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Background: Improving quality of care for patients presenting with ST elevation Myocardial infarctions (STEMI) is a national priority. However, recent data demonstrate that mortality has not changed despite numerous targeted efforts. Identifying potential areas in care that can be further optimized to decrease mortality remains a priority. Methods: We performed a root cause analysis of all patients who died following primary PCI during index hospitalization from 2008 to 2013 at the University of Michigan (n=25 deaths). Using a standardized data collection form, two interventional cardiologists reviewed patient care received prior to arrival to the catheterization lab, while in the catheterization lab, and after primary PCI to determine cause of death and to rate potential preventability of death on a Likert scale. Results: Majority of deaths were deemed unpreventable. Symptom-onset-to-medical care time was rated as the most common potentially preventable factor. Conclusion: Mortality following primary PCI was deemed mostly unpreventable. However, improvement in total ischemic time, and in particular symptom-onset to-medical care, was identified as one potential target that might be of value in further reducing the mortality associated with STEMI.

Background: Despite taking initiatives to be sustainable, health care systems continue to underachieve their potential and produce exorbitant amounts of waste. We examined the personal sustainability practices of healthcare workers, contrasting their behavior at work with that at home, since the actions of people ultimately determine the effectiveness of sustainability campaigns. Methods: We gave 52 full-time employees of the University of Michigan Cardiac Catheterization Laboratories an anonymous online survey pertaining to sustainability practices at home and work. Paired t-tests were used to compare parallel questions about recycling and energy saving habits between work and home and the Wilcoxon Mann Whitney test was used to examine demographic trends. Results: Participant sustainability habits at home consistently scored lower means, indicating a higher degree of sustainability engagement, than at work_except for the recycling of bottles, containers, and paper products, which showed no significant difference, and the use of motion sensor power strips. Physicians were found to engage in energy saving habits at home significantly less than non-physician employees (mean score, 2.7 versus 2.1; p = .0014) but otherwise, no other demographic varied significantly. Conclusion: Healthcare employees have the personal mindset to be sustainable, but the workplace offers fewer opportunities to do so than their own homes. Healthcare systems may improve sustainability by better designing care processes to maximize recycling and minimize waste, and fostering the personal responsibility for sustainability that is found in the home environment by emulating the sustainability opportunities at home.

Introduction: Few data describe temporal trends in presentation, treatment and outcome in men and women with acute ST-segment elevation myocardial infarction (STEMI). Methods: Swiss STEMI patients enrolled in the AMIS Plus registry from1997-2010 were analyzed using multivariate logistic regression. Results: From 20,363 STEMI patients, 5458 were women and 14,905 men. Women were 8.6 years older, had more co-morbidities (Charlson Index ≥2 16.9% vs 12.8%; P Conclusion: Therapy of STEMI patients has changed greatly during the past 14 years in Switzerland, largely in accordance with guideline recommendations.

Background: Many patients undergoing elective percutaneous coronary intervention (PCI) do not have prior stress testing. It is unknown if these patients have more severe angina or obstructive coronary artery disease (CAD), whereby proceeding directly to PCI would represent sound clinical judgment and efficient use of resources. Methods: We identified elective PCIs performed between 1/1/09 - 3/31/11 in the NCDR CathPCI Registry ® and assessed for differences in angina (CCS class) and severity of CAD in those with and without pre-procedural stress testing. To further understand whether proceeding to PCI without prior stress testing could be justified because of a high pre-test probability for obstructive CAD (e.g., >70% stenosis in an epicardial coronary artery), we evaluated cardiac catheterizations performed within the registry during the same period to assess the diagnostic yield of obstructive CAD in patients with and without prior stress testing. Results: Of 246,629 elective PCIs, 89,084 (36.1%) were performed without prior stress testing. A substantial proportion of both groups undergoing PCI were asymptomatic (no stress test group: 28.9% vs. stress test group: 30.7%), with only a modest difference in the frequency of CCS class III/IV angina (16.2% vs. 11.9%; Table). No meaningful differences in the frequency of proximal LAD (29.7 % vs. 29.9%), left main (5.6% vs. 7.2%) or 3-vessel coronary artery disease (21.1% vs. 19.5%) were observed in the 2 PCI groups. Moreover, the diagnostic yield for obstructive CAD on cardiac catheterization for patients without prior stress testing (n=462,611) was 35.4%, as compared with 58.0%, 38.8%, and 24.1% for those with severe, moderate, and mild ischemia, on pre-procedural stress testing. Conclusion: For elective PCI, the current practice of proceeding to coronary angiography and PCI without prior stress testing does not identify higher risk coronary anatomy or more symptomatic patients and may not improve diagnostic yield.