Jakarta Cardiovascular Care Unit

Network System

Surya Dharma, MD, PhD

FIHA, FICA, 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 of the Network

Background
Pre-Hospital Care
In-Hospital Care
Future Concept

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
Earlier treatment

vs

Primary PCI
improved prognosis
Boersma E, et al. Lancet 1996;348:771-5
De Luca, et al. Circulation 2004;109:1223-5

2013 ACCF/AHA Guideline for the Management of STElevation Myocardial Infarction: A Report of the
American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines
(JACC 2013;61:e78-e140)

STEMI networks emphasized !

Patient

Percentage of patient diagnosed with ACS admitted to

emergency room
13000
12159
12000
11420
11000
10617
10188
10000
8661 9634
8306
9000 8060
8007
8000
7000
6000
5000
2332
24%
(35%) 28%
22%
4000
1882
1678
1499
(30,4%)3402 2832
3035
2911 2569
3000
(18,6%)(20,2%) (23,5%)
2000
1000
0
2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
Total patient admitted to ER
Number of ACS patient

Source: Jakarta Acute Coronary Syndrome Registry Data Base 2015,

Emergency Unit National Cardiovascular Center Harapan Kita

ACS registrys patient distribution

Consecutive ACS
N=2797

No reperfusion
N= 510 (59%)

STEMI
N= 869 (31,1%)

NSTEMI
N= 789 (28,2%)

Fibrinolytic
N= 96 (11%)

Primary PCI
N= 263 (30%)

Source: JAC registry data base 2010, NCCHK

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

UAP
N= 1139 (40,7%)

Description of STEMI patient without reperfusion

(N=510)
Variables

Description

Source of referral, n (%)

Walk in / ambulance
Primary physician

145 (28%)
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
>12 h

90 (18%)
416 (82%)

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

In-hospital mortality
P<0.001
P<0.03

Percentage
(%)

5,3

PPCI

13,3

6,2

Fibrinolytic

No reperfusion

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

Common cause of time delay in Jakarta

Other Time Delays:

- patient delay: lack awareness of symptom of heart attack,
fear of hospital, insurance problem
- Diagnosis and treatment delay
- Transportation delay: Traffic jam
- Lack collaboration between hospitals and doctors
- Ambulance organization

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 2011

22 July 2010

Therapeutic Strategies for AMI

In-hospital

Pre-hospital
AED + BLS

Acute

Early Diagnostic

Primary PCI

Post-discharge

Chronic
Secondary prevention
CV continuum prevention

Pre-hospital
Fibrinolytic

MISSION !

2013

14

JAKARTA CCU NETWORK SYSTEM

PASIEN DENGAN NYERI DADA
Puskesmas, RSUD, RS swasta, klinik

Rekam EKG 12 lead

119

Transmisi EKG
(Heart Line):
- Direct line: 5682424

Ambulans, koordinasi
Pemda DKI Jakarta

RS RUJUKAN YG MEMILIKI
FASILITAS PCI (PCI CENTER)

Presented at EuroPCR 2015, Paris.

Fax: 29414874
heartlinepjnhk@gmail.com

- (BBM): PIN:284BB6B1
- WA: 081934178177

e
Dharma S, et al. Open Heart 2015.

Jakarta Map

RSUD
CENGKARENG

RSUD
TANGERANG
PJNHK
RS
TARAKAN
RSCM dan
RSPAD

RS
PERSAHABATAN

RS PASAR
REBO

-11 million
-15.000/km2

RS
Fatmawati

Karakteristik pasien serangan jantung di DKI Jakarta

sebelum dan setelah diberlakukannya sistem jejaring
Variabel

2008 2010
Periode sebelum
ada jejaring
(N=869)

2011
Periode setelah
adanya jejaring
(N=636)

281 (32.3%)

221 (34.7%)

43 (4.9%)

13 (2.0%)

488 (56.2%)

390 (61.2%)

57 (6.6%)

13 (2.0%)

< 12 jam

422 (48.8%)

299 (46.9%)

12 jam

442 (51.2%)

338 (53.1%)

Fibrinolytic

96 (26.7%)

42 (16.9%)

Kateterisasi jtg + stent

263 (73.3%)

206 (83.1%)

Nilai P

Sumber rujukan
Datang sendiri/amb
Dokter primer
RS/fasyankes lain
Intra-hospital

<0.001*

Onset serangan jantung

0.466

Pilihan pengobatan

Dharma S, et al. Eur Heart J 2013;34:402 (Abstract).

0.005*

Karakteristik pasien serangan jantung di DKI Jakarta

sebelum dan setelah diberlakukannya sistem jejaring
Variable

2007 2010
Periode sebelum
ada jejaring
(N=869)

2011
Periode setelah
adanya jejaring
(N=636)

Nilai P

Anterior

530 (61.0%)

376 (59.1%)

Non anterior

339 (39.0%)

260 (40.9%)

Killip I

598 (69.2%)

429 (68.5%)

Killip II

223 (25.8%)

151 (24.1%)

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

60 (6.9%)

53 (8.3%)

0.303

Lokasi STEMI
NS

Killip class

Angka kematian di RS

Dharma S, et al. Eur Heart J 2013;34:402 (Abstract).

NS

Awareness Campaign for the community

Pelatihan di IGD RS Jantung dan

Pembuluh Darah Harapan Kita

October 2013

Melihat tindakan Primary PCI secara langsung

Melihat terapi fibrinolitik secara langsung

FREE
REFERENCES

References

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
access
(3 min)

0
1

Xylocaine
(2 min)

Guiding
catheter
(7 min)

5
6

Angiography
(6 min)

10
9

Guidewire
(9 min)

Thrombus
aspiration
(11 min)

11

12

NTG
(14 min)

13

Stenting
(13 min)

15
14

Final
angiogram
(15 min)

The importance of STEMI networking

Symptom to
seek help

EMS
activation

ED
evaluation/R
x strategy

Reperfusion
therapy

Future Concept

PANGGILAN GAWAT DARURAT

Puskesmas, RSUD, RS swasta, klinik, pasien

119 (Call Center Pusat)

119
(Call Center Daerah)
Dikelola DinKes setempat

FIRST MEDICAL CONTACT

Heart Line

Open Heart 2015.

STEMI Chain of Survival

PRE-HOSPITAL

Door In
Symptom to
seek help

IN-HOSPITAL

Door Out
Primary
hospital/
Referral center

Ambulance
activation

Reperfusion
therapy in
PCI Center

Wang TY et al. JAMA 2011;305:2540-2547

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

JAC Registry (56 centers, N=3015)

1024 STEMI patients, October 2014-July 2015

Multivariate predictor of prolonged DI-DO time (>180 minutes) in

patients transferred for primary PCI, N=238
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, et al. Submitted for publication

TIM SPGDT KEM-KES RI

April 2015

Call Center Dinkes DKI

Updated May 2015

AGD Dinkes DKI Jakarta

Heart Line (Jakarta Cardiovascular Care Unit Network System)

in Emergency Unit of NCCHK

Temporal trends in mortality of STEMI patients:

A half-decade experience after application of a STEMI network
(Jakarta Cardiovascular Care Unit Network System)

9.6%

ARR= 3%
RRR= 31%
6.6%

2008/2009

2014/2015

Overall in-hospital mortality of STEMI patients

JAC registry database. Dharma S, et al. Submitted for publication

Nama Rumah Sakit :

JAKARTA ACUTE CORONARY SYNDROME (JAC) REGISTRY

Tanggal Masuk:

Jam Masuk :

Faktor Risiko PJK

Hipertensi
Diabetes Melitus
Riwayat Keluarga
Dislipidemia
Merokok

Tanggal Keluar :

STEMI, Lokasi
Onset:
Killip:
Non-STEMI
UAP

Rujukan dari :
Klinik
:
Puskesmas
:
Interhospital :
Intrahospital :
Datang sendiri :
Door in Door out :

ada

Grace :

Skor TIMI :

Pasien dirawat / dirujuk

Rujuk Ke

mmHg

HR :

x/menit

TB :

cm

Jenis Kelamin : Laki / Perempuan

BB :

kg

Usia

tidak ada

Rescue PCI
Urgent PCI
Elective PCI
Medical Management

Tgl. Kejadian :
Kematian
Sebab
(Jantung / Bukan Jantung)

IABP
- Tgl. Pemasangan :
- Tgl. Pelepasan :
- Ukuran Balon :

Pendarahan
Tipe : (Mayor / Minor) :
Urgent / Early PCI

Etnis

Angina berulang dengan perubahan ST/T

Komplikasi Mekanik
Tipe :
VSD
MR

Aspirin
Clopidogrel
-blocker
ACE inhibitor
Statin
Lain - lain :

Aspirin
Clopidogrel
-blocker
ACE inhibitor
Statin
Lain - lain :

mL

Heparin berat molekul rendah

Enoxaparin / Fondaparinux
Dosis :

Aritmia
Tipe :
Echo 1

Echo 2
)

(Tanggal :

tahun

Terapi dalam 24 jam :

Obat Pulang :

Antikoagulan
Unfractionated Heparin
Dosis : Loading :
Maintenance :

Stroke
Tipe : Hemoragik / Iskemik

EDD
ESD
EF
TAPSE
E/A
LA
Aorta
Lain-lain

Telepon

CABG Tanggal :

Infark Miokard Berulang

(Tanggal :

menit

Primary PCI
- Akses : Radial Femoral
- Door to Device:
menit
- Trombektomi : Ya
Tidak
Tipe:
Ukuran:
F
- TIMI Flow
Pre :
Post :
- MBG
Post :
- Tipe Stent : DES / BMS

menit

No. Rekam Medis :

Tgl. Lahir :
Pendidikan :
Alamat
:

Terapi Fibrinolitik
Nama obat :
Door to Needle :

Infarct Related Artery :

Hasil Angiografi Koroner :
- 1VD / 2VD / 3VD / LM
Arteri Koroner yang terlibat :
- RCA / LAD / LCX / LM
Outcome :

TIMI:

Jam Keluar :
TD :

Laboratorium
Hb
Ht
Leukosit
Ureum
Kreatinin
Gula Darah
Sewaktu
Na
Kalium
Kolesterol
HDL
LDL
Trigliserida
Asam Urat
CKMB 1
CKMB 2
hs-TnT 1
hs-TnT 2
CCT

Open Heart 2015.

Conclusions
1. STEMI patients should receive a timely reperfusion

2. Jakarta CCU Network System was build to improve the

treatment of AMI patients in Jakarta
1. Improvement of Pre-hospital Care:
a. DI-DO time
b. Total ischemia time is the main metrics for performance
measure
c. Extensive use of pre-hospital care form (data sheet)
d. Wide
extension
of
JAC
Registry
(jakartastemiregistry@gmail.com)

4. Improvement of In-hospital care:

a. By-passing ED may minimize reperfusion times
b. Similar performance for primary PCI at off-hours
and regular hours

5. STEMI networking plays a central role in AMI

treatment