1. GUSTO I 90-93 GUSTO I 90-93 2.8 Median Time (hrs) Between Symptom Onset and Treatment GUSTO III 95-97 GUSTO III 95-97 InTIME II 97-99 InTIME II 97-99 ASSENT 3 00-01 ASSENT 3 00-01 ASSENT II 97-98 ASSENT II 97-98 GUSTO V 99-01 GUSTO V 99-01 2.8 2.7 2.9 Gibson CM, Circulation 2001;104:2632-2634

2. National Registry of Myocardial Infarction,1990-2006 Trends in symptom onset-to-door time among STEMI patients, stratified by sex Gibson CM, ACC 2008

3. The AngelMed Guardian System An Implantable Device (IMD) - Implantable cardiac event recorder with ST-segment measurement and alarm. Records electrogram and will issue an alarm for acute ST shift changesAn Implantable Device (IMD) - Implantable cardiac event recorder with ST-segment measurement and alarm. Records electrogram and will issue an alarm for acute ST shift changes A Programmer to program the IMD and retrieve and process the data captured by the IMD.A Programmer to program the IMD and retrieve and process the data captured by the IMD. An External Device (EXD) that provides an additional (audio) alarm and telemetry up to 6 feet between the implant and the EXD. The EXD has an alert silence button, labeled LEDs to indicate the type of alarm and printed patient instructions.An External Device (EXD) that provides an additional (audio) alarm and telemetry up to 6 feet between the implant and the EXD. The EXD has an alert silence button, labeled LEDs to indicate the type of alarm and printed patient instructions.

4. Patient B9 Acute ST Elevation Event September 2007 2 nd Em. Alarm Emergency Alarm at 12:20 pm 9/17/07 Arrival at hospital ~1 hour later

5. Start of Arterial Occlusion Patient B9 – ST Elevation 1st Emergency Alarm Patient arrives at the hospital

6. Patient B9 – ST Elevation Emergency Alarms 1 st Em. Alarm2 nd Em. Alarm (in hospital) Patient put on Heparin and Clopidogrel

7. Ruptured Plaque Site in Pt. B9 Circumflex March 1, 2007 Sept 18, 2007

8. Gersh, B. J. et al. JAMA 2005;293:979-986. Relationship Between Duration of Symptoms of Acute MI Before Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial Salvage

9. Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent of Flow in Artery 16% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) Gibson, JACC 2004 Normal Large Capillary Lumen Clinical Picture: Open Artery Closed Muscle Blistering of Capillaries & Endothelium “Blistered” / Swollen Endothelium / wall of the capillary Normal non- infarcted wall without edema Infarcted wall with edema (white areas) Interstitial Edema EHJ (2004) 25, 794–803 Gibson CM 2008

10. Symptom – balloon inflation (min) One-year mortality, % 6 RCTs of Primary PCI by Zwolle Group 1994 – 2001 N = 1791 RR = 1.08 for each 30 min delay (P = 0.04) P < 0.0001 12 10 8 6 4 2 0 060120180240300360 Symptom Onset-Balloon Time and Mortality in Primary PCI for STEMI DeLuca, Suryapranata, Circ 109:1223, 2004 The relative risk of 1-year mortality increases by 7.5% for each 30-minute delay

11. Trend in door-to-needle time among reperfusion-eligible STEMI patients receiving fibrinolytic therapy Gibson CM, ACC 2008 National Registry of Myocardial Infarction, 1990-2006

12. National Registry of Myocardial Infarction, 1994-2006 Trend in in-hospital mortality among reperfusion-eligible STEMI patients treated with fibrinolytic therapy Gibson CM, ACC 2008

13. National Registry of Myocardial Infarction, 1994-2006 Trends in door-to-balloon time among reperfusion-eligible STEMI patients treated with primary PCI, stratified by transfer status Gibson CM, ACC 2008

14. National Registry of Myocardial Infarction, 1994-2006 Trends in in-hospital mortality among reperfusion-eligible STEMI patients treated with primary PCI, stratified by transfer status Gibson CM, ACC 2008