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Objectives: Target door-to-device (DTD) time for ST-elevation myocardial infarction (STEMI) patients has been 90 minutes, with no distinction between urban and rural hospitals. Rural hospitals have longer DTD times for transferred patients attributed to long transportation times from referring hospitals. Longer DTD times have also been reported during after-hours. The aim of the study was to determine whether DTD times at our rural facility were impacted by arrival method, arrival time period, and season. Design: Retrospective chart review.Setting: Rural tertiary care center in central Wisconsin. Methods:We studied 412 patients presenting with STEMI after initiation of the Rescue One program for rapid triage and transfer from October 2006 through December 2012. They were subdivided by arrival method, arrival time (ON=Monday-Friday, 8 AM-5 PM; OFF=after-hours, weekends, holidays), and season. Median DTD times and proportions below and above 90 minutes were compared. Results:Median DTD time for all groups, which include both directly admitted and transferred patients, was 85 minutes with 60% of patients achieving DTD times below 90 minutes while 30-day mortality was 5.3%. Median DTD time was 67 minutes for the Emergency Department (ED) (n=164), 95 minutes for Transfers (n=204), 68 minutes for Urgent Care (n=22) and 86 minutes for Field (n=22). ED had the highest proportion of patients achieving goal DTD time (81%) compared to Transfers (42%). Patients arriving by ED during OFF hours had a median DTD time 28 minutes longer than during ON hours with 21% fewer patients achieving goal DTD time, attributed to the time required to call in the catheterization team. Seasonal variability was observed due to differences in pre-hospital ambulance transportation times in the Field group. Conclusions:Our data confirm that in a rural facility such as ours, ED patients arriving during afterhours and transferred patients have longer DTD times. Methods are being implemented to shorten the time to assemble the catheterization lab team during after-hours. Better performance will be seen once the first medical contact to device (FTD) time goal of 120 minutes for transferred patients is adopted at our institution. Fibrinolytic therapy should be considered at referring institutions where the FTD time is expected to exceed 120 minutes.

Statins have variable effects on high density lipoprotein (HDL) cholesterol. Prior data suggest that the atorvastatin dose‐response may be biphasic. The current study tests this hypothesis retrospectively, in a population‐based cohort. The Marshfield Clinic Personalized Medicine Research Project includes >19,000 participants. Using natural language processing (NLP) software, we linked drug dosage to fasting HDL cholesterol levels for 2432 PMRP participants exposed to atorvastatin during the course of their routine clinical care. Mean HDL level prior to atorvastatin exposure was 46.2 mg/dl (S.D. = 11.9, N=2432). Mean baseline HDL of females (Mean=50.2, S.D. = 12.2, N=1256) was higher than males (Mean =41.9, S.D. = 10.0, N=1176). The lowest initial dose (5 mg daily) resulted in an increase in mean HDL to 51.01 mg/dl (male=46.3, female=55.4). Beyond 5 mg, however, each subsequent doubling of the daily dose resulted in a linear decrease in the mean HDL level. This biphasic dose‐response was noted in both genders. At the maximum daily dose of 80 mg, mean HDL was 46.62 mg/dl (male=43.8, female=50.2). Funding source U01HL069757‐06

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