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

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

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