Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology

Utilization of ST-segment deviation sum and change scores to identify acute myocardial infarction

OBJECTIVE

No information is currently available regarding the optimal cutoff values of the baseline ST-segment deviation sum (STDsum(baseline)) and 60-minute ST-segment deviation change (STDchange(60 min)) for predicting acute myocardial infarction (AMI).

METHODS

A retrospective study was performed in 783 admitted patients with chest pain who had suspected acute coronary syndrome and absence of left ventricular hypertrophy or bundle branch block on the initial electrocardiogram (ECG). The STDsum(baseline) was defined as the sum in millimeters (1 mm = 0.1 mV) of the absolute value of ST-segment deviations in all 12 leads at the initiation of continuous 12-lead ECG monitoring session. The STDchange(60 min) was defined as the absolute value of the difference between the baseline and 60-minute STDsum. Three cutoff values are reported and represent the smallest values in which the positive likelihood ratio (+LR) for AMI was greater than or equal to 5, 10, and 20, respectively.

RESULTS

Acute myocardial infarction occurred in 162 (20.7%) patients. The smallest cutoff value of the STDsum(baseline) for AMI with a +LR equal to or greater than 5, 10, and 20 was 9.6, 12.4, and 14.1 mm, respectively. In the subset of 699 patients without ST-segment elevation AMI on initial ECG, the smallest cutoff value of the STDchange(60 min) for AMI with a +LR equal to or greater than 5, 10, and 20 was 2.4, 3.5, and 7.9 mm, respectively.

CONCLUSIONS

Clinical studies need to be performed to determine if STDsum and STDchange, in conjunction with physician pretest probability of AMI, can be used to select patients who may benefit from emergent reperfusion therapy and other aggressive medical management strategies.

[Acute myocardial infarction in Mid-Norway: transportation for thrombolytic treatment or primary percutaneous coronary intervention?]

BACKGROUND

Occluded coronary arteries should be opened urgently in patients who have acute myocardial infarction and ST-elevation in ECG. When transport times are long, thrombolytic treatment is a good alternative to primary percutaneous coronary intervention (PCI). The purpose of this study was to assess choice of treatment strategy in cases where time after start of symptoms and transport time are decisive for the outcome.

MATERIAL AND METHODS

A cohort study of 379 patients, who had myocardial infarction and ST-elevation, and were admitted to St. Olav's Hospital, Trondheim, Norway in the period 1.11.2007-31.1.2009.

RESULTS

268 patients (71 %) were treated with PCI, and 111 patients (29 %) with thrombolytic treatment. 173 patients (46 %) were transported by helicopter. The counties in Mid-Norway used markedly different treatment strategies for these patients.

INTERPRETATION

Great regional differences were observed in the use of PCI and thrombolytic treatment in Mid-Norway.

Impact of thrombectomy with EXPort Catheter in Infarct-Related Artery during Primary Percutaneous Coronary Intervention (EXPIRA Trial) on cardiac death

In ST-segment elevation myocardial infarction (STEMI) impairment of microcirculatory function is a negative independent predictor of myocardial function recovery. In the Impact of Thrombectomy with EXPort Catheter in Infarct-Related Artery during Primary Percutaneous Coronary Intervention (PCI; EXPIRA) trial we found that manual thrombectomy resulted in a better myocardial reperfusion expressed by an improved procedural outcome and a decrease of infarct size compared to conventional PCI. The aim of the present study was to investigate whether the early efficacy of thrombus aspiration translates into very long-term clinical benefit. We randomized 175 patients with STEMI with occlusive thrombus at baseline undergoing primary PCI to thromboaspiration with a manual device (Export Medtronic, n = 88) or standard PCI (n = 87). No differences in baseline, clinical, and angiographic preprocedural findings were observed between the 2 groups except for incidence of hypertension and cholesterol levels. After 24 months major adverse cardiac events were 13.7% versus 4.5% (p = 0.038, log-rank test) and cardiac death was 6.8% versus 0% (p = 0.012, log-rank test). A strict correlation was observed between cardiac death incidence and tissue reperfusion parameters (postprocedural myocardial blush grade and ST-segment resolution). In conclusion, manual thrombus aspiration before stenting of the infarct-related artery in selected patients with STEMI improving myocardial reperfusion significantly decrease cardiac death and major adverse cardiac events at 2 years.

Prevalence, clinical characteristics and risk of myocardial infarction in patients with cocaine-related chest pain

INTRODUCTION AND OBJECTIVES

To investigate the frequency of recent cocaine use in patients attending an emergency department for acute chest pain, to describe the clinical characteristics of these patients, and to estimate the incidence of acute coronary syndrome in this population.

METHODS

Observational cohort study using a standard questionnaire that includes items on recent cocaine consumption.

RESULTS

During a 1-year period, 1240 patients aged under 55 years presented with chest pain. Of these, 63 (5%) had cocaine-related chest pain (7% of men and 1.8% of women). These patients were younger (35+/-10 years vs. 39+/-10 years; P=.002), were more frequently male (87% vs. 62%; P< .001), and were more frequently smokers (59% vs. 35%; P< .001). Patients who had used cocaine recently had a higher incidence of acute myocardial infarction (16 vs. 4%; P< .001), especially ST-segment-elevation myocardial infarction (11.1% vs. 1.6%; P< .01). After adjusting for coronary risk factors, history of cardiovascular disease and previous treatment, the odds ratio for myocardial infarction with recent cocaine consumption was 4.3 (95% confidence interval, 2-9.4).

CONCLUSIONS

Cocaine-related chest pain is often encountered in emergency departments, especially in men aged under 55 years. It is associated with a four-fold increase in the risk of acute myocardial infarction. All male patients aged under 55 years with acute chest pain should be asked about cocaine use.

Effect of coronary collaterals on long-term prognosis in patients undergoing primary angioplasty for acute ST-elevation myocardial infarction

The aim of this study was to examine the effect of coronary collateral flow before reperfusion on long-term clinical prognosis in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. We studied 235 patients with STEMI within 12 hours after symptom onset. All patients had Thrombolysis In Myocardial Infarction grade < or =1 flow before percutaneous coronary intervention. Collateral flow was graded according to the Rentrop classification. Patients were categorized as having absent or poor collateral flow to the infarct-related artery (group A) or significant flow (group B). In 166 patients there was absent or weak collateral flow (group A), whereas 69 had significant flow (group B). Long-term follow-up was available in 227 patients (97%) at a median of 797 days. Overall, 25 patients died during the follow-up period, 22 patients (13.8%) in group A and 3 patients (4.4%) in group B (p = 0.04). A total of 12 (7.5%) nonfatal recurrent myocardial infarctions occurred in group A compared to 2 (2.9%) in group B (p = 0.18). The combined major adverse cardiovascular event end point (death or nonfatal reinfarction) showed a significantly lower event rate in group B (p = 0.02). Extensive collateral flow at baseline was a significant predictor for a favorable long-term clinical outcome on multivariable analysis after adjustment for established prognostic markers. In conclusion, the presence of a well-developed collateral network before mechanical reperfusion in patients with STEMI is associated with improved long-term survival and lower major adverse cardiovascular event rates.

'Ins' and 'outs' of triple therapy: Optimal antiplatelet therapy in patients on chronic oral anticoagulation who need coronary stenting

Chronic oral anticoagulant treatment is obligatory in patients (class I) with mechanical heart valves and in patients with atrial fibrillation with CHADS2 score >1. When these patients undergo percutaneous coronary intervention with placement of a stent, there is also an indication for treatment with aspirin and clopidogrel. Unfortunately, triple therapy is known to increase the bleeding risk. For this group of patients, the bottom line is to find the ideal therapy in patients with indications for both chronic anticoagulation therapy and percutaneous intervention to prevent thromboembolic complications such as stent thrombosis without increasing the risk of bleeding. (Neth Heart J 2010;18:444-50.).

Treatment patterns in patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

The Antiplatelet Therapy Observational Registry (APTOR) is a prospective observational study of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) in a 'real world' clinical setting. Here the authors report on the management of ACS patients in three European countries during the hospital phase and through 12-months' follow-up, including use of antiplatelet agents, co-medications and stents, as well as clinical outcomes at 12 months.

METHODS

ACS patients undergoing PCI (N = 1525) from January to August 2007 were planned to be consecutively recruited in France, Spain and the UK.

RESULTS

Index diagnosis was unstable angina/non-ST-segment elevation myocardial infarction (MI) in 62% and ST-segment elevation MI in 38%. Prior to the index ACS event, 17% were prescribed both aspirin and clopidogrel. While in-hospital clopidogrel and aspirin use was similar across countries, considerable variation was observed between countries at 12 months (clopidogrel 66-75%; aspirin 86-95%). The UK most frequently used a 300-mg clopidogrel loading dose (70%) compared with France (53%) and Spain (56%), while >300 mg was used in 21%, 34% and 16% patients, respectively. Bare metal stents only were used in 42% of subjects, drug-eluting stents (DES) only in 40%, and both in 10%, with the highest rates of DES use in Spain (70%) followed by the UK (47%) and France (31%). The composite endpoint of cardiovascular (CV) death, MI or stroke occurred in 4.7% of patients by 12 months.

CONCLUSIONS

APTOR shows marked variation in ACS management between countries in antiplatelet therapy, co-medications and stent use. Due to the observational design of the registry, statistical testing was not applied and data should be seen as hypothesis generating. These data provide a useful benchmark for comparison with current guidelines.

Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction

AIMS

The rate and type of reperfusion, as well as time delays to reperfusion are directly associated with mortality and are established as performance measures (PMs) in the treatment of ST elevation myocardial infarction (STEMI). To date, little information exists about PMs for reperfusion in clinical practice in Europe and their temporal changes.

METHODS AND RESULTS

Using the Euro Heart Survey ACS-III data set (2 years of inclusions between 2006 and 2008, 138 centres in 21 countries), we selected patients with STEMI eligible for reperfusion therapy. Recorded variables corresponded to the CARDS data set. The rate and type of reperfusion, as well as door to needle and door to artery times were assessed and compared between periods. Timely reperfusion was defined as a door to needle time < 30 min, or a door to artery time < 90 min. We assessed changes in PMs for reperfusion over the 2 years of recruitment. Among 19 205 patients included in the registry, 7655 had STEMI, and 6481 were admitted within the first 12 h and eligible for reperfusion. The rate of patients who underwent reperfusion increased from 77.2 to 81.3%, with an increase in the use of primary percutaneous coronary intervention (P-PCI). The door to needle and door to artery times decreased significantly during the study period, from 20 to 15 min (P = 0.0011) and from 60 to 45 min (P < 0.0001) respectively. As a result, the number of eligible patients receiving reperfusion therapy in a timely manner increased from 53.1 to 63.5% (P < 0.0001). In parallel, over the 2-year period, in-hospital mortality decreased from 8.1 to 6.6% (P = 0.047).

CONCLUSION

In centres participating in the Euro Heart Survey ACS III, PMs for reperfusion in STEMI improved significantly between 2006 and 2008, with greater use of PCI. Similarly, the rate of patients reperfused in a timely manner also increased, with a significant reduction in door to needle and door to artery times.

[Impact of the angles and the age of the thrombus on efficacity of thromboaspiration device. A bench study]

INTRODUCTION

Coronary thrombectomy is usually used to treat acute coronary syndrome. Many studies evaluated its benefit in this context however, it is still unknown if coronary characteristics are predictive of success or failure. The aim of our laboratory bench study was to evaluate the impact of angiographic characteristics on the thromboaspiration efficiency.

METHODS

Glass tubes of 150 mm in the length were used, with five diameters: 2; 2.6; 3; 3.6 and 4 mm; and for each diameter, three angulations: no angulation; 90° and 120°. Blood sample were taken from healthy subject and thrombi of 3 and 6 hours old were performed, with a constant volume for each test. Thromboaspirations were performed with an Export(®) catheter (Medtronic). The primary endpoint was total thrombectomy. A total of 240 thromboaspirations were performed.

RESULTS

A total thrombectomy was obtained for 71.2% of the tests. It was achieved more frequently with the smaller diameter, respectively: 100% for 2 mm, 81.3% for 2.6 mm, 89.6% for 3 mm vs 54.2% for 3.6 mm and 31.3% for 4 mm (P<0.001). No differences were observed between the 2 thrombi ages (73.3% for the 3 hours old thrombi and 69.2% for the 6 hours old thrombi, P = 0.476), nor between the three tube's angulations (77.5% for no angle, 66.3% for 90° and 70.0% for 120°, P = 0.278).

RESULTS AND CONCLUSION

This study shows an impact of the coronary diameters on the rate of thromboaspiration success with an Export(®) catheter. Beyond 3 mm of diameter, the rate of success is divided by 2: for diameters less or equal to 3 mm, 90.3% of success vs 42.7% for diameters greater than 3 mm (P<0.001). There is no difference of efficiency between the 3 and 6 hours old thrombi, neither between the tube's angulations. However, this is a preliminary and further works are needed to clarify how to optimize the aspiration and the impact of other catheters.

ISAR--a story of trials with impact on practice

Since its inception approximately 15 years ago, the ISAResearch group has completed more than 40 randomized controlled trials (RCT) in the field of interventional cardiology, including more than 40,000 patients. Three main principles have characterized the ISAR trials: first, simplicity: 1 question 1 answer; second, a focus on issues that are relevant for practice at the given moment and third, a strong spirit of performing industry-independent studies. The seamless integration of clinical trials into everyday practice and a stringent study discipline allowed inclusion of more than 90% of the patients in 1 of the device or drug trials, the prerequisite for fast recruitment and evaluation of an all-comers population. Moreover, the early setup and maintenance of a comprehensive database with routine follow-up of all patients undergoing percutaneous coronary intervention made it possible to build up a large registry to answer questions beyond clinical trials. Finally, the close collaboration with basic research working groups within the department has triggered new innovations and facilitated translational research from bench to bedside.

Fatty acids from fish: the anti-inflammatory potential of long-chain omega-3 fatty acids

Omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids (PUFA) are precursors of potent lipid mediators, termed eicosanoids, which play an important role in the regulation of inflammation. Eicosanoids derived from n-6 PUFAs (e.g., arachidonic acid) have proinflammatory and immunoactive functions, whereas eicosanoids derived from n-3 PUFAs [e.g., eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] have anti-inflammatory properties, traditionally attributed to their ability to inhibit the formation of n-6 PUFA-derived eicosanoids. While the typical Western diet has a much greater ratio of n-6 PUFAs compared with n-3 PUFAs, research has shown that by increasing the ratio of n-3 to n-6 fatty acids in the diet, and consequently favoring the production of EPA in the body, or by increasing the dietary intake of EPA and DHA through consumption of fatty fish or fish-oil supplements, reductions may be achieved in the incidence of many chronic diseases that involve inflammatory processes; most notably, these include cardiovascular diseases, inflammatory bowel disease (IBD), cancer, and rheumatoid arthritis, but psychiatric and neurodegenerative illnesses are other examples.

Knowledge of a patient-dependant phase of acute myocardial infarction in Polish adults: the role of physician's advice

BACKGROUND

Effective management of acute myocardial infarction (AMI) is limited by patient delay in calling an ambulance. We aimed to assess knowledge related to a patient-dependant phase of AMI and its determinants in adults.

METHODS

Questionnaire survey was conducted among a random sample of 942 men (48%) and women (52%) aged 63.50 ± 6.50 selected from population registers in Cracow (Poland). Questions from the Behavioral Risk Factor Surveillance System were used to assess knowledge of AMI symptoms. The respondents were further asked about the first thing they would do in response to AMI symptoms, the emergency phone number and whether a doctor advised them about AMI.

RESULTS

All suggested AMI symptoms were recognized by 51 (5.4%) respondents. More persons would call an ambulance in response to AMI symptoms in another person than if they appear in themselves (87.4% vs. 74.4%, P = 0.02). Only 644 (68%) participants knew the emergency phone number and 104 (11%) were advised about AMI by their doctors. Such advice was associated with higher rates of knowledge of AMI symptoms and the emergency phone number but not with a declaration of the appropriate reaction to AMI symptoms. Participants after AMI did not represent better knowledge of a patient-dependant phase of AMI but paradoxically less frequently than other persons declared calling an ambulance in response to AMI symptoms.

CONCLUSION

Improvement in knowledge and attitudes related to a patient-dependant phase of AMI is needed in adults even if they experienced AMI before. A routine advice from a doctor may contribute significantly to this improvement.

Antithrombotic therapy in acute coronary syndromes: guidelines translated for the clinician

The use of anticoagulant and antiplatelet therapy during the management of acute coronary syndromes (ACS) has been associated with improvements in short- and long-term clinical outcomes, regardless of whether patients are managed conservatively or with acute coronary revascularization. Translating the existing evidence for selection of the most appropriate antithrombotic strategy has been summarized in available guideline recommendations. Given the breadth of antithrombotic recommendations across existing U.S. and European guidelines, synthesis of these recommendations for practicing clinicians who treat patients with ACS are increasingly desired. Providing a summary of the similarities across guidelines while noting the areas where divergence exists becomes an important facet in translating optimal antithrombotic management in ACS for the treating clinician. This review highlights the important aspects of clinical practice guidelines that practicing physicians should consider when selecting antithrombotic therapies to reduce ischemic risk while minimizing hemorrhagic risk across all ACS subtypes.

Epidemiology and patterns of care of patients admitted to Italian Intensive Cardiac Care units: the BLITZ-3 registry

BACKGROUND

Intensive cardiac care units (ICCUs) have shifted from the observation of patients with myocardial infarction to the care of different acute cardiac diseases. However, few data on such an evolution are available.

METHODS AND RESULTS

From 7 to 20 April 2008, 6986 consecutive patients admitted to 81% of Italian ICCUs were prospectively enrolled. Patients observed were mainly elderly men (median age 72 years) with several co-morbidities. Most of them were triaged to ICCU from the emergency room, but 15% of admissions were transfer-in from other hospitals. Several diagnostic and therapeutic procedures were applied (78% had echocardiography and 35% coronary angiography) during the ICCU stay [median length 4 days, interquartile range (IQR) 2-5]. The discharge diagnosis was ST-elevation acute coronary syndrome (ACS) in 21%, non-ST-elevation ACS in 31%, acute heart failure (AHF) in 14% and other acute non-ACS, non-AHF cardiac diseases in 34%. Of those with ST-elevation ACS, 60% received reperfusion (15% fibrinolysis and 45% primary percutaneous coronary intervention). The overall in-ICCU crude mortality was 3.3%.

CONCLUSION

The BLITZ-3 survey provides a unique snapshot of current epidemiology and patterns of care of patients admitted to ICCUs. Although ACS still remains the most frequent admission diagnosis, the number of non-ACS patients is substantial. However, the correct standard of care for these non-ACS patients has to be defined.

Expression of Toll-like receptor 4 on peripheral blood mononuclear cells and its effects on patients with acute myocardial infarction treated with thrombolysis

BACKGROUND AND AIMS

TLR4 has been shown to mediate inflammation in animal models of myocardial ischemia/reperfusion injury (MI/RI). Here we hypothesized that TLR4 on peripheral blood mononuclear cells (PBMCs) may be involved in the inflammatory response in this type of clinical event.

METHODS

Seventy two patients with acute myocardial infarction (AMI) who underwent thrombolysis were assigned into reperfusion group (n = 43) and non-reperfusion group (n = 29) according to recanalization of infarct-related artery (IRA) and 40 healthy volunteers were enrolled in this experiment. Eight mL of venous blood was taken from all patients 0 h before and 2, 6, 12, and 24 h after thrombolysis. Flow cytometry (FCM) was used to detect TLR4 protein expression and real-time quantitative RT-PCR was performed to determine TLR4 mRNA and myeloid differentiation protein-88 (Myd88) mRNA expression. The concentration of tumor necrosis factor-α (TNF-α) in plasma was evaluated using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Compared with controls, all detected indicators in AMI patients were upregulated before thrombolysis (p <0.01). After thrombolysis, they were further increased. In reperfusion group, all attained their peaks in earlier hours and the peak values were lower compared with non-reperfusion group. In both cases, either reperfusion or non-perfusion, TLR4 mRNA expression was positively correlated with the levels of Myd88 mRNA (r = 0.886 and 0.694, p <0.01), respectively.

CONCLUSIONS

TLR4 expression on PBMCs was markedly elevated in AMI patients either reperfused or non-reperfused. Inflammatory reaction by activated TLR4 in MI/RI in patients may be through TLR4-Myd88-dependent signal pathway.

Role of the paclitaxel-eluting stent and tirofiban in patients with ST-elevation myocardial infarction undergoing postfibrinolysis angioplasty: the GRACIA-3 randomized clinical trial

BACKGROUND

A catheter-based approach after fibrinolysis is recommended if fibrinolysis is likely to be successful in patients with acute ST-elevation myocardial infarction. We designed a 2x2 randomized, open-label, multicenter trial to evaluate the efficacy and safety of the paclitaxel-eluting stent and tirofiban administered after fibrinolysis but before catheterization to optimize the results of this reperfusion strategy.

METHODS AND RESULTS

We randomly assigned 436 patients with acute ST-elevation myocardial infarction to (1) bare-metal stent without tirofiban, (2) bare-metal stent with tirofiban, (3) paclitaxel-eluting stent without tirofiban, and (4) paclitaxel-eluting stent with tirofiban. All patients were initially treated with tenecteplase and enoxaparin. Tirofiban was started 120 minutes after tenecteplase in those patients randomly assigned to tirofiban. Cardiac catheterization was performed within the first 3 to 12 hours after inclusion, and stenting (randomized paclitaxel or bare stent) was applied to the culprit artery. The primary objectives were the rate of in-segment binary restenosis of paclitaxel-eluting stent compared with that of bare-metal stent and the effect of tirofiban on epicardial and myocardial flow before and after mechanical revascularization. At 12 months, in-segment binary restenosis was similar between paclitaxel-eluting stent and bare-metal stent (10.1% versus 11.3%; relative risk, 1.06; 95% confidence interval, 0.74 to 1.52; P=0.89). However, late lumen loss (0.04+/-0.055 mm versus 0.27+/-0.057 mm, P=0.003) was reduced in the paclitaxel-eluting stent group. No evidence was found of any association between the use of tirofiban and any improvement in the epicardial and myocardial perfusion. Major bleeding was observed in 6.1% of patients receiving tirofiban and in 2.7% of patients not receiving it (relative risk, 2.22; 95% confidence interval, 0.86 to 5.73; P=0.14).

CONCLUSIONS

This trial does not provide evidence to support the use of tirofiban after fibrinolysis to improve epicardial and myocardial perfusion. Compared with bare-metal stent, paclitaxel-eluting stent significantly reduced late loss but appeared not to reduce in-segment binary restenosis.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov. Unique identifier: NCT00306228.

Cost and health outcome of primary percutaneous coronary intervention versus thrombolysis in acute ST-segment elevation myocardial infarction-Results of the Swedish Early Decision reperfusion Study (SWEDES) trial

BACKGROUND

In ST-elevation myocardial infarction, primary percutaneous coronary intervention (PCI) has a superior clinical outcome, but it may increase costs in comparison to thrombolysis. The aim of the study was to compare costs, clinical outcome, and quality-adjusted survival between primary PCI and thrombolysis.

METHODS

Patients with ST-elevation myocardial infarction were randomized to primary PCI with adjunctive enoxaparin and abciximab (n = 101), or to enoxaparin followed by reteplase (n = 104). Data on the use of health care resources, work loss, and health-related quality of life were collected during a 1-year period. Cost-effectiveness was determined by comparing costs and quality-adjusted survival. The joint distribution of incremental costs and quality-adjusted survival was analyzed using a nonparametric bootstrap approach.

RESULTS

Clinical outcome did not differ significantly between the groups. Compared with the group treated with thrombolysis, the cost of interventions was higher in the PCI-treated group ($4,602 vs $3,807; P = .047), as well as the cost of drugs ($1,309 vs $1,202; P = .001), whereas the cost of hospitalization was lower ($7,344 vs $9,278; P = .025). The cost of investigations, outpatient care, and loss of production did not differ significantly between the 2 treatment arms. Total cost and quality-adjusted survival were $25,315 and 0.759 vs $27,819 and 0.728 (both not significant) for the primary PCI and thrombolysis groups, respectively. Based on the 1-year follow-up, bootstrap analysis revealed that in 80%, 88%, and 89% of the replications, the cost per health outcome gained for PCI will be <$0, $50,000, and $100,000 respectively.

CONCLUSION

In a 1-year perspective, there was a tendency toward lower costs and better health outcome after primary PCI, resulting in costs for PCI in comparison to thrombolysis that will be below the conventional threshold for cost-effectiveness in 88% of bootstrap replications.

Combined oral anticoagulants and antiplatelets: benefits and risks

Combined antiplatelet and anticoagulant therapy has been suggested for those clinical conditions in which conventional antithrombotic regimens have shown suboptimal efficacy, and in patients with indication for both: antiplatelet and anticoagulant therapy. Clinical trials aimed at assessing the clinical benefit of the association with respect to mono-therapy have been conducted in patients with atrial fibrillation, in patients with recent myocardial infarction, and in patients with prosthetic heart valves. Overall, a favorable benefit-risk profile of combined therapy in comparison to anticoagulant alone has been observed in patients with mechanical prosthetic heart valves and in those with coronary artery disease while no clear advantage has been shown in patients with atrial fibrillation. In almost all these studies, however, a higher risk of major bleeding has been observed in patients receiving combined therapy in comparison to patients receiving warfarin alone. Thus, a combined regimen of anticoagulant and antiplatelet therapy should be reserved for selected patients at high risk of thromboembolic events who have a low risk of bleeding.

Impact of multivessel coronary artery disease and noninfarct-related artery revascularization on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER Registry)

The aim of the study was to assess the impact of multivessel coronary artery disease (MVD) and noninfarct-related artery (non-IRA) revascularization during index percutaneous coronary intervention (PCI) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI). Data on 1,598 of 1,650 patients with complete angiographic data, with >or=1 significantly stenosed epicardial coronary artery, and without previous coronary artery bypass grafting were retrieved from the EUROTRANSFER Registry database. Patients with 1-, 2-, and 3-vessel disease made up 48.5%, 32.0%, and 19.5% of the registry population, respectively. Patients with MVD were less likely to achieve final Thrombolysis In Myocardial Infarction grade 3 flow (1- vs 2- vs 3-vessel disease, 93.6% vs 89.3% vs 87.9%, respectively, p = 0.003) and ST-segment resolution >50% within 60 minutes after PCI (1- vs 2- vs 3-vessel disease, 80.9% vs 77.5% vs 69.3%, respectively, p <0.001). They were also at higher risk of death during 1-year follow-up (1- vs 2- vs 3-vessel disease, 4.9% vs 7.4% vs 13.5%, respectively, p <0.001), and MVD was identified as an independent predictor of 1-year death. In 70 patients (9%) non-IRA PCI was performed during index PCI. These patients were at higher risk of 30-day and 1-year death compared to patients without non-IRA PCI, but this difference in mortality was no longer significant after adjustment for covariates. In conclusion, patients with MVD have decreased epicardial and myocardial reperfusion success and had worse prognosis after primary PCI for STEMI compared to patients with 1-vessel disease. In this large multicenter registry, non-IRA PCI during the index procedure was performed in 9% of patients with MVD and it was associated with increased 1-year mortality.

The quality of emergency medical care in baden-württemberg (Germany): four years in focus

BACKGROUND

In 2004, the German federal state of Baden-Württemberg implemented a quality management system for pre-hospital emergency care. Since then, there has been a semi-annual assessment of the frequency of different types of emergency medical interventions and the quality of care.

METHODS

The frequencies of different types of intervention were determined and reported both in absolute numbers and as incidence figures, i.e., interventions per 1000 inhabitants per year. The quality of care was rated with the Mainz Emergency Evaluation Score (MEES), and analyses of resuscitation outcomes and guideline implementation were performed.

RESULTS

From 2004 to 2008, there were a total of 524,833 pre-hospital emergency medical interventions in Baden-Württemberg. The annual incidence of emergency interventions rose by 22% over this period (from 16.2 to 19.9 interventions per 1000 inhabitants per year), and the percentage of patients who were severely ill or severely injured rose as well, from 47.3% to 51.1%. The percentage of patients over age 75 rose from 29.1% to 31.3%. 11,858 patients with myocardial infarction (MI) were treated in 2008; the incidence of treatment for MI rose by 60% from 2004 to 2008, from 0.907 to 1.448 interventions per 1000 inhabitants per year. A major improvement in the diagnostic evaluation of MI came about through the purchase of more 12-channel ECG machines. In 2008, the emergency medical teams succeeded in improving the patient's condition in 69.07% of all cases (77.9% for MI, 63.2% for stroke, 74.4% for multiple trauma). 21 patients per 100,000 inhabitants per year arrived in the hospital alive after out-of-hospital cardiac arrest and pre-hospital resuscitation.

CONCLUSIONS

Even in the face of increasing utilization, the quality of emergency medical care in Baden-Württemberg has remained high. Since a quality management system was introduced in 2004, the physicians in charge of emergency medical teams have had access to the data that they need in order to evaluate and further develop the services that they provide.

Impact of early vs. late microvascular obstruction assessed by magnetic resonance imaging on long-term outcome after ST-elevation myocardial infarction: a comparison with traditional prognostic markers

AIMS

Early and late microvascular obstruction (MO) assessed by magnetic resonance imaging (MRI) are prognostic markers for combined clinical endpoints after ST-elevation myocardial infarction (STEMI). However, there are only limited data for hard endpoints and no consensus exists which of the two best predicts clinical outcome. Furthermore, it is unclear whether the assessment of MO by MRI adds incremental prognostic information independent of traditional outcome markers.

METHODS AND RESULTS

STEMI patients reperfused by primary angioplasty (n = 438) < 12 h after symptom onset underwent MRI at a median of 3 days after the index event. Microvascular obstruction was measured 1 and 15 min after gadolinium injection (early and late MO). Clinical follow-up was conducted after a median of 19 months. The primary endpoint was defined as a composite of death, non-fatal myocardial re-infarction, and congestive heart failure. In contrast to the presence and extent of early MO, the presence and extent of late MO were independently associated with the composite primary endpoint in the multivariable Cox regression analysis adjusting for post-percutaneous coronary intervention TIMI-flow, ST-resolution, TIMI-risk score, ejection fraction, and infarct size. The presence of late MO was identified as the strongest independent predictor for the occurrence of the composite endpoint (hazard ratio 4.23, 95%CI 1.73-10.34, P = 0.002). Furthermore, the presence and extent of late MO provided an incremental prognostic value above the traditional prognostic markers.

CONCLUSION

In contrast to early MO, the presence and extent of late MO are strong independent prognosticators after STEMI. www.ClinicalTrials.gov: NCT00299377.

[Care of ST elevated myocardial infarction patients in Vendée in 2008: observational and descriptive study]

PURPOSE OF THE STUDY

Estimating the quality of care of the patients presenting an ST-elevation myocardial infarction in Vendee.

PATIENTS AND METHOD

Prospective observational study carried out over the year 2008. Included patients presenting a myocardial infarction for less than 24 hours, they were alive when emergency team arrived, and were taken care of by the SMUR, the emergencies or the cardiology of the hospital of La Roche-sur-Yon.

RESULTS

Two hundred and seventeen patients were included, 163 men and 54 women, average age: 65 years. Fifty-six percent of the patients called initially the emergency medical service, half of those within an hour after pain began. Seventy-two percent of them were looked after by a SMUR. Twenty-six percent consulted initially a general practitioner, and one third of those were redirected towards the emergency medical service. Thirty percent of all patients followed the ideal procedure defined by succession of chest pain, emergency medical service call, SMUR, angioplasty or fibrinolysis. The average time between the ECG and the fibrinolysis is 36 minutes, or of the arrival in coronarography room is 105 minutes. The balloon is inflated 42 minutes later. Eighty-six percent of the patients taken care of in the acute phase benefited from a strategy of reperfusion, primary angioplasty (63%) or fibrinolysis (21%). Ninety percent of revascularisations were successful.

CONCLUSION

In the case of the chest pain, the emergency medical service is under-used. The number of revascularised patients is satisfactory, but the whole procedure takes too much time, especially when the treatment is the angioplasty.

Sphingosine 1-phosphate levels in plasma and HDL are altered in coronary artery disease

High-density lipoproteins (HDL) are the major plasma carriers for sphingosine 1-phosphate (S1P) in healthy individuals, but their S1P content is unknown for patients with coronary artery disease (CAD). The aim of the study was to determine whether the S1P levels in plasma and HDL are altered in coronary artery disease. S1P was determined in plasma and HDL isolated by ultracentrifugation from patients with myocardial infarction (MI, n = 83), stable CAD (sCAD, n = 95), and controls (n = 85). In our study, total plasma S1P levels were lower in sCAD than in controls (305 vs. 350 pmol/mL). However, normalization to HDL-cholesterol (a known determinant of plasma S1P) revealed higher normalized plasma S1P levels in sCAD than in controls (725 vs. 542 pmol/mg) and even higher ones in MI (902 pmol/mg). The S1P amount contained in isolated HDL from these individuals was lower in sCAD than in controls (S1P per protein in HDL: 132 vs. 153 pmol/mg). The amount of total plasma S1P bound to HDL was lower in sCAD and MI than in controls (sCAD: 204, MI: 222, controls: 335 pmol/mL), while the non-HDL-bound S1P was, accordingly, higher (sCAD: 84, MI: 81, controls: 10 pmol/mL). HDL-bound plasma S1P was dependent on the plasma HDL-C in all groups, but normalization to HDL-C still yielded lower HDL-bound plasma S1P in patients with sCAD than in controls (465 vs. 523 pmol/mg). The ratio of non-HDL-bound plasma S1P to HDL-C-normalized HDL-bound S1P was also higher in both sCAD (0.18 mg/mL) and MI (0.15 mg/mL) than in controls (0.02 mg/mL). Remarkably, levels of non-HDL-bound plasma S1P correlated with the severity of CAD symptoms as graded by Canadian Cardiovascular Score, and discriminated patients with MI and sCAD from controls. Furthermore, a negative association was present between non-HDL-bound plasma S1P and the S1P content of isolated HDL in controls, but was absent in sCAD and MI. Finally, MI patients with symptom duration of less than 12 h had the highest levels of total and normalized plasma S1P, as well as the highest levels of S1P in isolated HDL. The HDL-C-normalized plasma level of S1P is increased in sCAD and even further in MI. This may be caused by an uptake defect of HDL for plasma S1P in CAD, and may represent a novel marker of HDL dysfunction.

Gastrointestinal bleeding associated with low-dose aspirin use: relevance and management in clinical practice

IMPORTANCE OF THE FIELD

Aspirin reduces the risk of cardiovascular events, but it is well documented that it can also damage the gastrointestinal (GI) tract. However, the reasons why some people develop serious lesions, whereas most only have minor, clinically irrelevant lesions are poorly understood.

AREAS COVERED IN THIS REVIEW

A number of risk factors can be used to determine which patients are more likely to develop aspirin-associated GI bleeding, mainly in the upper GI tract; these include a previous GI ulcer, ulcer complications, dyspepsia, and concomitant drug therapy with non-steroidal anti-inflammatory drugs (NSAIDs) or clopidogrel. The possible role of Helicobacter pylori infection is also considered.

WHAT THE READER WILL GAIN

Aspirin-induced GI damage can be reduced, and a number of strategies can be implemented to shift the risk-benefit ratio in favour of aspirin. Proton pump inhibitors are more effective than H(2)-receptor antagonists in preventing dyspeptic symptoms, peptic ulcers and bleeding ulcers in aspirin users. Although H. pylori infection may be a risk factor of aspirin-induced ulcer bleeding, the role of its eradication in the prevention of this outcome requires further investigation.

TAKE HOME MESSAGE

The individual assessment of the benefits and risks with aspirin, based on the underlying GI and cardiovascular risk factors, is the key to successful therapy. Understanding the effect of aspirin on colorectal cancer can also alter the risk-benefit ratio in at-risk aspirin users.

Corrà U, Piepoli MF, Carré F, Heuschmann P, Hoffmann U, Verschuren M, Halcox J, Giannuzzi P, Saner H, Wood D, Piepoli MF, Corrà U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler ADO, Schmid JP. Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation

Cardiac patients after an acute event and/or with chronic heart disease deserve special attention to restore their quality of life and to maintain or improve functional capacity. They require counselling to avoid recurrence through a combination of adherence to a medication plan and adoption of a healthy lifestyle. These secondary prevention targets are included in the overall goal of cardiac rehabilitation (CR). Cardiac rehabilitation can be viewed as the clinical application of preventive care by means of a professional multi-disciplinary integrated approach for comprehensive risk reduction and global long-term care of cardiac patients. The CR approach is delivered in tandem with a flexible follow-up strategy and easy access to a specialized team. To promote implementation of cardiac prevention and rehabilitation, the CR Section of the EACPR (European Association of Cardiovascular Prevention and Rehabilitation) has recently completed a Position Paper, entitled 'Secondary prevention through cardiac rehabilitation: A condition-oriented approach'. Components of multidisciplinary CR for seven clinical presentations have been addressed. Components include patient assessment, physical activity counselling, exercise training, diet/nutritional counselling, weight control management, lipid management, blood pressure monitoring, smoking cessation, and psychosocial management. Cardiac rehabilitation services are by definition multi-factorial and comprehensive, with physical activity counselling and exercise training as central components in all rehabilitation and preventive interventions. Many of the risk factor improvements occurring in CR can be mediated through exercise training programmes. This call-for-action paper presents the key components of a CR programme: physical activity counselling and exercise training. It summarizes current evidence-based best practice for the wide range of patient presentations of interest to the general cardiology community.

Prognostic value of lead V1 ST elevation during acute inferior myocardial infarction

BACKGROUND

Lead V(1) directly faces the right ventricle and may exhibit ST elevation during an acute inferior myocardial infarction when the right ventricle is also involved. Leads V(1) and V(3) indirectly face the posterolateral left ventricle, and ST depression ("mirror-image" ST elevation) in V(1) through V(3) may reflect concomitant posterolateral infarction. The prognostic significance of V(1) ST elevation during an acute inferior myocardial infarction may therefore be dependent on V(3) ST changes.

METHODS AND RESULTS

In 7967 patients with acute inferior myocardial infarction in the Hirulog and Early Reperfusion or Occlusion-2 (HERO-2) trial, V(1) ST levels were analyzed with adjustment for lead V(3) ST level for predicting 30-day mortality. V(1) ST elevation at baseline, analyzed as a continuous variable, was associated with higher mortality. Unadjusted, each 0.5-mm-step increase in ST level above the isoelectric level was associated with approximately 25% increase in 30-day mortality; this was true whether V(3) ST depression was present or not. The odds ratio for mortality was 1.21 (95% confidence interval, 1.07 to 1.37) after adjustment for inferolateral ST elevation and clinical factors and 1.24 (95% confidence interval, 1.09 to 1.40) if also adjusted for V(3) ST level. In contrast, lead V(1) ST depression was not associated with mortality after adjustment for V(3) ST level. V(1) ST elevation >or=1 mm, analyzed dichotomously in all patients, was associated with higher mortality. The odds ratio was 1.28 (95% confidence interval, 1.01 to 1.61) unadjusted, 1.51 (95% confidence interval, 1.19 to 1.92) adjusted for V(3) ST level, and 1.35 (95% confidence interval, 1.04 to 1.76) adjusted for ECG and clinical factors. Persistence of V(1) ST elevation >or=1 mm 60 minutes after fibrinolysis was associated with higher mortality (10.8% versus 5.5%, P=0.001).

CONCLUSIONS

V(1) ST elevation identifies patients with acute inferior myocardial infarction who are at higher risk.

Shock in acute myocardial infarction: the Cape Horn for trials?

Despite therapeutic improvements, cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial infarction (AMI). In addition to percutaneous coronary intervention, inotropes, fluids, adjunctive medication, intra-aortic balloon counterpulsation, and also assist devices are widely used for treatment. However, currently, there is only limited evidence for any of the above treatments. This review will therefore outline the underlying causes, pathophysiology, and treatment of CS complicating AMI with major focus on interventional techniques and advancement of new therapeutical arsenals, both pharmacological and mechanical.

Primary angioplasty for any patient with ST-elevation myocardial infarction? Guideline-adherent feasibility and impact on mortality in a rural infarction network

AIMS

The aim of this study was to assess the guideline-adherent feasibility of area-wide primary angioplasty in rural German surroundings and its impact on reperfusion and outcome in patients with acute ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

All consecutive patients with acute STEMI (n = 347) admitted to any of the hospitals (5 non invasive and 1 invasive with established 24 h/7 days primary angioplasty service) in a 350.000 inhabitant rural area during the year 2002 (n = 184) and 2005 (n = 163) were included in this registry. In 2002, emergency medical services transferred acute STEMI patients to the nearest emergency room, where reperfusion therapy (fibrinolysis or primary angioplasty) was organised. In 2005, all patients were transferred directly to the cathlab bypassing any emergency room when possible. Primary angioplasty increased from 53 to 89% (p < 0.01), fibrinolysis decreased from 27 to 2% (p < 0.01) and the no revascularisation rate from 21 to 9% (p < 0.01). Onset of pain to balloon time in primary angioplasty was reduced from median 339 to 191 min (p < 0.01), median first medical contact to balloon time in 2005 was 101 min. Overall, 6-month mortality decreased from 19 to 10% (p = 0.03).

CONCLUSIONS

After transition to a uniform primary angioplasty concept, an increase in overall reperfusion rates and a decrease in time delays could be observed in a rural German infarction network.

Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis

AIMS

Multiple trials in patients with ST-segment elevation myocardial infarction (STEMI) compared early routine percutaneous coronary intervention (PCI) after successful fibrinolysis vs. standard therapy limiting PCI only to patients without evidence of reperfusion (rescue PCI). These trials suggest that all patients receiving fibrinolysis should receive mechanical revascularization within 24 h from initial hospitalization. However, individual trials could not demonstrate a significant reduction in 'hard' endpoints such as death and reinfarction. We performed a meta-analysis of randomized controlled trials to define the benefits of early PCI after fibrinolysis over standard therapy on clinical and safety endpoints in STEMI.

METHODS AND RESULTS

We identified seven eligible trials, enrolling a total of 2961 patients. No difference was found in the incidence of death at 30 days between the two strategies. Early PCI after successful fibrinolysis reduced the rate of reinfarction (OR: 0.55, 95% CI: 0.36-0.82; P = 0.003), the combined endpoint death/reinfarction (OR: 0.65, 95% CI: 0.49-0.88; P = 0.004) and recurrent ischaemia (OR: 0.25, 95% CI: 0.13-0.49; P < 0.001) at 30-day follow-up. These advantages were achieved without a significant increase in major bleeding (OR: 0.93, 96% CI: 0.67-1.34; P = 0.70) or stroke (OR: 0.63, 95% CI: 0.31-1.26; P = 0.21). The benefits of a routine invasive strategy over standard therapy were maintained at 6-12 months, with persistent significant reduction in the endpoints reinfarction (OR: 0.64, 95% CI: 0.40-0.98; P = 0.01) and combined death/reinfarction (OR: 0.71, 95% CI: 0.52-0.97; P = 0.03).

CONCLUSION

Early routine PCI after fibrinolysis in STEMI patients significantly reduced reinfarction and recurrent ischaemia at 1 month, with no significant increase in adverse bleeding events compared to standard therapy. Benefits of early PCI persist at 6-12 month follow-up.

Relation between renal function, presentation, use of therapies and in-hospital complications in acute coronary syndrome: data from the SWEDEHEART register

OBJECTIVE

To examine clinical characteristics, presenting symptoms, use of therapy and in-hospital complications in relation to renal function in patients with myocardial infarction (MI).

DESIGN

Observational study.

SETTING

Nationwide coronary care unit registry between 2003-2006 in Sweden.

SUBJECTS

Consecutive MI patients with available creatinine (n = 57,477).

RESULTS

Glomerular filtration rate was estimated with the Modification of Diet in Renal Disease Study formula. With declining renal function patients were older, had more co-morbidities and more often used cardio-protective medication on admission. Compared to patients with normal renal function, fewer with renal failure presented with chest pain (90% vs. 67%, P < 0.001), Killip I (89% vs. 58%, P < 0.001) and ST-elevation myocardial infarction (STEMI) (41% vs. 22%, P < 0.001). In a logistic regression model lower renal function was independently associated with a less frequent use of anticoagulant and revascularization in non-ST-elevation MI. The likelihood of receiving reperfusion therapy for STEMI was similar in patients with normal-to-moderate renal dysfunction, but decreased in severe renal dysfunction or renal failure. Reperfusion therapy shifted from primary percutaneous coronary intervention in 71% of patients with normal renal function to fibrinolysis in 58% of those with renal failure. Renal function was associated with a higher rate of complications and an exponential increase in in-hospital mortality from 2.5% to 24.2% across the renal function groups.

CONCLUSION

Renal insufficiency influences the presentation and reduces the likelihood of receiving treatment according to current guidelines. Short-term prognosis remains poor.

The Strategic Reperfusion Early After Myocardial Infarction (STREAM) study

BACKGROUND

Primary percutaneous coronary intervention (PCI) has emerged as the preferred therapy for acute ST-elevation myocardial infarction (STEMI) provided it is performed in a timely fashion at an expert 24/7 facility. Fibrinolysis is a well-accepted alternative, especially in patients presenting early after symptom onset. The STREAM study will provide novel information on whether prompt fibrinolysis at first medical contact, followed by timely catheterization or rescue coronary intervention in STEMI patients presenting within 3 hours of symptom onset, represents an appropriate alternative strategy to primary PCI.

METHODS

Acute STEMI patients presenting early after symptom onset are eligible if PCI is not feasible within 60 minutes of first medical contact. This is an open-label, prospective, randomized, parallel, comparative, international multicenter trial. Patients are randomized to fibrinolysis combined with enoxaparin, clopidogrel, and aspirin, and cardiac catheterization within 6 to 24 hours or rescue coronary intervention if reperfusion fails within 90 minutes of fibrinolysis versus PCI performed according to local guidelines. Composite efficacy end points at 30 days include death, shock, heart failure, and reinfarction. Safety end points include ischemic stroke, intracranial hemorrhage, and major nonintracranial bleeding. Follow-up is extended to 1 year and includes all-cause mortality.

DISCUSSION

Continuing delays in achieving timely PCI remain a difficult issue. Many patients fail to achieve the desired reperfusion times of 90 to 120 minutes after first medical contact. The STREAM results will provide useful additional data on which to base informed therapeutic decisions.