1. Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008) CVN Weekly Interventional Update December 8, 2008 Jeffrey J. Popma and Christopher P. Cannon

2. National Performance Measures have focused on the timeliness of reperfusion in STEMI 1994-1995: Cooperative Cardiovascular Project 1998-1999: National AMI Project Baseline 2000-2001: Time to PCI reperfusion decreased by 19 minutes (with a median time: 107 minutes) from 1998-99 2006: TJC CMS published aligned criteria that evolved from benchmarks of median Door-to-Balloon times from 120 minutes to 90 minutes 2006: ACC AHA performance measures for AMI 2008: ACC-AHA Focused Guidelines Updated Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008) Antman EM et al JACC 2008; 51, on line

3. EMS Activation of Cath Lab (  15.4 minutes) ED Activates Cath Lab (  8.2 minutes) “Code STEMI” Beeper (  13.8 minutes) Response Time < 20 mins (  19.3 minutes) Interventionalist in Hospital 24/7 (  14.6 minutes) ED-cath lab staff real time feedback (  8.6 mins) EMS Activation of Cath Lab (  15.4 minutes) ED Activates Cath Lab (  8.2 minutes) “Code STEMI” Beeper (  13.8 minutes) Response Time < 20 mins (  19.3 minutes) Interventionalist in Hospital 24/7 (  14.6 minutes) ED-cath lab staff real time feedback (  8.6 mins) Bradley EH et al NEJM 2006; 355:2308-2320

4. Stakeholders in Time to Reperfusion ACC-AHA 2007 Focused Update: Guidelines recommends a first medical contact to balloon time < 90 minutes CMS and TJC: Core Measures for AMI - Median D2B and % < 90 minutes Hospital Compare - http://www.hospitalcompare.hhs.gov/Hospital NCDR Registry  State reporting in MA AHA Get With the Guidelines ACC D2B (Door to Balloon) Alliance Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008)

5. The Qualifying EKG by CMS-TJC ECG Interpretation: derived from abstraction of data from the medical record on the interpretation of the EKG and not by an independent review of the EKG. Misinterpretations of the initial EKGs may not be included in the analysis ECG Timing : only the ECG obtained closest to the arrival to the hospital, or within the one hour prior to arrival, is used for inclusion for analysis. In-hospital ECG STEMIs are not included Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008)

6. Key Exclusions For Reperfusion Time Performance Assessment Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008)

7. Time of Device Use for PCI Time to Use of First Device, including balloons, stents, and thrombectomy devices -Important to “synchronize” time clocks, ECGs, etc -Specific recommendations on the “start time” are needed from CMS-TJC. Does not account for “time to reperfusion” from initial angiographic assessment or wire crossing: Should be considered a measure of “process” rather than “coronary flow” Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008)

8. Unresolved Issues Measuring the time to reperfusion among patients who receive this therapy does not address the decision to provide reperfusion therapy among eligible patients. -EKG definitions should conform to guidelines -But not all ST segment elevations warrant PCI First Medical Contact to Reperfusion Time has been recommended by the most recent ACC-AHA STEMI guidelines update but not for CMS-TJC Performance Measures -EMS activation v. first in-field EKG  needs validation In-Hospital STEMIs are currently excluded from CMS-TJC data abstraction because of difficulties assessing the “start time”. ACC-AHA recommends that the in-hospital STEMI patients be reviewed for quality improvement purposes Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008)

9. Future Considerations Electronic health records (EHRs) provide a platform for data collection with the potential to reduce data abstraction times and variability of interpretation -Specific performance measures should be included but have not been widely included to date Participation in clinical data registries and quality improvement initiatives, e.g. ACC NCDR and AHA Get with the Guidelines” -Data collected in “real time” to avoid the need for duplicate data entry and allows ongoing monitoring -Newer registries data collection elements should be aligned with existing performance measures Masoudi FA et al J Am Coll Cardiol (Published online 27 November 2008)