1. Dallas 2015 TFQO: Karen Woolfrey #COI 261 EVREV 1: Karen Woolfrey # COI 261 EVREV 2: Daniel Pichel #COI 513 Taskforce: ACS ACS 872: Pre-hospital Diversion to PCI

2. Dallas 2015 COI Disclosure EVREV 1 COI#261 Commercial/industry No conflicts of Interest Potential intellectual conflicts No conflicts of Interest EVREV 2 COI# 513 Commercial/industry No conflicts of Interest Potential intellectual conflicts No conflicts of Interest

3. Dallas 2015 2010 Treatment Recommendation It is reasonable to consider direct transport to PCI capable facilities for PPCI for patients diagnosed with STEMI by EMS in the pre-hospital setting, bypassing closer EDs as necessary, in systems where time intervals between first medical contact and balloon time are brief. In patients presenting early after the onset of chest pain (2 hours) and in certain clinical subsets (>65 years-of-age, anterior STEMI), pre-hospital fibrinolysis may offer similar outcomes to PPCI

4. Dallas 2015 C2015 PICO Population: Patients with suspected ST-Elevation Myocardial Infarction (STEMI) identified outside the hospital (pre-hospital) Intervention: Transport to regional percutaneous coronary intervention (PCI) centre Comparison: Transport to local hospital for fibrinolytic therapy Outcomes: Short-term mortality (9); major bleeding (6); non-fatal stroke (6); non-fatal re-infarction (5)

5. Dallas 2015 Inclusion/Exclusion & Articles Found Only randomized control trials (RCT) were included Exclusions No Emergency Department (ED) comparator group Studies that did not randomize patients in the pre- hospital setting The search yielded a total of 464 RCT 38 full text articles reviewed 34 excluded ( 1-not relevant; 25–no PH randomization; 9–no comparison group; 1-protocol only; 1-no clinical outcomes; 1–duplicate) 4 RCT were eligible for bias assessment (2 requested unpublished data) 3 RCT were included for bias assessment

6. Dallas 2015 Draft Treatment Recommendations We suggest where PCI facilities are available, that direct transport for PCI is preferred (moderate quality of evidence based, weak recommendation) We suggest that where PCI facilities are not available, that transport to local ED for fibrinolysis is a reasonable alternative (low quality of evidence, weak recommendation) In making this recommendation, we place a higher value on avoiding iatrogenic harm and a lower value on uncertain benefits for mortality

7. Dallas 2015 Risk of Bias in studies

8. Dallas 2015 30-day Mortality (9)

9. Dallas 2015 Major Bleeding (6)

10. Dallas 2015 Non-fatal Stroke (6)

11. Dallas 2015 Non-fatal Re-Infarction (5)

12. Dallas 2015 30-day Mortality (9)

13. Dallas 2015 Major Bleeding (6)

14. Dallas 2015 Non-fatal Stroke (6)

15. Dallas 2015 Non-fatal Re-Infarction (5)

16. Dallas 2015 Proposed Consensus on Science statements For the critical outcome of short-term mortality (30-day), we have identified moderate quality of evidence (downgraded for imprecision) from three RCTs (Armstrong 2006, Thiele 2005, Bonnefoy 2002) enrolling 1099 patients showing no benefit to either therapy (OR 1.16 95% CI 0.63-2.13) For the important outcome of major bleeding, we have identified low quality of evidence (downgraded for inconsistency and imprecision) from three RCTs (Armstrong 2006, Thiele 2005, Bonnefoy 2002) enrolling 1099 patients showing no benefit to either therapy (OR 1.82 95% CI 0.56-5.92)

17. Dallas 2015 Proposed Consensus on Science statements For the important outcome of non-fatal stroke, we have identified moderate quality of evidence (downgraded for imprecision) from two RCTs (Thiele 2005, Bonnefoy 2002) enrolling 1004 patients showing no benefit to either therapy (OR 0.18 95% CI 0.02-1.57) For the important outcome of non-fatal re- infarction, we have identified moderate quality of evidence (downgraded for imprecision) from three RCTs (Armstrong 2006, Thiele 2005, Bonnefoy 2002) enrolling 1099 patients in favour of intervention over control (OR 0.40 95% CI 0.19-0.81)

18. Dallas 2015 Draft Treatment Recommendations We suggest where PCI facilities are available, that direct transport for PCI is preferred (weak recommendation, moderate quality of evidence) We suggest that where PCI facilities are not available, that transport to local ED for fibrinolysis is a reasonable alternative (weak recommendation, low quality of evidence) In making this recommendation, we place a higher value on avoiding iatrogenic harm and a lower value on uncertain benefits for mortality

19. Dallas 2015 Knowledge Gaps Specific research required RCT enrolling larger numbers of patients Time specific data