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Bates ER. Achieving Aspirational Goals in Providing Primary Percutaneous Coronary Intervention Care. JACC Cardiovasc Interv 2019; 12:2269-2271. [PMID: 31678082 DOI: 10.1016/j.jcin.2019.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
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202
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Rios-Navarro C, Marcos-Garces V, Bayes-Genis A, Husser O, Nuñez J, Bodi V. Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction: Looking Back to Move Forward. Focus on CMR. J Clin Med 2019; 8:E1805. [PMID: 31661823 PMCID: PMC6912395 DOI: 10.3390/jcm8111805] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 12/14/2022] Open
Abstract
After a myocardial infarction (MI), despite the resolution of the coronary occlusion, the deterioration of myocardial perfusion persists in a considerable number of patients. This phenomenon is known as microvascular obstruction (MVO). Initially, the focus was placed on re-establishing blood flow in the epicardial artery. Then, the observation that MVO has profound negative structural and prognostic repercussions revived interest in microcirculation. In the near future, the availability of co-adjuvant therapies (beyond timely coronary reperfusion) aimed at preventing, minimizing, and repairing MVOs and finding convincing answers to questions regarding what, when, how, and where to administer these therapies will be of utmost importance. The objective of this work is to review the state-of-the-art concepts on pathophysiology, diagnostic methods, and structural and clinical implications of MVOs in patients with ST-segment elevation MIs. Based on this knowledge we discuss previously-tested and future opportunities for the prevention and repair of MVO.
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Affiliation(s)
| | | | - Antoni Bayes-Genis
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), 28029 Madrid, Spain.
- Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol (Badalona) and Department of Medicine Universitat Autonoma de Barcelona, 08916 Barcelona, Spain.
| | - Oliver Husser
- Department of Cardiology, St-Johannes Hospital, 44137 Dortmund, Germany.
| | - Julio Nuñez
- Institute of Health Research INCLIVA, 46010 Valencia, Spain.
- Cardiology Department, Hospital Clínico Universitario, 46010 Valencia, Spain.
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), 28029 Madrid, Spain.
- Department of Medicine, Universidad de Valencia, 46010 Valencia, Spain.
| | - Vicente Bodi
- Institute of Health Research INCLIVA, 46010 Valencia, Spain.
- Cardiology Department, Hospital Clínico Universitario, 46010 Valencia, Spain.
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), 28029 Madrid, Spain.
- Department of Medicine, Universidad de Valencia, 46010 Valencia, Spain.
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203
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Oliveira JC, Almeida‐Santos MA, Cunha‐Oliveira J, Oliveira LCS, de Carvalho Barreto ID, Clair RemacreMunareto Lima T, Andreline Maia Arcelino L, Andrade Prado LF, Serra Silveira F, Augusto da Silva Nascimento T, Pereira Ferreira EJ, Vasconcelos Barreto R, Vieira Moraes E, Teles de Mendonça J, Sousa ACS, Barreto‐Filho JA. Disparities in Access and Mortality of Patients With ST-Segment-Elevation Myocardial Infarction Using the Brazilian Public Healthcare System: VICTIM Register. J Am Heart Assoc 2019; 8:e013057. [PMID: 31581873 PMCID: PMC6818046 DOI: 10.1161/jaha.119.013057] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/19/2019] [Indexed: 12/19/2022]
Abstract
Background There is a scarcity of knowledge as to whether rates of myocardial reperfusion use and 30-day mortality for patients with ST-segment-elevation myocardial infarction are similar among patients using the Brazilian Public Health System (SUS) and those using the private healthcare system. Methods and Results A total of 707 patients were analyzed using the VICTIM (Via Crucis for the Treatment of Myocardial Infarction) register database; 589 patients from the SUS and 118 from the private network with ST-segment-elevation myocardial infarction, who attended hospitals with the capacity to perform primary percutaneous coronary intervention (PCI) were investigated. The timeline, rates of use of PCI, and the 30-day probability of death were investigated, comparing the SUS patients to those in the private system. The mean time between symptom onset and arrival at the PCI hospital was higher for SUS patients compared with users of the private system (25.4±36.5 versus 9.0±21 hours; P<0.001, respectively). Rates of primary PCI were low in both groups, but significantly lower for the SUS patients (45% versus 78%; P<0.001). The 30-day mortality rate of SUS patients was 11.9% and of private patients was 5.9% (P=0.04). In the fully adjusted model, the odds ratio for 30-day mortality for the SUS patients was higher (odds ratio, 2.96; 95% CI, 1.15-7.61; P=0.02). Conclusions The delay in reaching a PCI hospital was almost 3 times higher for the SUS patients. Primary PCI was underused in both groups, especially in the SUS patients. The SUS patients were more likely to die during the 30-day follow-up.
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Affiliation(s)
- Jussiely Cunha Oliveira
- Postgraduate Program in Health SciencesFederal University of SergipeAracajuSergipeBrazil
- Tiradentes UniversityAracajuSergipeBrazil
| | - Marcos Antonio Almeida‐Santos
- Postgraduate Program in Health and EnvironmentTiradentes UniversityAracajuSergipeBrazil
- Clinic and Hospital São Lucas—Rede D′Or São LuizAracajuSergipeBrazil
| | - Jeferson Cunha‐Oliveira
- Postgraduate Program in Health SciencesFederal University of SergipeAracajuSergipeBrazil
- Department of PharmacyFederal University of SergipeLagartoSergipeBrazil
- Hospital PrimaveraAracajuSergipeBrazil
| | - Laís Costa Souza Oliveira
- Postgraduate Program in Health SciencesFederal University of SergipeAracajuSergipeBrazil
- Hospital PrimaveraAracajuSergipeBrazil
| | | | | | | | | | | | | | - Eduardo José Pereira Ferreira
- Clinic and Hospital São Lucas—Rede D′Or São LuizAracajuSergipeBrazil
- Surgery Foundation HospitalAracajuSergipeBrazil
- Department of MedicineFederal University of SergipeLagartoSergipeBrazil
- Division of CardiologyUniversity HospitalFederal University of SergipeAracajuSergipeBrazil
| | | | | | - José Teles de Mendonça
- Clinic and Hospital São Lucas—Rede D′Or São LuizAracajuSergipeBrazil
- Heart HospitalAracajuSergipeBrazil
- Division of CardiologyUniversity HospitalFederal University of SergipeAracajuSergipeBrazil
| | - Antonio Carlos Sobral Sousa
- Postgraduate Program in Health SciencesFederal University of SergipeAracajuSergipeBrazil
- Clinic and Hospital São Lucas—Rede D′Or São LuizAracajuSergipeBrazil
- Division of CardiologyUniversity HospitalFederal University of SergipeAracajuSergipeBrazil
| | - José Augusto Barreto‐Filho
- Postgraduate Program in Health SciencesFederal University of SergipeAracajuSergipeBrazil
- Clinic and Hospital São Lucas—Rede D′Or São LuizAracajuSergipeBrazil
- Division of CardiologyUniversity HospitalFederal University of SergipeAracajuSergipeBrazil
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204
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Baldetti L, Beneduce A, Pappalardo F. Primary mechanical unloading in high-risk myocardial infarction: Perspectives in view of a paradigm shift. Int J Cardiol 2019; 293:32-38. [DOI: 10.1016/j.ijcard.2019.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/24/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
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205
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Wanamaker BL, Seth MM, Sukul D, Dixon SR, Bhatt DL, Madder RD, Rumsfeld JS, Gurm HS. Relationship Between Troponin on Presentation and In-Hospital Mortality in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. J Am Heart Assoc 2019; 8:e013551. [PMID: 31547767 PMCID: PMC6806038 DOI: 10.1161/jaha.119.013551] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Troponin release in ST-segment-elevation myocardial infarction (STEMI) has predictable kinetics with early levels reflective of ischemia duration. Little research has examined the value of admission troponin levels in STEMI patients undergoing primary percutaneous coronary intervention. We investigated the relationship between troponin on presentation and mortality in a large, real-world cohort of STEMI patients undergoing primary percutaneous coronary intervention. Methods and Results We used multivariable adaptive regression modeling to examine the association between admission troponin levels and in-hospital mortality for patients who underwent primary percutaneous coronary intervention for STEMI. We adjusted for known clinical risk factors using a validated mortality risk model derived from the NCDR (National Cardiovascular Data Registry) CathPCI database, and this same model was used to calculate patients' predicted mortality based on clinical and demographic factors. Patients were then stratified by troponin groups to compare predicted versus observed mortality. Of the 14 061 patients included in the cohort, 47.2% had initial troponin levels that were undetectable or within the reference range. Admission troponin was an independent predictor of in-hospital mortality, and any value above the reference range was associated with increased mortality (1.8% versus 5.1%, [standardized difference, 18.2%]). Patients with the highest predicted risk for mortality (13% predicted) in the highest admission troponin grouping experienced an observed mortality of 19.5%. Patients in low troponin groupings consistently demonstrated lower than predicted mortality based on their clinical and demographic risk profile. Conclusions Nearly half of patients undergoing primary percutaneous coronary intervention had normal troponin on presentation and had a relatively good outcome. Mortality increases with elevated admission troponin levels, regardless of baseline clinical risk. The substantial number of patients who present with markedly elevated troponin and their relatively worse outcomes highlights the need for continued improvement in prehospital STEMI detection and care.
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Affiliation(s)
- Brett L Wanamaker
- Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Milan M Seth
- Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Devraj Sukul
- Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Simon R Dixon
- Department of Cardiovascular Medicine Beaumont Hospital Royal Oak Royal Oak MI
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center Harvard Medical School Boston MA
| | - Ryan D Madder
- Frederik Meijer Heart & Vascular Institute Spectrum Health Grand Rapids MI
| | - John S Rumsfeld
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI
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206
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Murphy AC, Yudi MB, Farouque O, Dinh D, Duffy SJ, Brennan A, Reid CM, Andrianopoulos N, Koshy AN, Martin L, Dagan M, Freeman M, Blusztein D, Ajani AE, Clark DJ. Impact of Gender and Door-to-Balloon Times on Long-Term Mortality in Patients Presenting With ST-Elevation Myocardial Infarction. Am J Cardiol 2019; 124:833-841. [PMID: 31327488 DOI: 10.1016/j.amjcard.2019.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/21/2022]
Abstract
Guidelines mandate emergent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of gender. We sought to compare the door-to-balloon times and the impact of timely reperfusion on clinical outcomes in women compared with men presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI). We analyzed data from 6,179 consecutive patients presenting with STEMI undergoing PPCI from the Melbourne Interventional Group registry (2005 to 2017). The primary outcome was long-term mortality. Of the 6,179 patients included 1,258 (20.3%) were female. Female patients were older (69 ± 13 vs 62 ± 12 years; p < 0.001), had more co-morbidities and had longer median symptom-to-balloon times (204 [interquartile range {IQR} 154 to 294] vs 181 [IQR 139 to 258] minutes; p < 0.001) and longer median door-to-balloon times (81 [IQR 55 to 102] vs 75 [IQR 51 to 102)] minutes; p < 0.001), while receiving less drug-eluting stents (39% vs 43%; p = 0.01) and having less radial access for PPCI (15% vs 21%; p < 0.001). Furthermore, female patients received less guideline-directed medical therapy than men with less prescription of aspirin (93.4% vs 95.4%; p = 0.02), statins (96.5% vs 97.6%; p < 0.05), and beta blockers (84.3% vs 89.4%; p < 0.001). Unadjusted in-hospital and 30-day mortality rates were higher in women (8.8% vs 6.2%, 9.8% vs 6.9%; p < 0.001). However, on Cox-proportional hazards modeling, gender was not an independent predictor of long-term mortality (hazards ratio 0.99, 95% confidence interval 0.83 to 1.18; p = 0.92) at a mean follow-up of 4.8 ± 3.5 years. In conclusion, in this large multicenter registry of patients with STEMI, women had longer ischemic times, higher risk profiles, and differing interventional approaches compared with men. Addressing these gender inequalities with early identification of symptoms, adherence to guideline-directed medical therapy, as well as higher rates of radial access and use of drug-eluting stents has the potential to further improve outcomes in women with STEMI.
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Affiliation(s)
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Diem Dinh
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Angela Brennan
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Christopher M Reid
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Nick Andrianopoulos
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Lorelle Martin
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Victoria, Australia
| | - David Blusztein
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew E Ajani
- University of Melbourne, Melbourne, Australia; Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
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A Novel Algorithm for Improving the Diagnostic Accuracy of Prehospital ST-Elevation Myocardial Infarction. Prehosp Disaster Med 2019; 34:489-496. [PMID: 31507262 DOI: 10.1017/s1049023x19004849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation. HYPOTHESIS An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers. METHODS Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another. RESULTS There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01). CONCLUSION Prehospital STEMI ECGs can be accurately stratified to high, intermediate, and low probabilities for STEMI using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in CCL activation and decreased requirements for physician overread. This may have significant clinical and quality implications.
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208
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Mirzaei S, Steffen A, Vuckovic K, Ryan C, Bronas UG, Zegre-Hemsey J, DeVon HA. The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome. Eur J Cardiovasc Nurs 2019; 19:142-154. [PMID: 31510786 DOI: 10.1177/1474515119871734] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death. AIMS The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset. METHODS This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire. RESULTS Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046). CONCLUSION Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.
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Affiliation(s)
- Sahereh Mirzaei
- Department of Biobehavioral Health Science, University of Illinois, USA
| | - Alana Steffen
- Department of Health Systems Science, University of Illinois at Chicago, USA
| | - Karen Vuckovic
- Department of Biobehavioral Health Science, University of Illinois, USA
| | - Catherine Ryan
- Department of Biobehavioral Health Science, University of Illinois, USA
| | - Ulf G Bronas
- Department of Biobehavioral Health Science, University of Illinois, USA
| | | | - Holli A DeVon
- Department of Biobehavioral Health Science, University of Illinois, USA
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The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate. PLoS One 2019; 14:e0222019. [PMID: 31498823 PMCID: PMC6733447 DOI: 10.1371/journal.pone.0222019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/20/2019] [Indexed: 01/03/2023] Open
Abstract
Background Little is known about the components and contributing factors of door-to-balloon time after implementation of Door-to-Balloon Alliance quality-improving (QI) strategies, including the impact of door-to-ECG time on door-to-balloon time. Objective We investigated whether modification of emergency department (ED) triage processes could improve door-to-ECG and door-to-balloon times after implementation of QI strategies. Methods This was a retrospective before-and-after study of a prospectively collected database. From June 2014 to October 2014, interventions were implemented in our ED, including a protocol-driven ECG initiation and moving an ECG station and technician to the triage area. The primary outcome was the percentage of patients with ST-elevation myocardial infarction (STEMI) who received ECG within 10 min of arrival; the secondary outcome was the percentage of patients with door-to-balloon times of <90 min from arrival. Patients from the year pre- and post-QI initiative were defined as the control and intervention groups, respectively. Results Enrollment comprised 214 patients with STEMI: 109 before the intervention and 105 after the intervention. We analyzed the components of the door-to-balloon process and found the door-to-ECG process was the most critical interval of delay (20.8%). Unrecognized symptoms were the most common cause of delay in the door-to-ECG process resulting in a significant impact on the door-to-balloon time. The intervention group had a higher percentage of patients with door-to-ECG times <10 min than did the control group (93.3% vs. 79.8%, p = 0.005), with a corresponding improvement in door-to-balloon times <90 min (91.1% vs. 76.2%, p = 0.007). In subgroup analysis, the intervention benefits occurred only in non-transferred or walk-in patients. After adjustment for possible co-variates, the QI interventions remained a significant contributing factor for achieving the door-to-ECG and door-to-balloon targets. Conclusions The modification of ED triage processes through implementation of QI strategies are effective in achieving better door-to-ECG times and thus, achieving door-to-balloon times <90 min. In patients presenting with ambiguous symptoms, improved door-to ECG target achievement rates, through a protocol-driven and multidisciplinary approach allows for earlier identification of STEMI.
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210
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Nursing driven approaches to improving emergency department discharge. Am J Emerg Med 2019; 37:1784-1787. [DOI: 10.1016/j.ajem.2019.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 11/20/2022] Open
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Mallidi J, Ulahannan J, Chaubey VK, Atreya AR, Shakoor MT, Fisher D, Garb J, Lotfi A. Comparison of Clinical Outcomes: Bivalirudin With Transfemoral Access Versus Heparin With Transradial Access in Patients With ST segment Elevation Myocardial Infarction. Crit Pathw Cardiol 2019; 18:130-134. [PMID: 31348072 DOI: 10.1097/hpc.0000000000000182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION The best combination of access site and anticoagulant used during primary percutaneous coronary intervention (PCI) in patients presenting with ST segment elevation myocardial infarction is not known. METHODS We conducted a retrospective cohort study of all patients >18 years of age who underwent primary PCI in 2 large regional ST segment elevation myocardial infarction centers in Massachusetts between 2012 and 2014. The cohort was divided into 3 groups: bival/fem, hep/rad, or off-protocol, based on anticoagulation and access used. We used multiple logistic regression model to compare major cardiovascular events-major adverse cardiovascular events (MACE) and bleeding complications between the 2 on-protocol groups (bival/fem and hep/rad). RESULTS Of the 1074 patients in this study, there were 443 (41%), 501 (47%), and 130 (12%) patients in bival/fem, hep/rad, and off-protocol groups, respectively. There were significantly higher number of cardiogenic shock patients in the bival/fem compared to the hep/rad group (6.5% vs. 3.0%, P < 0.001). There was a trend toward reduced MACE in the hep/rad group compared to bival/fem (2.8 % vs. 5.1%, P = 0.068). When cardiogenic shock patients are excluded, there is no significant difference in mortality rates (bival/fem: 2.7% vs. hep/rad: 1.0%, P = 0.07) or bleeding complications between the groups (hep/rad: 4.5% vs. bival/fem: 2.1%, P = 0.06). CONCLUSIONS In patients undergoing primary PCI, there was a trend toward reduced inpatient MACE with the use of heparin and radial access compared with bivalirudin with femoral access. In patients without cardiogenic shock, there is no significant difference in mortality or bleeding rates between the 2 groups.
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Affiliation(s)
- Jaya Mallidi
- From the Division of Cardiology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
| | - John Ulahannan
- From the Division of Cardiology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
| | - Vinod K Chaubey
- From the Division of Cardiology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
| | - Auras R Atreya
- From the Division of Cardiology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
| | - Muhammad T Shakoor
- From the Division of Cardiology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
| | - Daniel Fisher
- Division of Cardiology, Department of Internal Medicine, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School, Worcester, MA
| | - Jane Garb
- Division of Biostatistics, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
| | - Amir Lotfi
- From the Division of Cardiology, Department of Internal Medicine, Baystate Medical Center, Springfield, MA
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Lange DC, Conte S, Pappas-Block E, Hildebrandt D, Nakamura M, Makkar R, Kar S, Torbati S, Geiderman J, McNeil N, Cercek B, Tabak SW, Rokos I, Henry TD. Cancellation of the Cardiac Catheterization Lab After Activation for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 11:e004464. [PMID: 30354373 DOI: 10.1161/circoutcomes.117.004464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCLX) remain a challenging problem. We examined the reasons for CCLX, clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCLX. METHODS AND RESULTS We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCLX (n=866; 65%). Reasons for CCLX included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCLX (C statistic, 0.985). CCLX subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCLX; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCLX was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009). CONCLUSIONS In this study, prehospital ECG without overreading or transmission lead to frequent CCLX. CCLX subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCLX patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCLX and influence clinical outcomes.
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Affiliation(s)
- David C Lange
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA (D.C.L.)
| | - Stanley Conte
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Effie Pappas-Block
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - David Hildebrandt
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Mamoo Nakamura
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Raj Makkar
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Saibal Kar
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Sam Torbati
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joel Geiderman
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Nathan McNeil
- Department of Emergency Medicine (S.T., J.G., N.M.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bojan Cercek
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Steven W Tabak
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
| | - Ivan Rokos
- Department of Emergency Medicine, UCLA Olive View Medical Center, Los Angeles, CA (I.R.)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute (S.C., E.P.-B., D.H., M.N., R.M., S.K., B.C., S.W.T., T.D.H.)
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Green JL, Jacobs AK, Holmes D, Chiswell K, Blanco R, Bates ER, French W, Kupas DF, Mears G, Roe M, Nallamothu BK. Taking the Reins on Systems of Care for ST-Segment-Elevation Myocardial Infarction Patients: A Report From the American Heart Association Mission: Lifeline Program. Circ Cardiovasc Interv 2019; 11:e005706. [PMID: 29716933 DOI: 10.1161/circinterventions.117.005706] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 03/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early success with regionalization of ST-segment-elevation myocardial infarction (STEMI) care has led many states to adopt statewide prehospital STEMI hospital destination policies, allowing emergency medical services to bypass non-percutaneous coronary intervention-capable hospitals. The association between adoption of these policies and patterns of care among STEMI patients is unknown. METHODS AND RESULTS Using data from January 1, 2013, to December 31, 2014, from the National Cardiovascular Data Registry and Acute Coronary Treatment and Intervention Outcomes Network Registry, 6 states with bypass policies (cases included Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts) were matched to 6 states without bypass policies (controls included South Carolina, Minnesota, Virginia, Texas, New York, and Connecticut) a priori on region, hospital density, and percent state participation in the registry. Using the matched sample, logistic regression models were adjusted for patient- and state-level characteristics. Outcomes were receipt of reperfusion and receipt of timely percutaneous coronary intervention. Our study cohort included 19 287 patients at 379 sites across 12 states. Patients from states with hospital destination policies were similar in age, sex, and comorbidities to patients from states without such policies. After adjustment for patient- and state-level characteristics, 57.9% (95% confidence intervals, 53.2%-62.5%) of patients living in states with hospital destination policies when compared with 47.5% (95% confidence intervals, 43.4%-51.7%) living in states without hospital destination policies received primary percutaneous coronary intervention within their relevant guideline-recommended time from first medical contact. CONCLUSIONS Statewide adoption of STEMI hospital destination policies allowing emergency medical services to bypass non-percutaneous coronary intervention-capable facilities is associated with significantly faster treatment times for patients with STEMI.
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Affiliation(s)
- Jacqueline L Green
- From the Department of Internal Medicine, University of Michigan, Ann Arbor (J.L.G., E.R.B., B.K.N.)
| | - Alice K Jacobs
- Department of Internal Medicine, Boston University School of Medicine, Boston University, MA (A.K.J.)
| | - DaJuanicia Holmes
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Karen Chiswell
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Rosalia Blanco
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Eric R Bates
- From the Department of Internal Medicine, University of Michigan, Ann Arbor (J.L.G., E.R.B., B.K.N.)
| | - William French
- Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA (W.F.)
| | - Douglas F Kupas
- Department of Emergency Medicine, Geisinger Medical Center, Mechanicsville, PA (D.F.K.)
| | | | - Matthew Roe
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Brahmajee K Nallamothu
- From the Department of Internal Medicine, University of Michigan, Ann Arbor (J.L.G., E.R.B., B.K.N.)
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Door-to-balloon time and cardiac mortality in acute myocardial infarction by total occlusion of the left circumflex artery. Coron Artery Dis 2019; 29:409-415. [PMID: 29570469 DOI: 10.1097/mca.0000000000000616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) caused by total occlusion of the left circumflex artery (LCX) can present as non-ST-segment elevation myocardial infarction (NSTEMI). We evaluate whether door-to-balloon time (DBT) is associated with cardiac mortality in patients with total occlusion of the LCX. PATIENTS AND METHODS From the Korea Acute Myocardial Infarction Registry, patients with AMI who had total occlusion with a Thrombolysis In Myocardial Infarction flow grade of 0 were included. We determined the factors for delay in primary percutaneous coronary intervention (DBT>90 min) and evaluated cardiac mortality for a median period of 14 months. RESULTS Mean DBT was 68 min (interquartile range=50-156 min), and the achievement rate of DBT less than or equal to 90 min was 66.9% in the entire study population. More than half of patients with total occlusion of LCX were presented as NSTEMI (57.7%). Among patients with total occlusion of the LCX, the mean DBT was 136 min (interquartile range=60-484 min), and the achievement rate of DBT less than or equal to 90 min was 42.8%. On multivariate analysis, LCX occlusion was an important factor for DBT more than 90 min (odds ratio: 1.766, P<0.001). Among patients with LCX occlusion, cardiac mortality was higher in patients with ST-segment elevation (6.2 vs. 11.0%, P=0.024). CONCLUSION This study showed that LCX occlusion was a significant factor for the delay in primary percutaneous coronary intervention on account of presenting as NSTEMI. Cardiac mortality was not associated with DBT more than 90 min but with ST-segment elevation in AMI patients with total occlusion of the LCX.
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216
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Darwesh AM, Sosnowski DK, Lee TYT, Keshavarz-Bahaghighat H, Seubert JM. Insights into the cardioprotective properties of n-3 PUFAs against ischemic heart disease via modulation of the innate immune system. Chem Biol Interact 2019; 308:20-44. [DOI: 10.1016/j.cbi.2019.04.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/17/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022]
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Fiorilli PN, Kolansky DM. Getting to the Right Place at the Right Time: Another Piece of the STEMI Puzzle. Circ Cardiovasc Interv 2019; 11:e006700. [PMID: 29716934 DOI: 10.1161/circinterventions.118.006700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul N Fiorilli
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Daniel M Kolansky
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.
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218
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The Taiwan Heart Registries: Its Influence on Cardiovascular Patient Care. J Am Coll Cardiol 2019; 71:1273-1283. [PMID: 29544612 DOI: 10.1016/j.jacc.2018.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Abstract
Taiwanese heart registries for the main cardiovascular diseases have been conducted in the past 10 years, with the goal of examining the quality of cardiovascular patient care, which cannot be guaranteed by the universal Taiwan National Health Insurance. The results show suboptimal adherence to guideline recommendations. Door-to-balloon time and dual antiplatelet therapy use in acute coronary syndrome, standard medications for management of heart failure, low-density lipoprotein cholesterol levels in dyslipidemia, anticoagulant agent use in atrial fibrillation, and the understanding of sudden arrhythmia death syndrome were all found to be inadequate. However, all were improved, either by changing National Health Insurance policy or through continuous education for physicians and patients. Thus, specific cardiovascular disease registries could help examine the status of real-world practice, find inadequacies in guideline implementation and understanding of rare diseases, facilitate lobbying to policy makers and education for physicians and patients, and influence and improve cardiovascular patient care.
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219
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Yekefallah L, Pournorooz M, Noori H, Alipur M. Evaluation of Door-To-Balloon Time for Performing Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients Transferred by Pre-Hospital Emergency System in Tehran. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2019; 24:281-285. [PMID: 31333742 PMCID: PMC6621504 DOI: 10.4103/ijnmr.ijnmr_130_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: The suggested treatment for patients with ST-segment elevation is the Primary Percutaneous Coronary Intervention (PPCI) for coronary reperfusion. This study aimed to evaluate the contribution of pre-hospital and hospital emergency systems in the interval time for PPCI among patients with the ST-segment elevation myocardial infarction (STEMI) in selected hospitals of Tehran city. Materials and Methods: This cross-sectional study was carried out on patients with typical chest pain transferred to the emergency wards of three large general hospitals in Tehran city by Emergency Medical Services. They received the PPCI. The information about admission time to the triage, time of conducting electrocardiography (ECG), diagnosis time of STEMI, and time of the PPCI were recorded and analyzed using descriptive and inferential statistics. Results: In this study, 121 patients were evaluated, and of which 94 (77.68%) were men and 27 (22.32%) were women. The average time (SD) of patient admission in the triage until to receive the PPCI (door-to-balloon) was 104.60 (62.30) min. Conclusions: The door-to-balloon time was 104.60 min. If ECG is taken by pre-hospital emergency nursing staff and diagnosis of STEMI is performed by the pre-hospital emergency service, and the patient is delivered directly to the angiography department, the door-to-balloon time is significantly reduced.
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Affiliation(s)
- Leili Yekefallah
- Department of Nursing, Social Determinants of Health Research Center, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mahdi Pournorooz
- Department of Intensive Care Nursing, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Mahmood Alipur
- Department of Biostatistics, Qazvin University of Medical Sciences, Qazvin, Iran
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Genetic Deletion or Pharmacological Inhibition of Soluble Epoxide Hydrolase Ameliorates Cardiac Ischemia/Reperfusion Injury by Attenuating NLRP3 Inflammasome Activation. Int J Mol Sci 2019; 20:ijms20143502. [PMID: 31319469 PMCID: PMC6678157 DOI: 10.3390/ijms20143502] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Activation of the nucleotide-binding oligomerization domain-like receptor (NLR) family pyrin domain containing 3 (NLRP3) inflammasome cascade has a role in the pathogenesis of ischemia/reperfusion (IR) injury. There is growing evidence indicating cytochrome p450 (CYP450)-derived metabolites of n-3 and n-6 polyunsaturated fatty acids (PUFAs) possess both adverse and protective effects in the heart. CYP-derived epoxy metabolites are rapidly hydrolyzed by the soluble epoxide hydrolase (sEH). The current study hypothesized that the cardioprotective effects of inhibiting sEH involves limiting activation of the NLRP3 inflammasome. Isolated hearts from young wild-type (WT) and sEH null mice were perfused in the Langendorff mode with either vehicle or the specific sEH inhibitor t-AUCB. Improved post-ischemic functional recovery and better mitochondrial respiration were observed in both sEH null hearts or WT hearts perfused with t-AUCB. Inhibition of sEH markedly attenuated the activation of the NLRP3 inflammasome complex and limited the mitochondrial localization of the fission protein dynamin-related protein-1 (Drp-1) triggered by IR injury. Cardioprotective effects stemming from the inhibition of sEH included preserved activities of both cytosolic thioredoxin (Trx)-1 and mitochondrial Trx-2 antioxidant enzymes. Together, these data demonstrate that inhibiting sEH imparts cardioprotection against IR injury via maintaining post-ischemic mitochondrial function and attenuating a detrimental innate inflammatory response.
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221
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Myocardial hypothermia induced after reperfusion does not prevent adverse left ventricular remodeling nor improve cardiac function. Life Sci 2019; 229:98-103. [PMID: 30991060 DOI: 10.1016/j.lfs.2019.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/21/2022]
Abstract
AIMS The purpose of the study was to determine whether late therapeutic hypothermia (LTH), administered after reperfusion, could prevent adverse left ventricular (LV) remodeling and improve cardiac function in the rat myocardial ischemia/reperfusion model. MAIN METHODS Rats were randomized to normothermia (n = 10) or LTH (initiated at 1 min after coronary artery reperfusion, n = 10) and subjected to 30 min of coronary occlusion followed by 6 weeks of reperfusion. Hypothermia was induced by pumping cold saline over the anterior surface of the LV until the temperature cooled to <32 °C. In the normothermic group, the heart was bathed in saline at 38 °C. KEY FINDINGS After 6 weeks of recovery, fractional shortening of the LV was comparable in the LTH (20.2 ± 0.6%) and normothermic group (20.0 ± 2.1%; p = 0.918). Postmortem LV volume (0.47 ± 0.04 ml in LTH and 0.44 ± 0.05 ml in normothermic group) and lung wet/dry weight ratio were similar in both groups. There were no significant differences in scar size, scar thickness, infarct expansion index, LV cavity or transmurality (%) between groups. This data contrasts with our previous study showing that hypothermia administered during the ischemic phase significantly reduced the scar size; decreased LV cavity, infarct expansion index and transmurality (%), and improved the scar thickness. SIGNIFICANCE LTH did not prevent adverse LV remodeling nor improve cardiac function in the rat myocardial ischemia/reperfusion model. To have a long term benefit on remodeling, hypothermia must be administered during the ischemic phase and not just the reperfusion phase.
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Affiliation(s)
- Nichole Bosson
- Los Angeles County EMS Agency, Santa Fe Springs, California, USA.,Los Angeles County Harbor-UCLA Medical Center, Torrance, California, USA
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223
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Niccoli G, Montone RA, Ibanez B, Thiele H, Crea F, Heusch G, Bulluck H, Hausenloy DJ, Berry C, Stiermaier T, Camici PG, Eitel I. Optimized Treatment of ST-Elevation Myocardial Infarction. Circ Res 2019; 125:245-258. [PMID: 31268854 DOI: 10.1161/circresaha.119.315344] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Primary percutaneous coronary intervention is nowadays the preferred reperfusion strategy for patients with acute ST-segment-elevation myocardial infarction, aiming at restoring epicardial infarct-related artery patency and achieving microvascular reperfusion as early as possible, thus limiting the extent of irreversibly injured myocardium. Yet, in a sizeable proportion of patients, primary percutaneous coronary intervention does not achieve effective myocardial reperfusion due to the occurrence of coronary microvascular obstruction (MVO). The amount of infarcted myocardium, the so-called infarct size, has long been known to be an independent predictor for major adverse cardiovascular events and adverse left ventricular remodeling after myocardial infarction. Previous cardioprotection studies were mainly aimed at protecting cardiomyocytes and reducing infarct size. However, several clinical and preclinical studies have reported that the presence and extent of MVO represent another important independent predictor of adverse left ventricular remodeling, and recent evidences support the notion that MVO may be more predictive of major adverse cardiovascular events than infarct size itself. Although timely and complete reperfusion is the most effective way of limiting myocardial injury and subsequent ventricular remodeling, the translation of effective therapeutic strategies into improved clinical outcomes has been largely disappointing. Of importance, despite the presence of a large number of studies focused on infarct size, only few cardioprotection studies addressed MVO as a therapeutic target. In this review, we provide a detailed summary of MVO including underlying causes, diagnostic techniques, and current therapeutic approaches. Furthermore, we discuss the hypothesis that simultaneously addressing infarct size and MVO may help to translate cardioprotective strategies into improved clinical outcome following ST-segment-elevation myocardial infarction.
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Affiliation(s)
- Giampaolo Niccoli
- From the Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (G.N., R.A.M., F.C.).,Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (G.N., F.C.)
| | - Rocco A Montone
- From the Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (G.N., R.A.M., F.C.)
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (B.I.).,Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain(B.I.).,CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain (B.I.)
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (H.T.)
| | - Filippo Crea
- From the Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (G.N., R.A.M., F.C.).,Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (G.N., F.C.)
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Germany (G.H.)
| | - Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.)
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.).,Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School (D.J.H.).,National Heart Research Institute Singapore, National Heart Centre (D.J.H.).,Yong Loo Lin School of Medicine, National University Singapore (D.J.H.).,The Hatter Cardiovascular Institute, University College London, United Kingdom (D.J.H.).,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, Research and Development, United Kingdom (D.J.H.).,Department of Cardiology, Tecnologico de Monterrey, Centro de Biotecnologia-FEMSA, Nuevo Leon, Mexico (D.J.H.)
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, United Kingdom (C.B.).,British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (C.B.)
| | - Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany (T.S., I.E.)
| | - Paolo G Camici
- Vita-Salute University and San Raffaele Hospital, Milan, Italy (P.G.C.)
| | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany (T.S., I.E.)
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ST-Elevation Acute Myocardial Infarction in Australia—Temporal Trends in Patient Management and Outcomes 1999–2016. Heart Lung Circ 2019; 28:1000-1008. [DOI: 10.1016/j.hlc.2018.05.191] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 04/12/2018] [Accepted: 05/23/2018] [Indexed: 11/20/2022]
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Rossello X, Lobo-Gonzalez M, Ibanez B. Editor's Choice- Pathophysiology and therapy of myocardial ischaemia/reperfusion syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 8:443-456. [PMID: 31172789 DOI: 10.1177/2048872619845283] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There is a need to find interventions able to reduce the extent of injury in reperfused ST-segment elevation myocardial infarction (STEMI) beyond timely reperfusion. In this review, we summarise the clinical impact of STEMI from epidemiological, clinical and biological perspectives. We also revise the pathophysiology underlying the ischaemia/reperfusion syndrome occurring in reperfused STEMI, including the several players involved in this syndrome, such as cardiomyocytes, microcirculation and circulating cells. Interventions aimed to reduce the resultant infarct size, known as cardioprotective therapies, are extensively discussed, putting the focus on both mechanical interventions (i.e. ischaemic conditioning) and promising pharmacological therapies, such as early intravenous metoprolol, exenatide and other glucose modulators, N-acetylcysteine as well as on some other classic therapies which have failed to be translated to the clinical arena. Novel targets for evolving therapeutic interventions to ameliorate ischaemia/reperfusion injury are also discussed. Finally, we highlight the necessity to improve the study design of future randomised clinical trials in the field, as well as to select patients better who can most likely benefit from cardioprotective interventions.
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Affiliation(s)
- Xavier Rossello
- 1 Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain.,2 CIBER de enfermedades CardioVasculares (CIBERCV), Spain
| | - Manuel Lobo-Gonzalez
- 1 Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain
| | - Borja Ibanez
- 1 Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain.,2 CIBER de enfermedades CardioVasculares (CIBERCV), Spain.,3 Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, Spain
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Abstract
ST-segment elevation myocardial infarction (STEMI) is the most acute manifestation of coronary artery disease and is associated with great morbidity and mortality. A complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel is the cause of STEMI in the majority of cases. Early diagnosis and immediate reperfusion are the most effective ways to limit myocardial ischaemia and infarct size and thereby reduce the risk of post-STEMI complications and heart failure. Primary percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy in patients with STEMI; if PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered to dissolve the occluding thrombus. The initiation of networks to provide around-the-clock cardiac catheterization availability and the generation of standard operating procedures within hospital systems have helped to reduce the time to reperfusion therapy. Together with new advances in antithrombotic therapy and preventive measures, these developments have resulted in a decrease in mortality from STEMI. However, a substantial amount of patients still experience recurrent cardiovascular events after STEMI. New insights have been gained regarding the pathophysiology of STEMI and feed into the development of new treatment strategies.
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Tungsubutra W, Ngoenjan D. Door-to-balloon time and factors associated with delayed door-to-balloon time in ST-segment elevation myocardial infarction at Thailand's largest tertiary referral centre. J Eval Clin Pract 2019; 25:434-440. [PMID: 30417495 DOI: 10.1111/jep.13061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyse door-to-balloon (DTB) time and to identify factors significantly associated with delayed DTB in patients with ST-segment elevation myocardial infarction (STEMI) at Thailand's largest tertiary referral centre. BACKGROUND DTB time is considered an important measure of performance quality. METHODS This observational study analysed DTB time in patients with STEMI who presented to our institute's emergency department and underwent primary percutaneous coronary intervention (PCI) during June 2008 to May 2011. DTB time greater than 90 minutes was considered delayed. Data were collected to determine which clinical variables were associated with delays. RESULTS One hundred thirty-three patients were included. The mean age of patients was 61.1 ± 13.2 years, and 71.4% were male. Delayed DTB was observed in 70.7% of patients. Median DTB time was 117 (interquartile range [IQR], 86-168), 66 (IQR, 58-84), and 135 (IQR, 112-194) minutes in all patients, in nondelayed patients, and in delayed patients, respectively. Univariate analysis revealed triage to urgent care (P = 0.001) and presentation during on-call hours (P < 0.001) to be significantly associated with delayed DTB. Patients who were triaged to urgent care had a DTB time of 184 vs 105 minutes for triage to the emergency room. Patients who presented during on-call hours had a DTB time of 128 vs 86 minutes for work hour presentation. Presentation during on-call hours was the only significant predictor of DTB time >90 minutes in multivariate analysis (odds ratio [OR], 7.86; 95% confidence interval [CI], 3.39-18.22; P < 0.001). All patients that were triaged to urgent care were delayed; thus, association between urgent care triage and on-call hour service could not be determined. CONCLUSIONS Delayed DTB time occurred in 70.7% of patients. Two key factors that significantly contributed to delayed DTB were patient mistriage to urgent care and presentation during on-call hours.
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Affiliation(s)
- Wiwun Tungsubutra
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Deachart Ngoenjan
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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228
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Salvia miltiorrhiza and Carthamus tinctorius Extract Prevents Cardiac Fibrosis and Dysfunction after Myocardial Infarction by Epigenetically Inhibiting Smad3 Expression. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:6479136. [PMID: 31275414 PMCID: PMC6582873 DOI: 10.1155/2019/6479136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
The incidence of cardiac dysfunction after myocardial infarction (MI) continues to increase despite advances in treatment. Excessive myocardial fibrosis plays a vital role in the development of adverse cardiac remodeling and deterioration of cardiac function. Understanding the molecular and cellular mechanism of the fibrosis process and developing effective therapeutics are of great importance. Salvia miltiorrhiza and Carthamus tinctorius extract (SCE) is indicated for angina pectoris and other ischemic cardiovascular diseases in China. SCE has been shown to inhibit the platelet activation and aggregation, ameliorate ROS-induced myocardial necrosis by inhibiting mitochondrial permeability transition pore opening, and promote angiogenesis by upregulating the expression of vascular endothelial growth factor (VEGF). However, whether SCE has effect on cardiac fibrosis after MI is not fully clear. Here, a mouse model of MI was established to observe the effect of SCE upon survival, cardiac function, myocardial fibrosis, and inflammation. Quantitative PCR and western blot assays were used to determine the expression of genes related to transforming growth factor-β (TGF-β) cascade and inflammatory responses in vivo. Additionally, the effects of SCE upon the collagen production, TGF-β/Smad3 (SMAD family member 3) signaling, and the levels of histone methylation in primary cardiac fibroblasts were detected. We found that SCE treatment significantly improved survival and left ventricular function in mice after MI. Inhibition of inflammation and fibrosis, as well as decreased expression of Smad3, was observed with SCE treatment. In TGF-β-stimulated cardiac fibroblasts, SCE significantly decreased the expression of collagen, α-smooth muscle actin (α-SMA), and Smad3. Furthermore, SCE treatment downregulated the levels of H3K4 trimethylation (H3K4me3) and H3K36 trimethylation (H3K36me3) at the Smad3 promoter region of cardiac fibroblasts, leading to inhibition of Smad3 transcription. Our findings suggested that SCE prevents myocardial fibrosis and adverse remodeling after MI with a novel mechanism of suppressing histone methylation of the Smad3 promoter and its transcription.
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229
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Anesi GL, Admon AJ, Halpern SD, Kerlin MP. Understanding irresponsible use of intensive care unit resources in the USA. THE LANCET RESPIRATORY MEDICINE 2019; 7:605-612. [PMID: 31122898 DOI: 10.1016/s2213-2600(19)30088-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/27/2019] [Accepted: 02/27/2019] [Indexed: 12/19/2022]
Abstract
Use of intensive care unit (ICU) resources in the USA far outpaces that of other countries. This increased use is not accompanied by superior clinical outcomes and is at times discordant with patient desires. This Series paper seeks to identify major drivers of ICU resource use in the USA, and to offer steps towards better aligning ICU resource use with clinical needs and patient preferences. After considering several factors, such as organisational, ethical, and economic factors, we suggest that there are four intersecting drivers of irresponsible use of ICU resources in the USA: first, excess ICU bed capacity and a scarcity of data to understand which patients that truly benefit from ICU compared with ward care; second, clinicians misinterpreting the goals and means of patient autonomy; third, an extreme fear of rationing by the general public; and fourth, fee-for-service driven use of advanced medical technologies and procedures that beget ICU expansion.
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Affiliation(s)
- George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, and Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Scott D Halpern
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Meeta P Kerlin
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA; Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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230
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Yajima S, Miyagawa S, Fukushima S, Isohashi K, Watabe T, Ikeda H, Horitsugi G, Harada A, Sakaniwa R, Hatazawa J, Sawa Y. Microvascular Dysfunction Related to Progressive Left Ventricular Remodeling due to Chronic Occlusion of the Left Anterior Descending Artery in an Adult Porcine Heart. Int Heart J 2019; 60:715-727. [PMID: 31105143 DOI: 10.1536/ihj.18-346] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Occlusion of a major coronary artery induces myocardial infarction (MI), leading to left ventricle (LV) remodeling due to progressive microvasculature dysfunction. Irreversible impairment in microvascular function has been suggested to extend from the infarcted region into the infarct-border or remote regions, depending on the time to revascularization. Our aim was to determine whether the occlusion of a major coronary artery induces microvascular dysfunction in the adjacent area perfused by intact coronary arteries using a porcine model for chronic total occlusion of the left anterior descending artery (LAD). MI was induced via an ameroid constrictor ring around the LAD in adult Göttingen pigs (Sus scrofa domesticus, n = 5). Age-matched normal pigs were treated as controls (n = 3). Cardiac magnetic resonance showed reduced systolic regional wall motion in the left circumflex (LCx) and right coronary artery (RCA) territories, with a progressively worsening motion in the infarction-adjacent area over an eight-week period. On 13N-ammonia positron emission tomography (PET), myocardial blood flow (MBF) during hyperemia was significantly greater in the LCx and RCA territories (particularly in the infarction-adjacent area) compared to that in the LAD territory at four weeks after infarct induction. Subsequently, the flow significantly decreased, approaching that in the LAD territory at eight weeks after infarct induction. Fluoroscopy-guided pressure-wire studies showed significantly higher microvascular resistance in the LCx area at eight weeks compared to that in controls. Electron microscopy showed endothelium swelling and microvasculature disruption in areas adjacent to the LCx and RCA territories. Anterior MI caused coronary microvascular dysfunction in the adjacent area, associated with a reduced MBF and regional wall motion.
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Affiliation(s)
- Shin Yajima
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kayako Isohashi
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine
| | - Tadashi Watabe
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine
| | - Hayato Ikeda
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine
| | - Genki Horitsugi
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine
| | - Akima Harada
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Ryoto Sakaniwa
- Public Health, Osaka University Graduate School of Medicine
| | - Jun Hatazawa
- Department of Nuclear Medicine and Tracer Kinetics, Osaka University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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231
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Lüscher TF, Obeid S. From Eisenhower's heart attack to modern management: a true success story! Eur Heart J 2019; 38:3066-3069. [PMID: 29040468 DOI: 10.1093/eurheartj/ehx569] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Thomas F Lüscher
- University Heart Center, Department of Cardiology, University Hospital and Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,Royal Brompton & Harefield Hospital Trust and Imperial College, London, UK
| | - Slayman Obeid
- University Heart Center, Department of Cardiology, University Hospital and Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,Royal Brompton & Harefield Hospital Trust and Imperial College, London, UK
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232
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Murphy A, Hamilton G, Andrianopoulos N, Yudi MB, Farouque O, Duffy SJ, Lefkovits J, Brennan A, Reid CM, Ajani AE, Clark DJ. One-Year Outcomes of Patients With Established Coronary Artery Disease Presenting With Acute Coronary Syndromes. Am J Cardiol 2019; 123:1387-1392. [PMID: 30797559 DOI: 10.1016/j.amjcard.2019.01.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
The risk of major adverse cardiovascular events (MACE) remains high in patients with established coronary artery disease (CAD). The aim of this study was to assess the prognostic significance of established CAD in patients who present with acute coronary syndromes (ACS) using a large established multicenter registry. Consecutive patients from the Melbourne Interventional Group registry who presented with ACS and underwent percutaneous coronary intervention from 2005 to 2015 were included. Patients with a history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery were included in the established CAD cohort. The primary end points were 12-month mortality and 12-month MACE. Of the 12,878 ACS patients included in our study, 3,542 (28%) patients had established CAD. Over the 10-year study period, the proportion of patients presenting with established CAD decreased (30.7% to 25.2%; p-for-overall-trend <0.001). Non-ST elevation myocardial infarction was the most prominent presentation in the established CAD cohort (45.1%) whereas ST-elevation myocardial infarction was the most prominent in the de novo CAD cohort (51%; p< 0.001). The patients in the established CAD cohort were older, had more co-morbidities and were more likely to present with high-risk features such as atrial fibrillation, left main disease, multivessel CAD and left ventricular dysfunction (all p < 0.001). Regarding revascularization in ST-elevation myocardial infarction presentations, symptom-to-door time was shorter, whereas door-to-balloon-time was longer in those with established CAD (p < 0.001). On multivariate analysis, established CAD was an independent risk factor for 12-month MACE (odds ratio 1.40, 95% confidence intervals 1.23 to 1.58, p < 0.001), but not for 12-month mortality (odds ratio 1.08, 95% confidence intervals 0.77 to 1.52, p = 0.66). In conclusion, patients with a history of myocardial infarction or previous revascularization have a higher rate of MACE at 12 months. Despite this they do not appear to suffer from higher mortality.
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233
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Mallidi J, Visintainer P, Pallekonda I, Fisher D, Barringhaus K, Kugelmass A, Lotfi A. Clinical Outcomes of Transferred Versus Onsite Primary Percutaneous Coronary Intervention for Patients With STEMI: Time to Look Beyond Door to Balloon Time. Crit Pathw Cardiol 2019; 17:13-18. [PMID: 29432371 DOI: 10.1097/hpc.0000000000000117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is currently unknown if the delay due to practical aspects associated with transfer of patients from a non-percutaneous coronary intervention (PCI) facility to a primary PCI facility is associated with adverse outcomes. METHODS We conducted a retrospective cohort study of all patients who presented with ST-segment elevation myocardial infarction (STEMI) and underwent primary PCI in 2 large regional STEMI centers in Massachusetts between January 2005 and June 2009. The cohort was divided into onsite patients who presented directly to the primary PCI center and transferred patients referred from another facility. The primary outcome was a composite of in-hospital major cardiovascular events (death, myocardial infarction, and stroke). Secondary outcomes were the individual components of the composite endpoint and bleeding complications. RESULTS The cohort included a total of 1236 patients. Among them, 426 (34%) patients were transferred patients and 810 (66%) were onsite patients. The median door to balloon time was significantly higher at for transferred patients (124 vs. 71 minutes). There was no significant difference in primary composite endpoint between the 2 groups (onsite 3.8% vs. transfer 5.3%, odds ratio 1.50, 95% confidence interval 0.79-2.84; P = 0.21). Adjusted risk estimates did not show a statistical difference in all-cause bleeding rates between the groups (onsite 10.1% vs. transfer 7.3%, odds ratio 0.68, 95% confidence interval 0.41-1.14; P = 0.14). CONCLUSIONS This study confirms that well-established and integrated regional STEMI programs provide equivalent care to transferred patients and onsite patients. Parameters beyond door to balloon times should be investigated for their contributions to improve patient outcomes.
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234
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ST-Elevation Myocardial Infarction Associated With Infective Endocarditis. Am J Cardiol 2019; 123:1239-1243. [PMID: 30890259 DOI: 10.1016/j.amjcard.2019.01.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/02/2019] [Accepted: 01/07/2019] [Indexed: 12/12/2022]
Abstract
ST-elevation myocardial infarction (STEMI) as a complication of infective endocarditis (IE) is a rarely reported entity. No clear guidelines exist with regards to the management of this medical emergency. We sought to systematically review the clinical presentation and management of this condition. We searched relevant articles on STEMI associated with IE and extracted data on demographic variables, key clinical characteristics upon presentation, treatment strategies, and clinical outcomes. We identified 100 patients from 95 articles. The mean age at presentation was 53 ± 17 years with male preponderance (n = 63, 63%, p = 0.01). Most patients (63 of 100, 63%) presented with STEMI as their first manifestation of IE, with others occurring at 15 ± 17 days after diagnosis of IE. Findings that suggested possible septic emboli were not consistently present, including history of prosthetic valve placement (15%), presence of other embolic disease (27%), fever (42%) increased leukocyte count (80%), and presence of murmur (88%). Atherosclerotic disease was absent in 95% on cardiac catheterization. Eleven patients receiving tissue plasminogen activator fared poorly, with 9 major bleeds; balloon angioplasty was successful in 56% (9 of 16 cases), aspiration thombectomy in 68% (21 of 31 cases), and coronary stenting in 81% (14 of 16 cases). The 30-day mortality was 43%. In conclusion, patients with STEMI in the face of recent IE, new precordial murmur, fever, increased leukocyte count or other embolic events, septic emboli should be considered as a cause for STEMI. Best practices for management are not known, but thrombolytics appear to carry significant bleeding and embolic risks.
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235
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Gibson CM, Holmes D, Mikdadi G, Presser D, Wohns D, Yee MK, Kaplan A, Ciuffo A, Eberly AL, Iteld B, Krucoff MW. Implantable Cardiac Alert System for Early Recognition of ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2019; 73:1919-1927. [DOI: 10.1016/j.jacc.2019.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
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236
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Nakamura M, Hori M, Nakagaito M, Kuwahara H, Kinoshita O, Ono M, Yokoyama S, Doi T, Fukahara K, Kinugawa K. A case of cardiogenic shock due to acute coronary syndrome successfully recovered by percutaneous and paracorporeal left ventricular assist device. J Artif Organs 2019; 22:249-252. [PMID: 30937678 PMCID: PMC6685920 DOI: 10.1007/s10047-019-01101-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/26/2019] [Indexed: 11/29/2022]
Abstract
We recently experienced a 70-year-old woman with left main trunk-acute coronary syndrome who was initially supported by Impella 5.0 which converted to paracorporeal left ventricular assist device (LVAD) implantation as a bridge to recovery. Optimized guideline-directed medical therapy with cardiac rehabilitation resulted in successful explantation of LVAD and she discharged on foot.
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Affiliation(s)
- Makiko Nakamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-City, 930-0194, Japan.
| | - Masakazu Hori
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-City, 930-0194, Japan
| | - Masaki Nakagaito
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-City, 930-0194, Japan
| | - Hiroyuki Kuwahara
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-City, 930-0194, Japan
| | - Osamu Kinoshita
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
| | - Shigeki Yokoyama
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Toshio Doi
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Kazuaki Fukahara
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-City, 930-0194, Japan
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237
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Curran J, Burkhoff D, Kloner RA. Beyond Reperfusion: Acute Ventricular Unloading and Cardioprotection During Myocardial Infarction. J Cardiovasc Transl Res 2019; 12:95-106. [PMID: 30671717 PMCID: PMC6497619 DOI: 10.1007/s12265-019-9863-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/02/2019] [Indexed: 12/21/2022]
Abstract
Heart failure is a major cause of morbidity and mortality around the world, and myocardial infarction is its leading cause. Myocardial infarction destroys viable myocardium, and this dead tissue is replaced by a non-contractile scar that results in impaired cardiac function and a significantly increased likelihood of the patient developing heart failure. Limiting infarct scar size has been the target of pre-clinical and clinical investigations for decades. However, beyond reperfusion, few therapies have translated into the clinic that limit its formation. New approaches are needed. This review will focus on new clinical and pre-clinical data demonstrating that acute ventricular unloading prior to reperfusion by means of percutaneous left ventricular support devices reduces ischemia-reperfusion injury and limits infarct scar size. Emphasis will be given to summarizing our current mechanistic understanding of this new therapeutic approach to treating myocardial infarction.
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Affiliation(s)
| | | | - Robert A Kloner
- Huntington Medical Research Institutes, Pasadena, CA, USA
- University of Southern California, Los Angeles, CA, USA
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238
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Standardized Team-Based Care for Cardiogenic Shock. J Am Coll Cardiol 2019; 73:1659-1669. [DOI: 10.1016/j.jacc.2018.12.084] [Citation(s) in RCA: 214] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 11/23/2022]
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239
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Huded CP, Kumar A, Johnson M, Abdallah M, Ballout JA, Kravitz K, Menon V, Gullett TC, Hantz S, Ellis SG, Podolsky SR, Meldon SW, Kralovic DM, Brosovich D, Smith E, Kapadia SR, Khot UN. Incremental Prognostic Value of Guideline-Directed Medical Therapy, Transradial Access, and Door-to-Balloon Time on Outcomes in ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2019; 12:e007101. [PMID: 30871354 DOI: 10.1161/circinterventions.118.007101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systems to improve ST-segment-elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown. METHODS AND RESULTS We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P<0.001). After adjusting for known clinical predictors of STEMI in-hospital mortality, achievement of at least 2 STEMI care metrics was associated with significantly reduced in-hospital mortality (odds ratio, 0.39; 95% CI, 0.16-0.96; P=0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P<0.001). CONCLUSIONS Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.
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Affiliation(s)
- Chetan P Huded
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Anirudh Kumar
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Michael Johnson
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Mouin Abdallah
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | | | - Kathleen Kravitz
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Venu Menon
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Travis C Gullett
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Scott Hantz
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Stephen G Ellis
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Seth R Podolsky
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Stephen W Meldon
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Damon M Kralovic
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Deborah Brosovich
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Elizabeth Smith
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Samir R Kapadia
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Umesh N Khot
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
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Fujiwara M, Matoba T, Koga JI, Okahara A, Funamoto D, Nakano K, Tsutsui H, Egashira K. Nanoparticle incorporating Toll-like receptor 4 inhibitor attenuates myocardial ischaemia–reperfusion injury by inhibiting monocyte-mediated inflammation in mice. Cardiovasc Res 2019; 115:1244-1255. [DOI: 10.1093/cvr/cvz066] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/22/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- Masaki Fujiwara
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun-Ichiro Koga
- Department of Cardiovascular Research, Development, and Translational Research, Kyushu University, Fukuoka, Japan
| | - Arihide Okahara
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daiki Funamoto
- Department of Cardiovascular Research, Development, and Translational Research, Kyushu University, Fukuoka, Japan
| | - Kaku Nakano
- Department of Cardiovascular Research, Development, and Translational Research, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kensuke Egashira
- Department of Cardiovascular Research, Development, and Translational Research, Kyushu University, Fukuoka, Japan
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The Implications of Acute Clinical Care Responsibilities on the Contemporary Practice of Interventional Cardiology. JACC Cardiovasc Interv 2019; 12:595-599. [DOI: 10.1016/j.jcin.2018.12.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/03/2018] [Accepted: 12/26/2018] [Indexed: 11/23/2022]
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Goebel M, Bledsoe J. Push Notifications Reduce Emergency Department Response Times to Prehospital ST-segment Elevation Myocardial Infarction. West J Emerg Med 2019; 20:212-218. [PMID: 30881538 PMCID: PMC6404709 DOI: 10.5811/westjem.2018.12.40375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/03/2018] [Accepted: 12/13/2018] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Prehospital acquisition of electrocardiograms (ECG) has been consistently associated with reduced door-to-balloon times in the treatment of ST-segment myocardial infarction (STEMI). There is little evidence establishing best hospital practices once the ECG has been received by the emergency department (ED). This study evaluates the use of a push notification system to reduce delays in cardiac catheterization lab (CCL) activation for prehospital STEMI. METHODS In this prospective before-and-after study, we collected prehospital ECGs with computer interpretation of STEMI from May 2012 to October 2013. Push notifications were implemented June 1, 2013. During the study period, we collected timestamps of when the prehospital ECG was received (email timestamp of receiving account), CCL team activation (timestamp in paging system), and patient arrival (timestamp in ED tracking board). When prehospital ECGs were received in the ED, an audible alert was played via the Vocera WiFi communication system, notifying nursing staff that an ECG was available for physician interpretation. We compared the time from receiving the ECG to activation of the CCL before and after the audible notification was implemented. RESULTS Of the 56 cases received, we included 45 in our analysis (20 cases with pre-arrival CCL activation and 25 with post-arrival activation). For the pre-arrival group, the interval from ECG received to CCL activation prior to implementation was 9.1 minutes with a standard deviation (SD) of 5.7 minutes. After implementation, the interval was reduced to 3.33 minutes with a SD of 1.63 minutes. Delay was decreased by 5.8 minutes (p < 0.01). Post-implementation activation times were more consistent, demonstrated by a decrease in SD from 5.75 to 1.63 min (p < 0.01). For patients with CCL activation after arrival, there was no significant change in mean delay after implementation. CONCLUSION In this small, single-center observational study, we demonstrated that the use of push notifications to ED staff alerting that a prehospital STEMI ECG was received correlated with a small reduction in, and increased consistency of, ED CCL activation.
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Affiliation(s)
- Mathew Goebel
- University of California San Diego School of Medicine, Department of Emergency Medicine, San Diego, California
| | - Joseph Bledsoe
- Intermountain Medical Center, Department of Emergency Medicine, Murray, Utah
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243
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Nozari Y, Geraiely B, Alipasandi K, Jalali A, Omidi N, Aghajani H, Hajizeinali A, Alidoosti M, Pourhoseini H, Salarifar M, Amirzadegan A, Nematipour E, Nomali M. Time to Treatment and In-Hospital Major Adverse Cardiac Events Among Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (PCI) According to the 24/7 Primary PCI Service Registry in Iran: Protocol for a Cross-Sectional Study. JMIR Res Protoc 2019; 8:e13161. [PMID: 30821693 PMCID: PMC6418487 DOI: 10.2196/13161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 12/28/2022] Open
Abstract
Background Patients with ST-segment elevation myocardial infarction (STEMI) experience major adverse cardiac events (MACEs) following primary percutaneous coronary intervention (PCI). Although the relationship between time to treatment (eg, door-to-balloon time, symptom onset-to-balloon time, and symptom onset-to-door time) and 1-month all-cause mortality was assessed previously, its relationship with in-hospital MACEs and the effect of some clinical characteristics on this relationship were not considered. Furthermore, previous studies that were conducted in developed countries with a different quality of care cannot be applied in Iran, as Iran is a developing country and the studies were not performed according to the 24/7 primary PCI service registry. Objective The objective of this study protocol is to determine the relationship between time to treatment and in-hospital MACEs. Methods This cross-sectional study will take place at the Tehran Heart Center (THC), which is affiliated with Tehran University of Medical Sciences (TUMS) in Tehran, Iran. Data related to patients with STEMI, who underwent primary PCI between March 2015 and March 2019, that have been prospectively recorded in the THC’s 24/7 primary PCI service registry will be analyzed. The study outcome is the occurrence of in-hospital MACEs. Data analysis will be conducted using SPSS for Windows, version 16.0 (SPSS Inc). We will perform chi-square tests, independent-samples t tests, or the Mann-Whitney U test, as well as univariate and multivariate binary logistic regression with a significance level of less than .05 and 95% CI for odds ratios. Results From March 2015 to September 2017, 1586 patients were included in the THC service registry, consecutively. We will conduct a retrospective analysis of this registry on patient entries between March 2015 and March 2019 and data will be analyzed and published by the end of 2019. Conclusions To our knowledge, this is the first observational study based on the 24/7 primary PCI service registry in Iran. The findings of this study may reveal current problems regarding time to treatment in STEMI management in the THC. Results from this study may help determine appropriate preventive strategies that need to be applied in order to reduce time-to-treatment delays and improve patients’ outcomes following primary PCI in the setting of STEMI at the THC and similar clinical centers. International Registered Report Identifier (IRRID) DERR1-10.2196/13161
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Affiliation(s)
- Younes Nozari
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Babak Geraiely
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Kian Alipasandi
- Department of Cardiology, School of Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Arash Jalali
- Department of Research and Biostatistics, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Negar Omidi
- Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Hassan Aghajani
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Alimohammad Hajizeinali
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Mohammad Alidoosti
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Hamidreza Pourhoseini
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Mojtaba Salarifar
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Alireza Amirzadegan
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Ebrahim Nematipour
- Department of Interventional Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Mahin Nomali
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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Maslov LN, Tsibulnikov SY, Prokudina ES, Popov SV, Boshchenko AA, Singh N, Zhang Y, Oeltgen PR. Trigger, Signaling Mechanism and End Effector of Cardioprotective Effect of Remote Postconditioning of Heart. Curr Cardiol Rev 2019; 15:177-187. [PMID: 30813880 PMCID: PMC6719390 DOI: 10.2174/1573403x15666190226095820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 11/22/2022] Open
Abstract
The hypothetical trigger of remote postconditioning (RPost) of the heart is the high-molecular weight hydrophobic peptide(s). Nitric oxide and adenosine serve as intermediaries between the peptide and intracellular structures. The role of the autonomic nervous system in RPost requires further study. In signaling mechanism RPost, kinases are involved: protein kinase C, PI3, Akt, JAK. The hypothetical end effector of RPost is aldehyde dehydrogenase-2, the transcription factors STAT, Nrf2, and also the BKCa channel.
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Affiliation(s)
- Leonid N Maslov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Sergey Y Tsibulnikov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Ekaterina S Prokudina
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Sergey V Popov
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Alla A Boshchenko
- Laboratory of Experimental Cardiology, Cardiology Research Institute, Tomsk National Research Medical Center of the Russian Academy of Science, Tomsk, Russian Federation
| | - Nirmal Singh
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, India
| | - Yi Zhang
- Department of Physiology, Hebei Medical University, Shijiazhuang, China
| | - Peter R Oeltgen
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, United States
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245
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McNair PW, Bilchick KC, Keeley EC. Very late presentation in ST elevation myocardial infarction: Predictors and long-term mortality. IJC HEART & VASCULATURE 2019; 22:156-159. [PMID: 30828600 PMCID: PMC6383163 DOI: 10.1016/j.ijcha.2019.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/03/2019] [Indexed: 01/17/2023]
Abstract
Background Despite improvements in ST elevation myocardial infarction (STEMI) care, total ischemic time remains long in patients who present late. Our goal was to identify predictors of very late presentation (≥12 h) of STEMI and determine long-term mortality. Methods We retrospectively examined consecutive patients admitted with STEMI to our institution using the ACTION Registry™. Time of symptom onset to first medical contact (FMC) was calculated and categorized as <12 h or ≥12 h. Predictors of very late presentation were determined. Results Compared to patients who presented <12 h (n = 365), those who presented ≥12 h (n = 49) after symptom onset were more likely women, diabetics, and those with prior coronary revascularization. In addition, patients who presented ≥12 h had worse ventricular function, were less likely to report chest pain, and were less likely to be transported by ambulance and to undergo coronary angiography. Late presenters had higher rates of heart failure, longer hospitalizations, and were less likely to be discharged home. Diabetes, female sex, and absence of chest pain were strong predictors of late presentation. Long-term survival was significantly lower in late presenters (73% vs. 93%, p = 0.007). Conclusions Female sex, diabetes, and absence of chest pain are strong predictors of presentation delay, and long-term mortality is significantly increased in those presenting very late. A proportion of patients with acute myocardial infarction present late after symptom onset. Women, diabetics and patients who do not experience typical chest pain are more likely to present late. Patients with myocardial infarction who present late have increased mortality at one year.
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Affiliation(s)
- Patrick W McNair
- Department of Medicine, Division of Cardiology, University of Virginia, Charlottesville, VA, United States of America
| | - Kenneth C Bilchick
- Department of Medicine, Division of Cardiology, University of Virginia, Charlottesville, VA, United States of America
| | - Ellen C Keeley
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
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Relation of lowering door-to-balloon time and mortality in ST segment elevation myocardial infarction patients undergoing percutaneous coronary intervention. Clin Res Cardiol 2019; 108:1053-1058. [DOI: 10.1007/s00392-019-01438-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
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Kapur NK, Alkhouli MA, DeMartini TJ, Faraz H, George ZH, Goodwin MJ, Hernandez-Montfort JA, Iyer VS, Josephy N, Kalra S, Kaki A, Karas RH, Kimmelstiel CD, Koenig GC, Lau E, Lotun K, Madder RD, Mannino SF, Meraj PM, Moreland JA, Moses JW, Kim RL, Schreiber TL, Udelson JE, Witzke C, Wohns DH, O’Neill WW. Unloading the Left Ventricle Before Reperfusion in Patients With Anterior ST-Segment–Elevation Myocardial Infarction. Circulation 2019; 139:337-346. [DOI: 10.1161/circulationaha.118.038269] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Navin K. Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA (N.K.K., R.H.K., C.D.K., J.E.U.)
| | - Mohamad A. Alkhouli
- West Virginia University Heart and Vascular Institute, Morgantown (M.A.A., J.A.M.)
| | | | | | | | | | | | | | - Noam Josephy
- Massachusetts Institute of Technology, Cambridge (N.J.)
| | | | - Amir Kaki
- Detroit Medical Center, MI (A.K., T.L.S.)
| | - Richard H. Karas
- The CardioVascular Center, Tufts Medical Center, Boston, MA (N.K.K., R.H.K., C.D.K., J.E.U.)
| | - Carey D. Kimmelstiel
- The CardioVascular Center, Tufts Medical Center, Boston, MA (N.K.K., R.H.K., C.D.K., J.E.U.)
| | | | | | | | | | | | | | - Jason A. Moreland
- West Virginia University Heart and Vascular Institute, Morgantown (M.A.A., J.A.M.)
| | | | | | | | - James E. Udelson
- The CardioVascular Center, Tufts Medical Center, Boston, MA (N.K.K., R.H.K., C.D.K., J.E.U.)
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Li YH, Chiu YW, Cheng JJ, Hsieh IC, Lo PH, Lei MH, Ueng KC, Chiang FT, Sung SH, Kuo JY, Chen CP, Lai WT, Lee WL, Chen JH. Changing Practice Pattern of Acute Coronary Syndromes in Taiwan from 2008 to 2015. ACTA CARDIOLOGICA SINICA 2019; 35:1-10. [PMID: 30713394 PMCID: PMC6342842 DOI: 10.6515/acs.201901_35(1).20180716b] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with acute coronary syndrome (ACS), including ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation (NSTE)-ACS have a significant risk of morbidity and mortality. This study evaluated the practice patterns of ACS care in Taiwan from 2005 to 2018. METHODS Data from two nationwide ACS registries (2008-2010 and 2012-2015) were used. ACS patients who received percutaneous coronary interventions (PCIs) during admission were compared between the two registries. RESULTS In STEMI, the door-to-balloon time for primary PCI decreased by 25 min from a median of 96 to 71 min (p < 0.0001) from the first to second registry. More complex PCI procedures and drug-eluting stents were used for ACS. However, the onset-to-door time was still long for both STEMI and NSTE-ACS. The D2B time for NSTE-ACS was long, especially in the elderly and female patients. Although the prescription rate of secondary preventive medications for ACS increased, it was still relatively low compared with Western data, especially in NSTE-ACS. CONCLUSIONS The registry data showed that ACS care quality has improved in Taiwan. However, areas including onset-to-door time and use of secondary preventive medications still need further improvements.
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Affiliation(s)
- Yi-Heng Li
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Yu-Wei Chiu
- Far Eastern Memorial Hospital, New Taipei City
| | | | - I-Chang Hsieh
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan
| | - Ping-Han Lo
- China Medical University Hospital and College of Medicine, Taichung
| | | | | | - Fu-Tien Chiang
- National Taiwan University Hospital and Fu-Jen Catholic University Hospital
| | - Shih-Hsien Sung
- Taipei Veterans General Hospital and National Yang Ming University
| | | | | | - Wen-Ter Lai
- Kaohsiung Medical University Hospital, Kaohsiung City
| | | | - Jyh-Hong Chen
- College of Medicine, China Medical University, Taichung, Taiwan
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Allencherril J, Alam M, Levine G, Jneid H, Atar D, Kloner RA, Birnbaum Y. Do We Need Potent Intravenous Antiplatelet Inhibition at the Time of Reperfusion During ST-Segment Elevation Myocardial Infarction? J Cardiovasc Pharmacol Ther 2018; 24:215-224. [PMID: 30563349 DOI: 10.1177/1074248418812167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute myocardial infarction (MI) is still a large source of morbidity and mortality worldwide. Although early reperfusion therapy has been prioritized in the modern era of percutaneous coronary intervention and thrombolysis, attempts at incremental improvements in clinical outcomes by reducing MI size have not been successful so far. Herein, we review the studies that have evaluated immediate-onset antiplatelet therapy as attempts to improve meaningful clinical outcomes in ST-segment elevation MI (STEMI). Unfortunately, many of the adjunctive pharmacotherapies have proven to be disappointing. Recent studies performed in the background of routine oral administration of P2Y12 adenosine receptor inhibitors, which may take several hours to take full effect, and aspirin have largely shown no improvement in outcomes, despite an earlier onset of antiplatelet activity of the investigative agents. Further progress in improving outcomes during STEMI may depend on exploring therapeutics that modulate the pathophysiology of microvascular damage during ischemia-reperfusion injury, a phenomenon whose effects evolve over hours to days. We speculate that the dynamic nature of the no-reflow phenomenon may be an explanation for these disappointing results with the intravenous antiplatelet agents. We hope that appreciation for what has not worked in this domain may direct future research efforts to focus on novel pathways. Myocardial ischemia and reperfusion injury are very much still a lingering issue. Despite significant improvements in door-to-balloon times, rates of in-hospital mortality for STEMI remain unchanged. Outcomes following successfully reperfused STEMI are likely determined by the initial size of myocardial necrosis (ie, cardiomyocyte death during the period of ongoing ischemia), patency of the infarct-related epicardial coronary artery, possible reperfusion injury, the microvascular no-reflow phenomenon, and adverse remodeling after infarction.
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Affiliation(s)
| | - Mahboob Alam
- 1 Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Glenn Levine
- 1 Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- 1 Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Dan Atar
- 2 Department of Cardiology B, Oslo University Hospital, and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Robert A Kloner
- 3 Huntington Medical Research Institute, Pasadena, CA, USA
- 4 Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Yochai Birnbaum
- 1 Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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