1. Inter-Hospital Transfer of High Risk STEMI Patients for PCI is Safe and Feasible David M. Larson, Katie M. Menssen, Scott W. Sharkey, Marc C. Newell, Anil K. Poulose, Ivan J. Chavez, Yale L. Wang, Barbara T. Unger, Timothy D. Henry Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN

2. Presenter Disclosure Information DISCLOSURE INFORMATION: None David M. Larson, MD Inter-Hospital Transfer of High Risk ST-Segment Elevation Myocardial Infarction Patients for Percutaneous Coronary Intervention is Safe and Feasible

3. Background Primary PCI is superior to fibrinolysis for treatment of STEMI if performed in a timely manner at experienced centers Only 25% of US hospitals have PCI capability Recent ACC/AHA guideline recommends transfer for PCI in high risk patients (cardiogenic shock, Killip class ≥3), although the risk of transfer of this group of patients has not been well documented

4. Fibrinolysis generally preferred Invasive strategy not an option Cath lab occupied/not available Vascular access difficulties No access to skilled PCI center Delay to invasive strategy Prolonged transport Door to balloon >90 minutes >1 hour vs. lysis now Very early presentation <1-2 hours from symptoms ACC/AHA STEMI Guideline Invasive Strategy generally preferred Skilled PCI center available/short delay Operator experience  75 cases/yr Team experience  36 PCI/yr Door to balloon <90 minutes High risk from STEMI Cardiogenic shock (age <75) Killip  3 Increased bleeding risk Especially ICH Late presentation >2-3 hours from symptoms Diagnosis in doubt

5. Number of pts transferred ExclusionsDeaths During Transfer V-fib During Transfer Danami 2 (n=559) Cardiogenic shock Mechanical ventilation 08 Prague 2 (n=425) None 23 Prague (n=201) Terminal cardiogenic shock Problems with transport 02 Maastricht (n=149) Age ≥80 Cardiogenic shock 02 Air PAMI (n=71) Cardiogenic shock 00 Total (n=1405) 2 (0.14%)15 (1.1%) Complications During Transfer

6. Study Objective To assess the risk of inter-hospital transfer of an unselected high risk cohort of STEMI patients for primary or facilitated PCI With particular focus on high risk patients including cardiogenic shock, out of hospital cardiac arrest, advanced age, long distance

7. Minneapolis Heart Institute/Abbott Northwestern Hospital (ANW) A tertiary Cardiovascular Center in Minneapolis, MN 2,500 PCI/year 600 STEMI-PCI 46 Cardiologists 10 Interventional Cardiologists

8. Methods A standardized protocol (“Level 1 MI program”) for transfer of STEMI patients for primary or facilitated PCI from 28 rural and community hospitals was implemented based on the Trauma system concept in 2003 Consecutive patients presenting with ST- elevation or new LBBB with symptoms <24 hours were included

9. Methods No patients were excluded from transfer or analysis including elderly, cardiogenic shock and post cardiac arrest patients Extensive clinical and angiographic data including time intervals, complications during transfer and clinical outcomes were entered in to a prospective registry

11. Results From 7/03 to 6/06, 861 consecutive STEMI patients were transferred from the emergency department for PCI from 28 non-PCI hospitals Transfer distances ranged from 17-210 miles

12. Mode of Transfer Helicopter – 69% Ground ALS – 31% Zone 1 – 55 % Zone 2 – 93% Zone 1 – 45 % Zone 2 – 7%

15. High Risk Patients Age  80: 117 (13.5%) Cardiogenic shock: 98 (11.4%) Cardiac arrest (pre-transfer): 61 (7.1%) Endotracheal intubation (pre-transfer): 44 (5.1%)

16. Time Intervals (median) 66 95 120

17. Complications During Transfer Cardiopulmonary arrest - 17 (2%) Intubation - 6 (0.7%) Death - 1 (0.1%)

18. Cardiopulmonary Arrest During Transfer 15 patients transferred by helicopter 2 patients transferred by ground ambulance

19. Cardiopulmonary Arrest During Transfer – 17 (2%) Ventricular fibrillation - 12 (1.4%) Asystole – 4 (0.4%) Respiratory arrest – 1 (0.1%) 13/17 (76%) of the patients were Killip 4 pre- transfer

20. Outcomes of Cardiac Arrest During Transfer Of the 17 patients who arrested, all but 1 were resuscitated with return of spontaneous circulation on arrival to cath lab 3 died in the cath lab before PCI due to refractory cardiogenic shock 2 died post PCI in hospital 11 discharged and alive at 30 days

21. Conclusion Transfer of STEMI patients including high risk, unstable patients with cardiogenic shock and post cardiac arrest from community hospitals for PCI utilizing an established transfer protocol is safe and effective. Death during transfer occurred in 0.1% similar to previous clinical data of 0.14% despite the inclusion of very high risk patients This data represents the largest reported series to date of STEMI patients transferred for Primary PCI