1. Ambulance Victoria and MonashHEART Acute Myocardial Infarction (Mon-AMI) 12 lead ECG project. An update On behalf of the MonAMI Team A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Meredith. Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine (MMC), Monash University, Melbourne, Australia. (MMC), Monash University, Melbourne, Australia. Metropolitan Ambulance Service, Melbourne Australia. Metropolitan Ambulance Service, Melbourne Australia. Southern Health Emergency, Southern Health, Melbourne Australia. On behalf of the MonAMI Team A Hutchison, Y Malaiapan, B Barger, I Jarvie, E Watkins, G Braitberg, T Kambourakis, JD Cameron, IT Meredith. Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine Monash Cardiovascular Research Centre, MonashHEART, Southern Health & Department of Medicine (MMC), Monash University, Melbourne, Australia. (MMC), Monash University, Melbourne, Australia. Metropolitan Ambulance Service, Melbourne Australia. Metropolitan Ambulance Service, Melbourne Australia. Southern Health Emergency, Southern Health, Melbourne Australia.

2. Emergency Coronary Angioplasty for Acute Heart Attack at Monash Rescue AMI Primary AMI Total AMI Year

3. Time Delay to Treatment in Acute Heart Attack Angioplasty & Mortality Zwolle AMI Study Group 1994-2001 n = 1791 Zwolle AMI Study Group 1994-2001 n = 1791 1.Every minute delay in Rx affects mortality in both Thrombolytic & 1 o PCI groups. 2.Every 30 min delay = Relative in 1 year mortality by 7.5%. 1.Every minute delay in Rx affects mortality in both Thrombolytic & 1 o PCI groups. 2.Every 30 min delay = Relative in 1 year mortality by 7.5%. G.De Luca Circulation. 2004;109:1223 -1225 Early recognition, rapid transport and treatment is absolutely vital

4. Door to Balloon time affects in hospital mortality US National registry of myocardial infarction J Am Coll Cardiol, 2006 47:2180-2186 In patient Mortality %

5. Symptom onset < 1 hour before presentation PCI available within 1 hour † YESNO PCIFibrinolysis ‡ Symptom onset 1–3 hours before presentation PCI available within 90 minutes † YESNO PCIFibrinolysis ‡ Symptom onset 3–12 hours before presentation PCI available within 90 minutes (onsite) or 2 hours (offsite, including transport) † YESNO PCIFibrinolysis ‡ * Assuming no contraindications to fibrinolytic therapy; † Time delay refers to time from first medical contact to balloon; ‡ Patients with ongoing symptoms or instability should be transferred for PCI. PCI = percutaneous coronary intervention Acute Coronary Syndrome Guidelines Working Group Med J Aust 2006;184(8 Suppl):S9-29. Hospital Management of STEMI*

6. Time to presentation MonashHEART experience

7. GuidelinesGuidelines AHA / ACC: AHA / ACC: D2BT < 90 minutes in 75% of patients. D2BT < 90 minutes in 75% of patients. 29.3% of US patients are treated in under 90 minutes in 2006. 29.3% of US patients are treated in under 90 minutes in 2006. Median US D2BT: 116 minutes. Median US D2BT: 116 minutes. AHA / ACC: AHA / ACC: D2BT < 90 minutes in 75% of patients. D2BT < 90 minutes in 75% of patients. 29.3% of US patients are treated in under 90 minutes in 2006. 29.3% of US patients are treated in under 90 minutes in 2006. Median US D2BT: 116 minutes. Median US D2BT: 116 minutes. J Am Coll Cardiol, 2006 47:2180-2186

8. Aims of MonAMI To determine if paramedic performed field 12 lead ECG and activation of the infarct team, via the emergency physician, reduced D2BT in patients undergoing primary PCI (PPCI)

9. MethodsMethods Prospective interventional study in a single Australian metropolitan health care network. Prospective interventional study in a single Australian metropolitan health care network. 560 patients 560 patients MonAMI group MonAMI group All patients (n=186) who underwent PPCI following field ECG All patients (n=186) who underwent PPCI following field ECG Non-MonAMI group Non-MonAMI group Patients (n=254) who underwent PPCI following standard triage during the time of field ECG capability Patients (n=254) who underwent PPCI following standard triage during the time of field ECG capability Pre-MonAMI group. Pre-MonAMI group. The D2BT of 120 consecutive patients who underwent PPCI prior to initiation of field triage The D2BT of 120 consecutive patients who underwent PPCI prior to initiation of field triage Prospective interventional study in a single Australian metropolitan health care network. Prospective interventional study in a single Australian metropolitan health care network. 560 patients 560 patients MonAMI group MonAMI group All patients (n=186) who underwent PPCI following field ECG All patients (n=186) who underwent PPCI following field ECG Non-MonAMI group Non-MonAMI group Patients (n=254) who underwent PPCI following standard triage during the time of field ECG capability Patients (n=254) who underwent PPCI following standard triage during the time of field ECG capability Pre-MonAMI group. Pre-MonAMI group. The D2BT of 120 consecutive patients who underwent PPCI prior to initiation of field triage The D2BT of 120 consecutive patients who underwent PPCI prior to initiation of field triage

10. 12 Lead ECG Project Patient with CP MICA Traditional AMI Communication Strategy: MICA Transports Patient to ED Patient Triaged in ED 12 Lead ECG Performed by ED Staff Diagnosis Made ED Resident/Registrar or Consultant Calls Cardiology Registrar Cardiology Registrar sights ECG & calls CCU Ward Service Consultant Interventional Cardiologist Contact Infarct Team Activated

11. 12 Lead ECG Project Patient with CP MICA Attends & Performs 12 Lead ECG On Site New lines of Communication: MICA Transports Patient to Monash Heart Cath Labs 12 Lead ECG Electronically Transmitted to ED Diagnosis Made by ED Consultant Interventional Cardiologist Contact Infarct Team Ready & Waiting in Cath Labs Page

12. Pre Mon-AMINon Mon-AMIMon-AMI P value Male81%74%81% 0.20 Age (Years)58.561.263.5 0.003 Hypertension38%47%40% 0.22 Diabetes16%19%14% 0.20 Hyperlipidaemia32%37%41% 0.16 Smoker (current)42%40%37% 0.42 Family History19%23%24% 0.52 Out of hours54%63%53% 0.08 Patient Demographics

13. MonAMI Pilot Study December 2007 – July 2008 MonAMI Pilot Study December 2007 – July 2008 ED stand down N = 85 (41%) STEMI N = 0 ACS (excluding STEMI) N = 35 Field ECG faxed to MMC 204 204 No ACS N = 52 Primary PCI N = 107 Taken to Cath Lab N = 119 (59%) CAD no PCI N = 3* No overt CAD N = 9 * Severe Triple Vessel Disease (CABG)

14. Median D2B Times P < 0.001 December 2007 – July 2009

15. Median Times Pre MonAMINon MonAMIMonAMIP value D2BT102102.556.5 <0.001 Door-to-cath lab time 697026 <0.001 Cath lab-to- Balloon time 28 27 0.44

16. Ambulance times (minutes) P = 0.31

17. Proportion of cases achieving D2B time under 90 minutes 75%* *AHA /ACC/SCAI guidelines

18. ConclusionConclusion The performance of field 12 lead ECG to triage and pre hospital activation of the infarct team significantly improves door to balloon times and results in a greater proportion of patients achieving guideline recommendations.

19. MonAMI Pilot Study Ambulance Victoria Greg CooperAmbulance Victoria Group Manager Danny McGennisken Operations Manager Paramedic Education & Training Eddy Watkins Clinical support Officer Bill Barger Manager Clinical Standards & Audits Ian Jarvie Ambulance Victoria Clinical Support Officer Monash Heart Prof Ian Meredith Director MonashHeart Dr Yuvi Malaiapan Head Interventional Services SH Emergency Dept Prof George Braitberg Professor and Director SH Emergency Medicine Dr Tony Kambourakis Director Emergency Monash Clayton Mr Damien GibneyNUM Emergency Monash Clayton Strategy Planning & Performance Ms Fiona Webster Executive Director SPP Ms Ruth Smith Director Access, Innovation & Service Improvement Ms Karen Barker Project Officer Southern Health Information Technology Mr Charles BurgessExecutive Director IT Mr Peter Kinsman Director IT Monash Sector Executive Mr Adam HorsburghDirector Monash sector Ambulance Victoria Greg CooperAmbulance Victoria Group Manager Danny McGennisken Operations Manager Paramedic Education & Training Eddy Watkins Clinical support Officer Bill Barger Manager Clinical Standards & Audits Ian Jarvie Ambulance Victoria Clinical Support Officer Monash Heart Prof Ian Meredith Director MonashHeart Dr Yuvi Malaiapan Head Interventional Services SH Emergency Dept Prof George Braitberg Professor and Director SH Emergency Medicine Dr Tony Kambourakis Director Emergency Monash Clayton Mr Damien GibneyNUM Emergency Monash Clayton Strategy Planning & Performance Ms Fiona Webster Executive Director SPP Ms Ruth Smith Director Access, Innovation & Service Improvement Ms Karen Barker Project Officer Southern Health Information Technology Mr Charles BurgessExecutive Director IT Mr Peter Kinsman Director IT Monash Sector Executive Mr Adam HorsburghDirector Monash sector