Catheterization Laboratory Activation Research Articles

FACTORS INFLUENCING LATE PROGNOSIS IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION TREATED WITH DIRECT PERCUTANEOUS CORONARY INTERVENTION.

Objective: To investigate factors influencing the late prognosis of patients with acute ST-segment elevation myocardial infarction treated by direct percutaneous coronary intervention. Methods: We retrospectively analyzed 349 ST-segment elevation myocardial infarction patients treated with direct percutaneous coronary intervention. Patients were categorized based on catheter laboratory activation time (CLAT) (≤15 or >15 min), time of arrival (working hours or out-of-hours), and mode of arrival (emergency medical services transportation or self-presentation). The primary endpoint was the 2-year major adverse cardiovascular events (MACEs), defined as all-cause death, nonfatal myocardial infarction, and target vessel revascularization. Results: Patients with CLAT ≤15 min showed significant differences in oxygen saturation, FMC-to-device time, symptom-to-device time, symptom-to-FMC time, presentation mode, presentation duration, and MACEs (all P < 0.005). Self-presentation (odds ratio = 0.593, 95% confidence interval = 0.413-0.759) and out-of-hours presentation (odds ratio = 0.612, 95% confidence interval = 0.433-0.813) were risk factors for CLAT >15 min. The working-hours group showed significant differences in FMC-to-device time, activation-to-arrival time at the catheter laboratory, and the number of cases with activation time ≤15 min (all P < 0.005). The emergency medical services and self-presentation groups differed significantly in age, blood pressure, FMC-to-device time, and electrocardiography-to-CLAT (all P < 0.005). Conclusion: Reducing CLAT to 15 min significantly lowers the 2-year MACE rate. Self-presentation and out-of-hours presentation are risk factors for delayed catheter laboratory activation.

Development of Clinically Validated Artificial Intelligence Model for Detecting ST-segment Elevation Myocardial Infarction

ObjectiveAlthough the importance of primary percutaneous coronary intervention (PCI) has been emphasized for ST-segment elevation myocardial infarction (STEMI), the appropriateness of the cardiac catheterization laboratory (CCL) activation remains suboptimal. This study aimed to develop a precise artificial intelligence (AI) model for diagnosis of STEMI and accurate CCL activation. MethodsWe used electrocardiography (ECG) waveform data from a prospective PCI registry in Korea in this study. Two independent board-certified cardiologists established a criterion standard (STEMI or Not-STEMI) for each ECG based on corresponding coronary angiography data. We developed a deep ensemble model by combining five convolutional neural networks. In addition, we performed clinical validation based on a symptom-based ECG dataset, comparisons with clinical physicians, and external validation. ResultsWe used 18,697 ECGs for the model development dataset and 1,745 (9.3%) were STEMI. The AI model achieved an accuracy of 92.1%, sensitivity of 95.4% and specificity of 91.8 %. The performances of the AI model were well-balanced and outstanding in the clinical validation, comparison with clinical physicians, and the external validation. ConclusionsThe deep ensemble AI model showed a well-balanced and outstanding performance. As visualized with the Grad-CAM, the AI model has a reasonable explainability. Further studies with prospective validation regarding clinical benefit in a real-world setting should be warranted.

Integrating Pharmacomechanical Treatments for Pulmonary Embolism Management within a Hub-and-Spoke System in the Swiss Ticino Region.

The Swiss Ticino regional pulmonary embolism response team (PERT) features direct access to various pharmacomechanical PE management options within a hub/spoke system, by integrating evidence, guidelines' recommendations and personal experiences. This system involves a collaborative management of patients among the hospitals distributed throughout the region, which refer selected intermediate-high or high PE patients to a second-level hub center, located in Lugano at Cardiocentro Ticino, belonging to the Ente Ospedaliero Cantonale (EOC). The hub provides 24/7 catheterization laboratory activation for catheter-based intervention (CBI), surgical embolectomy and/or a mechanical support system such as extracorporeal membrane oxygenation (ECMO). The hub hosts PE patients after percutaneous or surgical intervention in two intensive care units, one specialized in cardiovascular anesthesiology, to be preferred for patients without relevant comorbidities or with hemodynamic instability and one specialized in post-surgical care, to be preferred for PE patients after trauma or surgery or with relevant comorbidities, such as cancer. From April 2022 to December 2023, a total of 65 patients were referred to the hub for CBI, including ultrasound-assisted catheter-directed thrombolysis (USAT) or large-bore aspiration intervention. No patient received ECMO or underwent surgical embolectomy.

Impact of chest pain center quality control indicators on mortality risk in ST-segment elevation myocardial infarction patients: a study based on Killip classification.

Despite the crucial role of Chest pain centers (CPCs) in acute myocardial infarction (AMI) management, China's mortality rate for ST-segment elevation myocardial infarction (STEMI) has remained stagnant. This study evaluates the influence of CPC quality control indicators on mortality risk in STEMI patients receiving primary percutaneous coronary intervention (PPCI) during the COVID-19 pandemic. A cohort of 664 consecutive STEMI patients undergoing PPCI from 2020 to 2022 was analyzed using Cox proportional hazards regression models. The cohort was stratified by Killip classification at admission (Class 1: n = 402, Class ≥2: n = 262). At a median follow-up of 17 months, 35 deaths were recorded. In Class ≥2, longer door-to-balloon (D-to-B) time, PCI informed consent time, catheterization laboratory activation time, and diagnosis-to-loading dose dual antiplatelet therapy (DAPT) time were associated with increased mortality risk. In Class 1, consultation time (notice to arrival) under 10 min reduced death risk. In Class ≥2, PCI informed consent time under 20 min decreased mortality risk. CPC quality control metrics affect STEMI mortality based on Killip class. Key factors include time indicators and standardization of CPC management. The study provides guidance for quality care during COVID-19.

Does Inclusion of Residents in EKG screening in the ED change the Time to Catheterization Lab Activation?

Does Inclusion of Residents in EKG screening in the ED change the Time to Catheterization Lab Activation?

Impact of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol on Key Process Metrics in Black Americans

Impact of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol on Key Process Metrics in Black Americans

Does Inclusion of Emergency Medicine (EM) Residents in ECG Screening for STEMI Change the Time to Catheterization Lab Activation?

Emergency medicine physicians must rapidly obtain and interpret an electrocardiogram (ECG) to quickly identify life-threatening cardiac emergencies such as ST-elevation myocardial infarction (STEMI). Although ECG interpretation is a critical component of residency education, few high-powered studies exploring the accuracy of resident ECG interpretation exist. This study aims to evaluate whether or not the inclusion of Third Year Emergency Medicine Resident ECG interpretations is noninferior to attending-only ECG interpretations in regard to time to STEMI activation. This was a retrospective noninferiority study of STEMI activation times before and after the inclusion of Third Year Emergency Medicine Resident resident ECG interpretations into the workflow at an academic, urban tertiary care center between November 2020 and April 2022, excluding prehospital activations. The primary outcome was the proportion of successful STEMI activations initiated within 5 minutes of ECG completion. An absolute decrease of 10% between groups was chosen as the noninferiority margin. In the attending-only group, 26 (66.7%) cases resulted in successful STEMI activations compared to 31 cases (77.5%) in the combined group. The proportion of successful STEMI activations did not differ with resident screening, X 2 = 1.15, P = 0.28. The absolute difference between groups' successful activations was an increase of 11%, which lies within the noninferiority margin (+11%, 95% confidence interval, -8.68% to 30.7%). Average times to STEMI activation in the attending-only and combined groups were 7.59 minutes (Standard Deviation [SD], 10.19) and 5.13 minutes (SD, 6.95), respectively. Average door-to-balloon times for those undergoing Percutaneous Coronary Intervention were 72.74 minutes (SD, 20.76) in the attending-only group and 89.90 minutes (SD, 67.74) in the combination group. Two sample t-test showed no statistically significant difference between the 2 groups for average time to STEMI activation (difference = 2.46 minutes, 95% CI, -1.46 to 6.38) and average door-to-balloon time (difference = 17.16, 95% CI, -39.73 to 5.41). The inclusion of emergency medicine PGY-3 residents in the ECG screening workflow is noninferior to attending-only interpretation of ECGs with regard to STEMI activation time.

A mobile application for STEMI care optimization: pilot implementation project report

Abstract Background In an effort to improve outcomes of STEMI patients, we developed a secure mobile application (app) to streamline real-time communication and coordination between multiple teams taking care of STEMI patients in a large health care system. The app includes multi-level alarm and notification systems, instant EKG transmission for quick interpretation, activation of the cardiac catheterization laboratory (CCL) after expert case review, secure video chat among team members facilitating clinical discussion, continuous updates on patients' clinical status and ambulance location tracking. Purpose One of the major shortcomings in STEMI system of care has been long delays in transfer of patients from non-PCI capable hospitals to a receiving center for primary PCI. To address the challenges of interhospital transfer, we designed a pilot project employing the app for STEMI transfer from a first contact hospital to our CCL. This report assesses the effect of the app on door-to-device time by comparing the key metric for STEMI transfer before (historic) and after app launch. Methods The pilot project involved key leadership stakeholders from Emergency Medicine and Nursing Departments at the referring hospital, CCL and our transfer center. During pilot period (July 2021 to January 2022) the referring center activated STEMI alarms using app activation in parallel with the previously established STEMI activation process via traditional phone calls to the transfer center. The built-in workflow redundancy was introduced to ensure the rapid and efficient, and at the same time, safe and reliable response to STEMI alert. In preparation for the pilot, more than 250 people were provisioned accounts, trained on their user-specific roles and scheduled in the app according to their schedules. Results A total of 40 suspected STEMIs were activated through the app during the pilot study; among them 30 cases were accepted for transfer and 10 rejected. After excluding patients who expired during transfer, were intubated, or had normal coronaries, final study population included 13 STEMI cases activated through the app. These cases were compared with 43 STEMIs activated through the traditional pathway from January 2019 to July 2021 before app launch. After implementing the app, the mean door-to-device time for STEMI transfer decreased from 120.3±48.3 to 91.8±15.4 min (P=0.002) (Figure 1). The significant improvement, 29 min (24%), of the key metric for interhospital transfer resulted in all STEMI cases meeting AHA goal of door-to-device time ≤120 minutes after the app launch. The respective percent of STEMI cases meeting the goal before app was 71% (Figure 2). Conclusions Implementation of a mobile app into STEMI workflow of a large urban healthcare system had a significant impact on the quality of care for transfer of STEMI patients, which has also helped bring our clinical practice closer to the AHA guidelines pertaining to the first door-to-device time. Funding Acknowledgement Type of funding sources: None.

Medicine Where It Matters.

Medicine Where It Matters.

A mobile application for STEMI care optimization: pilot implementation project report

Abstract Background In an effort to improve outcomes of STEMI patients, we developed a secure mobile application (app) to streamline real-time communication and coordination between multiple teams taking care of STEMI patients in a large health care system. The app includes multi-level alarm and notification systems, instant EKG transmission for quick interpretation, activation of the cardiac catheterization laboratory (CCL) after expert case review, secure video chat among team members facilitating clinical discussion, continuous updates on patients' clinical status and ambulance location tracking. Purpose One of the major shortcomings in STEMI system of care has been long delays in transfer of patients from non-PCI capable hospitals to a receiving center for primary PCI. To address the challenges of interhospital transfer, we designed a pilot project employing the app for STEMI transfer from a first contact hospital to our CCL. This report assesses the effect of the app on door-to-device time by comparing the key metric for STEMI transfer before (historic) and after app launch. Methods The pilot project involved key leadership stakeholders from Emergency Medicine and Nursing Departments at the referring hospital, CCL and our transfer center. During pilot period (July 2021 to January 2022) the referring center activated STEMI alarms using app activation in parallel with the previously established STEMI activation process via traditional phone calls to the transfer center. The built-in workflow redundancy was introduced to ensure the rapid and efficient, and at the same time, safe and reliable response to STEMI alert. In preparation for the pilot, more than 250 people were provisioned accounts, trained on their user-specific roles and scheduled in the app according to their schedules. Results A total of 40 suspected STEMIs were activated through the app during the pilot study; among them 30 cases were accepted for transfer and 10 rejected. After excluding patients who expired during transfer, were intubated, or had normal coronaries, final study population included 13 STEMI cases activated through the app. These cases were compared with 43 STEMIs activated through the traditional pathway from January 2019 to July 2021 before app launch. After implementing the app, the mean door-to-device time for STEMI transfer decreased from 120.3±48.3 to 91.8±15.4 min (P=0.002) (Figure 1). The significant improvement, 29 min (24%), of the key metric for interhospital transfer resulted in all STEMI cases meeting AHA goal of door-to-device time ≤120 minutes after the app launch. The respective percent of STEMI cases meeting the goal before app was 71% (Figure 2). Conclusions Implementation of a mobile app into STEMI workflow of a large urban healthcare system had a significant impact on the quality of care for transfer of STEMI patients, which has also helped bring our clinical practice closer to the AHA guidelines pertaining to the first door-to-device time. Funding Acknowledgement Type of funding sources: None.

Exploring decision making ‘noise’ when interpreting the electrocardiogram in the context of cardiac cath lab activation

In this commentary paper, we discuss the use of the electrocardiogram to help clinicians make diagnostic and patient referral decisions in acute care settings. The paper discusses the factors that are likely to contribute to the variability and noise in the clinical decision making process for catheterization lab activation. These factors include the variable competence in reading ECGs, the intra/inter rater reliability, the lack of standard ECG training, the various ECG machine and filter settings, cognitive biases (such as automation bias which is the tendency to agree with the computer-aided diagnosis or AI diagnosis), the order of the information being received, tiredness or decision fatigue as well as ECG artefacts such as the signal noise or lead misplacement. We also discuss potential research questions and tools that could be used to mitigate this ‘noise’ and improve the quality of ECG based decision making.

Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation.

ObjectivesWe examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation.BackgroundThe incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results.MethodsWe identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation.ResultsAmong 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% (n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST‐segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST‐segment elevation (n = 20, 4.0%), and others.ConclusionsPH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.

Prehospital STEMI Referral Systems and Sex-Related Bias in Canada: A National Survey

BackgroundPrehospital electrocardiographic ST-elevation myocardial infarction (STEMI) diagnosis and prehospital cardiac catheterization laboratory activation have been shown to significantly reduce average treatment delay, and further standardization of such systems may help reduce sex-related treatment and outcome gaps. However, what types of prehospital STEMI activation systems are in place across Canada, and to what extent sex-based STEMI treatment disparities are tracked, is unknown. MethodsWe conducted a national survey of catheterization laboratory directors between October 11 and December 25, 2021. Seventeen catheterization laboratory directors representing 6 community and 11 academic centres completed the survey (40% response rate). Results: All responding centres use a prehospital STEMI diagnosis and cardiac catheterization laboratory activation system, and the majority (59%) rely on real-time physician oversight. Slightly less than half (47%) of percutaneous coronary intervention centres reported prospectively tracking sex-related differences in STEMI care, and only one respondent believed that a significant systemic sex-related bias was present in their prehospital STEMI referral system. Patient factors (symptom description or time to presentation; 23.5%) and limitations of electrocardiogram diagnosis of STEMI in women (23.5%) were cited most frequently as contributing to sex-related bias in STEMI referral systems. In contrast, implicit bias in the referral algorithm, prehospital provider bias, and physician bias were not considered important contributing factors. ConclusionsAlthough all responding centres employ prehospital activation systems, less than half tracked sex-related differences, and most respondents believed that no sex-related bias existed in their prehospital STEMI system.

Cardiac catheterization laboratory activation by social media reduces reperfusion time of patients transferred for primary percutaneous coronary intervention in community hospital

Objective: The objective of the study is to evaluate the impact of cardiac catheterization laboratory (CCL) activation by WeChat in community hospitals transfer for primary percutaneous coronary intervention (PCI) bypassing emergency department (ED) on time delay in ST-segment elevation myocardial infarction (STEMI) patients. Methods: This was a retrospective, cohort study of STEMI patients who were transferred from community hospitals to Luhe Hospital for primary PCI. Patients were divided into two groups: in CCL group, electrocardiogram (ECG) was transmitted through WeChat in the community hospital and the patients were transferred directly to CCL by emergency medical services (EMS) (n = 43); in control group, patients without ECG transmission were transferred by EMS to ED before CCL arrival (n = 57). The primary endpoint was median first medical contact (FMC)-to-device (FMC2D) times. The secondary endpoint was door-to-device (D2D) times. Results: The baseline clinical data and angiographic features among the two groups were similar (all P &gt; 0.05. There was no difference in the symptom onset-to-FMC time (median interquartile range [IQR] min, 100.00 [74.50–247.00] vs. 105.00 [70.00–180.00], P &gt; 0.05) between the two groups. Compared to control group, CCL group had shortened FMC2D times (median IQR min, 95.00 [72.60–160.58] vs. 160.79 [124.72–205.50], P &lt; 0.001) and shortened D2D time (median IQR min, 17.18 [13.77–21.15] vs. 49.27 [40.26–64.90], P &lt; 0.001). Achievement of the FMC2D time goal of &lt;120 min rose from 29.82% in the control group to 76.74% in the CCL group (P &lt; 0.001). Conclusion: CCL activated by WeChat can reduce reperfusion time of STEMI patients who are transferred for PCI from community hospitals.

Early Diagnosis and Management of Non ST-Segment Elevation Acute Myocardial Infarction

Acute myocardial infarction (MI) is a cardiovascular disease with high mortality. Acute MI is usually divided into ST-segment elevation MI (STEMI) and non ST-segment elevation MI (NSTEMI) based on the electrocardiogram (ECG). NSTEMI is often misdiagnosed in patients presenting to emergency departments with acute chest pain because its clinical course varies and is atypical compared to STEMI. The symptoms can be vague and the ECG is often not diagnostic. In this setting, an early accurate diagnosis and risk stratification could improve the mortality of patients with NSTEMI. Cardiac biomarkers such as high-sensitivity cardiac troponin (hs-cTn) help to diagnose NSTEMI. Serial hs-cTn assays should be considered to differentiate other conditions, especially in an ambiguous clinical situation. If acute MI is strongly suspected based on the symptoms, ECG, and cardiac biomarkers, catheterization laboratory activation should be timely considered to evaluate the coronary arteries and possible revascularization with percutaneous or surgical strategies depending on risk factors. After successful revascularization, antianginal medications, risk factor control, and early recognition of heart failure are essential to improve the cardiovascular prognosis.

A Retrospective Clinical Evaluation of an Artificial Intelligence Screening Method for Early Detection of STEMI in the Emergency Department.

BackgroundRapid revascularization is the key to better patient outcomes in ST-elevation myocardial infarction (STEMI). Direct activation of cardiac catheterization laboratory (CCL) using artificial intelligence (AI) interpretation of initial electrocardiography (ECG) might help reduce door-to-balloon (D2B) time. To prove that this approach is feasible and beneficial, we assessed the non-inferiority of such a process over conventional evaluation and estimated its clinical benefits, including a reduction in D2B time, medical cost, and 1-year mortality.MethodsThis is a single-center retrospective study of emergency department (ED) patients suspected of having STEMI from January 2021 to June 2021. Quantitative ECG (QCG™), a comprehensive cardiovascular evaluation system, was used for screening. The non-inferiority of the AI-driven CCL activation over joint clinical evaluation by emergency physicians and cardiologists was tested using a 5% non-inferiority margin.ResultsEighty patients (STEMI, 54 patients [67.5%]) were analyzed. The area under the curve of QCG score was 0.947. Binned at 50 (binary QCG), the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 98.1% (95% confidence interval [CI], 94.6%, 100.0%), 76.9% (95% CI, 60.7%, 93.1%), 89.8% (95% CI, 82.1%, 97.5%) and 95.2% (95% CI, 86.1%, 100.0%), respectively. The difference in sensitivity and specificity between binary QCG and the joint clinical decision was 3.7% (95% CI, −3.5%, 10.9%) and 19.2% (95% CI, −4.7%, 43.1%), respectively, confirming the non-inferiority. The estimated median reduction in D2B time, evaluation cost, and the relative risk of 1-year mortality were 11.0 minutes (interquartile range [IQR], 7.3–20.0 minutes), 26,902.2 KRW (22.78 USD) per STEMI patient, and 12.39% (IQR, 7.51–22.54%), respectively.ConclusionAI-assisted CCL activation using initial ECG is feasible. If such a policy is implemented, it would be reasonable to expect some reduction in D2B time, medical cost, and 1-year mortality.

Barriers to the Implementation of Primary PCI in the Management of STEMI in Egypt

Introduction: Evidence-based guidelines recommend primary percutaneous coronary intervention (PPCI) be the mainstay reperfusion strategy for the treatment of ST-segment elevation myocardial infarction (STEMI) if it is performed in the proper time window. However, the Egyptian health care system is still struggling to provide such an important service. The aim of the present study, through a quantitative questionnaire, is to explore the current practice of STEMI management in Egypt, and to identify the barriers, opportunities, and potential areas for improvement. Methods and Results: The questionnaire was conducted in Egypt via face-to-face qualitative in-depth interviews with cardiologists from 14 PPCI-capable hospitals and 26 non-PPCI-capable hospitals. Participants were selected in view of their experience and knowledge. The study identified potential barriers to the implementation of PPCI among STEMI patients in Egypt. These barriers included the prehospital patient delay and emergency medical service delay, delay in the emergency department and delay in patient transfer to the CCU, unavailable equipment, catheterization laboratory activation delay, lack of trained interventional cardiologists, lack of regional STEMI networks and hospital policies, and insufficient ICU beds. Conclusion: Limited resources and health care system inadequacies have led to potential barriers that prevent suboptimal implementation of PPCI in Egypt. Efforts from all health care providers should be directed to overcome these identified barriers.

Abstract 14290: Implementation of a Comprehensive STEMI Protocol Improves Key Process Metrics for Transfer STEMI Patients

Introduction: Despite improvements in STEMI door-to-balloon time (D2BT), the majority of patients who present to US hospitals without PCI capability do not achieve the national goal D2BT of ≤ 120 minutes for transfer STEMI patients. We sought to determine the impact of a comprehensive STEMI protocol (CSP) on key process and outcome metrics in transfer STEMI patients. Methods: The CSP is a 4-step STEMI protocol aimed at minimizing STEMI care variability. The protocol streamlines STEMI care by (1) allowing catheterization lab activation by emergency physicians without cardiology consultation, (2) standardizing early administration of guideline-directed medical therapy (GDMT), (3) ensuring immediate transfer to a PCI-capable facility, and (4) implementing a radial artery-first approach (RAFA). We evaluated outcomes in 499 STEMI patients transferred to our hospital from January 1, 2011 to July 14, 2014 prior to implementation of CSP (control group) and 775 patients presenting from July 15, 2014 to July 15, 2019, after implementation of the CSP. Results: Compared to the control group, after implementation of CSP there was a significant increase in the number of STEMI patients transferred to our hospital who received GDMT (84.6% vs 93.9%, p&lt;0.001). There was a significant increase in the use of RAFA (19.0% vs 77.7%, p&lt;0.001). The median D2BT decreased from 114 minutes prior (IQR 94.0-146.0min, p&lt;0.001) to 97 minutes (IQR 82.0-115.0min) after CSP implementation, with substantially more patients reaching the target D2BT of 120 minutes (55.7% vs 80.1%, p&lt;0.001). There was a trend towards lower in-hospital mortality after CSP implementation (4.4% vs 2.8%, p=0.180) though the results were not powered to show statistical significance. Conclusion: The CSP significantly improved STEMI care key process metrics (GDMT, RAFA, and D2BT) with a trend to lower mortality for patients presenting with STEMI to outside facilities who are transferred to a CCF PCI-capable hospital.

Abstract 12666: Role of a Comprehensive ST-Elevation Myocardial Infarction Protocol in Improving Outcomes among Elderly Patients With ST-Elevation Myocardial Infarction

Introduction: Increasing age is a harbinger of poor outcomes from ST-elevation myocardial infarction (STEMI). It is uncertain whether measures can be implemented to improve care delivery and outcomes in this high-risk cohort. We assessed the impact of a comprehensive STEMI protocol (CSP) in elderly patients presenting with STEMI. Methods: A 4-step CSP was implemented, including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; and (4) radial-first percutaneous coronary intervention (PCI). Baseline characteristics, complications, procedural features, and outcomes were compared between consecutive STEMI patients &gt;65 years of age who underwent PCI at the Cleveland Clinic pre- (01/01/2011-07/14/2014) and post-CSP (07/15/2014-07/15/2019) implementation. Results: Among 265 and 445 elderly patients in the pre- and post-CSP cohorts, respectively, overall the mean age was 74 years and 58% were males. More active smoking and obesity and less prior myocardial infarction and coronary artery bypass graft were observed in the post-CSP group. Relative to pre-CSP, post-CSP patients experienced significantly less cardiogenic shock (19% vs 9%, p&lt;0.001) and cardiac arrest (16% vs 9%, p=0.009). Significant improvements were observed post-CSP implementation in median door-to-balloon time [111 (84-146) vs 89 (67-109) minutes, p&lt;0.001] and trans-radial access (16% vs 72%, p&lt;0.001), translating to significant reductions in major adverse cardiovascular events (14% vs 8%, p=0.02), major bleeding (16% vs 11%, p=0.05), and in-hospital mortality (12% vs 5%, p=0.001). Conclusion: The implementation of a CSP was associated with marked reductions in complications and improvements in in-hospital outcomes including mortality among elderly patients presenting with STEMI. Our findings highlight the opportunity to improve outcomes in high-risk elderly STEMI patients through a CSP.

Abstract 12267: Impact of a Comprehensive ST-Elevation Myocardial Infarction Protocol on Key Process Metrics in African American STEMI Patients

Background: Optimizing STEMI care processes for African Americans is a critical matter with important public health implications. We aimed to study if a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) could improve key process metrics in the African American (AA) population. Methods: We developed a 4-step CSP which included, 1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). Baseline characteristics and procedural characteristics were compared between all consecutive STEMI patients who underwent PCI at the Cleveland Clinic main campus between January 1, 2011, to July 14, 2014 (pre-CSP group) and July 15, 2014, to July 15, 2019 (post-CSP group). Results: There were a total of 208 AA patients in the pre-CSP group compared to 271 AA patients in the post-CSP group. Baseline characteristics were quite similar between the two groups except for a lower rate of MI in the post-CSP group (45% vs 30%, P=0.001). After implementation of our CSP, guideline-directed medical therapy increased from 71.6% to 81.9% (P=0.011), radial utilization went up from 14.4% to 73.8% (P&lt;0.001), door to balloon time decreased from 90 minutes (median IQR 64-120) to 70 minutes (median IQR 45-95) (P&lt;0.001), fluoro dose decreased from 1610 mGy (median IQR 980.25-2592.25) to 1147 mGy (median IQR 742-1844) (P&lt;0.001), and contrast dose decreased from 197.07 ml to 152.98 ml (P&lt;0.001). Conclusion: Implementing a CSP was able to significantly improve the key STEMI process metrics for African American patients. Optimizing key STEMI process metrics is an important initiative to ensure equitable STEMI care.