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Charles RA, Wee SL, Kwok BWK, Tan C, Lim SH, Anantharaman V, Hemanthakumari W, Chua TSJ. Improving Door-to-balloon Times in Primary Percutaneous Coronary Intervention for Acute ST-elevation Myocardial Infarction: The Value of an Audit-driven Quality Initiative. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n7p568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Introduction: The study was designed to reduce door-to-balloon times in primary percutaneous coronary intervention for patients presenting to the Emergency Department with acute STelevation myocardial infarction, using an audit as a quality initiative.
Materials and Methods: A multidisciplinary workgroup performed a pilot study over 3 months, then implemented various process and work-flow strategies to improve overall door-to-balloon times.
Results and Conclusion: We developed a guideline-based, institution-specific written protocol for triaging and managing patients who present to the Emergency Department with symptoms suggestive of STEMI, resulting in shortened median door-to-balloon times from 130.5 to 109.5 minutes (P <0.001).
Key words: Angioplasty, Quality indicators, ST elevation myocardial infarction
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Affiliation(s)
| | | | | | - Caren Tan
- Singapore Health Services Pte Ltd, Singapore
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102
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Song YB, Hahn JY, Gwon HC, Kim JH, Lee SH, Jeong MH. The impact of initial treatment delay using primary angioplasty on mortality among patients with acute myocardial infarction: from the Korea acute myocardial infarction registry. J Korean Med Sci 2008; 23:357-64. [PMID: 18583867 PMCID: PMC2526512 DOI: 10.3346/jkms.2008.23.3.357] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The impact of treatment delays to reperfusion on patient mortality after primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) is controversial. We analyzed 5,069 patients included in the Korea Acute Myocardial Infarction Registry (KAMIR) between November 2005 and January 2007. We selected 1,416 patients who presented within 12 hr of symptom onset and who were treated with primary PCI. The overall mortality at one month was 4.4%. The medians of door-to-balloon time, symptom onset-to-balloon time, and symptom onset-to-door time were 90 (interquartile range, 65-136), 274 (185-442), and 163 min (90-285), respectively. One-month mortality was not increased significantly with any increasing delay in door-to-balloon time (4.3% for < or =90 min, 4.4% for >90 min; p=0.94), symptom onset-to-balloon time (3.9% for < or =240 min, 4.8% for >240 min; p=0.41), and symptom onset-to-door time (3.3% for < or =120 min, 5.0% for >120 min; p=0.13). These time variables had no impact on one-month mortality in any subgroup. Thus, this first nationwide registry data in Korea showed a good result of primary PCI, and the patient prognosis may not depend on the initial treatment delay using the current protocols.
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Affiliation(s)
- Young Bin Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Hyung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hoon Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung-Ho Jeong
- Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, Gwangju, Korea
| | - KAMIR investigators
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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103
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Zanini R, Aroldi M, Bonatti S, Buffoli F, Izzo A, Lettieri C, Romano M, Tomasi L, Ferrari MR. Impact of prehospital diagnosis in the management of ST elevation myocardial infarction in the era of primary percutaneous coronary intervention: reduction of treatment delay and mortality. J Cardiovasc Med (Hagerstown) 2008; 9:570-5. [DOI: 10.2459/jcm.0b013e3282f2c9bd] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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104
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Ratner PA, Johnson JL, Mackay M, Tu AW, Hossain S. Knowledge of “Heart Attack” Symptoms in a Canadian Urban Community. Clin Med Cardiol 2008. [DOI: 10.4137/cmc.s709] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Pamela A. Ratner
- NEXUS and School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joy L. Johnson
- NEXUS and School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Martha Mackay
- School of Nursing, University of British Columbia & Clinical Nurse Specialist, Cardiology, Heart Centre, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Andrew W. Tu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Shahadut Hossain
- Research Satistician, NEXUS, University of British Columbia, Vancouver, British Columbia, Canada
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105
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Persse DE, McCarthy JJ, Vooletich M, Richter BK, Anderson HV, Denktas AE, Sdringola SM, Smalling RW. Prehospital Fibrinolysis in concert with rapid PCI. Clinical trial shows promising results for use of clot-dissolving agents in the field. JEMS : A JOURNAL OF EMERGENCY MEDICAL SERVICES 2008; 33:74-88. [PMID: 18328399 DOI: 10.1016/s0197-2510(08)70085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- David E Persse
- Department of Emergency Medicine, University of Texas Medical School, USA
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106
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Manari A, Tomasi C, Guiducci V, Zanoni P, Pignatelli G, Giacometti P. Time to treatment and ST-segment resolution in high-risk patients with acute myocardial infarction transferred from community hospitals for coronary angioplasty after pharmacological treatment. J Cardiovasc Med (Hagerstown) 2008; 9:32-8. [PMID: 18268416 DOI: 10.2459/01.jcm.0000302257.79467.fe] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the impact of symptom-onset-to-balloon delay on ST-segment resolution (STR) in patients with acute myocardial infarction transferred from community hospitals for angioplasty after pharmacological treatment. The study design was prospective, single centre registry. METHODS Between October 2000 and December 2003, 330 consecutive patients aged < or =75 years with high-risk myocardial infarction were considered; 193 patients underwent primary percutaneous coronary intervention (PCI) (group P), whereas 137 patients were given pharmacological therapy and were immediately transferred to the hospital with PCI facilities (group F). RESULTS Compared with group P, group F showed a longer time to treatment (253 +/- 136 vs. 195 +/- 141 min; P < 0.0001) and a higher percentage of Thrombolysis In Myocardial Infarction flow grade 2-3 at pre-PCI angiography (107 [78.1%] vs. 48 [24.8%]; P < 0.0001). The rate of STR > or =70% was similar in groups P and F (121 [62.7%] vs. 94 [68.6%]; P = 0.41). Even after accounting for baseline variables, STR <70% was not significantly related to the transfer strategy (adjusted hazard ratio 0.94, 95% confidence interval 0.94-1.77; P = 0.8). Patients with incomplete STR showed a higher six-month mortality compared with patients with complete STR (10 [8.85%] vs. 6 [2.76%]; P = 0.027). CONCLUSIONS The STR index predicts survival in patients with ST-elevation myocardial infarction treated with angioplasty either directly or after pharmacological treatment and hospital transfer. Pharmacological facilitation seems to be able to counterbalance the negative consequences of the transfer-related time delay on myocardial reperfusion as evaluated by the STR index.
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Affiliation(s)
- Antonio Manari
- Department of Cardiology, S. Maria Nuova Hospital, Reggio Emilia, Italy.
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107
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Giannitsis E, Baum H, Bertsch T, Juchum M, Müller-Bardorff M, Jørgensen B, Böhmer A, Rebmann M, Schäffler J, Schwab M, Zerback R. Multicentre evaluation of a new point-of-care test for the determination of CK-MB in whole blood. Clin Chem Lab Med 2008; 46:630-8. [DOI: 10.1515/cclm.2008.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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108
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109
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Singer AJ, Shembekar A, Visram F, Schiller J, Russo V, Lawson W, Gomes CA, Santora C, Maliszewski M, Wilbert L, Dowdy E, Viccellio P, Henry MC. Emergency Department Activation of an Interventional Cardiology Team Reduces Door-to-Balloon Times in ST-Segment-Elevation Myocardial Infarction. Ann Emerg Med 2007; 50:538-44. [DOI: 10.1016/j.annemergmed.2007.06.480] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 04/17/2007] [Accepted: 06/04/2007] [Indexed: 01/24/2023]
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110
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Affiliation(s)
- Brahmajee K Nallamothu
- Health Services Research and Development Center of Excellence, Ann Arbor Veterans Affairs Medical Center, and the Department of Internal Medicine, Division of Cardiovascular Disease, University of Michigan Medical School, Ann Arbor, USA
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111
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Pines JM, Localio AR, Hollander JE, Baxt WG, Lee H, Phillips C, Metlay JP. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med 2007; 50:510-6. [PMID: 17913298 DOI: 10.1016/j.annemergmed.2007.07.021] [Citation(s) in RCA: 224] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 07/09/2007] [Accepted: 07/26/2007] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia. METHODS We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics. RESULTS In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%). CONCLUSION ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.
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Affiliation(s)
- Jesse M Pines
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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112
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Pre-Hospital Reduced-Dose Fibrinolysis Coupled With Urgent Percutaneous Coronary Intervention Reduces Time to Reperfusion and Improves Angiographic Perfusion Score Compared With Prehospital Fibrinolysis Alone or Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2007; 50:1612-4. [DOI: 10.1016/j.jacc.2007.07.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 07/02/2007] [Accepted: 07/11/2007] [Indexed: 11/19/2022]
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113
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Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Baldazzi F, Silenzi S, Taglieri N, Bacchi-Reggiani ML, Gordini G, Guastaroba P, Grilli R, Branzi A. Usefulness of prehospital triage in patients with cardiogenic shock complicating ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Am J Cardiol 2007; 100:787-92. [PMID: 17719321 DOI: 10.1016/j.amjcard.2007.03.099] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 03/22/2007] [Accepted: 03/22/2007] [Indexed: 01/15/2023]
Abstract
We investigated the impact of ambulance-based prehospital triage on treatment delay and all-cause mortality (in hospital and long term) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock referred for primary percutaneous coronary intervention in a prospectively collected registry. During the study period (January 2003 to December 2005), a total of 121 patients was referred for primary percutaneous coronary intervention at our intervention laboratory through 2 main triage groups: (1) after prehospital, ambulance-telemedicine-based triage (42 patients) and (2) by more conventional routes (79 patients) represented by the institutional S. Orsola-Malpighi hospital emergency department triage (44 patients) and spoke hospital triage (35 patients). Total ischemic time was shorter in the prehospital triage (142 minutes, range 106 to 187, vs 212 minutes, range 150 to 366, p = 0.003). Patients with prehospital triage showed a lower rate (29% vs 54%, p = 0.01) of severely depressed (</=35%) left ventricular systolic function and a 68% decrease in in-hospital mortality (9, 21%, vs 36, 46%, odds ratio 0.32, 95% confidence interval 0.14 to 0.77, p = 0.01). In the entire study population, patients revascularized within an optimal time (2 hours from symptom onset or 90 minutes from STEMI diagnosis) showed remarkably low in-hospital mortality (20% and 29%, respectively). At the 1-year follow-up, patients with prehospital triage had a higher survival rate (74% vs 52%, p = 0.019). In conclusion, this study indicates that prehospital triage with direct transportation to the intervention laboratory is associated with shorter treatment delay and better clinical outcome in patients with STEMI complicated by cardiogenic shock.
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Affiliation(s)
- Paolo Ortolani
- Institute of Cardiology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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114
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Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, Mensah GA, Morris DL, Pancioli AM, Riegel B, Zerwic JJ. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. J Cardiovasc Nurs 2007; 22:326-43. [PMID: 17589286 DOI: 10.1097/01.jcn.0000278963.28619.4a] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.
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115
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Nallamothu B, Fox KAA, Kennelly BM, Van de Werf F, Gore JM, Steg PG, Granger CB, Dabbous OH, Kline-Rogers E, Eagle KA. Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events. Heart 2007; 93:1552-5. [PMID: 17591643 PMCID: PMC2095752 DOI: 10.1136/hrt.2006.112847] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Treatment delays may result in different clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who receive fibrinolytic therapy vs primary percutaneous coronary intervention (PCI). The aim of this analysis was to examine how treatment delays relate to 6-month mortality in reperfusion-treated patients enrolled in the Global Registry of Acute Coronary Events (GRACE). DESIGN Prospective, observational cohort study. SETTING 106 hospitals in 14 countries. PATIENTS 3959 patients who presented with STEMI within 6 h of symptom onset and received reperfusion with either a fibrin-specific fibrinolytic drug or primary PCI. MAIN OUTCOME MEASURES 6-month mortality. METHODS Multivariable logistic regression was used to assess the relationship between outcomes and treatment delay separately in each cohort, with time modelled with a quadratic term after adjusting for covariates from the GRACE risk score. RESULTS A total of 1786 (45.1%) patients received fibrinolytic therapy, and 2173 (54.9%) underwent primary PCI. After multivariable adjustment, longer treatment delays were associated with a higher 6-month mortality in both fibrinolytic therapy and primary PCI patients (p<0.001 for both cohorts). For patients who received fibrinolytic therapy, 6-month mortality increased by 0.30% per 10-min delay in door-to-needle time between 30 and 60 min compared with 0.18% per 10-min delay in door-to-balloon time between 90 and 150 min for patients undergoing primary PCI. CONCLUSIONS Treatment delays in reperfusion therapy are associated with higher 6-month mortality, but this relationship may be even more critical in patients receiving fibrinolytic therapy.
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Affiliation(s)
- B Nallamothu
- VA Health Services Research & Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, USA
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116
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Brodie BR, Webb J, Cox DA, Qureshi M, Kalynych A, Turco M, Schultheiss HP, Dulas D, Rutherford B, Antoniucci D, Stuckey T, Krucoff M, Gibbons R, Lansky A, Na Y, Mehran R, Stone GW. Impact of time to treatment on myocardial reperfusion and infarct size with primary percutaneous coronary intervention for acute myocardial infarction (from the EMERALD Trial). Am J Cardiol 2007; 99:1680-6. [PMID: 17560875 DOI: 10.1016/j.amjcard.2007.01.047] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Revised: 01/17/2007] [Accepted: 01/17/2007] [Indexed: 11/26/2022]
Abstract
The impact of time to treatment on outcomes after primary percutaneous coronary intervention (PCI) is controversial, and there are few data about time to treatment and infarct size. The EMERALD trial randomly assigned 501 high-risk patients with ST-elevation myocardial infarction undergoing primary PCI to stenting with or without GuardWire (Medtronic, Santa Rosa, California) distal protection. Infarct size using sestamibi imaging at 5 to 14 days and clinical outcomes were examined by time to treatment. There were no differences in outcomes between distal protection and control patients. Shorter time to reperfusion (<2 vs 2 to 3 vs >3 to 4 vs >4 hours) was associated with smaller infarct size (2% vs 9% vs 12% vs 11%, p=0.026), trends for better myocardial blush (p=0.08), and lower 6-month mortality rates (0% vs 0% vs 2.4% vs 5.3%, p=0.06). Incremental delays in reperfusion after 2 hours had little impact on infarct size. Shorter time to reperfusion impacted on infarct size in patients with anterior infarction (0% vs 17% vs 20.5% vs 30.5%, p=0.026), but not nonanterior infarction (3% vs 7% vs 7.5% vs 10%, p=0.23, p=0.022 for interaction). In conclusion, very early reperfusion with primary PCI is associated with smaller infarct size and has a much greater impact in anterior versus nonanterior infarction. Incremental delays in reperfusion after 2 hours have less effect on infarct size. These data have implications regarding the triage of patients for primary PCI.
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Affiliation(s)
- Bruce R Brodie
- LeBauer Cardiovascular Research Foundation and Moses Cone Heart and Vascular Center, Greensboro, North Carolina, USA.
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117
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Holmes DR. Percutaneous Coronary Intervention for Acute Myocardial Infarction. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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118
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Giglioli C, Margheri M, Valente S, Comeglio M, Lazzeri C, Chechi T, Armentano C, Romano SM, Falai M, Gensini GF. Timing, setting and incidence of cardiovascular complications in patients with acute myocardial infarction submitted to primary percutaneous coronary intervention. Can J Cardiol 2006; 22:1047-52. [PMID: 17036099 PMCID: PMC2568965 DOI: 10.1016/s0828-282x(06)70320-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND At the Istituto di Clinica Medica Generale e Cardiologia (Florence, Italy), the widespread use of percutaneous coronary intervention (PCI) has markedly changed the hospital course of patients with acute myocardial infarction (AMI). These patients are typically transferred to the coronary care unit (CCU) only after primary PCI, whereas during the thrombolytic era, patients were first admitted to CCU before reperfusion. OBJECTIVES AND METHODS The incidence, timing and setting of complications from symptom onset to hospital discharge in 689 consecutive AMI patients undergoing PCI were evaluated. RESULTS Ventricular fibrillation occurred in 11% of patients, and most episodes (94.7%) occurred before or during PCI. Of all patients, 6.3% developed complete atrioventricular block (CAVB), and in 86.3% of these cases, the CAVB occurred before or during PCI; in 94.5%, a CAVB resolution occurred in the catheterization laboratory (CL). Thirty-one patients (4.5%) had impending shock on admission to the CL. Cardiogenic shock developed in 2 9 patients (4.2%), mostly in the prehospital phase or in the CL. Only four patients (less than 1%) developed cardiogenic shock later during their hospital course. Similarly, circulatory and ventilatory support, as well as temporary pacing and cardiac defibrillation, were used mostly in the prehospital phase or in the CL. During the CCU stay, 45 patients (6.5%) had hemorrhagic or vascular complications, and the incidence of post-PCI ischemia and early reocclusion of the culprit vessel were low (2.1% and 0.6%, respectively). Thus, cardiac complications usually associated with AMI were observed mainly before hospital admission or in the CL during the reopening of the target vessel. These complications were rarely observed after a successful PCI. CONCLUSIONS For AMI patients, the CL is not only the site of PCI, it is also where most life-threatening cardiac complications are observed and treated.
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Affiliation(s)
- Cristina Giglioli
- Coronary Care Unit, Instituto di Clinica Medica Generale e Cardiologia, Florence, Italy.
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119
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Ueda H, Hayashi T, Tsumura K, Yoshimaru K, Nakayama Y, Yoshikawa J. QT dispersion and left ventricular function after stent placement in acute myocardial infarction. Int J Cardiol 2006; 111:286-91. [PMID: 16309762 DOI: 10.1016/j.ijcard.2005.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2005] [Accepted: 09/18/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND QT dispersion is increased in acute myocardial infarction (AMI), but the relation of QT dispersion to left ventricular (LV) function has not yet been fully elucidated. The purpose of this study was to evaluate the relationship between QT dispersion and LV function in patients with successful coronary stenting in AMI. METHODS Seventy five patients with AMI who underwent percutaneous transluminal coronary angioplasty (PTCA) were enrolled in this study. Corrected QT dispersion was measured before, immediately after, 24 h after, 48 h after, and 6 months after PTCA. Left ventricular ejection fraction (LVEF) was evaluated by left ventriculography at 6 months after PTCA. RESULTS Corrected QT dispersion at 24 h after and 48 h after PTCA were significantly related to LVEF by univariate analysis (r=-0.282, p<0.05 and r=-0.326, p<0.01, respectively). In multiple regression model, corrected QT dispersion at 24 h after and 48 h after PTCA revealed significant associations with LVEF (R(2)=0.441, coefficient=-0.283, p=0.006 and R(2)=0.411, coefficient=-0.225, p=0.039, respectively), but corrected QT dispersion before, immediately after, and 6 months after PTCA were not associated with LVEF. CONCLUSIONS Corrected QT dispersion at 24 h after and 48 h after PTCA in AMI correlate with LVEF at 6 months after PTCA.
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Affiliation(s)
- Hiroyasu Ueda
- Department of Cardiology, Ishikiriseiki Hospital, 18-28, Yayoi, Higashiosaka, Osaka, 579-8026, Japan.
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Cox DA, Stone GW, Grines CL, Stuckey T, Zimetbaum PJ, Tcheng JE, Turco M, Garcia E, Guagliumi G, Iwaoka RS, Mehran R, O'Neill WW, Lansky AJ, Griffin JJ. Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and non-ST-segment elevation acute myocardial infarction (from the CADILLAC trial). Am J Cardiol 2006; 98:331-7. [PMID: 16860018 DOI: 10.1016/j.amjcard.2006.01.102] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 01/31/2006] [Accepted: 01/31/2006] [Indexed: 11/22/2022]
Abstract
We determined the outcomes of patients with acute ST-segment elevation (STE) myocardial infarction (STEMI) and non-STEMI (NSTEMI) after primary percutaneous coronary intervention (PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for > 30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725 (87.8%) and NSTEMI in 239 (12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival (2.4 vs 1.8 hours, p = 0.0002) and increased door-to-balloon time (3.2 vs 1.9 hours, p < 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline (37.3% vs 19.4%, p < 0.0001) and higher ejection fraction (58.7% vs 55.8%, p = 0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality (3.4% vs 4.4%, p = 0.40) but higher rates of major adverse cardiac events (24.0% vs 16.6%, p = 0.007) that was driven by more frequent ischemic target vessel revascularization (21.8% vs 11.9%, p <0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.
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Affiliation(s)
- David A Cox
- Mid Carolina Cardiology, Charlotte, Durham, North Carolina, USA
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121
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Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med 2006; 13:873-8. [PMID: 16766743 DOI: 10.1197/j.aem.2006.03.568] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Antibiotics within four hours of arrival for patients with pneumonia and percutaneous intervention (PCI) within two hours for patients with acute myocardial infarction (AMI) are standard measures of emergency department (ED) quality. OBJECTIVES To assess the institutional-level association between measures of ED crowding and process measures for pneumonia and AMI. METHODS The authors used summary data from 24 academic hospitals in the University Health Consortium. Analysis included the 2004 ED cycle time survey and performance data from January to December 2004 regarding the Joint Commission for Accreditation of Healthcare Organizations' PN-5b (initial antibiotic administration within four hours) for pneumonia and AMI-8a (PCI received within 120 minutes). Spearman correlation coefficients were used to determine associations between crowding and performance measures. RESULTS Across all institutions, 59% (range 43%-77%) of pneumonia patients received antibiotics within four hours, and 57% (range 22%-95%) of AMI patients received PCI within two hours. An increase in overall ED length of stay (-0.44, p = 0.04) and for admitted patients (-0.37, p = 0.08) was associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. An increase in chest x-ray turnaround time (-0.83, p < 0.001) and an increase in the left-without-being-seen rate (-0.51, p = 0.01) were also associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. No measures of crowding exhibited an association with time to PCI for AMI patients. CONCLUSIONS Administrative measures of ED crowding showed an association with poorer performance on pneumonia quality of care measures but not with AMI quality of care measures. Hospitals might consider improving ED throughput, reducing boarding times for admitted patients, and reducing chest x-ray turnaround times to improve pneumonia care.
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Affiliation(s)
- Jesse M Pines
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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122
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Moser DK, Kimble LP, Alberts MJ, Alonzo A, Croft JB, Dracup K, Evenson KR, Go AS, Hand MM, Kothari RU, Mensah GA, Morris DL, Pancioli AM, Riegel B, Zerwic JJ. Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke. Circulation 2006; 114:168-82. [PMID: 16801458 DOI: 10.1161/circulationaha.106.176040] [Citation(s) in RCA: 450] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.
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123
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Kaltoft A, Bøttcher M, Nielsen SS, Hansen HHT, Terkelsen C, Maeng M, Kristensen J, Thuesen L, Krusell LR, Kristensen SD, Andersen HR, Lassen JF, Rasmussen K, Rehling M, Nielsen TT, Bøtker HE. Routine thrombectomy in percutaneous coronary intervention for acute ST-segment-elevation myocardial infarction: a randomized, controlled trial. Circulation 2006; 114:40-7. [PMID: 16801464 DOI: 10.1161/circulationaha.105.595660] [Citation(s) in RCA: 211] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Distal embolization during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction may result in reduced myocardial perfusion, infarct extension, and impaired prognosis. METHODS AND RESULTS In a prospective randomized trial, we studied the effect of routine thrombectomy in 215 patients with ST-segment-elevation myocardial infarction lasting <12 hours undergoing primary PCI. Patients were randomized to thrombectomy pretreatment or standard PCI. The primary end point was myocardial salvage measured by sestamibi SPECT, calculated as the difference between area at risk and final infarct size determined after 30 days (percent). Secondary end points included final infarct size, ST-segment resolution, and troponin T release. Baseline variables, including ST-segment elevation and area at risk, were similar. Salvage was not statistically different in the thrombectomy and control groups (median, 13% [interquartile range, 9% to 21%] and 18% [interquartile range, 7% to 25%]; P=0.12), but 24 patients in the thrombectomy group and 12 patients in the control group did not have an early SPECT scan, mainly because of poor general or cardiac condition (P=0.04). In the thrombectomy group, final infarct size was increased (median, 15%; [interquartile range, 4% to 25%] versus 8% [interquartile range, 2% to 18%]; P=0.004). CONCLUSIONS Thrombectomy performed as routine therapy in primary PCI for ST-elevation myocardial infarction does not increase myocardial salvage. The study suggests a possible deleterious effect of thrombectomy, resulting in an increased final infarct size, and does not support the use of thrombectomy in unselected primary PCI patients.
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Affiliation(s)
- Anne Kaltoft
- Department of Cardiology B, Aarhus University Hospital, Skejby, 8200 Aarhus N, Denmark.
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Pinto DS, Southard M, Ciaglo L, Gibson CM. Door-to-balloon delays with percutaneous coronary intervention in ST-elevation myocardial infarction. Am Heart J 2006; 151:S24-9. [PMID: 16777506 DOI: 10.1016/j.ahj.2006.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The benefits of reperfusion in ST-elevation myocardial infarction are time-dependent no matter if epicardial blood flow is restored with primary percutaneous coronary intervention (PCI) or fibrinolysis. Rapid, sustained, and early restoration of flow in the infarct-related artery is necessary to minimize myocardial damage and to improve clinical outcomes. Though fibrinolytic therapy is widely available, it is limited by unpredictable efficacy, reinfarction, and intracranial hemorrhage. PCI has predictable success in opening the artery but is limited by delays in implementation, particularly in transfer patients. The selection of PCI or fibrinolytic therapy for ST-elevation myocardial infarction should be based on knowledge of the benefits and limitations of each strategy. While PCI is the superior strategy if employed rapidly by competent personnel, fibrinolytic therapy should be considered when significant delays to implementation of PCI are anticipated. Continued efforts, aimed at reducing the time to therapy with PCI and fibrinolysis, are of paramount importance.
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Affiliation(s)
- Duane S Pinto
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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125
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Brodie BR, Stone GW, Cox DA, Stuckey TD, Turco M, Tcheng JE, Berger P, Mehran R, McLaughlin M, Costantini C, Lansky AJ, Grines CL. Impact of treatment delays on outcomes of primary percutaneous coronary intervention for acute myocardial infarction: analysis from the CADILLAC trial. Am Heart J 2006; 151:1231-8. [PMID: 16781224 DOI: 10.1016/j.ahj.2005.07.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2005] [Accepted: 07/14/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. METHODS The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab. RESULTS Earlier reperfusion (<3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality (2.6% vs 4.3% vs 4.8%, P = .046 for <3 vs > or = 3 hours), more frequent grade 2 to 3 myocardial blush (55% vs 53% vs 44%, P = .003), more frequent complete ST-segment resolution (64% vs 68% vs 47%, P = .006), and greater improvement in left ventricular function. Early reperfusion (<3 vs 3-6 vs > or = 3 hours) was associated with lower mortality in high-risk patients (3.8% vs 6.9% vs 7.0%, P = .051 for <3 vs > or = 3 hours) but not in low-risk patients (1.4% vs 0.6% vs 1.0%, P = .63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms (< or = 2 hours, hazard ratio 1.24, P = .013) but not late (>2 hours, heart rate 0.88, P = .33). CONCLUSIONS Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.
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Affiliation(s)
- Bruce R Brodie
- LeBauer Cardiovascular Research Foundation and Moses Cone Heart and Vascular Center, Greensboro, NC, USA.
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Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Serantoni C, Aquilina M, Silenzi S, Baldazzi F, Grosseto D, Taglieri N, Cooke RMT, Bacchi-Reggiani ML, Branzi A. Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarction. Eur Heart J 2006; 27:1550-7. [PMID: 16707549 DOI: 10.1093/eurheartj/ehl006] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS Treatment delay is a powerful predictor of survival in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated effectiveness of pre-hospital diagnosis of STEMI with direct referral to PCI, alongside more conventional referral strategies. METHODS AND RESULTS From January 2003 to December 2004, 658 STEMI patients were referred for primary PCI at our intervention laboratory. Three predefined referral routes were compared: (1) for patients within 90 min drive of the PCI centre, pre-hospital diagnosis and direct transportation (n=166), (2) diagnosis at the interventional hospital emergency department (n=316), (3) diagnosis at local hospitals before transportation (n = 176). Pre-hospital diagnosis was associated with more than 45 min reduction in treatment delay (P = 0.001). No significant difference in in-hospital mortality was apparent in the overall study population. In the cardiogenic shock subgroup (n = 80), pre-hospital diagnosis was associated with a two-thirds reduction in in-hospital mortality (P = 0.019); mortality was only 6.2% in shock patients who underwent PCI in < 2 h. CONCLUSION This study shows that pre-hospital diagnosis can provide a reduction in primary PCI treatment delay, and suggests the hypothesis that this referral strategy might provide survival benefits to patients with cardiogenic shock.
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Affiliation(s)
- Paolo Ortolani
- Institute of Cardiology, Azienda Ospedaliera S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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127
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McNamara RL, Wang Y, Herrin J, Curtis JP, Bradley EH, Magid DJ, Peterson ED, Blaney M, Frederick PD, Krumholz HM. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006; 47:2180-6. [PMID: 16750682 DOI: 10.1016/j.jacc.2005.12.072] [Citation(s) in RCA: 560] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 12/15/2005] [Accepted: 12/19/2005] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We sought to determine the effect of door-to-balloon time on mortality for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). BACKGROUND Studies have found conflicting results regarding this relationship. METHODS We conducted a cohort study of 29,222 STEMI patients treated with PCI within 6 h of presentation at 395 hospitals that participated in the National Registry of Myocardial Infarction (NRMI)-3 and -4 from 1999 to 2002. We used hierarchical models to evaluate the effect of door-to-balloon time on in-hospital mortality adjusted for patient characteristics in the entire cohort and in different subgroups of patients based on symptom onset-to-door time and baseline risk status. RESULTS Longer door-to-balloon time was associated with increased in-hospital mortality (mortality rate of 3.0%, 4.2%, 5.7%, and 7.4% for door-to-balloon times of < or =90 min, 91 to 120 min, 121 to 150 min, and >150 min, respectively; p for trend <0.01). Adjusted for patient characteristics, patients with door-to-balloon time >90 min had increased mortality (odds ratio 1.42; 95% confidence interval [CI] 1.24 to 1.62) compared with those who had door-to-balloon time < or =90 min. In subgroup analyses, increasing mortality with increasing door-to-balloon time was seen regardless of symptom onset-to-door time (< or =1 h, >1 to 2 h, >2 h) and regardless of the presence or absence of high-risk factors. CONCLUSIONS Time to primary PCI is strongly associated with mortality risk and is important regardless of time from symptom onset to presentation and regardless of baseline risk of mortality. Efforts to shorten door-to-balloon time should apply to all patients.
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Affiliation(s)
- Robert L McNamara
- Department of Medicine, Section of Cardiovascular Medicine, Seattle, Washington, USA
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128
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Vaught C, Young DR, Bell SJ, Maynard C, Gentry M, Jacubowitz S, Leibrandt PN, Munsey D, Savona MR, Wall TC, Wagner GS. The failure of years of experience with electrocardiographic transmission from paramedics to the hospital emergency department to reduce the delay from door to primary coronary intervention below the 90-minute threshold during acute myocardial infarction. J Electrocardiol 2006; 39:136-41. [PMID: 16580408 DOI: 10.1016/j.jelectrocard.2005.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2004] [Accepted: 12/12/2005] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Emergency medical services (EMS), hospital emergency departments, and cardiologists have taken steps to reduce time to reperfusion therapy by implementation of aggressive acute myocardial infarction treatment and triage protocols. Data indicate that significant myocardial salvage requires reperfusion within 2 hours, and the current American College of Cardiology guideline is 90 minutes after hospital emergency department admission. MATERIALS AND METHODS To minimize delays in time to reperfusion in an urban-rural North Carolina County, Guilford County EMS and the Moses Cone Hospital have collaborated to implement transmission of EMS electrocardiographs (ECGs) to the emergency department. The study population included 92 patients who were transported by EMS and received primary coronary intervention during the second, third, and fourth years after initiation of this intervention in 1993. RESULTS The median time from symptom onset to the initial ECG was 77 minutes. There was an additional 23 minutes between the availability of this ECG and the arrival of the patient at the emergency department. In the first year of the intervention, the time from hospital arrival to percutaneous coronary intervention was 80 minutes. In years 2 through 4, they were 93, 85, and 94 minutes, respectively. In 2003, 10 years after the intervention, the time from hospital arrival to percutaneous coronary intervention was 113 minutes. CONCLUSION Initial gains in the time from hospital arrival to percutaneous coronary intervention, attributed to acquisition of the ECG in the prehospital setting, were not sustained over 10 years.
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Affiliation(s)
- Creighton Vaught
- Department of medicine, Duke University Medical Center, Durham, NC 27705, USA
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Abstract
The last decade has seen extraordinary advances in the cardiovascular arena, particularly in the evaluation and management of the patient who has acute coronary syndromes. From bedside markers of myocardial damage to drug-eluting stents, technical advances are proliferating. Efforts in developing an international registry for acute aortic dissection have helped elucidate the acute presentation, management, and prognosis of this uncommon but lethal disease. Finally, the multiple research efforts in coordinating clinical decision-making with serologic markers and advanced imaging for the diagnosis of pulmonary embolism is changing the approach to the patient at risk for thromboembolic disease.
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Affiliation(s)
- Luis H Haro
- Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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130
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Abstract
Improvements in the management of ST-segment elevation myocardial infarction(STEMI) have led to a reduction in the acute and long-term mortality rates. The first important decision in the care of patients who have STEMI is the method of reperfusion. Whether percutaneous intervention (PCI) or fibrinolytic therapy is chosen depends on a number of factors. This article reviews the data on PCI and fibrinolytics in the context of consensus guidelines, outlines adjunctive medical therapies important in the first 24 hours, and discusses a strategy for making the decisions and a hypothetical construct for evaluating new drugs and procedures in the future.
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Affiliation(s)
- Amish C Sura
- Division of Cardiology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21202, USA
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131
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Sekulic M, Hassunizadeh B, McGraw S, David S. Feasibility of early emergency room notification to improve door-to-balloon times for patients with acute ST segment elevation myocardial infarction. Catheter Cardiovasc Interv 2006; 66:316-9. [PMID: 16224783 DOI: 10.1002/ccd.20505] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
An algorithm to lower time from first contact in the field by EMS personnel to in-hospital mechanical reperfusion is described. ECG tracings were telemetered via cellular phone to an emergency room physician, who then activated the cardiac catheterization call team to bypass usual delays seen during ER triage. Seventy-one ECGs were sent to the ER in the time interval from October 2003 to October 2004. Five ECGs (7.0%) failed to transmit due to failure of the cellular phone to receive an adequate signal. Sixty-six patients (93.0%) had an adequate ECG transmitted to the ER and six patients with ST elevation myocardial infarction were identified. Door-to-balloon times were lowered to 44 +/- 17.4 min, a substantial decrease over historical norms that range from 120 min (25th percentile) to 289 min (75th percentile).
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Affiliation(s)
- Milan Sekulic
- Providence Heart Institute, Southfield, Michigan 48075, USA
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132
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Ince H, Petzsch M, Kleine HD, Eckard H, Rehders T, Burska D, Kische S, Freund M, Nienaber CA. Prevention of left ventricular remodeling with granulocyte colony-stimulating factor after acute myocardial infarction: final 1-year results of the Front-Integrated Revascularization and Stem Cell Liberation in Evolving Acute Myocardial Infarction by Granulocyte Colony-Stimulating Factor (FIRSTLINE-AMI) Trial. Circulation 2006; 112:I73-80. [PMID: 16159869 DOI: 10.1161/circulationaha.104.524827] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Experimental and clinical evidence has recently shown that pluripotent stem cells can be mobilized by granulocyte colony-stimulating factor (G-CSF) and may enhance myocardial regeneration early after primary percutaneous coronary intervention (PCI) management of acute myocardial infarction. Sustained or long-term effects of mobilized CD34-positive mononuclear stem cells, however, are unknown. METHODS AND RESULTS Thirty consecutive patients with ST-elevation myocardial infarction undergoing primary PCI with stenting and abciximab were selected for the study 85+/-30 minutes after PCI; 15 patients were randomly assigned to receive subcutaneous G-CSF at 10 microg/kg body weight for 6 days in addition to standard care including aspirin, clopidogrel, an angiotensin-converting enzyme inhibitor, beta-blocking agents, and statins. In patients with comparable demographics and clinical and infarct-related characteristics, G-CSF stimulation led to sustained mobilization of CD34 positive mononuclear cells (MNC(CD34+)), with a 20-fold increase (from 3+/-2 at baseline to 66+/-54 MNC(CD34+)/microL on day 6; P<0.001); there was no evidence of leukocytoclastic effects, accelerated restenosis rate, or any late adverse events. Within 4 months, G-CSF-induced MNC(CD34+) mobilization led to enhanced resting wall thickening in the infarct zone of 1.16+/-0.29 mm (P<0.05 versus control), which was sustained at 1.20+/-0.28 after 12 months (P<0.001 versus control). Similarly, left ventricular ejection fraction improved from 48+/-4% at baseline to 54+/-8% at 4 months (P<0.005 versus control) and 56+/-9% at 12 months (P<0.003 versus control and paralleled by sustained improvement of wall-motion score index from 1.70+/-0.22 to 1.42+/-0.26 and 1.33+/-0.21 at 4 and 12 months, respectively), after G-CSF (P<0.05 versus baseline and P<0.03 versus controls). Accordingly, left ventricular end-diastolic diameter showed no remodeling and stable left ventricular dimensions after G-CSF stimulation, whereas left ventricular end-diastolic diameter in controls revealed enlargement from 55+/-4 mm at baseline to 58+/-4 mm (P<0.05 versus baseline) at 12 months after infarction and no improvement in diastolic function. CONCLUSIONS Mobilization of MNC(CD34+) by G-CSF after primary PCI may offer a pragmatic strategy for improvement in ventricular function and prevention of left ventricular remodeling 1 year after acute myocardial infarction.
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Affiliation(s)
- Hüseyin Ince
- Division of Cardiology, Department of Medicine, University Hospital Rostock, Rostock School of Medicine, Rostock, Germany
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133
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Affiliation(s)
- B R Brodie
- Moses Cone Heart and Vascular Center, 313, Moses Cone Hospital, North Elm Street, Greensboro, NC 27408, USA.
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Rizik DG, Klassen KJ, Dowler DA, Villegas BJ, Dixon SR. Promising though not yet proven: Emerging strategies to promote myocardial salvage. Catheter Cardiovasc Interv 2006; 68:596-606. [PMID: 16969843 DOI: 10.1002/ccd.20892] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Remarkable advances in our ability to achieve early and sustained culprit vessel patency in acute myocardial infarction have been satisfying, but our enthusiasm must be tempered by the knowledge that the overall treatment strategy often leaves an inadequate long term clinical result. Early success of percutaneous therapy as judged at angiography does not ensure recovery of normal left ventricular function, the most important determinant of survival in acute myocardial infarction. That congestive heart failure and death still complicate apparently successful percutaneous procedures underscores the need to develop novel therapies which salvage jeopardized myocardium, limit infarct size and preserve left ventricular function. An ever-increasing body of data demonstrates a multifactorial mechanism of myocyte injury and microvascular collapse and also demonstrates that these injuries seem to have a profound impact on long-term outcomes. Given these findings, microvascular protection during the acute event has become the focus of a variety of emerging technologies. The goal of these mechanical and pharmacologic therapies is the restoration of normal metabolic function at the myocyte level. The acute pathologic mechanisms which contribute to sustained left ventricular dysfunction despite angiographically successful revascularization will be reviewed as will be several strategies being developed to counter these pathologic mechanisms.
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Affiliation(s)
- David G Rizik
- Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, Arizona 85258, USA.
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136
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Ince H, Petzsch M, Kleine HD, Schmidt H, Rehders T, Körber T, Schümichen C, Freund M, Nienaber CA. Preservation from left ventricular remodeling by front-integrated revascularization and stem cell liberation in evolving acute myocardial infarction by use of granulocyte-colony-stimulating factor (FIRSTLINE-AMI). Circulation 2005; 112:3097-106. [PMID: 16275869 DOI: 10.1161/circulationaha.105.541433] [Citation(s) in RCA: 227] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Considering experimental evidence that stem cells enhance myocardial regeneration and granulocyte colony-stimulating factor (G-CSF) mediates mobilization of CD34+ mononuclear blood stem cells (MNCCD34+), we tested the impact of G-CSF integrated into primary percutaneous coronary intervention (PCI) management of acute myocardial infarction in man. METHODS AND RESULTS Fifty consecutive patients with ST-segment elevation myocardial infarction were subjected to primary PCI stenting with abciximab and followed up for 6 months; 89+/-35 minutes after successful PCI, 25 patients were randomly assigned in this pilot study (PROBE design) to receive subcutaneous G-CSF at 10 microg/kg body weight for 6 days in addition to standard care, including aspirin, clopidogrel, an ACE inhibitor, beta-blocking agents, and statins. By use of CellQuest software on peripheral blood samples incubated with CD45 and CD34, mobilized MNCCD34+ were quantified on a daily basis. With homogeneous demographics and clinical and infarct-related characteristics, G-CSF stimulation led to mobilization of MNCCD34+ to between 3.17+/-2.93 MNCCD34+/microL at baseline and 64.55+/-37.11 MNCCD34+/microL on day 6 (P<0.001 versus control); there was no indication of leukocytoclastic effects, significant pain, impaired rheology, inflammatory reactions, or accelerated restenosis at 6 months. Within 35 days, G-CSF and MNCCD34+ liberation led to enhanced resting wall thickening in the infarct zone of between 0.29+/-0.22 and 0.99+/-0.32 mm versus 0.49+/-0.29 mm in control subjects (P<0.001); under inotropic challenge with dobutamine (10 microg.kg(-1).min(-1)), wall motion score index showed improvement from 1.66+/-0.23 to 1.41+/-0.21 (P<0.004 versus control) and to 1.35+/-0.24 after 4 months (P<0.001 versus control), respectively, coupled with sustained recovery of wall thickening to 1.24+/-0.31 mm (P<0.001 versus control) at 4 months. Accordingly, resting wall motion score index improved with G-CSF to 1.41+/-0.25 (P<0.001 versus control), left ventricular end-diastolic diameter to 55+/-5 mm (P<0.002 versus control), and ejection fraction to 54+/-8% (P<0.001 versus control) after 4 months. Morphological and functional improvement with G-CSF was corroborated by enhanced metabolic activity and 18F-deoxyglucose uptake in the infarct zone (P<0.001 versus control). CONCLUSIONS G-CSF and mobilization of MNC(CD34+) after reperfusion of infarcted myocardium may offer a pragmatic strategy for preservation of myocardium and prevention of remodeling without evidence of aggravated restenosis.
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Affiliation(s)
- Hüseyin Ince
- Department of Internal Medicine, University Hospital Rostock, School of Medicine, Rostock, Germany
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137
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Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Mitsuba N, Hata T, Nakama Y, Kisaka T, Kijima Y. Spontaneous anterograde flow of the infarct artery preserves myocardial perfusion and fatty acid metabolism in patients with anterior acute myocardial infarction. Circ J 2005; 69:427-31. [PMID: 15791037 DOI: 10.1253/circj.69.427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND It remains unclear whether spontaneous anterograde flow preserves myocardial fatty acid metabolism in patients with acute myocardial infarction (AMI). METHODS AND RESULTS The present study comprised 129 patients with a first anterior AMI in whom Thrombolysis in Myocardial Infarction (TIMI) 3 flow was obtained on the final angiogram: 28 patients with spontaneous anterograde flow and 101 patients with total occlusion on the initial angiogram. Thallium-201 (201Tl) and iodine-123-beta-methyl-p-iodophenyl penta-decanoic acid (123I-BMIPP) dual-isotope myocardial single-photon emission computed tomography (SPECT) was performed at 6.5+/-4.2 days after onset. The SPECT image was divided into 17 segments, and each segment was graded with scores between 0 and 4 (0, normal uptake; 4, defective). The sum of each score was defined as the total defect score (TDS). TDS values for 201Tl (9.0 +/-7.4 vs 16.8+/-12.2, p < 0.01) and 123I-BMIPP (19.3+/-11.6 vs 24.1 +/-10.4, p < 0.05) were significantly lower in patients with spontaneous anterograde flow than in those with total occlusion. CONCLUSIONS These results suggest that spontaneous anterograde flow of the infarct artery preserves not only myocardial perfusion but also fatty acid metabolism in patients with AMI. 123I-BMIPP SPECT image may underestimate the area at risk especially in patients with spontaneous anterograde flow.
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Affiliation(s)
- Satoshi Kurisu
- Department of Cardiology, Hiroshima City Hospital, Hiroshima 730-8518, Japan.
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138
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Clemmensen P, Sejersten M, Sillesen M, Hampton D, Wagner GS, Loumann-Nielsen S. Diversion of ST-elevation myocardial infarction patients for primary angioplasty based on wireless prehospital 12-lead electrocardiographic transmission directly to the cardiologist's handheld computer: a progress report. J Electrocardiol 2005; 38:194-8. [PMID: 16226101 DOI: 10.1016/j.jelectrocard.2005.06.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Time to reperfusion is critical for outcome in patients with ST-elevation myocardial infarction (STEMI). In our region, patients are routinely treated by primary percutaneous coronary intervention (pPCI), but rerouting patients from the primary receiving hospital to a catheterization center can cause unacceptable delays that may exceed 1 hour in the emergency department. Wireless transmission of prehospital electrocardiograms (ECGs) to receiving stations in hospitals has been shown to reduce time from symptom onset to reperfusion. However, transmission directly to a cardiologist's handheld digital device has not been investigated. AIM To report preliminary data from a larger ongoing trial evaluating prehospital 12-lead ECG transmission to a cardiologist's handheld device in patients with symptoms suggesting an acute coronary syndrome. METHOD Patients suffering acute, nontraumatic chest pain have their prehospital ECG transmitted by wireless technology directly to a cardiologist's handheld device at an invasive hospital, allowing diversion of STEMI cases to rapid pPCI. Transmission failures are documented. Times for symptom onset, 911 alert, ECG recording, hospital arrival, and pPCI are obtained. All time intervals are summarized as median values and are compared with historic controls from the Danish multicenter study, DANAMI-2. RESULTS During the first 15 months of the trial, prehospital ECGs were transmitted for 408 chest pain patients with an overall success rate of 93%. Cardiologist receiving the ECGs recommended that 113 patients (28%) be diverted for pPCI. Mean time from symptom onset to 911 alert was 2 hours 16 minutes (range, 1 minute to 23 hours 15 minutes), and the ambulance response interval was 5 minutes (range, 1-25 minutes). The ambulance on-scene time had increased by 7 minutes compared with historic controls (P<.05). Time from ECG recording to hospital arrival was 25 minutes. The total prehospital time was 2 hours 57 minutes. The hospital treatment time was substantially reduced among diverted patients. Hospital arrival to procedure start was 40 minutes, compared with 94 minutes in the DANAMI-2 historic control group (P<.01). CONCLUSION These preliminary data suggest that transmission of prehospital 12-lead ECGs directly to the attending cardiologist using handheld devices is a technologically sound concept without major safety concerns and markedly reducing time to reperfusion in patients with STEMI.
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Affiliation(s)
- Peter Clemmensen
- Department of Cardiology B, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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139
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Young D, Barbagelata A, Wagner G. Have we made progress in reducing time to reperfusion in the management of acute myocardial infarction? A last decade overview. J Electrocardiol 2005; 38:94-5. [PMID: 16226081 DOI: 10.1016/j.jelectrocard.2005.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 11/21/2022]
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140
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Nagashima M, Itoh A, Otsuka M, Kasanuki H, Haze K. Reperfusion phenomenon is a strong predictor of left ventricular remodeling after acute myocardial infarction. Circ J 2005; 69:884-9. [PMID: 16041154 DOI: 10.1253/circj.69.884] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many clinicians have seen the reperfusion phenomenon, a paradoxical response that includes a transient increase of chest pain, additional ST-segment elevation or ventricular arrhythmias immediately after coronary reperfusion, in patients with acute myocardial infarction (AMI). The aim of the present study was to investigate the impact of this phenomenon during coronary reperfusion on left ventricular (LV) remodeling in patients with AMI. METHODS AND RESULTS One hundred and thirty-eight consecutive patients with a first anterior-wall AMI, undergoing coronary reperfusion treatment within 24 h of onset were prospectively evaluated for reperfusion phenomenon and followed up with scheduled evaluations of LV function and morphology with left ventriculography for 1 year. Of the 138 enrolled patients, 77 underwent serial left ventriculography at the acute, subacute and 1-year phases. Of these 77 patients, 39 demonstrated the reperfusion phenomenon. The LV end-diastolic volume index significantly increased from the acute to subacute phase and to the 1-year phase, but was unchanged in the 38 patients without reperfusion phenomenon. In multivariate analysis, reperfusion phenomenon was the only determinant of LV dilatation after AMI. CONCLUSIONS Reperfusion phenomenon was a strong predictor of LV remodeling after reperfusion therapy for AMI.
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Affiliation(s)
- Michitaka Nagashima
- Department of Cardiology, the Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan.
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141
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McGinn AP, Rosamond WD, Goff DC, Taylor HA, Miles JS, Chambless L. Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987-2000. Am Heart J 2005; 150:392-400. [PMID: 16169313 DOI: 10.1016/j.ahj.2005.03.064] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2004] [Accepted: 03/15/2005] [Indexed: 01/14/2023]
Abstract
BACKGROUND Prolonged delay in seeking care for acute myocardial infarction (AMI) is associated with decreased use of time-dependent treatments and increased mortality and morbidity. METHODS Time from symptom onset to arrival at hospital and emergency medical service use were abstracted from medical records of 18,928 patients hospitalized for AMI and captured in the community surveillance component of the ARIC study from 1987 to 2000. A cut point of 4 hours was used to assess clinically relevant delay time recommendations for treatment with current therapies. RESULTS In 2000, the overall proportion of persons with delays from symptom onset to hospital arrival of > or = 4 hours was 49.5%. Blacks and women consistently delayed longer than whites and men. Between 1987 and 2000, there was no statistically significant change in the proportion of patients delaying > or = 4 hours (relative change +0.6% in men, -7.4% in women, -2.3% in whites, -8.9% in blacks, -7.9% in persons with diabetes, and -0.8% in persons without diabetes); however, there is a noticeable narrowing of gaps between sex, race, and diabetes status over the study period. The percentage of those who used emergency medical services increased significantly over the study period (1987 37.1%, 2000 44.5%, P < or = .0001). CONCLUSIONS Many patients continue to experience prolonged delays from onset of symptoms to hospital arrival. Delay time for hospitalized AMI changed little in the ARIC communities from 1987 to 2000. New public health strategies should be developed to facilitate rapid access to acute care for AMI.
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Affiliation(s)
- Aileen P McGinn
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC 27514, USA
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142
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Steg PG, Juliard JM. Primary percutaneous coronary intervention in acute myocardial infarction: time, time, and time! Heart 2005; 91:993-4. [PMID: 16020578 PMCID: PMC1769058 DOI: 10.1136/hrt.2004.050625] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Longer door-to-balloon times, total duration of ischaemia, and time of presentation relative to symptom onset all have an impact on outcome following primary percutaneous coronary intervention.
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143
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Zahn R, Vogt A, Zeymer U, Gitt AK, Seidl K, Gottwik M, Weber MA, Niederer W, Mödl B, Engel HJ, Tebbe U, Senges J. In-hospital time to treatment of patients with acute ST elevation myocardial infarction treated with primary angioplasty: determinants and outcome. Results from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte. Heart 2005; 91:1041-6. [PMID: 16020592 PMCID: PMC1769038 DOI: 10.1136/hrt.2004.045336] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice. DESIGN Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK). PATIENTS Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed. RESULTS Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography" time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% > or = 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for > or = 20/year, p = 0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p = 0.397). CONCLUSIONS In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.
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Affiliation(s)
- R Zahn
- Herzzentrum, Kardiologie, Ludwigshafen, Germany.
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144
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Möckel M, Bocksch W, Strohm S, Kühnle Y, Vollert J, Nibbe L, Dietz R. Facilitated percutaneous coronary intervention (PCI) in patients with acute ST-elevation myocardial infarction: Comparison of prehospital tirofiban versus fibrinolysis before direct PCI. Int J Cardiol 2005; 103:193-200. [PMID: 16080980 DOI: 10.1016/j.ijcard.2004.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2004] [Revised: 08/11/2004] [Accepted: 10/04/2004] [Indexed: 11/21/2022]
Abstract
AIMS Early start of treatment including coronary revascularization has been recognized as crucial variable in the outcome of acute ST-segment elevation myocardial infarction (STEMI). The lack of availability and the realisation that an optimum reperfusion strategy will need to incorporate mechanical reperfusion as part of that strategy has led to a great deal of interest in pharmacologic reperfusion combined with mechanical reperfusion or facilitated PCI. It is not clear whether GPIIb/IIIa-blockade or fibrinolysis better facilitates PCI. METHODS We identified 138 patients who have been primarily treated by our mobile emergency care mobile from July 2001 until February 2003 with tirofiban or fibrinolysis. Seventy-nine patients had ST-elevation myocardial infarction (STEMI) and available angiograms within 24 h. RESULTS Forty-four patients had tirofiban (TIRO; 60.6 S.D. 11.4 years, 64% male) and 35 patients underwent fibrinolysis (FIB; 31.4% tenecteplase, 54.3% reteplase, 11.4% alteplase, 2.9% streptokinase; 58.8 S.D. 12.2 years, 80% male). Data were analyzed with respect to TIMI-flow and corrected frame count (cTFC) before and after PCI, bleeding complications at 30 days and long-term follow up for major adverse events (median 288 days; MACE: Death, hospitalized re-infarction, intracranial hemorrhage). Catheter films were re-analyzed by an investigator blinded to the prehospital therapy. Time from onset of symptoms to first medical contact was 1.98 h in TIRO compared to 0.5 h in FIB (p<0.001) and time from first prehospital medical contact to catheter was 1.46 h in the TIRO compared to 2.85 h in the FIB group (p<0.001). TIMI 3-flow before PCI was observed in 20.5% of TIRO and 62.9% in FIB (p<0.001). After PCI TIMI 3-flow was achieved in 90.5% and 90.0%, respectively (p=n.s.). Final cTFC was 24 in TIRO and 29 in FIB (p=n.s.). Visible thrombi were detected in 30.2% in TIRO and 23.5% in FIB (p=n.s.). Major bleeding occurred in one TIRO patient (fatal lung bleeding after ultima ratio abciximab on top of tirofiban), 2 patients (4.5%) received transfusions. In FIB 2 intracerebral hemorrhages, 5 transfusions (14.3%) and 3 pulmonary bleedings during mandatory ventilation were observed. After 30 days 4.5% in TIRO and 22.9% in FIB had MACE (p=0.015). During long-term follow up the primary endpoint was observed in 4.5% of TIRO and 28.6% (p=0.003) of FIB. Two patients died in TIRO and 9 patients in FIB. CONCLUSIONS We conclude that (1) prehospital start of tirofiban for facilitated PCI is safe and effective if administered by experienced emergency physicians; (2) routine fibrinolysis should be limited to areas where catheter based therapy is not available within 90 min and (3) fibrinolysis should be given for facilitated PCI in randomized trials only at the moment.
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Affiliation(s)
- Martin Möckel
- Department of Cardiology, Charité-University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
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145
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García E. Intervencionismo en el contexto del infarto de miocardio. Conceptos actuales. Rev Esp Cardiol 2005. [DOI: 10.1157/13074847] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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146
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Roncalli J, Galinier M, Fourcade J, Carrié D, Puel J, Fauvel JM. [Long-term follow-up after primary angioplasty: is stenting beneficial?]. Ann Cardiol Angeiol (Paris) 2005; 54:80-5. [PMID: 15828462 DOI: 10.1016/j.ancard.2004.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI). OBJECTIVES The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction. METHODS We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR). RESULTS The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different. CONCLUSION In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.
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Affiliation(s)
- J Roncalli
- Service de cardiologie A, département de cardiologie, fédération des services de cardiologie, CHU de Rangueil, 1, avenue Jean-Poulhès, 31403 Toulouse, France.
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147
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Lansky AJ, Pietras C, Costa RA, Tsuchiya Y, Brodie BR, Cox DA, Aymong ED, Stuckey TD, Garcia E, Tcheng JE, Mehran R, Negoita M, Fahy M, Cristea E, Turco M, Leon MB, Grines CL, Stone GW. Gender Differences in Outcomes After Primary Angioplasty Versus Primary Stenting With and Without Abciximab for Acute Myocardial Infarction. Circulation 2005; 111:1611-8. [PMID: 15811868 DOI: 10.1161/01.cir.0000160362.55803.40] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women with acute myocardial infarction (AMI) undergoing primary angioplasty have higher rates of morbidity and mortality than do men. Whether contemporary interventional treatment strategies have improved outcomes for women compared with men is unknown. METHODS AND RESULTS In the CADILLAC trial, 2082 patients (27% women) with AMI within 12 hours of symptom onset were randomized to balloon angioplasty (PTCA; n=518), PTCA+abciximab (n=528), stenting (n=512), and stenting+abciximab (n=524). As compared with men, women had a lower body surface area; had a greater prevalence of diabetes, hypertension, and hyperlipidemia; experienced significant delays to treatment; and had better baseline and final TIMI grade 3 flows. Unadjusted 1-year event rates were higher for women, including death (7.6% versus 3.0%, P<0.001), ischemic target-vessel revascularization (TVR; 16.7% versus 12.1%, P=0.006), and major adverse cardiac events (MACE; 23.9% versus 15.3%, P<0.001). Female gender was an independent predictor of MACE and bleeding complications, although comorbid risk factors and body surface area but not gender predicted 1-year death. For women, primary stenting resulted in a reduction in 1-year MACE from 28.1% to 19.1% (P=0.01) and in ischemic TVR from 20.4% to 10.8% (P=0.002) compared with PTCA. The addition of abciximab to primary stenting significantly reduced the 30-day ischemic TVR without increasing bleeding or stroke rates. CONCLUSIONS The higher mortality rate in women compared with men after interventional treatment for AMI may be explained by differences in body size and clinical risk factors, although female gender remains an important independent determinant of overall adverse outcomes. For women in the CADILLAC trial, the addition of abciximab reduced 30-day TVR without increasing bleeding risk, and primary stenting reduced 1-year TVR and MACE rates compared with PTCA.
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Affiliation(s)
- Alexandra J Lansky
- College of Physicians and Surgeons, Columbia University, and the Cardiovascular Research Foundation, New York, NY 10022, USA.
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148
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Abstract
Thrombolytic therapy is an essential tool in the array of therapies designed to reopen arteries and veins occluded with thrombus. As the use of thrombolytic agents has entered mainstream practice, their application has expanded to include a wide variety of indications and settings. Thrombolytic agents are used in patients who have thrombosis of coronary arteries, precerebral and cerebral arteries, the aorta, iliac and mesenteric arteries, and peripheral arteries. The use of thrombolysis in venous thrombosis has included deep venous thrombosis of the upper and lower extremities and vena cava, mesenteric veins, cerebral veins, and central access catheters. Guidelines are available from the American College of Cardiology/American Heart Association regarding thrombolysis in myocardial infarction and from the American Stroke Association regarding thrombolysis in acute ischemic stroke.
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Affiliation(s)
- William F Baker
- Center for Health Sciences, University of California-Los Angeles, Los Angeles, CA, USA.
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149
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Abstract
Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.
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Affiliation(s)
- Flavio Ribichini
- Division of Cardiology Universita del Piemonte Orientale, Ospedale Maggiore della Carita, Novara, Italy
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150
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Kosuge M, Kimura K, Ishikawa T, Shimizi T, Hibi K, Toda N, Tahara Y, Kanna M, Tsukahara K, Okuda J, Nozawa N, Umemura S. Persistent Hyperglycemia is Associated With Left Ventricular Dysfunction in Patients With Acute Myocardial Infarction. Circ J 2005; 69:23-8. [PMID: 15635197 DOI: 10.1253/circj.69.23] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The relationship of changes in blood glucose concentrations after admission to left ventricular (LV) dysfunction in patients with recanalized anterior acute myocardial infarction (AMI) remains unclear. METHODS AND RESULTS Blood glucose concentrations were measured on admission and 24 h after symptom onset in 210 patients with recanalized anterior AMI within 6 h of symptom onset. Of them, 142 had hyperglycemia on admission, defined as a blood glucose >or=8.9 mmol/L, and 68 patients did not. Among the patients with admission hyperglycemia, 49 had persistent hyperglycemia, defined as a blood glucose >or=8.9 mmol/L 24 h after onset, and 93 did not. The incidences of myocardial blush grade of 0/1 after recanalization indicating impaired myocardial perfusion (71%), and peak creatine kinase concentration (5,631+/-2,855 mU/ml) were higher and predischarge LV function (43+/-11%) was lower in patients with persistent hyperglycemia than in those without (p<0.01). Multivariate analysis showed that persistent hyperglycemia was independently associated with LV dysfunction, defined as a predischarge LV ejection fraction <or=40% (odds ratio 7.38, p=0.001). CONCLUSIONS Persistent hyperglycemia at 24 h after symptom onset is associated with LV dysfunction before discharge in patients with recanalized anterior AMI.
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Affiliation(s)
- Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
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