Indonesia STEMI Network

Bimo Bintoro
RSUD BAHTERAMAS, SOUTH EAST SULAWESI
INDONESIA
 Global iSTEMI & NCC-HK Meeting
April 2014

Preliminary Survey- Jakarta

Area: 740.3 km2 /Population: 11 million (15.000/km2)
Registry (2008-2010)

24 hours Call center –

NCC Harapan Kita 2008

Low reperfusion rate: 41%

West Jakarta
Late presenter (> 12 hours) : 53.1% Population: 2,260,825
Area: 127.11 km2
• AMI Incidence Rate 222.3/100.000 per-year
Inter-hospital Referral: 61% = 2.260.825/100.000 x 222,3 = 5026
•Approximately 5026 AMI case per-year
Ref: Singapore Myocardial Infarction Registry Report No.2,
Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259) Trends in Acute Myocardial Infarction in Singapore 2007-2012
 • Area: 38,140 km2
• 2,551,008 population
SOUTH EAST • 6 Cardiologists
SULAWESI

• Area: 297 km2

• 359,371 population
• 4 cardiologists (2 interventional
Kendari cardiologists)

Sultra.bps.go.id (sensus 2016)

Transportation for referral
 Our challenges to build the network
• Only 2 hospitals available to deliver (minimum)
the lytics management.
• Primary PCI can only be done in 1 hospital, and
it’s considered “too far” from the central capital
city area.
• The Imaginary borders: According to the referral
regulation, “RS Kota Kendari” tends to receive the
intra-city referral (other hospitals in kendari), and
“RSUD Bahteramas” –mostly– tends to receive
the referral from the outside of the city (other
regencies).
 Hub and Spokes Model in iSTEMI
PCI & Fibrinolysis (+) 2 Government Hospitals
Fibrinolysis (+) 4 Private Hospitals, PCI (+), UHC (-)
PCI & Fibrinolysis (-) 8 Primary Health Care Center
4 Private Hospitals Hospital, UHC (+)
PHC Cinta Kasih 2 Private Hospital, UHC (-)

Kalideres Tzu-Chi Hospital * UHC: Universal Health Coverage

Cengkareng PHC
Gov. Hospital PHC PHC
Grogol Tambora Taman Sari
RS Hermina Petamburan
Daan Mogot

PHC RSIA Ibnu

Royal Taruma
Sina
Cengkareng Grha Kedoya Hospital
Hospital
RS Sumber
Tarakan
Waras
Puri Indah Puri Mandiri Gov. Hospital
PHC Kedoya Hospital
Hospital
Kembangan NCCHK
Siloam Pelni
Hospital Petamburan
PHC Kebon Patria IKKT Hospital
Main Referral
Jeruk Hospital
Alternative Referral Bhakti Mulia
PHC
Hospital
iSTEMI didukung oleh Medtronic
Palmerah
iSTEMI Network + Tertiary Facility (2 Years)
West Jakarta & Thousand Island
24 months data from 30th June 2014 – 30th June 2016 in iSTEMI
network (West Jakarta + NCC-HK)

ACS
N=6313

STEMI UAP/NSTEMI
N= 2433 N= 3880
(38.5%) (61.9%)
 STEMI Patient Characteristics (2 Years)
N=2433

Gender - Male 85.4% Risk Factors

• Smoking 63.8%
Age 55.80 + 10.17
• Hypertension 52.9%
Insurance Status
• Diabetes Mellitus 27.5%
• UHC 72.6% • Dyslipidemia 26.3%
• Personal 22.5% • Family history 8.8%
• Company Insurance 4.6% Clinical Presentation
• Unknown 0.3% Sistolic BP (mmHg) 128.42+ 28.70
Symptoms
Diastolic BP (mmHg) 79.41 + 23.05
• Chest pain 86.1%
Heart rate freq. (bpm) 84.31 + 26.08
• Autonomic symptoms 78.3%
Location of Infarction: Anterior 55.1%
• Lasting > 20 minutes 73.6%

• New onset of angina 37.2% Creatinine (mg/dL) 1.32 + 1.13

• Referred pain 48.5% Cardiac arrest 4.8%

24 months data from 30th June 2014 – 30th June 2016 in iSTEMI network (West Jakarta + NCC-HK)
 Reperfusion Strategy
First Year Second Year

P Value < 0.001 P Value < 0.001

Primary
Primary
PCI 89.8%
PCI 89.0%
Fibrinolysis Fibrinolysi
54.0% s 59.1%
Primary…
Primar… Fibrinolysi
Fibrinolysis s
10.2% 11,0%
87 74 57 500 88 61 51 412

Secondary Facility Tertiary Facility Secondary Facility Tertiary Facility

N=161 N=557 N=149 N=463
12 Months data, 30 June 2014 – 30 July 2015 12 Months data, 1 July 2015 – 30 June 2016
in iSTEMI Network(West Jakarta + NCCHK) in iSTEMI Network(West Jakarta + NCCHK)
 Total Reperfusion Rate
Total Reperfusion Rate First Year Total Reperfusion Rate Second Year

1325 1108

969
57.9% 776 59%
61.4% 762
63.8% 652

595 495

332
356 46.9% 47.3%
167 157

Secondary Tertiary Total Secondary Tertiary Total

STEMI Patient Reperfusion STEMI Patient Reperfusion

12 Months data, 30 June 2014 – 30 July 2015 in 12 Months data, 1 July 2015 – 30 June 2016 in
iSTEMI Network(West Jakarta + NCCHK) iSTEMI Network(West Jakarta + NCCHK)
EVALUATION OF STEMI PROCESS AND PROCEDURE

STEMI
N : 2.433

INCOMPLETE DATA
PROCESS & PROCEDURE
N : 166

TOTAL EVALUATED
N : 2.267

NOT
REPERFUSED
REPERFUSED
N : 1.344
N : 923

*24 Months Data, From 30 Juni 2014 – 30 juni 2016 in ISTEMI Network (West Jakarta)
 STEMI PROCESS & PROCEDURE
NCC-HK 1st Year (538) NCCHK 2nd Year (457)
Time
Median Min - max Median Min - max

Onset – FMC 120 25-660 150 4-585

Transfer Time 210 30-600 210 20-587

Door to Device 82 32-480 69 26-365

Door to Needle 58 22-243 68 10-163

Ischemic Time 433.5 60-720 386 60-720

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)
FMC: First Medical Contact
 STEMI Standard of Care: NCC-HK

433 min (7’ 13”)

DTD 82 min
1st Year 12O min 210 min DTN 58 min

Onset Spokes Hub Reperfusion

(FMC)

2nd Year
150 min 210 min DTD 69 min
DTN 68 min

386 min (6’ 26”)

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)
Presentation of Reperfused Patients with DTD < 90 Min
NCC-HK
100%
90% 89% 88% 89% 90% 89% 83% 93%
85% 86%
80% 79% 79%
71%
70% 66%
78% 65% 62% 1st Year
60% 65% 63% 63% 2nd Year
57%
50%
41%
40% 43%
34%
30%
20%
8%
10%
0%
Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May
(18) (1) (27) (28) (35) (22) (30) (32) (16) (24) (24) (14)
N:44 N:12 N:41 N:43 N:45 N:35 N:35 N:49 N:37 N:39 N:42 N:41

(48) (35) (27) (35) (32) (22) (24) (23) (27) (16) (38) (25)
N:54 N:41 N:38 N:40 N:36 N:28 N:38 N:29 N:30 N:18 N:46 N:27
 STEMI PROCESS & PROCEDURE
iSTEMI Network iSTEMI Network
Time 1st Year(147) 2nd Year (159)
Median Min-max Median Min-max

Onset – FMC 120 25-640 150 21-710

Transfer Time 155 40-480 120 21-450

Door to Device 104 45-474 101.5 25-344

Door to Needle 80 27-325 85 16-360

Ischemic Time 330 75-705 330 65-710

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)
FMC: First Medical Contact
 STEMI Standard of Care: iSTEMI Network

330 min (5’ 30”)

DTD 104 min
1st Year 12O min 155 min DTN 80 min

Onset Spokes Hub Reperfusion

(FMC)

2nd Year
150 min 120 min DTD 101 min
DTN 85 min

330 min (5’ 30”)

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)
 In Hospital Mortality Rate
(8)
Based on Killip Class
P-value= 0.000 P-value= 0.000

56.3% 56.8%
(40) (42)

(8)

(9) 41.9% (4)

(76)
(18) (58)

33.3% Killip I
(12) Killip II
(16)
Killip III
(25)
(17) Killip IV
(47)

10.4% (29)
9.0%
(30) (20)
3.8% 2.1%
N= N= 655 (16)N= 563 N= 451
(35)
N:288 N 762
: 43 N : 71 N:222 N : 36 N : 74
N:923 N:776

Year 1 Year 2

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)
 In Hospital Mortality Rate
based on Reperfusion Strategy
P-value= 0.163

13,3%
(19) (76)
(58)

8.6% P-value= 0.235

(12)
Year 1
Year 2
(47) 4.4%
(29) (25)
3.0%
(14)

N= 762
143 139
N= 655 N= 563
574 N=
N=473
451
N=

Fibrinolisis Primary PCI

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)
 Summary
• Trend improved in hospital Mortality
– Fibrinolysis to 13.3% to 8.6%
– PPCI to 4.3% to 3%
• STEMI Process
– Regionalizing STEMI network shorten transfer time
– Secondary facility
• Improved median transfer time 150 to 120 minutes
• STEMI procedure
– Tertiary facility - Improved median DTD 82 to 69
minutes
 Challenges
• STEMI Process
– Secondary facility
• Further Improved transfer time
• Measured DIDO – to further identify problem in transfer
– Tertiary facilities
• Improve transfer time
• STEMI procedure
– Secondary facilities
• Improve DTD time
– Tertiary facility
• maintain DTD
• Further increased the number DTD as recommended guidelines
• Establishing EMS with Ambulances
 Online Real-time Data Entry
September 2015

ONLINE
WEBSITE MOBILE APP
www.istemi.id
Primary PCI Center
Non-PCI Center
Pre-hospital Care
Data Collection
Stage 1
Establish a system
Protocol for rapid primary PCI
for patients presenting to
emergency department
Protocol for fibrinolytic therapy
for patients presenting to
emergency department
Establish EMS system
Data Collection at PCI hospitals
Improving Integrated Care in Low- and Middle- Income Countries:
The Final STEMI Frontier?
Stage 2
Develop a transfer system
Receive transfers from Non-PCI
centers
Transfer to PCI center for:
- Rescue PCI
- Routine or early transfer after
fibrinolytic therapy
- Primary PCI
EMS transfer from clinics and non-PCI
centers
Data Collection at all hospitals
Rao M. J Int Cardiol 2014
Stage 3
Full integration of system
Early Cath lab activation
ED bypass
Routine transfer to PCI centers for:
- Rescue PCI
- Early transfer after fibrinolytic therapy
- Primary PCI when door to device time
is < 120 min
Pre hospital ECG
Pre hospital cath lab activation
Preferential transfer of patients to PCI
centers
Integrated data collection between EMS
and all hospitals
iSTEMI MILESTONE

Jun 2014 Sept 2015 Oct 2015 Jan 2016 Mar 2016

West Jakarta
iSTEMI Registry Members until
Web West Jakarta’s
iSTEMI iSTEMI
Application First iSTEMI
iSTEMI
Pilot Program
and Online
input system
Feb 2017
Meeting and
Conference
Expansion to
Central Jakarta
Expansion to
Bengkulu City

90 Healthcare Facilities
35 Cities, and 11 Province
Mar 2016 Apr 2016 May 2016 Jul 2016 Sept 2016
With 9234 cases submitted

National iSTEMI
Socialization iSTEMI iSTEMI
iSTEMI Expansion
iSTEMI Expansion to Expansion to
Expansion to Network &
Network and East Jakarta Bandung and
East Java Registry to
Registry Palembang
Bali
THANK YOU
Distribution of Killip Presentation in
PPCI

Year I Year II

Killip I
killip II
KillipIII Killip I
Killip IV Killip II
Killip III
Killip IV