INTRO: The AHA Mission Lifeline recommends an EMS first medical contact (FMC) to balloon time of 90 minutes for patients STEMI when presenting directly to a percutaneous coronary intervention (PCI) hospital but 120 minutes for those requiring transfer from a non-PCI hospital. We examine the impact of direct air medical transport from the scene to a PCI center of rural patients without access to a local PCI capable hospital versus EMS transport to and subsequent transfer from a non-PCI hospital. METHODS: A regional STEMI transport system was developed in 2012 for western Pennsylvania between non-PCI capable hospitals, local EMS agencies, and UPMC Presbyterian Hospital. This system was designed to improve transfer times and one component of this was to allow local EMS companies to activate the cath lab directly. In this program, an emergency helicopter meets the EMS and allows for direct transport of the patient to PCI hospital, bypassing the local ED. We compared reperfusion times in consecutive patients brought directly to the PCI center versus patients taken by EMS to a local ED first in 2012-2013. Patients were then matched based on distance from PCI center. RESULTS: A total of 22 patients were brought directly to the PCI center and 32 patients were taken by local EMS to their local non-PCI hospital followed by helicopter transport for primary PCI. Median FMC to balloon times for patients taken directly from the scene to PCI center was 22 minutes less (113 vs 135 minutes, p=0.0006) than when first taken to a local ED. There was no difference in PCI arrival to balloon times (26 vs 20 minutes, p=0.128) and breakdown of median times listed in table 1. The average linear flight distance between groups was 37 vs 41 miles (p=0.2123). CONCLUSIONS: In this regional system, transport of rural patients with STEMI directly to a PCI center improves FMC to balloon times when compared to patients taken to a local non-PCI hospital first. Despite shortening reperfusion times with implementation of this system, some of these patients would fall out of the recommended AHA guidelines because they are considered to present directly to the PCI hospital. Further investigation on the benefits of direct transport of rural patients to a PCI center is warranted and whether the AHA recommended FMC to balloon time needs adjustment in this scenario.

all-cause mortality and secondary outcomes of time to heart transplantation and dialysis. Results: Baseline characteristics were notable for a mean age of 56±13 years, 54% ischemic cardiomyopathy, 45% destination therapy, 53% HMII device, and 445±476 days on device. Of the 160 patients, WRF developed in 38 (24%) at 3 months after implant. In multivariate regression tree analysis, longer LVAD operative duration and lower preimplant total bilirubin were independently associated with a higher risk of WRF. During a median follow-up of 2.2 years, there were 56 heart transplants, 34 cases of dialysis, and 70 deaths from all causes. WRF was associated with a nonsignificant lower rate of heart transplantation (HR 0.4; CI 0.2, 1.2; P= 0.12). WRF was associated with significantly higher rates of dialysis (HR 4.0; CI 1.8, 9.1; P< 0.001) and worse survival (HR 2.7; CI 1.5, 4.9; P= 0.001). Conclusion: WRF occurs in nearly one out of four CF LVAD patients. At any point after implant, LVAD recipients with WRF had 2.7 times the risk of death and 4.0 times the risk of needing dialysis.

Introduction: The Friedewald equation (F-LDL-C) and the Martin-Hopkins algorithm (MH-LDL-C) estimate direct LDL-C from a standard lipid panel. Discordant LDL-C estimates by the two methods may carry significant clinical implications. We evaluated the clinical variables associated with discordant LDL-C estimates and the association of discordance with risk of incident atherosclerotic cardiovascular disease (ASCVD) in the Dallas Heart Study (DHS), a multi-ethnic, population based prospective cohort. Methods: We estimated F-LDL-C and MH-LDL-C in 2824 DHS participants (42% male; mean age 43.5 years) with TG ≤ 400 mg/dL, who were not on baseline lipid lowering therapy and were free of prior ASCVD. We divided the cohort into quintiles of LDL-C discordance (MH-LDL-C minus F-LDL-C, in mg/dL) and assessed associations with ASCVD risk factors. We evaluated associations between discordance and incident ASCVD by sequentially adjusted Cox regression models, and we generated restricted cubic spline plots of discordance and hazard for ASCVD. Results: There were 228 ASCVD events over a median of 12.3 years. Clinical characteristics across discordance quintiles are shown in the Table . After adjustment for traditional ASCVD risk factors, there was a linear association between higher LDL-C discordance and increased risk of ASCVD events ( Figure ) with the highest hazard in Quintile 5 (HR 1.5, 95% CI 1.1 - 2.0). Conclusions: Discordant LDL-C estimates were largely associated with male sex, White and Hispanic races, and characteristics of the metabolic syndrome. Individuals in the highest quintile of discordant LDL-C estimates, with MH-LDL-C > F-LDL-C, had greater risk for incident ASCVD.