1. Dallas 2015 TFQO: Karen Woolfrey COI #261 EVREV 1: Karen Woolfrey COI #261 EVREV 2: Daniel Pichel COI #513 Taskforce: ACS ACS 873: Pre-hospital STEMI Activation of Cath Lab

2. Dallas 2015 COI Disclosure EVREV 1 COI# 261 Commercial/industry No conflicts of Interest Potential intellectual conflicts No conflicts of Interest EVREV 2 COI# 513 Commercial/industry No conflicts of Interest Potential intellectual conflicts No conflicts of Interest

3. Dallas 2015 2010 Treatment Recommendation Hospitals should implement pre-hospital activation of the catheterization laboratory for patients with suspected STEMI who arrive by EMS This review was part of a larger ‘systems of care’ analysis

4. Dallas 2015 C2015 PICO Population: Patients with suspected ST-Elevation Myocardial Infarction (STEMI) identified outside the hospital (pre-hospital) Intervention: Pre-hospital activation of catheterization laboratory Comparison: No pre-hospital activation Outcomes: Short-term mortality(9); major bleeding(6); non-fatal stroke (6); non-fatal re- infarction (5)

5. Dallas 2015 Inclusion/Exclusion & Articles Found Randomized control trials (RCT) and observational studies were included Exclusions No comparator group (hospital activation) Studies that did not randomize patients in the pre- hospital setting; STEMI ‘walk-ins’ Studies that did not activate cath lab pre-hospital (enroute) Comparator group was transferred from another facility Studies that did not preform pre-hospital ECG for confirmation of STEMI diagnosis

6. Dallas 2015 Inclusion/Exclusion & Articles Found The search yielded a total of 1518 studies/ 389 RCT Excluded 1510 8 full text articles reviewed 6 excluded (no comparator group; no clinical outcomes reported; not relevant to question) 0 RCT included 2 observational studies included for bias assessment 7 articles were reviewed by reference list review 6 excluded 1 observational study included after full text review 1 systematic review and meta-analysis reviewed 10 full text articles reviewed 7 excluded (2-activation from local ED not pre-hospital) 3 observational studies included for bias assessment

7. Dallas 2015 Draft Treatment Recommendations We recommend when primary PCI (PPCI) is the planned strategy, that pre-hospital activation of catheterization lab for PPCI is preferred over no pre-hospital activation (strong recommendation, moderate quality of evidence) In making this recommendation we place higher value of benefit to patient outcomes over the potential increased resource utilization.

8. Dallas 2015 Risk of Bias in studies

9. Dallas 2015 30-day Mortality (9)

10. Dallas 2015 Major Bleeding (6)

11. Dallas 2015 Non-fatal Stroke (6)

12. Dallas 2015 Non-fatal Re-Infarction (5)

13. Dallas 2015 Mortality (9)

14. Dallas 2015 Major Bleeding (6)

15. Dallas 2015 Non-fatal Stroke (6)

16. Dallas 2015 Non-fatal Infarction (5)

17. Dallas 2015 Proposed Consensus on Science statements For the critical outcome of 30-day mortality, we have identified moderate quality of evidence (upgraded for large effect size) from six observational studies (Le May 2006, 1329; Carstensen 2007, 2313; Brown 2008, 158; Qui 2011, 805; Sorensen 2011, 430; Horvath 2012, 186) enrolling 1805 patients in favour of pre-hospital activation of the catheterization lab over no activation of catheterization lab (OR 0.41 95% CI 0.30-0.56)

18. Dallas 2015 Proposed Consensus on Science statements For the important outcome of major bleeding, we have identified very low quality of evidence (downgraded for imprecision) from one observational study (Horvath 2012, 186) enrolling 188 patients showing no benefit of pre-hospital activation of catheterization lab over no activation of catheterization lab (OR 0.68 95% CI 0.04-10.68)

19. Dallas 2015 Proposed Consensus on Science statements For the important outcome of non-fatal stroke, we have identified very low quality of evidence (downgraded for imprecision) from one observational study (Carstensen 2007, 2313) enrolling 301 patients showing no benefit of pre-hospital activation of catheterization lab over no activation of catheterization lab (OR 0.06 95% CI 0.00-1.13)

20. Dallas 2015 Proposed Consensus on Science statements For the important outcome of non-fatal re- infarction, we have identified very low quality of evidence (downgraded for imprecision) from three observational studies (Carstensen 2007, 2313; Qui 2012, 805; Horvath 2012, 186) enrolling 748 patients showing no benefit of pre-hospital activation of catheterization lab over no activation of catheterization lab (OR 0.48 95% CI 0.22-1.03)

21. Dallas 2015 Draft Treatment Recommendations We recommend when primary PCI (PPCI) is the planned strategy, that pre-hospital activation of catheterization lab for PPCI is preferred over no pre-hospital activation (strong recommendation, moderate quality of evidence) In making this recommendation we place higher value of benefit to patient outcomes over the potential increased resource utilization.

22. Dallas 2015 Knowledge Gaps Specific research required No RCTs on the topic