

STEMI Reperfused Non-reperfused

Profil STEMI Reperfusion at Dr. Iskak General
Hospital, January 2016 – July 2017
Causes of patients not reperfused
onset > 12 hours

Bad prognosis
4% 6%

contraindication not reperfused

11%
of fibrinolytic 28%
cost 6%

9%
Reperfused
64%
age 72%

others
 Method of STEMI Reperfusion at Dr. Iskak
General Hospital, January 2016 – July 2017
25
21
20
16
15
15 14 14
13
12 12
11
10 10 10
10 9 9 99
8 8 8 8 8
7
6 6 6
5 5
5
2 2 2 2
1 1
0 0 0 0 0
0

Thrombolytic PPCI
Response Time STEMI Reperfusion at
Dr. Iskak General Hospital
 Compared Data of FMC-Reperfusion Time
between Dr. Iskak General Hospital & National

Source : 13 months data from 1st July 2016 – 31st July 2017 in iSTEMI network (RSUD Dr. Iskak Tulungagung)
 Response Time STEMI Reperfusion at
Dr. Iskak General Hospital
300
Door to Needle & Door to Balloon
244
250
220
minute

200
163 169

141 147
150 137,5
122,5 117
112
97,1 99,6 95,5
88,8 93
100 86,28 81 86
78
61,73 65,5 62 66 65,5
53,4 56,6 47 47
50 38,25 40 76,5
32,5
20
0 0 0 0 0
0

Door to Needle Door to Balloon

 Compared Data of
Response Time STEMI Reperfusion
between Dr. Iskak General Hospital & National

450 419

400
350
290
300
minute

250 206
200
149
150 111 113
94 101
100 65

50 23

0
Time to FMC-Reperfusion Door to Needle Door to Balloon Ischemic Time
presentation
RSUD Dr. Iskak Nasional
Compared Data of First Medical Contact, Door
to Needle, Door to Balloon
Between Patients Via TEMS and Non-TEMS

189
200
180
160
130
140
120
Time (minute)

89,5
100 73
80
60
40 20
15
20
0
First Medical Contact Door to Needle Door to Balloon

TEMS non-TEMS
What is New in 2017
Guidelines?
Recommendation for Reperfusion Therapy

ESC Guideline. European Heart Journal (2017) 00, 1–66

 Problem Cause of Delayed Service
“Reperfusion Time”

1. The number of patients and other patient conditions

in Red Zone Dr. Iskak Tulungagung General Hospital.
2. Diagnosis and decisions making of the Cardiologist
for patients to undergo Thrombolytic or Primary PCI.
3. Family and patient decisions to be willing to get
reperfusion therapy (Thrombolytic or Primary PCI)
due to cost issues, side effects and patient prognosis.
4. Patient condition before reperfusion.
Our Effort To Face New Guidelines From ESC
1. Establish Tulungagung Emergency Medical Services to speed up
FMC.
2. Establish a Management Team for Acute Coronary Syndrome (ACS)
which has been approved by the Decree of Tulungagung Regent in
January 2016.
3. Socialization of ACS program to Primary Healthy and other hospitals
in Tulungagung.
4. Optimalization “Whatsapp group” that contains general practitioners
at the Primary Health care and privat hospitals in Tulungagung.
(temporary)
5. Creating a Reperfusion Team that contains doctor on duty Red Zone
emergency department, Cardiologist and Emergency Physician.
6. Make an intrahospital management of STEMI guideline (SOP).
 CONCLUSION

1. Monitoring & Evaluation is the most important thing in

ACS Management Program
2. The initial FMC plays an important role in the early
handling of STEMI cases, the pre hospital team has an
important role.
3. Socialization of STEMI to medical personnel in
peripheral and community so that reperfusion
rejection number and first medical contact time with
medical staff can decrease.
 CONCLUSION
4. A solid and organized team and regional networking is
needed to reduce reperfusion time in the STEMI case
through the regional ACS Team.
5. Tulungagung Emergency Medical Service as a
networking system and Emergency Medical Service
before admission for STEMI patients can shorten time
from onset to :
• FMC
• Door to balloon
• Door to needle
6. Based on data, improvement of intra hospital team at
Dr. Iskak Tulungagung general hospital is still needed
TULUNGAGUNG EMERGENCY MEDICAL
SERVICE (TEMS)
THANK YOU