1. Heart Alert Quandary Kiran K. Cheruku, MD Interventional Cardiologist Heart And Vascular Institute of Texas

2. Mr. W is a 76 yr old caucasian male with Pmhx of HTN and GERD was travelling through San Antonio. Staying at a RV park, while working on his trailer developed chest pain 10/10. Took 2 s/l ntg with no relief. Severely nauseated and diaphoretic. Wife called 911.

3. 911 call was placed at 09:33. EMS dispatched at 09:34 EMS arrived at scene 09:37 Found patient in severe distress with 10/10 worst chest pain in life, clutching his chest. Vitals signs showed BP 148/84 mmHg, P – 63 mmHg. One more s/l ntg was given with no relief.

4. EKG done in field at 09:43 am. Heart Alert activated at 09:44 am. EKG transmission attempted but unsuccessfull

6. NE Methodist notified of the Heart Alert and patient transported to NEM as it was the closest hospital. Patient arrived at NE Methodist at 09:54 am

7. Patient stable on arrival, but still in pain, 6/10. NE Methodist had another Heart Alert come in 15 minutes earlier and that patient was on the cath lab table. Only one team available as it was a weekend. WHAT TO DO NOW?

8. Thrombolytics Vs transfer to nearest PPCI center

9. 9 High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs 5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs Lytic therapy Front-loaded tPA 100 mg (n=782) Death / MI / Stroke at 30 Days DANAMI-2: Study Design Primary PCI with transfer (n=567) Primary PCI without transfer (n=223) Stopped early by safety and efficacy committee

10. 10 Death / MI / Stroke (%) Lytic Primary PCI P=0.0003 P=0.002 Combined Transfer Sites P=0.048 Non-Transfer Sites DANAMI-2: Primary Results RRR 45% Lytic Primary PCI Lytic Primary PCI RRR 40% RRR 45%

11. 11 Lytic Primary PCI P=0.35 Death DANAMI-2: Results Lytic Primary PCI P=0.15 Stroke Lytic Primary PCI P<0.0001 Recurrent MI

12. Door-to-Balloon Time (minutes) <1 / month N=4,740 P = 0.0008 <1 / month N=4,740 P = 0.0008 1-3 / month N=14,078 P < 0.0001 1-3 / month N=14,078 P < 0.0001 >3 / month N=14,078 P < 0.0001 >3 / month N=14,078 P < 0.0001 Primary PCI: Door-to-Balloon time vs. Mortality Stratified by Institutional Volume

13. 13 Hospital Volume of Primary PTCA vs. Mortality 0.87 0.72 0.83 P value for trend < 0.001 Canto. NEJM 2000 N: Pt = 2,825 5,245 9,303 19,162 Hosp =113 112 113 112

14. 14 DANAMI 2 Conclusions Among patients transferred for primary PCI with a median door to balloon time of 114 minutes, the incidence of the composite endpoint of death, recurrent MI, and stroke is reduced compared with the administration of tPA and heparin when used in conjunction with a rescue / adjunctive PCI rate of 2.5%. CM Gibson 2002

15. 15 DANAMI 2 Conclusions The median US door to balloon time for transfer patients is 198 minutes, and is not as rapid as in DANAMI 2 (114 minutes) The composite endpoint was driven primarily by a lower rate of recurrent MI among PCI patients Current strategies that employ higher rates of rescue and adjunctive PCI after fibrinolysis and higher rates of enoxaparin use have been associated with lower rates of recurrent MI than that reported in DANAMI 2 CM Gibson 2002

16. Cath lab at NE Baptist was activated and patient transported to NE Baptist. Patient left NE Methodist at 10:24 am Arrived at NE Baptist at 10:33 am Patient taken directly to the cath lab.

17. Access obtained in right CFA at 10:51 am Aspiration thrombectomy done at 11:07 RCA stented at 11:16 am with TIMI 3 flow and patient was chest pain free

20. 73 Door to balloon from NEM door to balloon – 73 minutes 34 Door to balloon at NEB – 34 minutes 85 EKG in field to balloon time – 85 minutes 94 911 call to balloon time – 94 minutes Great Job Guys !!!! Great Job Guys !!!!