Cardiovascular Disease and Stroke August 9, 2019 Overview of - - PowerPoint PPT Presentation

Presentation to the Texas Council on Cardiovascular Disease and Stroke August 9, 2019

Overview of Presentation

Part 2: Elizabeth Harker, MPH

• Summary of Heart Attack and Stroke Care

Hospital Performance Measures 2018 Reports

Part 1: Karen Nunley, PhD

• Results from DSHS’ Self-Measured Blood Pressure

(SMBP) Project

Adult Stroke Prevalence, by Public Health Region (PHR), Texas, 2017

Overall Stroke Prevalence in Texas = 3.5% (95% CI: 2.8 - 4.2)

Data Classification: Quantiles. Data Source: 2017 Texas Behavioral Risk Factor Surveillance System (BRFSS), Center for Health Statistics, Texas Department of State Health Services. Stroke is defined as "Yes" responses to the survey question, "Have you ever been told by a doctor or health professional that you have a stroke?"

Title (hide)

n/a n/a 4.5% 7.7% 3.3% 3.5% 4.2% 5.8% 2.1% n/a 2 4 6 8 10 18-29 30-44 45-64 ≥65 Male Female White Black Hispanic Other

PERCENT % Age Group (years) Sex Race/Ethnicity

Stroke Prevalence among Adults by Age Group (Years), Sex, and Race/Ethnicity, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services. n/a: Insufficient data, statistically unreliable to report at the indicated levels.

Title (hide)

n/a n/a 4.5% 7.7% 3.3% 3.5% 4.2% 5.8% 2.1% n/a 2 4 6 8 10 18-29 30-44 45-64 ≥65 Male Female White Black Hispanic Other

PERCENT % Age Group (years) Sex Race/Ethnicity

Stroke Prevalence among Adults by Age Group (Years), Sex, and Race/Ethnicity, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services. n/a: Insufficient data, statistically unreliable to report at the indicated levels.

Title (hide)

n/a n/a 4.5% 7.7% 3.3% 3.5% 4.2% 5.8% 2.1% n/a 2 4 6 8 10 18-29 30-44 45-64 ≥65 Male Female White Black Hispanic Other

PERCENT % Age Group (years) Sex Race/Ethnicity

Stroke Prevalence among Adults by Age Group (Years), Sex, and Race/Ethnicity, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services. n/a: Insufficient data, statistically unreliable to report at the indicated levels.

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Stroke Prevalence among Adults by Education And Annual Household Income, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services. n/a: Insufficient data, statistically unreliable to report at the indicated levels.

5.4% 3.7% 3.7% 1.6% 4.6% n/a n/a 2.4% 2 4 6 8 <HS Grad HS Grad Some College ≥College Grad <$35K $35K - <$50K $50K - <$75K ≥$75K

PERCENT % Education Annual Household Income

Title (hide)

Stroke Prevalence among Adults by Education And Annual Household Income, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services. n/a: Insufficient data, statistically unreliable to report at the indicated levels.

5.4% 3.7% 3.7% 1.6% 4.6% n/a n/a 2.4% 2 4 6 8 <HS Grad HS Grad Some College ≥College Grad <$35K $35K - <$50K $50K - <$75K ≥$75K

PERCENT % Education Annual Household Income

Title (hide)

Stroke Prevalence among Adults by Select Comorbidities, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

10.6% 2.5% 7.7% 1.4% 13.2% 3.1% 6.1% 2.9% 5.0% 3.1% 7.1% 2.8% 2 4 6 8 10 12 14 Yes No Yes No Yes No Yes No Yes No Yes No PERCENT % Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression

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Stroke Prevalence among Adults by Select Comorbidities, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

10.6% 2.5% 7.7% 1.4% 13.2% 3.1% 6.1% 2.9% 5.0% 3.1% 7.1% 2.8% 2 4 6 8 10 12 14 Yes No Yes No Yes No Yes No Yes No Yes No PERCENT % Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression

Title (hide)

Stroke Prevalence among Adults by Select Comorbidities, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

10.6% 2.5% 7.7% 1.4% 13.2% 3.1% 6.1% 2.9% 5.0% 3.1% 7.1% 2.8% 2 4 6 8 10 12 14 Yes No Yes No Yes No Yes No Yes No Yes No PERCENT % Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression

Title (hide)

Stroke Prevalence among Adults by Select Comorbidities, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

10.6% 2.5% 7.7% 1.4% 13.2% 3.1% 6.1% 2.9% 5.0% 3.1% 7.1% 2.8% 2 4 6 8 10 12 14 Yes No Yes No Yes No Yes No Yes No Yes No PERCENT % Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression

Title (hide)

Stroke Prevalence among Adults by Select Comorbidities, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

10.6% 2.5% 7.7% 1.4% 13.2% 3.1% 6.1% 2.9% 5.0% 3.1% 7.1% 2.8% 2 4 6 8 10 12 14 Yes No Yes No Yes No Yes No Yes No Yes No PERCENT % Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression

Title (hide)

Stroke Prevalence among Adults by Select Comorbidities, Texas, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

10.6% 2.5% 7.7% 1.4% 13.2% 3.1% 6.1% 2.9% 5.0% 3.1% 7.1% 2.8% 2 4 6 8 10 12 14 Yes No Yes No Yes No Yes No Yes No Yes No PERCENT % Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression

Evaluating Hospital Care of Stroke in Texas

Data from the 50 participating hospitals were evaluated for the period of January 2008-December 2018.

• Time to initial brain imaging
• Time to IV thrombolytic therapy
• IV tPA- patient arrives by 2 hours, treatment received by 3

hours

• Drip and Ship
• Endovascular therapy
• Thrombolytic complication (bleeding)
• Rehabilitation considered
• Discharge disposition

Stroke Cases, 2008-2017

Total Reported Cases Participating Hospitals Year N=115,903 (%) N 2008 4,845 (4.2) 21 2009 6,318 (5.5) 27 2010 8,329 (7.2) 33 2011 9,359 (8.1) 36 2012 10,429 (9.0) 40 2013 12,500 (10.8) 44 2014 14,046 (12.1) 49 2015 16,672 (14.4) 49 2016 16,779 (14.5) 50 2017 16,626 (14.3) 49 Final Stroke Diagnosis Reported Cases N=115,903 % Ischemic Stroke 76,674 66.4 TIA (<24hrs) 15,756 13.6 Intracerebral Hemorrhage 12,491 10.8 Subarachnoid Hemorrhage 4,273 3.7 Stroke NOS 1,669 1.4 Elective Carotid Intervention

• nly

3,191 2.8 No stroke related diagnosis 1,490 1.3 Missing 359 0.3

Time to Brain Imaging

70.7% 29.3% CT performed <= 25 minutes of hospital arrival CT performed >25 minutes of hospital arrival

53.3% 59.1% 67.6% 65.0% 63.0% 66.0% 70.1% 74.6% 76.7% 80.0% 20 40 60 80 100 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

Time to IV tPA

Yes 63.5% No 36.5%

IV tPA ≤60 Minutes

Yes 32.1% No 67.9%

IV tPA ≤45 Minutes

13.6 15.1

21.9

19.0 22.2 26.8 29.6 40.0 42.9 48.5 20.7 28.5 46.8 46.7 51.5 61.2 65.0 75.5 78.5 82.7 20 40 60 80 100 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

IV t-PA ≤ 45 Minutes IV t-PA ≤ 60 Minutes

IV tPA – Arrive by 2, Treat by 3

94.6% 5.4% IV tPA < 3 Hours of LKW IV tPA > 3 Hours of LKW

89.6% 91.6% 94.6% 94.5% 93.9% 95.3% 96.1% 96.0% 94.2% 93.9% 20 40 60 80 100 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

Drip and Ship

Adult Ischemic Drip-Ship Stroke Cases, 2008-2017

N = 789 (2.7%)

0.2% 0.6% 1.8% 1.8% 1.6% 1.7% 2.9% 12.3% 8.8% 9.9% 2 4 6 8 10 12 14 16 18 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

Endovascular Therapy

Adult Ischemic Stroke Cases, 2008-2017

IA catheter-based reperfusion

N n % 76,657 1,217 1.6

0.4% 1.6% 1.1% 0.9% 0.7% 0.9% 0.9% 2.0% 2.6% 2.8% 1 2 3 4 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

Thrombolytic Complication (bleeding)

95.1% 4.9%

No bleeding complicatons after thrombolytic therapy Bleeding complications after thrombolytic therapy

4.9% 4.8% 4.1% 6.4% 5.1% 6.3% 5.2% 4.6% 4.8% 4.0% 2 4 6 8 10 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

Rehabilitation Considered

98.0% 2.0%

Considered rehabilitation services Not considered rehabilitation services

94.7% 94.2% 96.1% 97.6% 97.9% 98.1% 98.7% 98.7% 99.2% 99.2% 25 50 75 100 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

PERCENT (%) Year

Discharge Disposition

52.5% 32.4% 5.7% 3.9% 3.0% 1.6% 1.0%

Home Other Health Care Facility Expired Acute Care Facility Hospice - Health Care Facility Hospice - Home Left Against Medical Advice/AMA

58.1% 1.1% 4.4% 35.6% 0.9%

Inpatient Rehabilitation Facility (IRF) Intermediate Care Facility (ICF) Long Term Care Hospital (LTCH) Skilled Nursing Facility (SNF) Other

Adult Heart Attack Prevalence, By Public Health Region (PHR), Texas, 2017

Overall heart attack prevalence in Texas = 3.9% (95% CI: 3.2 - 4.6)

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department

• f State Health Services.

Texas Heart Attack Prevalence by Age Group (Years), Sex, and Race/Ethnicity

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

4.6% 10.8% 4.5% 3.1% 5.4% 5.7% 1.9% 0% 2% 4% 6% 8% 10% 12% 18-29 30-44 45-64 65+ Male Female White Black Hispanic Other Age (years) Sex Race/ethnicity PERCENT %

n/a n/a n/a

Texas Heart Attack Prevalence by Age Group (Years), Sex, and Race/Ethnicity

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

4.6% 10.8% 4.5% 3.1% 5.4% 5.7% 1.9% 0% 2% 4% 6% 8% 10% 12% 18-29 30-44 45-64 65+ Male Female White Black Hispanic Other Age (years) Sex Race/ethnicity PERCENT %

n/a n/a n/a

Texas Heart Attack Prevalence by Age Group (Years), Sex, and Race/Ethnicity

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

4.6% 10.8% 4.5% 3.1% 5.4% 5.7% 1.9% 0% 2% 4% 6% 8% 10% 12% 18-29 30-44 45-64 65+ Male Female White Black Hispanic Other Age (years) Sex Race/ethnicity PERCENT %

n/a n/a n/a

Texas Heart Attack Prevalence by Education and Annual Household Income, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

6.1% 4.2% 3.8% 2.2% 4.8% 3.3% 2.7% 0% 2% 4% 6% 8% Less than HS HS grad Some college College grad <$35,000 $35,000-$49,999 $50,000-74,999 $75,000 Education Annual Household Income PERCENT %

n/a

Texas Heart Attack Prevalence by Education and Annual Household Income, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

6.1% 4.2% 3.8% 2.2% 4.8% 3.3% 2.7% 0% 2% 4% 6% 8% Less than HS HS grad Some college College grad <$35,000 $35,000-$49,999 $50,000-74,999 $75,000 Education Annual Household Income PERCENT %

n/a

Texas Heart Attack Prevalence by Select Comorbidities, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

13.0% 2.7% 8.8% 1.4% 15.8% 3.5% 7.1% 6.6% 5.0% 3.5% 8.1% 3.0% 0% 3% 6% 9% 12% 15% 18% Yes No Yes No Yes No Yes No Yes No Yes No Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression PERCENT %

Texas Heart Attack Prevalence by Select Comorbidities, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

13.0% 2.7% 8.8% 1.4% 15.8% 3.5% 7.1% 6.6% 5.0% 3.5% 8.1% 3.0% 0% 3% 6% 9% 12% 15% 18% Yes No Yes No Yes No Yes No Yes No Yes No Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression PERCENT %

Texas Heart Attack Prevalence by Select Comorbidities, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

13.0% 2.7% 8.8% 1.4% 15.8% 3.5% 7.1% 6.6% 5.0% 3.5% 8.1% 3.0% 0% 3% 6% 9% 12% 15% 18% Yes No Yes No Yes No Yes No Yes No Yes No Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression PERCENT %

Texas Heart Attack Prevalence by Select Comorbidities, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

13.0% 2.7% 8.8% 1.4% 15.8% 3.5% 7.1% 6.6% 5.0% 3.5% 8.1% 3.0% 0% 3% 6% 9% 12% 15% 18% Yes No Yes No Yes No Yes No Yes No Yes No Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression PERCENT %

Texas Heart Attack Prevalence by Select Comorbidities, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

13.0% 2.7% 8.8% 1.4% 15.8% 3.5% 7.1% 6.6% 5.0% 3.5% 8.1% 3.0% 0% 3% 6% 9% 12% 15% 18% Yes No Yes No Yes No Yes No Yes No Yes No Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression PERCENT %

Texas Heart Attack Prevalence by Select Comorbidities, 2017

Data source: Texas Behavioral Risk Factor Surveillance System (BRFSS), 2017, Center for Health Statistics, Texas Department of State Health Services.

13.0% 2.7% 8.8% 1.4% 15.8% 3.5% 7.1% 6.6% 5.0% 3.5% 8.1% 3.0% 0% 3% 6% 9% 12% 15% 18% Yes No Yes No Yes No Yes No Yes No Yes No Diabetes Hypertension Kidney Disease Current Smoker Obesity Depression PERCENT %

Evaluating Hospital Care for Heart Attack in Texas

Data from 48 participating hospitals were evaluated for the period of September 2008-December 2017 on select quality and achievement measures. 57,127 individual episodes of care for heart attack

• ccurred among 54,540 patients at participating

hospitals:

• 32.0% STEMI
• 60.0% of cases transported to the hospital by private vehicle
• 74.6% received their first ECG upon arriving at the hospital

ECG within 10 Minutes of First Medical Contact

79.1% 20.9% Received ECG within 10 minutes Did not receive ECG within 10 minutes

ECG within 10 Minutes of Hospital Arrival

71.7% 73.5% 59.9% 64.1% 0% 25% 50% 75% 100% Transfer Directly admitted

CASES RECEIVING ECG WITHIN 10 MINUTES OF HOSPITAL ARRIVAL PATIENT TYPE Personal Vehicle Ambulance

Dwell Time in the ED of Referral Hospital

45.5 50.0 20 40 60 80

Mode of arrival to STEMI referral hospital MEDIAN TIME (MINUTES) Personal vehicle Ambulance

Dwell Time in the ED of Receiving Hospital

21 42 35 28 20 40 60 Transfer Directly admitted

MEDIAN TIME (MINUTES) PATIENT TYPE Personal Vehicle Ambulance

Door to Needle Time Within 30 Minutes - Transfer Patients

34.3 38.5 20 40 60 80 100 Mode of arrival to first hospital % RECEIVED TREATMENT WITHIN 30 MINUTES Personal vehicle Ambulance

Door to Balloon Time

99 65 149 48

30 60 90 120 150 180

Transfer Directly admitted MEDIAN TIME (MINUTES) PATIENT TYPE Personal Vehicle Ambulance

Primary PCI within 90 Minutes

37.7 93.8 6.3 97.9

25 50 75 100 Transfer Directly admitted

% RECEIVED PCI WITHIN 90 MINUTES PATIENT TYPE Personal Vehicle Ambulance

First Door to Balloon Time within 120 minutes - Transfer Cases

70.7 25 25 50 75 100 % RECEIVED PCI WITHIN 120 MINUTES Mode of arrival to first hospital Personal Vehicle Ambulance

First Medical Contact (FMC) to balloon time - Directly Admitted Cases

95.0 89.5 87.0 83.0 82.0 83.5 77.0 83.0 81.0 83.0 80.0 76.0 73.0 73.0 20 40 60 80 100 2011 2012 2013 2014 2015 2016 2017

MEDIAN TIME (MINUTES) YEAR Rural Urban

Thank You for Your Time - Questions?

Thanks to Chronic Disease Epidemiologists Liping Mou, MPH, and Aashima Chopra, MPH, for preparing slides

Part 2

Results from DSHS’ Self-Measured Blood Pressure (SMBP) Project

Elizabeth Harker, MPH Chronic Disease Epidemiologist

High Blood Pressure (HBP)

• What happens when blood

pressure is high?

• Blood vessel walls are

stretched and injured.

• The heart works harder

than it should, hurting the arteries and heart.1

Sources: 1 https://www.cdc.gov/bloodpressure/about.htm

2 https://www.cdc.gov/bloodpressure/infographic.htm

• People with HBP are 3x more likely to die from

heart disease and 4x more likely to die from a stroke.2

Tyler

• Located in Smith County; which has a

Hypertension prevalence of 52.9%1.

• Overall Texas prevalence is 32.5%1.
• Is a medically underserved area2.

Sources: 1Texas Behavioral Risk Factor Surveillance System Public Use Data File, 2017. Texas Department of State Health Services, Austin, TX.

2Texas Primary Care Needs Assessment. Texas Department of State Health Services, 2016.

• Project conducted at the University of Texas Health

Science Center at Tyler (UTHSCT).

• UTHSCT physicians referred patients aged 18 years and
• lder who had uncontrolled high blood pressure (HBP) to

a Community Health Worker (CHW).

• BP >=140/90 mmHg

Methods: Recruitment

• CHW introduced project and invited

patient to an orientation for more information.

• CHW took baseline BP reading.
• Participants were provided with a BP monitor and

guidance on its usage.

• 2-3 seated blood pressure readings, twice daily,
• nce in the morning and evening, 5 days a

week.

• Participants attended bi-weekly workshops on HBP

and HBP control.

• UTHSCT ran 4 Cohorts during February 2017 to

December 2018.

• Each Cohort lasted, on average, 12 weeks.

Methods: Project

• Only those with at least two BP readings ten or more

weeks apart were included in the pre-post analysis (N=140).

• Paired t-tests and the Wilson Score Interval were used

to determine statistical significance of changes in systolic and diastolic blood pressure (SBP, DBP, respectively) and BP categories (Normal, Prehypertension, Hypertension Stage I, Hypertension Stage II) from baseline to project end (i.e., graduation).

Methods: Analysis

• 65% Female
• 48.6% White
• 55.4% High school graduates
• Median Age: 53 years
• Minimum: 18 years; Maximum: 89 years
• Average BMI: 34 kg/m2
• Minimum: 15 kg/m2; Maximum: 74 kg/m2

Results: Demographics

Results: Average Change in Blood Pressure, Baseline to Graduation Date

Blood Pressure (mmHg) Baseline Average Graduation Average Average Change, Baseline to Graduation

Paired T-Test p-value 95% CL* Systolic 151.4 126.8

• 24.6

<0.0001

• 28.07, -

21.23 Diastolic 87.0 79.2

• 7.9

<0.0001

• 9.77, -6.01

*CL: Confidence Limits

Changes in SBP and DBP

• 93.6% (N=131) of participants

had a decrease in SBP and/or DBP.

• 22.1% (N=31) had decrease in

SBP only.

• 2.9% (N=4) had decrease in DBP
• nly.
• 68.6% (N=96) had decrease in

both SBP and DBP.

17 mmHg increase in SBP 94 mmHg decrease in SBP

The average change in SBP was a 24.6 mmHg decrease The average change in DBP was a 7.9 mmHg decrease

20 mmHg increase in DBP 35 mmHg decrease in DBP

Blood Pressure Category Changes

• 900% increase in participants meeting

the criteria for Normal BP

• From 3 to 30 participants
• 158% increase in participants meeting

the criteria for Prehypertension

• From 31 to 80 participants
• 54.7% decrease in participants meeting

the criteria for Hypertension Stage 1

• From 53 to 24 participants
• 88.7% decrease in participants meeting

the criteria for Hypertension Stage 2

• From 53 to 6 participants

10 20 30 40 50 60 70 80 90 Hypertension Stage 2 Hypertension Stage 1 Prehypertension Normal

Blood Pressure Category, Baseline vs. Graduation Date

Baseline Graduation

• 1. At-home BP monitoring can lead to improved

management of BP.

• 2. Regular contact with CHWs may help patients in

lowering BP.

• 3. Similar strategies could be adopted by local

health departments or health systems.

Conclusions

References

Texas Behavioral Risk Factor Surveillance System Public Use Data File. Center for Health Statistics, Texas Department of State Health Services, 2017. American Heart Association. Types of Stroke. http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/Types-of-Stroke_UCM _308531_SubHomePage.jsp. 2018. American Heart Association/American Stroke Association. Guidelines for the Early Management of Adults with Ischemic Stroke. 2018. E.R. Jacobs and A.K. Bates, "Time to Treatment in Patients with STEMI," NEJM, vol. 369, no. 10, pp. 889-892, 2013.

• P. T. O'Gara, F. G. Kushner, D. D. Ascheim and et al,, "ACCF/AHA Ggideline for the Management of ST-

Elevation Myocardial Infarction: Executive Summary," Circulation, vol. 127, no. 4, pp. 529-555, 2013. American Heart Association, "Recommendations for criteria for STEMI systems of care," 2018. [Online]. Available: www.heart.org/HEARTORG/HealthcareResearch/MissionLifelineHomePage/EMS/Recommendations-for- Criteria-for_STEMI-Systems-of-Care_UCM_312070_Atricle.jsp.. [Accessed July 2018].

• J. L. Anderson, C. D. Adams, E. M. Antman and et al., "2011 ACCF/AHA Focused Update Incorporated

into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST- Elevation Myocardial Infarction," Circulation, vol. 123, pp. e426-e579, 2011.

Thank You!

Presentation prepared by Chronic Disease Epidemiology Branch Texas Department of State Health Services