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Ahmad K, Klaaborg KE, Hjortdal V, Nørgaard BL, Terkelsen CJ, Jensen K, Christiansen EH, Terp KA, Andersen G, Hvitfeldt S, Andersen HR. Prosthetic valve endocarditis after transcatheter aortic valve implantation-diagnostic and surgical considerations. J Thorac Dis 2016; 8:E1213-E1218. [PMID: 27867590 DOI: 10.21037/jtd.2016.10.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Prosthetic valve endocarditis (PVE) after transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) is a potential life threatening complication. Better understanding of the incidence, predictors, clinical presentation, diagnostic measures, complications and management of PVE may help improve TAVI long-term outcome. We report a case of TAVI-PVE in an 80-year-old high risk patient in whom SAVR was successfully performed. We have reviewed literature regarding TAVI-PVE.
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Støttrup NB, Jakobsen L, Krusell LR, Terkelsen CJ. Utility of Impella® left ventricular assist device during cardiac arrest: A case report. Int J Cardiol 2016; 225:111-112. [PMID: 27718442 DOI: 10.1016/j.ijcard.2016.09.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022]
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Ahmad K, Terkelsen CJ, Terp KA, Mathiassen ON, Nørgaard BL, Andersen HR, Poulsen SH. Transcatheter aortic valve implantation in a young heart transplant recipient crossing the traditional boundaries. J Thorac Dis 2016; 8:E711-4. [PMID: 27621906 DOI: 10.21037/jtd.2016.07.61] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is an established therapeutic alternative to surgical aortic valve replacement (SAVR) in high-risk or inoperable patients with symptomatic aortic valve stenosis. Hitherto, TAVI is not recommended in young and low-intermediate risk patients. However, TAVI may also serve as an alternative to SAVR in selected young patients, e.g., patients who have previously undergone multiple cardiac surgery procedures. We report a case of trans-femoral TAVI in a 25-year-old heart transplant (HTx) recipient with prior surgery for congenital heart disease.
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Thim T, Egholm G, Olesen KKW, Kaltoft A, Terkelsen CJ, Krusell LR, Kristensen SD, Bøtker HE, Christiansen EH, Maeng M. Staged re-evaluation of non-culprit lesions in ST segment elevation myocardial infarction: a retrospective study. Open Heart 2016; 3:e000427. [PMID: 27403331 PMCID: PMC4932309 DOI: 10.1136/openhrt-2016-000427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/18/2016] [Accepted: 05/03/2016] [Indexed: 01/21/2023] Open
Abstract
Objective It remains unknown whether complete revascularisation is optimally performed in patients with ST segment elevation myocardial infarction (STEMI) during the index or at staged procedures. The aims of this study were to quantify the number of primary percutaneous coronary intervention (PCI) procedures in which non-culprit lesions needed further evaluation, to determine the consequence of the re-evaluation and to quantify adverse cardiac events during the waiting time for re-evaluation and intervention. Methods The study was observational and retrospective and included all patients with STEMI treated with primary PCI during 1 year at our centre. Results Among the 507 patients with STEMI, 374 were considered sufficiently treated with culprit lesion PCI only. Complete primary multivessel revascularisation was performed in 11 patients. Non-culprit lesion re-evaluation was planned for 122 patients (24%). Of these 122 patients, 3 patients died during their index admission. Follow-up data were not available for 3 patients. Among the 116 patients, 187 non-culprit lesions were re-evaluated and 77 patients (66.4%) underwent revascularisation with treatment of 119 lesions (63.3%). Re-evaluation was performed after a median of 30 days (25th centile: 9 days, 75th centile: 35 days). During the waiting time for re-evaluation, two patients underwent a new primary PCI due to stent thrombosis of the index culprit lesion. Conclusions Staged re-evaluation of non-culprit lesions observed in patients with STEMI was required in 24% of a primary PCI cohort. Intervention was performed in 66.4% of patients scheduled for re-evaluation. We observed no adverse events related to the non-culprit lesions during the waiting time for a staged re-evaluation or intervention.
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Lønborg J, Kelbæk H, Holmvang L, Helqvist S, Vejlstrup N, Jørgensen E, Saunamäki K, Dridi NP, Kløvgaard L, Kaltoft A, Bøtker HE, Lassen JF, Clemmensen P, Terkelsen CJ, Engstrøm T. Comparison of Outcome of Patients With ST-Segment Elevation Myocardial Infarction and Complete Versus Incomplete ST-Resolution Before Primary Percutaneous Coronary Intervention. Am J Cardiol 2016; 117:1735-40. [PMID: 27062938 DOI: 10.1016/j.amjcard.2016.03.009] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 01/04/2023]
Abstract
Some patients presenting with ST-segment elevation myocardial infarction (STEMI) have complete ST resolution in the electrocardiogram, which may be clinical useful in the triage of patients with STEMI. However, the importance of complete ST resolution in these patients remains uncertain. Thus, the purpose was to describe the prognosis of patients with complete ST resolution before primary percutaneous coronary intervention (PCI). Continuous ST monitoring from arrival until 90 minutes after PCI was performed in 933 patients with STEMI. Complete ST resolution was defined as no residual significant ST elevations before intervention. The patients were followed clinically for 5.5 years (range 0 to 6.8 years). Infarct size and myocardial salvage were assessed in a subgroup of patients (n = 221) by cardiovascular magnetic resonance. Complete ST resolution was observed in 24% of the patients, who had a higher incidence of Thrombolysis In Myocardial Infarction grade 2/3 flow before intervention (64% vs 24%), smaller infarct size (6% vs 11%), and higher myocardial salvage index (0.82 vs 0.69; all p <0.001) compared with patients with continuous ST elevations. Complete ST resolution was associated with a significantly lower rate of the composite end point of all-cause death and admission for heart failure (14% vs 22%; p = 0.006) although it only tended to be an independent predictor in a multivariate analysis (hazard ratio 0.69, 95% CI 0.49 to 1.06; p = 0.09). In conclusion, compared to patients without incomplete ST resolution, patients with STEMI and complete ST resolution before primary PCI have a higher incidence of normalized epicardial flow before PCI, a larger myocardial salvage and smaller infarct size after the procedure and presumably improved long-term outcome compared with incomplete ST resolution.
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Eftekhari A, Eiskjær H, Terkelsen CJ, Nielsen SL, Christiansen EH, Poulsen SH. Perforation of the Anterior Mitral Leaflet After Impella LP 5.0 Therapy in Cardiogenic Shock. Am J Cardiol 2016; 117:1539-41. [PMID: 26971643 DOI: 10.1016/j.amjcard.2016.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/08/2016] [Accepted: 02/08/2016] [Indexed: 11/28/2022]
Abstract
A 52-year old man was admitted with out-of-hospital cardiac arrest, and he was resuscitated after 100 minutes. The initial hemodynamic condition was critical due to cardiogenic shock (left ventricular ejection fraction 10 % and mean arterial pressure 60 mmHg on inotropics). Acute coronary angiography did not reveal any new lesions. Due to persistent hemodynamic instability, mechanical support with Impella LP 5.0 was decided. The surgical procedure guided by fluoroscopy and transesophageal echocardiography was uncomplicated. The hemodynamic improved subsequently and after 17 days of intensive care, and additional 30 days of hospitalization, the patient was ready for discharge. Routine echocardiography prior to discharge revealed severe mitral regurgitation due to perforation of anterior mitral leaflet, a finding not observed in the previous echocardiograms. The patient was discharged to close follow up of the severe mitral regurgitation and future surgical intervention is likely. Therefore, close monitoring of mitral valve is necessary and explanation may be required if valve dysfunction is observed, as repositioning of the Impella system is not possible.
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Eftekhari A, Terp K, Mathiassen ON, Poulsen SH, Wiggers H, Christiansen EH, Terkelsen CJ. Sub-acute transcatheter aortic valve implantation as bridge to recovery from cardio-pulmonary support following ST-elevation myocardial infarction and cardiogenic shock. Int J Cardiol 2016; 207:211-2. [PMID: 26803247 DOI: 10.1016/j.ijcard.2016.01.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/03/2016] [Indexed: 11/29/2022]
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Pryds K, Terkelsen CJ, Sloth AD, Munk K, Nielsen SS, Schmidt MR, Bøtker HE. Remote ischaemic conditioning and healthcare system delay in patients with ST-segment elevation myocardial infarction. Heart 2016; 102:1023-8. [PMID: 26911520 DOI: 10.1136/heartjnl-2015-308980] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 02/03/2016] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE We investigated influence of remote ischaemic conditioning (RIC) on the detrimental effect of healthcare system delay on myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). METHODS A post-hoc analysis of a randomised controlled trial in patients with STEMI randomised to treatment with pPCI or RIC+pPCI. RIC was performed as four cycles of intermittent 5 min upper arm ischaemia and reperfusion. Healthcare system delay was defined as time from emergency medical service call to pPCI-wire. Myocardial salvage index (MSI) was assessed by single photon emission computerised tomography. RESULTS Data for healthcare system delay and MSI were available for 129 patients. MSI was negatively associated with healthcare system delay in patients treated with pPCI alone (-0.003 decrease in MSI/min of healthcare system delay; 95% CI -0.005 to -0.001, r(2)=0.11, p=0.008) but not in patients treated with RIC+pPCI (-0.0002 decrease in MSI/min of healthcare system delay; 95% CI -0.001 to 0.001, r(2)=0.002, p=0.74). In patients with healthcare system delay ≤120 min, RIC+pPCI did not affect median MSI compared with pPCI alone (0.75 (IQR: 0.49-0.99) and 0.70 (0.45-0.94), p=1.00). However, in patients with healthcare system delay >120 min, RIC+pPCI increased median MSI compared with pPCI alone (0.74 (0.52-0.93) vs 0.42 (0.22-0.68), p=0.02). Adjusting for potential confounders did not affect the results. CONCLUSIONS RIC as adjunctive to pPCI attenuated the detrimental effect of healthcare system delay on myocardial salvage in patients with STEMI, suggesting that the cardioprotective effect of RIC increases with the duration of ischaemia. TRIAL REGISTRATION NUMBER NCT00435266; post-results.
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Bøtker MT, Stengaard C, Andersen MS, Søndergaard HM, Dodt KK, Niemann T, Kirkegaard H, Christensen EF, Terkelsen CJ. Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study. Scand J Trauma Resusc Emerg Med 2016; 24:15. [PMID: 26872739 PMCID: PMC4751637 DOI: 10.1186/s13049-016-0204-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systematic management of patients suffering high-risk symptoms is essential in emergency medical services. Patients with chest pain receive algorithm-based work-up and treatment. Though dyspnea is recognized as an independent predictor of mortality, no generally accepted prehospital treatment algorithm exists and this may affect outcome. The objective of this study was to compare mortality in patients suspected of myocardial infarction (MI) presenting with dyspnea versus chest pain in the ambulance. METHODS Follow-up study in patients undergoing electrocardiogram-based telemedical triage because of suspected MI in an ambulance in the Central Denmark Region from 1 June 2008 to 1 January 2013. Primary outcome was 30-day mortality. Secondary outcomes were 4-year mortality and mortality rates in subgroups of patients with and without a confirmed MI. Absolute risk differences adjusted for comorbidity, age, systolic blood pressure and heart rate were calculated by a generalized linear regression model. RESULTS Of 17,398 patients, 12,230 (70%) suffered from chest pain, 1464 (8%) from dyspnea, 3540 (20%) from other symptoms and 164 (1%) from cardiac arrest. Among patients with dyspnea, 30-day mortality was 13% (CI 12-15) and 4-year mortality was 50% (CI 47-54) compared to 2.9% (CI 2.6-3.2) and 20% (CI 19-21) in patients with chest pain. MI was confirmed in 121 (8.3%) patients with dyspnea and in 2319 (19%) with chest pain. Patients with dyspnea and confirmed MI had a 30-day and 4-year mortality of 21 % (CI 15-30) and 60% (CI 50-70) compared to 5.0% (CI 4.2-5.8) and 23% (CI 21-25) in patients with chest pain and confirmed MI. Adjusting for age, comorbidity, systolic blood pressure and heart rate did not change these patterns. CONCLUSION Patients suspected of MI presenting with dyspnea have significantly higher short- and long-term mortality than patients with chest pain irrespective of a confirmed MI diagnosis. Future studies should examine if supplementary prehospital diagnostics can improve triage, facilitate early therapy and improve outcome in patients presenting with dyspnea.
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Balleby IR, Terkelsen CJ, Christiansen EH, Holm NR. Stent collapse after guide extension catheter collision. Signature procedural finding by optical coherence tomography. Int J Cardiol 2016; 202:488-9. [PMID: 26440457 DOI: 10.1016/j.ijcard.2015.08.160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/21/2015] [Indexed: 10/23/2022]
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Bøtker MT, Terkelsen CJ, Sørensen JN, Jepsen SB, Johnsen SP, Christensen EF, Andersen MS. Breathing difficulties entails high mortality in 112-callers – A register based follow-up study. Resuscitation 2015. [DOI: 10.1016/j.resuscitation.2015.09.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Nielsen-Kudsk JE, Christiansen EH, Terkelsen CJ, Nørgaard BL, Jensen KT, Krusell LR, Tang M, Terp K, Klaaborg KE, Andersen HR. Fracturing the Ring of Small Mitroflow Bioprostheses by High-Pressure Balloon Predilatation in Transcatheter Aortic Valve-in-Valve Implantation. Circ Cardiovasc Interv 2015. [DOI: 10.1161/circinterventions.115.002667] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
International guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) recommend various performance measures to monitor the quality of STEMI systems of care. Door-to-balloon (D2B) time (arrival at hospital to percutaneous coronary intervention, PCI) and overall health care system delay (first medical contact to reperfusion) are acknowledged as valuable performance measures when treating patients with primary percutaneous coronary intervention (PPCI). However, there is confusion regarding the exact definition of these performance measures, and moreover system delay and PCI-related delay (the extra delay acceptable to perform PPCI instead of fibrinolysis) are often used synonymously, which add confusion when considering reperfusion strategy. The present paper calls for a consensus regarding the use and definition of objective performance measures when treating patients with STEMI, and exemplifies why it is insufficient just to focus on D2B time.
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Lønborg J, Kelbæk H, Engstrøm T, Helqvist S, Kløvgaard L, Holmvang L, Vejlstrup N, Jørgensen E, Saunamäki K, Dridi NP, Kaltoft A, Bøtker HE, Clemmensen P, Terkelsen CJ. ST peak during percutaneous coronary intervention serves as an early prognostic predictor in patients with ST-segment elevation myocardial. EUROINTERVENTION 2015; 10:466-74. [PMID: 25138184 DOI: 10.4244/eijv10i4a80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the clinical importance of the ST peak phenomenon during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS Continuous ST monitoring was performed in 942 STEMI patients from arrival until 90 minutes after revascularisation. ST peak was defined as ≥1 mm increase in the ST-segment during PCI compared with the ST elevation before intervention. ST peak was observed in 26.9% of patients. During median follow-up of 4.1 years, 20.7% of patients experienced a major adverse cardiac event (MACE). ST peak was associated with higher rates of mortality (13.4% versus 9.3%; p=0.044), admission for heart failure (10.6% versus 5.2%; p=0.002) and MACE (26.9% versus 18.2%; p=0.002), but not reinfarction (7.1% versus 5.2%; p=0.14). In two different Cox regression analyses, adjusting for predictors of MACE and ST peak including ST resolution and epicardial flow, ST peak remained significantly associated with MACE: adjusted hazard ratio (HR) 1.40 (95% confidence interval [CI] 1.01-1.95) and 1.41 (95% CI: 1.02-1.96). CONCLUSIONS In the largest study hitherto evaluating the ST peak phenomenon during primary PCI, we demonstrated that ST peak is a strong predictor of adverse long-term outcome and provides independent prognostic information beyond that provided by ST resolution and epicardial flow.
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Raungaard B, Jensen LO, Tilsted HH, Christiansen EH, Maeng M, Terkelsen CJ, Krusell LR, Kaltoft A, Kristensen SD, Bøtker HE, Thuesen L, Aarøe J, Jensen SE, Villadsen AB, Thayssen P, Veien KT, Hansen KN, Junker A, Madsen M, Ravkilde J, Lassen JF. Zotarolimus-eluting durable-polymer-coated stent versus a biolimus-eluting biodegradable-polymer-coated stent in unselected patients undergoing percutaneous coronary intervention (SORT OUT VI): a randomised non-inferiority trial. Lancet 2015; 385:1527-35. [PMID: 25601789 DOI: 10.1016/s0140-6736(14)61794-3] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND New-generation drug-eluting coronary stents have reduced the risk of coronary events, especially in patients with complex disease or lesions. To what extent different stent platforms, polymers, and antiproliferative drugs affect outcomes, however, is unclear. We investigated the safety and efficacy of a third-generation stent by comparing a highly biocompatible durable-polymer-coated zotarolimus-eluting stent with a biodegradable-polymer-coated biolimus-eluting stent. METHODS This open-label, randomised, multicentre, non-inferiority trial was done at three sites across western Denmark. All patients who presented with stable coronary artery disease or acute coronary syndromes and at least one coronary artery lesion (more than 50% stenosis) from March, 2011, to August, 2012, were assessed for eligibility. Patients were randomly assigned in a 1:1 ratio to receive either the durable-polymer zotarolimus-eluting stent or the biodegradable-polymer biolimus-eluting stent. The primary endpoint was a composite of safety (cardiac death and myocardial infarction not clearly attributable to a non-target lesion) and efficacy (target-lesion revascularisation) at 12 months, analysed by intention to treat. The trial was powered to assess non-inferiority of durable-polymer zotarolimus-eluting stent compared with the biodegradable-polymer biolimus-eluting stent with a predetermined non-inferiority margin of 0·025. This trial is registered with ClinicalTrials.gov, number NCT01956448. FINDINGS Of 7103 screened, 1502 patients with 1883 lesions were assigned to receive the durable-polymer zotarolimus-eluting stent and 1497 patients with 1791 lesions to receive the biodegradable-polymer biolimus-eluting stent. 79 (5·3%) and 75 (5·0%) patients, respectively, met the primary endpoint (absolute risk difference 0·0025, upper limit of one-sided 95% CI 0·016%; p=0·004). The individual components of the primary endpoint did not differ significantly between stent types at 12 months. INTERPRETATION The durable-polymer-coated zotarolimus-eluting stent was non-inferior to the biodegradable-polymer-coated biolimus-eluting stent in unselected patients. FUNDING Medtronic Cardiovascular and Biosensors Interventional Technologies.
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Gustafsson I, Hvelplund A, Hansen KW, Galatius S, Madsen M, Jensen JS, Tilsted HH, Terkelsen CJ, Jensen LO, Jørgensen E, Madsen JK, Abildstrøm SZ. Underuse of an invasive strategy for patients with diabetes with acute coronary syndrome: a nationwide study. Open Heart 2015; 2:e000165. [PMID: 25685362 PMCID: PMC4322312 DOI: 10.1136/openhrt-2014-000165] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/05/2014] [Accepted: 11/19/2014] [Indexed: 01/20/2023] Open
Abstract
Background Guidelines recommend an early invasive strategy for patients with diabetes with acute coronary syndromes (ACS). We investigated if patients with diabetes with ACS are offered coronary angiography (CAG) and revascularisation to the same extent as patients without diabetes. Methods and results The study is a nationwide cohort study linking Danish national registries containing information on healthcare. The study population comprises all patients hospitalised with first-time ACS in Denmark during 2005–2007 (N=24 952). Diabetes was defined as claiming of a prescription for insulin and/or oral hypoglycaemic agents within 6 months prior to the ACS event. Diabetes was present in 2813 (11%) patients. Compared with patients without diabetes, patients with diabetes were older (mean 69 vs 67 years, p<0.0001), less often males (60% vs 64%, p=0.0001) and had more comorbidity. Fewer patients with diabetes underwent CAG: cumulative incidence 64% vs 74% for patients without diabetes, HR=0.72 (95% CI 0.69 to 0.76, p<0.0001); adjusted for age, sex, previous revascularisation and comorbidity HR=0.78 (95% CI 0.74 to 0.82, p<0.0001). More patients with diabetes had CAG showing two-vessel or three-vessel disease (53% vs 38%, p<0.0001). However, revascularisation after CAG revealing multivessel disease was less likely in patients with diabetes (multivariable adjusted HR=0.76, 95% CI 0.68 to 0.85, p<0.0001). Conclusions In this nationwide cohort of patients with incident ACS, patients with diabetes were found to be less aggressively managed by an invasive treatment strategy. The factors underlying the decision to defer an invasive strategy in patients with diabetes are unclear and merit further investigation.
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Jabbari R, Engstrøm T, Glinge C, Risgaard B, Jabbari J, Winkel BG, Terkelsen CJ, Tilsted HH, Jensen LO, Hougaard M, Chiuve SE, Pedersen F, Svendsen JH, Haunsø S, Albert CM, Tfelt-Hansen J. Incidence and risk factors of ventricular fibrillation before primary angioplasty in patients with first ST-elevation myocardial infarction: a nationwide study in Denmark. J Am Heart Assoc 2015; 4:e001399. [PMID: 25559012 PMCID: PMC4330064 DOI: 10.1161/jaha.114.001399] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to investigate the incidence and risk factors for ventricular fibrillation (VF) before primary percutaneous coronary intervention (PPCI) among patients with ST-segment elevation myocardial infarction (STEMI) in a prospective nationwide setting. METHODS AND RESULTS In this case-control study, patients presenting within the first 12 hours of first STEMI who survived to undergo angiography and subsequent PPCI were enrolled. Over 2 years, 219 cases presenting with VF before PPCI and 441 controls without preceding VF were enrolled. Of the 219 case patients, 182 (83%) had STEMI with out-of-hospital cardiac arrest due to VF, and 37 (17%) had cardiac arrest upon arrival to the emergency room. Medical history was collected by standardized interviews and by linkage to national electronic health records. The incidence of VF before PPCI among STEMI patients was 11.6%. Multivariable logistic regression analysis identified novel associations between atrial fibrillation and alcohol consumption with VF. Patients with a history of atrial fibrillation had a 2.80-fold odds of experiencing VF before PPCI (95% CI 1.10 to 7.30). Compared with nondrinkers, patients who consumed 1 to 7 units, 8 to 14 units, or >15 units of alcohol per week had an odds ratio (OR) of 1.30 (95% CI, 0.80 to 2.20), 2.30 (95% CI, 1.20 to 4.20), or 3.30 (95% CI, 1.80 to 5.90), respectively, for VF. Previously reported associations for preinfarction angina (OR 0.46; 95% CI 0.32 to 0.67), age of <60 years (OR 1.75; 95% CI 1.20 to 2.60), anterior infarction (OR 2.10; 95% CI 1.40 to 3.00), preprocedural thrombolysis in myocardial infarction flow grade 0 (OR 1.65; 95% CI 1.14 to 2.40), and family history of sudden death (OR 1.60; 95% CI 1.10 to 2.40) were all associated with VF. CONCLUSION Several easily assessed risk factors were associated with VF occurring out-of-hospital or on arrival at the emergency room before PPCI in STEMI patients, thus providing potential avenues for investigation regarding improved identification and prevention of life-threatening ventricular arrhythmias.
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Veien KT, Terkelsen CJ, Ilkjær LB. [A combination of cardiac arrest and cerebral haemorrhage treated with extracorporeal membrane oxygenation]. Ugeskr Laeger 2014; 176:V10120607. [PMID: 25497639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 46-year-old, healthy woman with sudden hemiplegia and nausea suffered cardiac arrest during transport to the hospital. This was treated en route with LUCAS-2. A computed tomography ruled out cerebral haemorrhage, and an electricardiogramme showed inferior myocardial infarction. During percutaneous intervention the patient had another cardiac arrest. Despite revascularization she was very unstable and received more than 20 cardioversions of ventricular fibrillation. In the catheterization laboratory, the patient was connected to a heart lung machine (extracorporeal membrane oxygenation) while treated with LUCAS-2. After two months of hospitalization, the patient was able to walk and had minor cognitive impairment.
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Laut KG, Hjort J, Engstrøm T, Jensen LO, Tilsted Hansen HH, Jensen JS, Pedersen F, Jørgensen E, Holmvang L, Pedersen AB, Christensen EF, Lippert F, Lang-Jensen T, Jans H, Hansen PA, Trautner S, Kristensen SD, Lassen JF, Lash TL, Clemmensen P, Terkelsen CJ. Impact of health care system delay in patients with ST-elevation myocardial infarction on return to labor market and work retirement. Am J Cardiol 2014; 114:1810-6. [PMID: 25438906 DOI: 10.1016/j.amjcard.2014.09.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/17/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
Abstract
System delay (delay from emergency medical service call to reperfusion with primary percutaneous coronary intervention [PPCI]) is acknowledged as a performance measure in ST-elevation myocardial infarction (STEMI), as shorter system delay is associated with lower mortality. It is unknown whether system delay also impacts ability to stay in the labor market. Therefore, the aim of the study was to evaluate whether system delay is associated with duration of absence from work or time to retirement from work among patients with STEMI treated with PPCI. We conducted a population-based cohort study including patients ≤67 years of age who were admitted with STEMI from January 1, 1999, to December 1, 2011 and treated with PPCI. Data were derived from Danish population-based registries. Only patients who were full- or part-time employed before their STEMI admission were included. Association between system delay and time to return to the labor market was analyzed using a competing-risk regression analysis. Association between system delay and time to retirement from work was analyzed using a Cox regression model. A total of 4,061 patients were included. Ninety-three percent returned to the labor market during 4 years of follow-up, and 41% retired during 8 years of follow-up. After adjustment, system delay >120 minutes was associated with reduced resumption of work (subhazard ratio 0.86, 95% confidence interval 0.81 to 0.92) and earlier retirement from work (hazard ratio 1.21, 95% confidence interval 1.08 to 1.36). In conclusion, system delay was associated with reduced work resumption and earlier retirement. This highlights the value of system delay as a performance measure in treating patients with STEMI.
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Lønborg J, Kelbæk H, Helqvist S, Holmvang L, Jørgensen E, Saunamäki K, Kløvgaard L, Kaltoft A, Bøtker HE, Lassen JF, Thuesen L, Terkelsen CJ, Kofoed KF, Clemmensen P, Køber L, Engstrøm T. The impact of distal embolization and distal protection on long-term outcome in patients with ST elevation myocardial infarction randomized to primary percutaneous coronary intervention – results from a randomized study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:180-8. [DOI: 10.1177/2048872614543780] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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96
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Ringborn M, Birnbaum Y, Nielsen SS, Kaltoft AK, Bøtker HE, Pahlm O, Wagner GS, Platonov PG, Terkelsen CJ. Pre-hospital evaluation of electrocardiographic grade 3 ischemia predicts infarct progression and final infarct size in ST elevation myocardial infarction patients treated with primary percutaneous coronary intervention. J Electrocardiol 2014; 47:556-65. [DOI: 10.1016/j.jelectrocard.2014.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Indexed: 10/25/2022]
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97
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Sørensen JT, Stengaard C, Sørensen CA, Thygesen K, Bøtker HE, Thuesen L, Terkelsen CJ. Diagnosis and outcome in a prehospital cohort of patients with bundle branch block and suspected acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 2:176-81. [PMID: 24222828 DOI: 10.1177/2048872613483591] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/02/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Immediate revascularization is beneficial in patients with presumed new-onset bundle branch block myocardial infarction (BBBMI). In the prehospital setting, it is a challenge to diagnose new-onset BBBMI and triage accordingly. METHODS ECG, final diagnosis, and mortality were assessed in a prehospital cohort of 4905 consecutive patients with suspected acute myocardial infarction (AMI). Bundle branch block (BBB) was defined as QRS duration ≥120 ms caused by delayed intraventricular conduction. Mortality and angiography data were obtained from the Central Office of Civil Registration and the Western Denmark Heart Registry. Definite diagnosis of AMI and the onset of BBB were determined by expert consensus. Patients were divided into four groups: with or without AMI and with or without BBB. Mortality was evaluated by Kaplan-Meier plots and compared using log-rank statistics. RESULTS AMI was diagnosed in 954 patients, of whom 118 had BBB. In 3951 patients without AMI, 436 had BBB. Patients with BBBMI were less often revascularized than patients with AMI without BBB (24 vs. 54%, p<0.001). BBBMI was categorized as new onset in 43 patients of whom two were triaged for acute angioplasty. One-year mortality was 47.2, 17.5, 20.8, and 8.6% (log-rank <0.001) in patients with BBBMI, patients with AMI without BBB, patients with BBB without AMI, and patients without AMI or BBB, respectively. CONCLUSIONS Patients with BBBMI have a high mortality. Less than 25% undergo revascularization and only very few patients with new-onset BBBMI are transferred for urgent revascularization. Focus on improving triage and prehospital identification of high-risk patients with BBB and chest pain could improve outcome.
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98
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Ayer A, Terkelsen CJ. Difficult ECGs in STEMI: lessons learned from serial sampling of pre- and in-hospital ECGs. J Electrocardiol 2014; 47:448-58. [PMID: 24792903 DOI: 10.1016/j.jelectrocard.2014.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Indexed: 12/13/2022]
Abstract
Prehospital interpretation of electrocardiograms (ECGs) is crucial to ensure early diagnosis and optimal treatment of patients with ST elevation myocardial infarction (STEMI). Recognition of ST-segment elevations (STE) by qualified personnel in the prehospital phase has successfully reduced the delay from the first medical contact to reperfusion. A few other ECG patterns without true STE, referred to as "STEMI equivalents", bear the same prognostic significance, reflect imminent or ongoing transmural ischemia, but are less easily identified. Hyperacute T waves, de Winter ST-T complex, Wellens' syndrome, and posterior STEMI, as well as myocardial infarction in the presence of left bundle branch block, paced rhythm or left ventricular hypertrophy, among others are diagnostic challenges. This article reviews some critical examples of ischemic ECG patterns that may be ephemeral, misinterpreted by medical staff or not identified by automated ECG algorithms, and it emphasizes the importance of serial ECG acquisition.
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Rasmussen MB, Frost L, Stengaard C, Brorholt-Petersen JU, Dodt KK, Søndergaard HM, Terkelsen CJ. Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triaging and treatment of STEMI. Heart 2014; 100:711-5. [DOI: 10.1136/heartjnl-2013-304576] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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100
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Stengaard C, Sørensen JT, Ladefoged SA, Christensen EF, Lassen JF, Bøtker HE, Terkelsen CJ, Thygesen K. Quantitative point-of-care troponin T measurement for diagnosis and prognosis in patients with a suspected acute myocardial infarction. Am J Cardiol 2013; 112:1361-6. [PMID: 23953697 DOI: 10.1016/j.amjcard.2013.06.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 06/24/2013] [Accepted: 06/24/2013] [Indexed: 11/15/2022]
Abstract
Improvement of prehospital triage is essential to ensure rapid management of patients with acute myocardial infarction (AMI). This study evaluates the feasibility of prehospital quantitative point-of-care cardiac troponin T (POC-cTnT) analysis, its ability to identify patients with AMI, and its capacity to predict mortality. The study was performed in the Central Denmark Region from May 2010 to May 2011. As a supplement to electrocardiography, a prehospital POC-cTnT measurement was performed by a paramedic in patients with suspected AMI. AMI was diagnosed according to the universal definition of myocardial infarction using the ninety-ninth percentile upper reference level as diagnostic cut point. The paramedics performed POC-cTnT measurements in 985 subjects with a symptom duration of 70 minutes (95% CI, 35 to 180); of whom, 200 (20%) had an AMI. The prehospital sample was obtained 88 minutes (range, 58 to 131) before the sample made on admission to the hospital. The sensitivity for detection of patients with an AMI was 39% (95% CI, 32% to 46%) and the diagnostic accuracy of the POC-cTnT values was 0.67 (95% CI, 0.64 to 0.71). Adjusted survival analysis showed a strong significant association between elevated prehospital POC-cTnT level above the detection level of 50 ng/L and mortality in patients with a suspected AMI irrespective of whether an AMI was diagnosed. In conclusion, large-scale quantitative prehospital POC-cTnT testing by paramedics is feasible. An elevated prehospital POC-cTnT value contains diagnostic information and is highly predictive of mortality in patients with a suspected AMI.
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