1. Around-the-Clock Primary Angioplasty: A Process of Care Analysis Comparing Off-Hours and Normal Hours Treatment of Acute STEMI R Leung, D Lundberg, D Galbraith, L Shewchuk, M Knudtson & M Traboulsi for the Foothills Interventional Cardiology Service* and the APPROACH Project Clinical Outcomes Time To Treatment Analysis Baseline Characteristics Time to Treatment Analysis Result Conclusion Background Methods Primary percutaneous coronary intervention (PPCI) by experienced centre is safe and effective in improving outcomes in patients presenting with acute ST elevation myocardial infarction (STEMI). Yet, performing PPCI in patients presenting during off- hours and weekends may introduce unnecessary delay in mechanical coronary reperfusion thus reducing its efficacy. Since early 1990s, Foothills Interventional Cardiology Service (FICS) offers PPCI to patients presenting with acute STEMI in the Calgary Health Region (CHR) 24 hours a day, 7 days a week & 365 days a year. Between Jan02 and Dec03, 529 patients presented for PPCI from 3 hospitals in the CHR. Patients presented during off-hours as defined by weekday from 1800 to 0759 and weekends (N=336) were compared to patients presented during normal operating hours (N=193). Although the median total ischemic time did not differ (199 vs. 198 min; p=0.315), the median door-to-balloon time is slightly prolonged during off-hours & weekends (100 vs. 94 min; p<0.05). Difference in 30-day mortality rates (4.5% vs. 3.6% p=0.822) was not demonstrated between the two groups in this study cohort. Data represented as Median (IQR) 0.048104 (86,139)93 (72,128)ER to Balloon 0.315225 (163,356)206 (159,323)Pain to Balloon 0.02435 (28,44)32 (26,40)Lab to Balloon 0.15165 (51,93)62 (45,93)ER to Lab 0.86730 (22,40)31 (25,39) EMS to ER 0.32746 (25,140)60 (30,124) Pain to EMS 0.73999 (59,209)104 (60,177)Pain to ER p-value Off Hours N=336 Normal Hours N=193 Data represented as Median (IQR) or N (%) 0.1115 (4,8) Length of Stay 0.82214 (4.2)7 (3.6)In-hospital Mortality 0.82215 (4.5)7 (3.6)30 Day Mortality p-value Off Hours N=336 Normal Hours N=193 Median (IQR) Predictors of 30 Day Mortality Normal Hours N=193 Off Hours N=336 p-value Age62.5±13.960.8±14.70.209 Male135 (69.6)251 (74.5)0.223 Hypertension75 (38.7)157 (46.6)0.141 Diabetes28 (14.4)57 (16.9)0.392 Prev Infarction21 (10.8)53 (15.7)0.157 History of Angina18 (9.3)45 (13.4)0.376 AntMI or LBBB50 (25.8)83 (24.6)0.770 Systolic128±29137±310.003 Heart Rate76±2277±210.622 Weight78±1782±180.063 Cardiogenic Shock19 (9.8)24 (7.1)0.466 TIMI Risk Score3.19±2.292.85±2.020.084 Peak CK2484±25412280±23780.370 Creatinine87±3695±760.198 LVEDP23±1022±90.287 IIbIIIa Used145 (75.5)262 (78.4)0.450 Transferred118 (60.8)172 (51.0)0.029 Data represented as N (%) or Mean ± SD Although, performing PPCI during off- hours in an experienced centre is safe with comparable process of care and clinical outcomes, overall ischemic time in both groups is not optimal. Public heath education and process of care improvements in emergency and cardiology services to reduce total ischemic time may further improve overall clinical outcomes. Since Jan 2002, demographic, process of care and clinical outcomes information of all patients presented for PPCI were prospectively collected as part of a STEMI initiative and APPROACH project. Objectives To compare the process of care indicator of time to treatment in patients presenting during working hours vs. off hours for primary angioplasty and the impact on clinical outcomes TIMI Risk Score > 3 * FICS includes TJ Anderson, F Charbonneau, MJ Curtis, DM Goodhart, JL Hansen, ML Knudtson, FP Spence & M Traboulsi

2. From Evidence to Practice: Examining Process and Outcomes of Acute STEMI Patients from a Canadian Primary Angioplasty Center R Leung, L Shewchuk, D Lundberg, TJ Anderson, F Charbonneau, MJ Curtis, DM Goodhart, JL Hansen, ML Knudtson, FP Spence & M Traboulsi for the Foothills Interventional Cardiology Service Clinical Outcomes Time To Treatment: EMS vs. Walk-in Baseline Characteristics Time to Treatment Analysis Result Conclusion Background Methods Current evidence supports primary percutaneous coronary intervention (PPCI) in experienced centre as the treatment for acute ST-elevation myocardial infarction (STEMI). Foothills Interventional Cardiology Service receives patients in the Calgary Health Region (CHR) for PPCI 24 hr a day since the early 1990’s. More than 95% of patients presenting within 12 hours of pain onset from 3 emergency departments are referred for PPCI. Between January 2002 to December 2003, a total of 529 patients received PPCI for acute STEMI from the CHR. The Median door-to-balloon time was 101 min with interquartile range of 82 and 136 minutes. Of which, 54.6% were transferred from non-interventional centers and 63.5% presented during off-hours & weekends. Patients who present through emergency medical services was shown to have a significantly shorter total ischemic time and door to balloon time than patients who presents directly through emergency department. IABP use36 (6.8) Length of stay (days)6 (4,8) In-hospital major bleed5 (0.95) In-hospital stroke1 (0.19) In-hospital mortality21 (4.0) 30-day mortality22 (4.2) Data shown in Median (IQR) or N (%) Time (minutes)Median25%75% Pain to ER10260197 Pain to EMS5030135 EMS to ER312339 ER to Cath Lab645093 Cath Lab to Balloon332742 Total Ischemic Time*216162340 Door to Balloon # 10182136 *Pain to balloon # ER to balloon Age61.47±14.4 Male386 (72.7) Hypertension232 (43.7) Diabetes85 (16) Prev Myocardial Infarction74 (13.9) History of Angina63 (11.9) Anterior MI or LBBB133 (25) Cardiogenic Shock43 (8.1) Systolic134±30.4 Heart Rate76.7±21.1 Weight80.4±17.6 TIMI Risk Score2.98±2.13 Peak CK2354±1243 Creatinine92±64 LVEDP22.4±9.4 IIbIIIa Inhibitors407 (77.4) Transferred289 (54.6) Peter Lougheed Centre139 (26.4) Rockyview Hospital150 (28.2) Off Hours & Weekends337 (63.5) Data represented as N (%) or Mean ± SD Selection of Patients with Primary PCI 706 566 556 529 Excluded Patients From Outside CRHA Excluded Patients with In-hospital STEMI Excluded Patients Received Fibrinolytics As part of the Cardiovascular Quality Improvement and Health Information Initiative, a prospective registry was established in Jan02 to assess the process-of-care indicators and clinical outcomes of all patients undergoing PCI for acute ST-elevation myocardial infarction. Although, clinical outcomes in our STEMI database are comparable to large registries and clinical trials, overall door-to-balloon time and length of stay is less than ideal. This registry provides a snapshot of characteristics and outcomes of patients with PPCI from which results of further quality-of-care improvements can be compared. Objectives To review the recent 2-year experiences with primary percutaneous coronary intervention in the treatment of STEMI with emphasis in time to treatment and clinical outcomes