1. STEMI/STROKE BOOT CAMP “Time is Muscle” Paul T. Frantz, MD Medical Director, Cardiac Services Carilion Clinic

2. Agenda “Time is Muscle” – what is the science behind this statement Case Reviews – with ‘take home’ messages Q & A

3. Full Disclosure Statement: Dr. Frantz receives no reimbursement from any of the companies or products sited in his presentation

4. Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque Adapted with permission from Falk E, et al. Circulation. 1995 ;92:657-671. Slide reproduced with permission from Cannon CP: Atherothrombosis slide compendium; www.theheart.org

11. 11 Treatment Delayed is Treatment Denied Antman EM et al. Circulation, 2004

12. Normal Right Coronary Arteriogram

15. Case # 1 “When all the stars are aligned” 54 y.o male with sudden onset chest pain before going to work Called 9-1-1, Fort Lewis crew responded c/o nausea, vomiting, right shoulder pain Cool and diaphoretic; BP 90/40 P 56 (weak) Loaded & IMI identified on 12 lead EKG Field Heart Alert called “ETA 10 minutes”

16. Field EKG @ 8:04 AM

17. Time Sequence for Case # 1 Dispatched 7:52 Arrived at Scene 7:56 Arrived at Patient 7:57 Field EKG 8:04 Transport 8:07 Heart Alert Called (“ETA 10 min”) 8:23 Arrived at CCL (direct admit) 8:35 Balloon Time 9:01 Door to Balloon Time 26 minutes EMS Contact to Balloon Time 64 minutes

18. Cardiac Catheterization/PCI

24. Normal Left Coronary Arteriogram

29. Case # 2 “Reinforcing That Time is Muscle” 61 y.o. male (R.M.) c/o severe c.p. beginning about 4:30 PM Called 9-1-1 after 5:00 and CPTS ground crew requested LG 10 on standby Clinical presentation and12 lead by ground crew suspicious for MI (rapid AF with wide complex QRS); LG 10 launched Given ASA, NTG, adenosine and fluid bolus Repeat 12 lead suspicious for MI and pt transferred to CRMH by air Remained hypotensive (100/72) with rapid, weak pulse during transport After evaluation in ED, Heart Alert called

30. CPTS 2nd EKG on ground CPTS 1st EKG on ground

31. LG 10 EKG while in air

33. Time Sequence for Case # 5 Standby Request for LG 1017:20 Launch Request17:55 Lift off17:59 Arrive at Scene18:23 Transport18:34 Arrive CRMH18:50 Arrived at ED19:00 Heart Alert called19:30 Balloon Time20:33 Door to Balloon Time93 minutes HA to Balloon Time63 minutes EMS Contact to Arrival CCL130 minutes

34. Cardiac Catheterization/PCI

41. 41 Bottom Line………………… the old mantra rings true! System saves time! System saves muscle! Systems saves lives! System saves time! System saves muscle! Systems saves lives!

42. 42 Treatment Delayed is Treatment Denied Antman EM et al. Circulation, 2004