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    DR Surya Darma

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    dpk ppnirsinu
    1) The document summarizes the experience and outcomes of a regional STEMI network in Indonesia over a five year period. 2) It describes improvements in pre-hospital care, in-hospital processes, and outcomes for STEMI patients after the introduction of the network, including reduced time to treatment. 3) The network facilitated coordination between hospitals to direct STEMI patients to centers capable of performing primary PCI, leading to more patients receiving reperfusion therapy and reduced mortality rates.

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    DR Surya Darma

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    dpk ppnirsinu
    191 views44 pages
    1) The document summarizes the experience and outcomes of a regional STEMI network in Indonesia over a five year period. 2) It describes improvements in pre-hospital care, in-hospital processes, and outcomes for STEMI patients after the introduction of the network, including reduced time to treatment. 3) The network facilitated coordination between hospitals to direct STEMI patients to centers capable of performing primary PCI, leading to more patients receiving reperfusion therapy and reduced mortality rates.

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    1) The document summarizes the experience and outcomes of a regional STEMI network in Indonesia over a five year period. 2) It describes improvements in pre-hospital care, in-hospital processes, and outcomes for STEMI patients after the introduction of the network, including reduced time to treatment. 3) The network facilitated coordination between hospitals to direct STEMI patients to centers capable of performing primary PCI, leading to more patients receiving reperfusion therapy and reduced mortality rates.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    191 views44 pages

    DR Surya Darma

    Uploaded by

    dpk ppnirsinu
    1) The document summarizes the experience and outcomes of a regional STEMI network in Indonesia over a five year period. 2) It describes improvements in pre-hospital care, in-hospital processes, and outcomes for STEMI patients after the introduction of the network, including reduced time to treatment. 3) The network facilitated coordination between hospitals to direct STEMI patients to centers capable of performing primary PCI, leading to more patients receiving reperfusion therapy and reduced mortality rates.

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    Hospital Outcomes After the Introduction

    of a Regional STEMI Network:


    Half Decade Experience
    Surya Dharma, MD, PhD
    FIHA, 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
    Overview
    • Background

    • Pre-Hospital Care

    • In-Hospital Care

    • Future Concept
    Background
    Comparison of leading causes of deaths, Global, 2000 and 2012

    Department of Health Statistics and Information Systems, WHO,


    2014
    RISKESDAS (Indonesia):
    Top 10 cause of mortality
    • 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 vs Primary PCI

    Earlier treatment improved prognosis

    Boersma E, et al. Lancet 1996;348:771-5


    De Luca, et al. Circulation 2004;109:1223-5
    ACS registry’s patient distribution
    Consecutive ACS
    N=2797

    STEMI NSTEMI UAP


    N= 869 (31,1%) N= 789 (28,2%) N= 1139 (40,7%)

    No reperfusion Fibrinolytic Primary PCI


    N= 510 (59%) N= 96 (11%) N= 263 (30%)

    Source: JAC registry data base 2010, NCCHK

    (Dharma S, et al. Neth Heart J 2012;20:254-259)


    Description of STEMI patient without reperfusion
    (N=510)
    Variables Description
    Source of referral, n (%)
    Walk in / ambulance 145 (28%)
    Primary physician 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)


    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 2010

    22 July 2010
    Therapeutic Strategies for AMI
    Pre-PCI center PCI center Post-discharge

    AED + BLS
    Acute Chronic
    Early Diagnostic Primary PCI Secondary prevention
    CV continuum prevention
    Pre-hospital
    Fibrinolytic

    MISSION !
    12
    2013
    JAKARTA CCU NETWORK SYSTEM
    PASIEN DENGAN NYERI DADA

    Puskesmas, RSUD, RS swasta, klinik 119

    Transmisi EKG
    Rekam EKG 12 lead (Heart Line):
    - Direct line: 5682424
    - Fax: 29414874
    Ambulans, koordinasi - heartlinepjnhk@gmail.com
    Pemda DKI Jakarta - (BBM): PIN:284BB6B1
    - WA: 081934178177
    RS RUJUKAN YG MEMILIKI e
    FASILITAS PCI (PCI CENTER)

    Presented at EuroPCR 2015, Paris. Dharma S, et al. Open Heart 2015.


    Jakarta Map
    RSUD
    CENGKARENG RSUD
    TANGERANG
    RSUD
    PJNHK KOJA
    RS HERMINA
    RS Kemayoran
    TARAKAN RS
    PERSAHABATANv
    JHC RSCM
    RSPAD

    RS POLRI

    RS PASAR
    RS REBO
    Fatmawati
    -11 million
    -15.000/km2
    Karakteristik pasien serangan jantung di DKI Jakarta
    sebelum dan setelah diberlakukannya sistem jejaring
    Variabel 2008 – 2010 2011 Nilai P
    Periode sebelum Periode setelah
    ada jejaring adanya jejaring
    (N=869) (N=636)
    Sumber rujukan
    Datang sendiri/amb 281 (32.3%) 221 (34.7%)
    Dokter primer 43 (4.9%) 13 (2.0%)
    <0.001*
    RS/fasyankes lain 488 (56.2%) 390 (61.2%)
    Intra-hospital 57 (6.6%) 13 (2.0%)
    Onset serangan jantung
    < 12 jam 422 (48.8%) 299 (46.9%)
    0.466
    ≥ 12 jam 442 (51.2%) 338 (53.1%)
    Pilihan pengobatan
    Fibrinolytic 96 (26.7%) 42 (16.9%)
    0.005*
    Kateterisasi jtg + stent 263 (73.3%) 206 (83.1%)
    Dharma S, et al. Eur Heart J 2013;34:402 (Abstract).
    Karakteristik pasien serangan jantung di DKI Jakarta
    sebelum dan setelah diberlakukannya sistem jejaring
    Variable 2007 – 2010 2011 Nilai P
    Periode sebelum Periode setelah
    ada jejaring adanya jejaring
    (N=869) (N=636)
    Lokasi STEMI
    Anterior 530 (61.0%) 376 (59.1%)
    NS
    Non anterior 339 (39.0%) 260 (40.9%)
    Killip class
    Killip I 598 (69.2%) 429 (68.5%)
    Killip II 223 (25.8%) 151 (24.1%)
    NS
    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
    Angka kematian di RS 60 (6.9%) 53 (8.3%) 0.303
    Dharma S, et al. Eur Heart J 2013;34:402 (Abstract).
    Pelatihan di IGD RS Jantung dan
    Pembuluh Darah Harapan Kita

    October 2013
    Melihat tindakan Primary PCI secara langsung
    Melihat terapi fibrinolitik secara langsung
    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 Guiding Thrombus NTG
    access catheter aspiration (14 min)
    0 (3 min) 5 (7 min) 10 (11 min)
    15
    1 2 3 4 6 7 8 9 11 12 13 14

    Xylocaine Angiography Guidewire Stenting Final


    (2 min) (6 min) (9 min) (13 min) angiogram
    (15 min)
    The importance of STEMI networking

    Symptom to EMS ED Reperfusion


    seek help activation evaluation/R therapy
    x strategy
    Future Concept
    PANGGILAN GAWAT DARURAT
    Puskesmas, RSUD, RS swasta, klinik, pasien

    119 (Call Center Pusat)

    119
    (Call Center Daerah) Heart Line
    Dikelola DinKes setempat

    FIRST MEDICAL CONTACT


    Open Heart 2015.
    British Medical Journal 2016;6:e012193.
    STEMI Chain of Survival
    PRE-HOSPITAL IN-HOSPITAL

    Door In Door Out

    Symptom to Primary Ambulance Reperfusion


    seek help hospital/ activation therapy in
    Referral center PCI Center
    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)):
    • 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
    Changing the DTD to total ischemia time as the main
    metrics for measuring the performance of reperfusion
    therapy

    Dharma S, Andriantoro H, et al. British Medical Journal 2016;6:e012193.


    AGD Dinkes DKI Jakarta (64 units)
    CALL CENTER AGD DINKES DKI JAKARTA
    Heart Line (Jakarta Cardiovascular Care Unit Network System)
    in Emergency Unit of NCCHK
    AsiaIntervention 2018;4:92-97
    AsiaIntervention 2018;4:92-97
    AsiaIntervention 2018;4:92-97
    Table 1. Patient characteristics.
    Year 2008/2009 Year 2015/2016 P-Value
    (N=624) (N=1052)

    Symptom onset >12 h, N (%) 232 (37) 306 (29%) <0.01


    Time metrics evaluation, minutes
    Door-to-device 94 (72-122) 82 (67-103) <0.001

    AsiaIntervention 2018;4:92-97
    Temporal trends in mortality of STEMI patients:
    A half-decade experience after application of a STEMI network
    (Jakarta Cardiovascular Care Unit Network System)
    WWW.JACREGISTRY.PJNHK.GO.ID
    Sudinkesehatantimur.jakarta.go.id
    Conclusion

    Half a decade after the implementation of the


    STEMI network in Jakarta (Jakarta CCU Network
    System), the result is better and faster care for
    patients with STEMI and this has been associated
    with lower in-hospital mortality

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