1. Regional Systems of Care to Optimize Timeliness of Reperfusion Therapy for STEMI: The Mayo Clinic Protocol Henry H. Ting, MD, MBA Associate Professor of Medicine Mayo Clinic College of Medicine Division of Cardiovascular Diseases Mayo Clinic, Rochester August 14, 2007

2. Study Objectives Improve door-to-balloon time (D2B) for non-transferred STEMI patients presenting to a PCI center (Saint Marys Hospital, Rochester, MN) Improve door-to-balloon time (D2B) for non-transferred STEMI patients presenting to a PCI center (Saint Marys Hospital, Rochester, MN) Develop, implement, and evaluate a system of care to improve first door-to- balloon time and door-to-needle time (D2N) for transferred STEMI patients initially presenting to regional hospitals without onsite PCI (28 regional hospitals up to 150 miles away from the PCI center located across 3 States) Develop, implement, and evaluate a system of care to improve first door-to- balloon time and door-to-needle time (D2N) for transferred STEMI patients initially presenting to regional hospitals without onsite PCI (28 regional hospitals up to 150 miles away from the PCI center located across 3 States) Ting HH, et al. Circulation 2007;116:729-736

3. Mayo Clinic STEMI Experience May 2004 to December 2006 Ting HH, et al. Circulation 2007;116:729-736

4. Consecutive STEMI patients presenting to Saint Marys Hospital Emergency Department (Rochester, MN) were all treated with primary PCI (Group A) Consecutive STEMI patients presenting to Saint Marys Hospital Emergency Department (Rochester, MN) were all treated with primary PCI (Group A) 4 out of the 6 ACC D2B strategies were implemented 4 out of the 6 ACC D2B strategies were implemented ED physician activates the Cath Lab ED physician activates the Cath Lab Single call to activate the Cath Lab Single call to activate the Cath Lab Cath Lab operational within 20 minutes of activation Cath Lab operational within 20 minutes of activation Real time data feedback for case review Real time data feedback for case review Remaining 2 ACC D2B strategies were not implemented due to cost and complexity Remaining 2 ACC D2B strategies were not implemented due to cost and complexity Reperfusion Strategy for PCI Center Ting HH, et al. Circulation 2007;116:729-736

5. ED physician activates the Cath Lab ED physician activates the Cath Lab Single call to activate the Cath Lab Single call to activate the Cath Lab Cath Lab operational within 20 minutes of activation Cath Lab operational within 20 minutes of activation Real time data feedback for case review Real time data feedback for case review  Having attending cardiologist always on site  Prehospital ECG to activate Cath Lab while patient is en route N Engl J Med 2006;355:2308-2320

6. 71 min90 min Saint Marys Hospital Emergency Department STEMI Patients Treated with Primary PCI (2004-2006) Compared with Historical Controls (2003) Ting HH, et al. Circulation 2007;116:729-736 P =0.004

7. Standard protocol for treatment and transfer called the Mayo Clinic Fast Track Standard protocol for treatment and transfer called the Mayo Clinic Fast Track AHA/ACC Class I reperfusion strategies utilized: AHA/ACC Class I reperfusion strategies utilized: If duration of symptoms >3 hours or contraindication to fibrinolytic therapy or very high clinical risk, then regional STEMI patients presenting to 28 regional hospitals located up to 150 miles away from Rochester, MN were immediately transferred for primary PCI (Group B) If duration of symptoms >3 hours or contraindication to fibrinolytic therapy or very high clinical risk, then regional STEMI patients presenting to 28 regional hospitals located up to 150 miles away from Rochester, MN were immediately transferred for primary PCI (Group B) If duration of symptoms <3 hours, then regional STEMI patients were treated with full dose fibrinolytic therapy and immediate transfer, followed by routine cardiac cath in 24-48hrs if successful reperfusion or immediate rescue PCI for failed reperfusion (Group C) If duration of symptoms <3 hours, then regional STEMI patients were treated with full dose fibrinolytic therapy and immediate transfer, followed by routine cardiac cath in 24-48hrs if successful reperfusion or immediate rescue PCI for failed reperfusion (Group C) Reperfusion Strategy for STEMI Patients Initially Presenting to Regional Hospitals Ting HH, et al. Circulation 2007;116:729-736

8. No STEMI patients were treated with a fibrinolytic-facilitated PCI strategy which is an AHA/ACC Class IIb indication No STEMI patients were treated with a fibrinolytic-facilitated PCI strategy which is an AHA/ACC Class IIb indication Regional hospitals were enrolled in the Mayo STEMI network only if Saint Marys Hospital was the closest PCI center. No PCI-capable hospitals were bypassed or flown over to transfer STEMI patients to Saint Marys Hospital Regional hospitals were enrolled in the Mayo STEMI network only if Saint Marys Hospital was the closest PCI center. No PCI-capable hospitals were bypassed or flown over to transfer STEMI patients to Saint Marys Hospital The 63 (10.5%) patients with presumed new ST- elevation or LBBB on initial ECG, but who turned out to have another diagnosis such as pericarditis, apical ballooning, etc…, were excluded from analysis and calculation of outcomes including mortality The 63 (10.5%) patients with presumed new ST- elevation or LBBB on initial ECG, but who turned out to have another diagnosis such as pericarditis, apical ballooning, etc…, were excluded from analysis and calculation of outcomes including mortality Key Points Ting HH, et al. Circulation 2007;116:729-736

9. Mayo Clinic FAST TRACK Protocol for Regional STEMI Patients Ting HH, et al. Circulation 2007;116:729-736

10. Minnesota Wisconsin Iowa Rochester Minneapolis/ St. Paul 0100200 Mayo Clinic Network 28 regional hospitals up to 150 miles away Ting HH, et al. Circulation 2007;116:729-736

11. Minnesota Blue Earth Cannon Falls Faribault Lake City LeSueur Madelia Mankato Northfield St Peter Owatonna Red Wing Springfield St. James New Ulm Wabasha Waseca Winona Durand Wisconsin Rochester Albert Lea Austin Charles City Cresco Decorah Fairmont New Hampton Osage La Crosse Iowa 0100200 Minneapolis/ St. Paul

12. Regional STEMI Patients Treated with Primary PCI or Fibrinolysis May 2004 to December 2006 (n=236) 25 min 116 min71 min Ting HH, et al. Circulation 2007;116:729-736

13. Mortality

14. Mortality and Door-to-Needle Time Ting HH, et al. Circulation 2007;116:729-736

15. Mortality and Door-to-Balloon Time Ting HH, et al. Circulation 2007;116:729-736

16. Mortality and Door-to-Needle / Door-to-Balloon Ting HH, et al. Circulation 2007;116:729-736

17. Conclusions Implementing simple strategies recommended by ACC D2B Quality Alliance can dramatically improve D2B at PCI-capable centers Implementing simple strategies recommended by ACC D2B Quality Alliance can dramatically improve D2B at PCI-capable centers D2B decreased from 90 minutes to 71 minutes at Saint Marys Hospital D2B decreased from 90 minutes to 71 minutes at Saint Marys Hospital Utilizing AHA/ACC guidelines for selecting reperfusion strategies, regional “systems of care” can be implemented to improve D2N and D2B at regional hospitals located up to 150 miles away from a PCI center across 3 States Utilizing AHA/ACC guidelines for selecting reperfusion strategies, regional “systems of care” can be implemented to improve D2N and D2B at regional hospitals located up to 150 miles away from a PCI center across 3 States D2N 25 minutes D2N 25 minutes First door-to-balloon 116 minutes First door-to-balloon 116 minutes Ting HH, et al. Circulation 2007;116:729-736