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Negi PC, Dsuza S, Kandoria A, Nijhavan R, Thakur P, Thakur M, Sharma M, Asotra S, Ganju N, Marwah R, Sharma R. Impact of capacity building and tele ECG based decision support on change in thrombolysis rate and inhospital and one year mortality in patients with STEMI, using hub and spoke model; multi-phasic intervention trial. Indian Heart J 2024:S0019-4832(24)00078-6. [PMID: 38885880 DOI: 10.1016/j.ihj.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 04/11/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND We report the impact of capacity building and teleconsultation on change in the thrombolysis rates and one-year mortality in patients with STEMI using a hub and the spoke model of STEMI care. METHODS Twenty secondary care public hospitals were linked with a teaching hospital as a hub centre and the impact of the intervention on change in ischemic time, thrombolysis rates and all-cause in-hospital and one-year mortality was compared. RESULTS 29 patients with STEMI were treated during pre-intervention from April 2020 to June 2020 and 255 patients during the post-intervention period from July 2020 to Oct 2021 in spoke centres. 245 patients were reported to a hub centre during the study period. The thrombolysis rate was significantly higher in the spoke centres after intervention (65.5%vs. 27.5 % p < 0.001) and was also significantly higher than in patients treated in a hub centre (65.5 % vs. 45.7 % p < 0.01). The in-hospital mortality was significantly lower in patients treated at spoke centres compared to those treated at the hub centre (7.8 % vs. 15.5 % < 0.003). The significant difference in mortality rate continued at one year (11.0 % vs.18.4 % p < 0.01). The median time from symptoms to thrombolytic therapy was significantly lower in STEMI patients treated in spoke centres compared to a hub centre (230 min vs. 356 min p < 0.001). CONCLUSION The hub and spoke model of STEMI care is effective in increasing thrombolysis rate, and decreasing in-hospital and one-year mortality rate.
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Affiliation(s)
| | - Savio Dsuza
- Indira Gandhi Medical College, Shimla, India
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2
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Arias-Mendoza A, Ortega-Hernández JA, Araiza-Garaygordobil D, González-Pacheco H, Martínez-García M, Hernández-Lemus E, Gopar-Nieto R, Sandoval-Aguilar TT, Sierra-Lara Martinez D, Mendoza-García S, Altamirano-Castillo A, Briseño-de-la-Cruz JL, Ortega-Hernández MA, Soliz-Uriona LA, Gaspar-Hernández J. Real-World Evaluation of a Pharmacoinvasive Strategy for STEMI in Latin America: A Cost-Effective Approach with Short-Term Benefits. Ther Clin Risk Manag 2023; 19:903-911. [PMID: 38023623 PMCID: PMC10644829 DOI: 10.2147/tcrm.s432683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose While pharmacoinvasive strategy (PI) is a safe and effective approach whenever access to primary percutaneous intervention (pPCI) is limited, data on each strategy's economic cost and impact on in-hospital stay are scarce. The objective is to compare the cost-effectiveness of a PI with that of pPCI for the treatment of ST-elevation myocardial infarction (STEMI) in a Latin-American country. Patients and Methods A total of 1747 patients were included, of whom 470 (26.9%) received PI, 433 (24.7%) pPCI, and 844 (48.3%) NR. The study's primary outcome was the incremental cost-effectiveness ratio (ICER) for PI compared with those for pPCI and non-reperfused (NR), calculated for 30-day major cardiovascular events (MACE), 30-day mortality, and length of stay. Results For PI, the ICER estimates for MACE showed a decrease of $-35.81/per 1% (95 confidence interval, -114.73 to 64.81) compared with pPCI and a decrease of $-271.60/per 1% (95% CI, -1086.10 to -144.93) compared with NR. Also, in mortality, PI had an ICER decrease of $-129.50 (95% CI, -810.57, 455.06) compared to pPCI and $-165.27 (-224.06, -123.52) with NR. Finally, length of stay had an ICER reduction of -765.99 (-4020.68, 3141.65) and -283.40 (-304.95, -252.76) compared to pPCI and NR, respectively. Conclusion The findings of this study suggest that PI may be a more efficient treatment approach for STEMI in regions where access to pPCI is limited or where patient and system delays are expected.
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Affiliation(s)
| | | | | | | | | | | | - Rodrigo Gopar-Nieto
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 487] [Impact Index Per Article: 487.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 508] [Impact Index Per Article: 169.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Sultan EZME, Meguid KRA, Mahmoud HB. Post-streptokinase PCI in STEMI patients exceeding the 24-h guidelines. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2021. [DOI: 10.1186/s43088-021-00162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Due to delay in obtaining approval from insurance institution, performing PCI after successful reperfusion using streptokinase was postponed for ˃24 h-1 week. The study was conducted to investigate safety and efficacy of such delay in comparison to the ideal guidelines of PCI (≤ 24 h) in 129 STEMI patients received streptokinase followed by PCI. Patients were divided into two groups: (group 1 = 57; early PCI ≤ 24 h.) and (group 2 = 72; late PCI > 24 h.).
Results
Primary end point was death, congestive heart failure and reinfarction up to 30 days. Secondary end point was TIMI flow < G3, ischemic stroke, intracranial hemorrhage and non-intracranial bleeding. No statistical significant difference was found between both groups regarding LVEF, dimensions and myocardium wall preservation and incidence of complications and TIMI flow. No primary endpoints were detected. Five patients had secondary endpoints in early PCI and four in the late PCI. Suction device and IV Eptifibatide were used more in early PCI (p = 0.003).
Conclusions
The study suggests that relatively late PCI (> 24 h–1wk) after successful reperfusion using streptokinase in STEMI patients seems to be safe and effective in 30-day follow-up, provided that patients received DAPT and were subjected to close observation. The results seem safely applicable when we are forced to this choice; however lack of more investigations to this hypothesis is considered a limitation.
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Yamaji K, Mitsutake Y, Nakano M, Nakamura T, Fukumoto Y. Robotic-assisted percutaneous coronary intervention in the COVID-19 pandemic. J Cardiol 2021; 79:455-459. [PMID: 34454811 PMCID: PMC8373664 DOI: 10.1016/j.jjcc.2021.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022]
Abstract
Coronavirus disease-2019 (COVID-19) has a profound impact on the health care system worldwide. In the COVID-19 pandemic, hospitals are required to halt elective surgeries and procedures for preventing nosocomial infections and saving medical resources. In these situations, emergency procedures are required for life-threatening cardiovascular diseases such as acute coronary syndrome and cardiogenic shock. To prevent the spread of COVID-19, a social distance is essentially required. In ordinary percutaneous coronary intervention (PCI), operators manipulate the devices standing at the patient's tableside during the whole procedure, which may involve a certain risk of exposure to patients with COVID-19. A robotic-assisted PCI (R-PCI) allows operators to manipulate devices remotely, sitting at a cockpit located several meters away from the patient, and in addition, the assistant can be at the foot of the bed, much further from the access site. R-PCI can help to minimize the radiation exposure and the amount of person-to-person contact, and consequently may reduce the risk for the exposure to the virus.
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Affiliation(s)
- Kazunori Yamaji
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoshiaki Mitsutake
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Kurume, Japan.
| | - Masaharu Nakano
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takuya Nakamura
- Center of Clinical Engineering, Kurume University Hospital, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Kurume University School of Medicine, Kurume, Japan
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Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings. Int J Angiol 2021; 30:67-75. [PMID: 34025097 DOI: 10.1055/s-0041-1723944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.
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Affiliation(s)
- Rod Partow-Navid
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Narut Prasitlumkum
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ashish Mukherjee
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Padmini Varadarajan
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ramdas G Pai
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
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Gopar-Nieto R, Araiza-Garaygordobil D, Raymundo-Martínez GI, Martínez-Amezcua P, Cabello-López A, Manzur-Sandoval D, Chávez-Gómez NL, Loáisiga-Sáenz AE, Baeza-Herrera LA, Dattoli-García CA, Gallardo-Grajeda LA, Jackson-Pedroza CN, Salas-Teles B, Arias-Mendoza A. Demographic description and outcomes of a metropolitan network for myocardial infarction treatment. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2021; 91:167-177. [PMID: 33471783 PMCID: PMC8295868 DOI: 10.24875/acm.20000133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/12/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of the study was to describe the myocardial infarction treatment network and compare in-hospital mortality in patients undergoing either primary angioplasty or pharmacoinvasive strategy in Mexico City and a broad metropolitan area. METHODS Cohort study including patients with ST-elevation myocardial infarction. We recorded demographic and clinical data, laboratory tests and in-hospital mortality in patients that underwent primary angioplasty and pharmacoinvasive strategy. Kaplan-Meier analysis was used to assess mortality and Cox-regression assessed mortality risk factors. RESULTS Three hundred forty patients from a network of 60 hospitals and 9 states were analyzed. Of the total population, 166 were treated with pharmacoinvasive strategy and 174 with primary angioplasty. Door to thrombolytic time was 54 min and door to wire crossing time was 72.5 min; no differences in total ischemia time were demonstrated. No differences for in-hospital mortality (6.3% vs. 5.4%, p = 0.49) were found when comparing pharmacoinvasive and primary angioplasty groups. The main predictors for in-hospital mortality were: glucose > 180 mg/dl (HR 3.73), total ischemia time > 420 min (HR 3.18), heart rate > 90 bpm (HR 5.46), Killip and Kimball > II (HR 11.03), and left ventricle ejection fraction < 40% (HR 3.21). CONCLUSIONS This myocardial infarction network covers a large area and constitutes one of the biggest in the world. There were no differences regarding in-hospital mortality between pharmacoinvasive strategy and primary angioplasty. Pharmacoinvasive strategy is an effective and safe option for prompt reperfusion in Mexico.
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Affiliation(s)
- Rodrigo Gopar-Nieto
- Coronary Unit, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
| | | | | | - Pablo Martínez-Amezcua
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Alejandro Cabello-López
- Unidad de Investigación de Salud en el Trabajo, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | | | - Nancy L. Chávez-Gómez
- Coronary Unit, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
| | | | - Luis A. Baeza-Herrera
- Coronary Unit, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
| | | | | | | | - Brandon Salas-Teles
- Coronary Unit, Instituto Nacional de Cardiología “Ignacio Chávez”, Mexico City, Mexico
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Jiang W, Xiong X, Du X, Ma H, Li W, Cheng F. Safety and efficacy study of prourokinase injection during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction. Coron Artery Dis 2021; 32:25-30. [PMID: 32310850 PMCID: PMC7713758 DOI: 10.1097/mca.0000000000000898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/22/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions in patients with acute ST-segment elevation myocardial infarction. METHODS Acute ST-segment elevation myocardial infarction patients underwent primary percutaneous coronary interventions were randomly divided into two groups: intracoronary prourokinase group (n = 125) and control group (n = 135). During primary percutaneous coronary interventions, prourokinase or saline was injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and major averse cardiovascular events (MACE) occurred in the 6-months follow-up were recorded. RESULTS No significant differences were observed between two groups with respect to baseline demographic, clinical, and thrombolysis in myocardial infarction grade (P > 0.05). In the intracoronary prourokinase group, more patients had ST-segment resolution (>50%) compared with control group (P < 0.05). Patients in the intracoronary prourokinase group showed lower levels of serum CK, creatine kinase-MB fraction, and troponin I than those in control group (P < 0.05). No significant differences in bleeding complications were observed between the two groups (P > 0.05). At 6-months follow-up, there was no statistically different of MACE between the two groups (P > 0.05). CONCLUSIONS Intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions effectively improved myocardial perfusion and no increased bleeding in ST-segment elevation myocardial infarction patients.
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Affiliation(s)
- Wenlong Jiang
- Department of Cardiovascular, Shenzhen Yantian People’s Hospital, Shenzhen, China
| | - Xiaoshuan Xiong
- Department of Cardiovascular, Shenzhen Yantian People’s Hospital, Shenzhen, China
| | - Xiaohui Du
- Department of Cardiovascular, Shenzhen Yantian People’s Hospital, Shenzhen, China
| | - Hua Ma
- Department of Cardiovascular, Shenzhen Yantian People’s Hospital, Shenzhen, China
| | - Wen Li
- Department of Cardiovascular, Shenzhen Yantian People’s Hospital, Shenzhen, China
| | - Fangzhou Cheng
- Department of Cardiovascular, Shenzhen Yantian People’s Hospital, Shenzhen, China
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Engel Gonzalez P, Omar W, Patel KV, de Lemos JA, Bavry AA, Koshy TP, Mullasari AS, Alexander T, Banerjee S, Kumbhani DJ. Fibrinolytic Strategy for ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv 2020; 13:e009622. [DOI: 10.1161/circinterventions.120.009622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The ongoing coronavirus disease 2019 pandemic has resulted in additional challenges for systems designed to perform expeditious primary percutaneous coronary intervention for patients presenting with ST-segment–elevation myocardial infarction. There are 2 important considerations: the guideline-recommended time goals were difficult to achieve for many patients in high-income countries even before the pandemic, and there is a steep increase in mortality when primary percutaneous coronary intervention cannot be delivered in a timely fashion. Although the use of fibrinolytic therapy has progressively decreased over the last several decades in high-income countries, in circumstances when delays in timely delivery of primary percutaneous coronary intervention are expected, a modern fibrinolytic-based pharmacoinvasive strategy may need to be considered. The purpose of this review is to systematically discuss the contemporary role of an evidence-based fibrinolytic reperfusion strategy as part of a pharmacoinvasive approach, in the context of the emerging coronavirus disease 2019 pandemic.
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Affiliation(s)
- Pedro Engel Gonzalez
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Wally Omar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Kunal V. Patel
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - James A. de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Anthony A. Bavry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Thomas P. Koshy
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Ajit S. Mullasari
- The Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India (A.S.M.)
| | - Thomas Alexander
- Department of Cardiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India (T.A.)
| | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
- VA North Texas Health Care System, Dallas (S.B.)
| | - Dharam J. Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
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Management and outcomes of uncomplicated ST-segment elevation myocardial infarction patients transferred after fibrinolytic therapy. Int J Cardiol 2020; 321:54-60. [PMID: 32810551 DOI: 10.1016/j.ijcard.2020.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/14/2020] [Accepted: 08/07/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy ('drip-and-ship') for ST-segment elevation myocardial infarction (STEMI) in the United States. METHODS During 2009-2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition. RESULTS A total of 27,454 STEMI admissions receiving a 'drip-and-ship strategy', 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11-0.27]; p < .001) but not CA without revascularization (OR 0.72 [95% CI 0.42-1.21]; p = .21) was associated with lower in-hospital mortality. The fibrinolysis alone cohort had higher use of do-not-resuscitate status (12.8%) and fewer discharges to home (56.6%) compared to cohorts undergoing CA without (1.7%; 86.9%) and with (0.3% and 91.2%) revascularization, respectively. Presence of complications, do-not-resuscitate status, and higher comorbidity were predictive of lower CA and revascularization use. CONCLUSION Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes.
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Fazel R, Joseph TI, Sankardas MA, Pinto DS, Yeh RW, Kumbhani DJ, Nallamothu BK. Comparison of Reperfusion Strategies for ST-Segment-Elevation Myocardial Infarction: A Multivariate Network Meta-analysis. J Am Heart Assoc 2020; 9:e015186. [PMID: 32500800 PMCID: PMC7429064 DOI: 10.1161/jaha.119.015186] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background We systematically reviewed trials comparing different reperfusion strategies for ST-segment-elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST-segment-elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as "facilitated PCI" when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a "pharmacoinvasive approach" when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61-0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59-1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment-elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment-elevation myocardial infarction, is not available.
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Affiliation(s)
- Reza Fazel
- Division of Cardiovascular Medicine Department of Medicine Beth Israel Deaconess Medical Center Boston MA
| | | | - Mullasari A Sankardas
- Department of Cardiology Institute of Cardiovascular Diseases The Madras Medical Mission Chennai India
| | - Duane S Pinto
- Department of Medicine Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Robert W Yeh
- Department of Medicine Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Dharam J Kumbhani
- Division of Cardiology Department of Medicine UT Southwestern Medical Center Dallas TX
| | - Brahmajee K Nallamothu
- Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence Ann Arbor Veterans Affairs Medical Center Ann Arbor MI.,Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Medical School Ann Arbor MI
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Milenkina SG, Belogurov AA, Delver EP, Staroverov II. [Pharmacoinvasive Approach to the Treatment of Acute ST-Segment Elevation Myocardial Infarction. Current State of the Problem]. ACTA ACUST UNITED AC 2020; 60:62-69. [PMID: 32245356 DOI: 10.18087/cardio.2020.1.n699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022]
Abstract
The articled focused on the pharmacoinvasive approach to the treatment of acute ST-segment elevation myocardial infarction. Current guidelines prioritize the primary transcutaneous coronary intervention. However, in both the Russian Federation and other countries, there are some peculiarities (logistic issues, specific aspects of infrastructure of medical facilities), which may hamper timely conduction of the endovascular treatment. In such cases, the thrombolytic therapy subsequently supplemented with transcutaneous coronary intervention would appear the most effective strategy aimed at the earliest recovery of coronary perfusion. The authors provided results of major studies that used such approach and the effect of using the thrombolytic therapy with recombinant prourokinase, a Russian third generation thrombolytic drug.
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Affiliation(s)
| | | | - E P Delver
- Russian Medical Research Center of Cardiology
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2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion. Can J Cardiol 2019; 35:107-132. [PMID: 30760415 DOI: 10.1016/j.cjca.2018.11.031] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022] Open
Abstract
Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.
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Abstract
BACKGROUND Ischemic heart disease represents the most important cause of mortality worldwide, and the management of patients with ST-elevation myocardial infarction (STEMI) still remains a great challenge. For a great number of patients who do not have immediate access to primary percutaneous coronary intervention (PCI), facilitated angioplasty may be a reasonable therapeutic option. AREAS OF UNCERTAINTY The goal of reperfusion therapy is achieving repermeabilization of the infarct-related artery. However, the restoration of normal epicardial flow is not always followed by microvascular tissue perfusion and the presence of myocardial blush. Early studies assessing the benefits of facilitated angioplasty over primary PCI encountered disappointing results, with an increased number of bleeding complications. The invasive strategy following fibrinolysis mainly consists in angiography and PCI of the infarct-related artery between 2 and 24 hours after successful fibrinolysis or rescue PCI in failed fibrinolysis, hemodynamic, electrical instability, or worsening ischemia. Currently, a strategy of routine early angiography after fibrinolysis is recommended, taking into account studies that have demonstrated a reduced rate of reinfarction and recurrent ischemia, without an increased risk of stroke or major bleeding complications. THERAPEUTIC ADVANCES After evaluating 1892 patients with STEMI within 3 hours after the onset of symptoms and revealing, beyond clear benefit of fibrinolysis, an increased risk of bleeding complications, the STREAM trial was the one that led to halving the tenecteplase dose for patients aged >75 years. A safety profile of adjusted-dose fibrinolytic therapy in elderly patients with STEMI will be further investigated by the ongoing STREAM-2 trial. CONCLUSIONS With the current increased burden of acute coronary syndromes and the lack of immediate primary PCI facilities for all patients with STEMI, facilitated angioplasty seems a feasible therapeutic option. Another benefit of facilitated angioplasty may be represented by a major contribution of thrombolytic therapy in re-establishing microvascular myocardial blood flow.
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18
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Meyer C, Bowers A, Jaiswal D, Checketts J, Engheta M, Severns C, Cook S, Walters C, Vassar M. An analysis of randomized controlled trials underpinning ST-elevation myocardial infarction management guidelines. Am J Emerg Med 2019; 37:2229-2238. [PMID: 30940409 DOI: 10.1016/j.ajem.2019.03.038] [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] [Received: 01/31/2019] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The fragility index (FI) is calculated by iteratively changing one outcome "event" to a "non-event" within a trial until the associated p-value exceeds 0.05. PURPOSE To investigate the FI and fragility quotient (FQ) of trial endpoints referenced in the ACCF/AHA/SCAI guidelines in the management of ST-elevation myocardial infarctions. Secondarily, we assess the post-hoc power and risk of bias for these specific outcomes and whether differences exist between adequately and inadequately powered studies on fragility measures. BASIC PROCEDURES All citations referenced in the guideline were screened for inclusion criteria. The FI and FQ for all included trials were then calculated. The Cochrane 'risk of bias' Tool 2.0 was used to evaluate the likelihood and sources of bias in the included trials. MAIN FINDINGS Forty-two randomized controlled trials were included for assessment. The median FI was 10 with a FQ of 0.0055. Seven trials were at a high risk of bias, all due to bias in the randomization process. Fifteen trials were found to be underpowered. Adequately powered studies had higher FIs and FQs compared to underpowered studies. PRINCIPAL CONCLUSIONS Our findings support the use of FI and FQ analyses with power analyses in future methodology of randomized control trials. With understanding and reporting of FI and FQ, evidence of studies can be readily available and quickly eliminate some readers' concern for possible study limitations.
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Affiliation(s)
- Chase Meyer
- Oklahoma State University Center for Health Sciences, Dept. of Institutional Research, United States of America
| | - Aaron Bowers
- Oklahoma State University Center for Health Sciences, Dept. of Institutional Research, United States of America
| | - Dev Jaiswal
- Oklahoma State University Medical Center, Internal Medicine, United States of America
| | - Jake Checketts
- Oklahoma State University Center for Health Sciences, Dept. of Institutional Research, United States of America
| | - Michael Engheta
- Oklahoma State University Medical Center, Internal Medicine, United States of America
| | - Caleb Severns
- Oklahoma State University Medical Center, Internal Medicine, United States of America
| | - Sharolyn Cook
- Oklahoma State University Medical Center, Cardiology, United States of America
| | - Corbin Walters
- Oklahoma State University Center for Health Sciences, Dept. of Institutional Research, United States of America.
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences, Dept. of Institutional Research, United States of America
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Kilic S, Turkoglu C. Timing of Coronary Angiography After Successful Fibrinolytic Therapy in ST-Segment Elevated Myocardial Infarction. Cardiol Res 2019; 10:34-39. [PMID: 30834057 PMCID: PMC6396801 DOI: 10.14740/cr817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 12/26/2018] [Indexed: 11/11/2022] Open
Abstract
Background We aimed to compare outcomes of patients received successful fibrinolytic treatment (FT) for ST-segment elevated myocardial infarction (STEMI) and performed coronary angiography (CAG) within 24 - 72 h or after 72 h. Methods Between March 2013 and November 2014, 76 STEMI patients received successful FT and performed CAG > 24 h were included in the study. Patients were divided into two groups according to the time-interval from FT admission to CAG performing (Group-1, 24 - 72 h (n = 29), Group-2, > 72 h (n = 47)). The primary end point was major adverse cardiac events (MACE) defined as cardiovascular death, non-fatal myocardial infarction, and heart failure. Results The mean age of patients were 56 ± 11.4 years old (27.6% female). CAG was performed within mean 2.17 ± 0.38 days in the Group-1 and 2.9 ± 11.5 days in the Group 2 (P < 0.001). At short-term follow-up (6 months), MACE rate was higher in Group-2 (21.3%) than Group-1(13.8%), but it was not statistically significant (P = 0.661). The rate of MACE was 37.9% in Group-1 and 38.3% in Group-2 (P = 0.974) in the long-term follow-up (median: 57 months). Overall cardiac mortality rate was 7.9%, the re-infarction rate was 19.7% and heart failure was 17.1% in long-term follow-up, and there were no significant difference between groups. Conclusions Present study has shown that performance of CAG after 24 h of successful FT, within 24 - 74 h or > 72 h, did not shown any difference in term of MACE both in short and long-term follow-up.
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Affiliation(s)
- Salih Kilic
- Department of Cardiology, Doctor Ersin Arslan Research and Training Horpital, Gaziantep, Turkey
| | - Cuneyt Turkoglu
- Department of Cardiology, Ege University Faculty of Medicine, Izmir, Turkey
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20
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Bawaskar HS, Bawaskar PH, Bawaskar PH. Preintensive care: Thrombolytic (streptokinase or tenecteplase) in ST elevated acute myocardial infarction at peripheral hospital. J Family Med Prim Care 2019; 8:62-71. [PMID: 30911482 PMCID: PMC6396635 DOI: 10.4103/jfmpc.jfmpc_297_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Coronary artery disease is a major cause of death in India. Sudden death preceded by chest pain is due to acute myocardial infarction. Villagers are aware and afraid of chest pain. Majority of chest pain victims attend the primary physician in golden hours. Hence, primary doctors can play important role for early thrombolysis and salvage the myocardium from irreversible injury. This study determined year mortality in a patient who received the rapid thrombolysis at primary care hospital (streptokinase or tenecteplase) at rural setting. Setting: Peripheral General Hospital Mahad on Mumbai–Goa highway. Patients and Methods: Patients with typical chest pain with electrocardiogram showed ST segment elevated myocardial infarction (STEMI) with or without risk factors admitted from 2005 to march 2016 were studied. Details clinically studied: time interval between chest pain to hospital, hospital to needle time, reperfusion and arrhythmias. Time required for regression of elevated ST segment, a response to thrombolytic (streptokinase or tenecteplase) therapy, is studied. Results: Total 244 patient reported with chest pain of these 35 cases brought dead with history of chest pain and convulsive moment before they died. Of these, 209 patients had acute STEMI. Of these, 162 received streptokinase (STK) and 47 received tenecteplase (TNP)]. Analysis of STK Vs TNP patients 18 (11.11%) versus 3 (6.38%) (P = 0.361) died during the treatment. Around 17 (18.49%) vs 5 (10.63%) (P = 0.941) did not show signs of reperfusion, respectively. Re infarction occurred during hospitalization 3 (2.5%) versus 3 (6.38%) (P = 0.094) cases. Around 12 (7.40%) versus 0% (P = 0.072) died at the end of 12 months of thrombolytic therapy. Conclusion: Thrombolysis of STEMI within golden hours improved the reperfusion. However, 1-year fatality is significance with streptokinase as compared with tenecteplase.
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Affiliation(s)
- Himmatrao S Bawaskar
- Department of Medicine, Bawaskar Hospital and Clinical Research Center, Mahad Raigad, Maharashtra, India
| | - Pramodini H Bawaskar
- Department of Medicine, Bawaskar Hospital and Clinical Research Center, Mahad Raigad, Maharashtra, India
| | - Parag H Bawaskar
- Department of Cardiology, Topiwala National Medical College and BYL Nair Hospital, Mumbai, Maharashtra, India
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Dotta G, Fonseca FAH, Izar MCDO, Souza MTD, Moreira FT, Pinheiro LFM, Barbosa AHP, Caixeta AM, Póvoa RMS, Carvalho AC, Bianco HT. Regional QT Interval Dispersion as an Early Predictor of Reperfusion in Patients with Acute Myocardial Infarction after Fibrinolytic Therapy. Arq Bras Cardiol 2018; 112:20-29. [PMID: 30570061 PMCID: PMC6317627 DOI: 10.5935/abc.20180239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/02/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Patients with ST-elevation acute myocardial infarction attending primary care centers, treated with pharmaco-invasive strategy, are submitted to coronary angiography within 2-24 hours of fibrinolytic treatment. In this context, the knowledge about biomarkers of reperfusion, such as 50% ST-segment resolution is crucial. OBJECTIVE To evaluate the performance of QT interval dispersion in addition to other classical criteria, as an early marker of reperfusion after thrombolytic therapy. METHODS Observational study including 104 patients treated with tenecteplase (TNK), referred for a tertiary hospital. Electrocardiographic analysis consisted of measurements of the QT interval and QT dispersion in the 12 leads or in the ST-segment elevation area prior to and 60 minutes after TNK administration. All patients underwent angiography, with determination of TIMI flow and Blush grade in the culprit artery. P-values < 0.05 were considered statistically significant. RESULTS We found an increase in regional dispersion of the QT interval, corrected for heart rate (regional QTcD) 60 minutes after thrombolysis (p = 0.06) in anterior wall infarction in patients with TIMI flow 3 and Blush grade 3 [T3B3(+)]. When regional QTcD was added to the electrocardiographic criteria for reperfusion (i.e., > 50% ST-segment resolution), the area under the curve increased to 0.87 [(0.78-0.96). 95% IC. p < 0.001] in patients with coronary flow of T3B3(+). In patients with ST-segment resolution >50% and regional QTcD > 13 ms, we found a 93% sensitivity and 71% specificity for reperfusion in T3B3(+), and 6% of patients with successful reperfusion were reclassified. CONCLUSION Our data suggest that regional QTcD is a promising non-invasive instrument for detection of reperfusion in the culprit artery 60 minutes after thrombolysis.
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Affiliation(s)
- Gabriel Dotta
- Universidade Federal de São Paulo, São Paulo, SP - Brazil
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22
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Helal AM, Shaheen SM, Elhammady WA, Ahmed MI, Abdel-Hakim AS, Allam LE. Primary PCI versus pharmacoinvasive strategy for ST elevation myocardial infarction. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2018; 21:87-93. [PMID: 30402534 PMCID: PMC6205251 DOI: 10.1016/j.ijcha.2018.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The rationale for pharmacoinvasive strategy is that many patients have a persistent reduction in flow in the infarct-related artery. The aim of the present study is to assess safety and efficacy of pharmacoinvasive strategy using streptokinase compared to primary PCI and ischemia driven PCI on degree of myocardial salvage and outcomes. METHODS AND RESULTS Sixty patients with 1st attack of acute STEMI within 12 h were randomized to 4 groups: primary PCI for patients presented to PPCI-capable centers (group I), transfer to PCI if presented to non-PCI capable center (group II), pharmacoinvasive strategy "Streptokinase followed by PCI within 3-24 h" (group III) and fibrinolytic followed by ischemia driven PCI (group IV). The primary endpoint is the infarction size and microvascular obstruction (MVO) measured by cardiac MRI (CMR) 3-5 days post-MI. Pharmacoinvasive strategy led to a significant reduction in infarction size, MVO and major adverse cardiac and cerebrovascular event (MACCE) compared to group IV but minor bleeding was significantly higher compared to other groups. CONCLUSIONS Pharmacoinvasive strategy resulted in effective reperfusion and smaller infarction size in patients with early STEMI who could not undergo primary PCI within 2 h after the first medical contact. This can provide a wide time window for PCI when the application of primary PCI within the optimal time limit is not possible. However, it was associated with a slightly increased risk of minor bleeding.
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Affiliation(s)
- Ayman M Helal
- Faculty of Medicine, Fayoum University, Cairo, Egypt
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Frampton J, Devries JT, Welch TD, Gersh BJ. Modern Management of ST-Segment Elevation Myocardial Infarction. Curr Probl Cardiol 2018; 45:100393. [PMID: 30660333 DOI: 10.1016/j.cpcardiol.2018.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 12/31/2022]
Abstract
Disruption of intracoronary plaque with thrombus formation resulting in severe or total occlusion of the culprit coronary artery provides the pathophysiologic foundation for ST-segment elevation myocardial infarction (STEMI). Management of STEMI focuses on timely restoration of coronary blood flow along with antithrombotic therapies and secondary prevention strategies. The purpose of this review is to discuss the epidemiology, pathophysiology, and diagnosis of STEMI. In addition, the review will focus on guideline-directed therapy for these patients and review potential associated complications.
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Siddiqi TJ, Usman MS, Khan MS, Sreenivasan J, Kassas I, Riaz H, Raza S, Deo SV, Sharif H, Kalra A, Yadav N. Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction. Am J Cardiol 2018; 122:542-547. [PMID: 30205885 DOI: 10.1016/j.amjcard.2018.04.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 12/24/2022]
Abstract
ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.
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Affiliation(s)
| | | | | | | | - Ibrahim Kassas
- Division of Cardiology, New York University School of Medicine, New York, New York
| | - Haris Riaz
- Division of Cardiology, Cleveland Clinic, Cleveland Ohio
| | - Sajjad Raza
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Salil V Deo
- Department of Cardiac Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Hasanat Sharif
- Department of Cardiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ankur Kalra
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Neha Yadav
- Division of Cardiology, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
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Couture EL, Huynh T. Drip-and-Ship vs Watchful Waiting: What Should Be the Optimal Approach After Fibrinolytic Therapy for Myocardial Infarction With ST-Segment Elevation? Can J Cardiol 2018; 34:700-702. [DOI: 10.1016/j.cjca.2018.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 10/17/2022] Open
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Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimský P. [2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.]. Eur Heart J 2018; 39:119-177. [PMID: 29457615 DOI: 10.1093/eurheartj/ehx393] [Citation(s) in RCA: 6036] [Impact Index Per Article: 1006.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Borja Ibanez
- Department of Cardiology, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.
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Mannsverk J, Steigen T, Wang H, Tande PM, Dahle BM, Nedrejord ML, Hokland IO, Gilbert M. Trends in clinical outcomes and survival following prehospital thrombolytic therapy given by ambulance clinicians for ST-elevation myocardial infarction in rural sub-arctic Norway. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:8-14. [PMID: 29256635 DOI: 10.1177/2048872617748550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND: Prehospital thrombolytic therapy given by ambulance emergency medical services to patients with acute ST-segment elevation myocardial infarction (STEMI) may produce earlier reperfusion than percutaneous coronary intervention. Clinical results from prehospital thrombolytic therapy in rural areas are scarce. METHODS: We studied outcomes during 11 years of a prehospital thrombolytic therapy system in rural sub-arctic Norway. Ambulance personnel gave protocol basic treatment and transmitted electrocardiograms to hospital physicians who made the decision for prehospital thrombolytic therapy. The study was divided into three time periods; 2000-2003, 2004-2007 and 2008-2011. RESULTS: A total of 385 STEMI patients received prehospital thrombolytic therapy, median patient age was 61.2 years, and 77% were men. Time saved by prehospital reperfusion therapy was 131 minutes. The proportion who got prehospital thrombolytic therapy within 2 hours of symptom onset increased from 21% in 2000-2003 to 39% in 2008-2011 ( P=0.003). The proportion who underwent coronary angiography or percutaneous coronary intervention within 24 hours of first medical contact increased from 56.4% to 95.4% ( P<0.001). Post-STEMI systolic heart failure decreased from 19.4% to 8.1% ( P=0.02), while 1-year mortality fell, non-significantly, by 50% over time to reach 5.6%. Thirteen patients suffered acute out-of-hospital cardiac arrest; all were successfully defibrillated. Ten patients had major bleeding events (2.6%). CONCLUSION: A decentralised prehospital thrombolytic therapy system based on ambulance personnel, telemetry and centralised 7/24 invasive diagnosis and treatment service, combined with system maturation over time, was associated with earlier reperfusion, improved clinical outcomes and better survival. Prehospital thrombolytic therapy is a feasible and safe intervention used in rural settings with long evacuation lines to percutaneous coronary intervention facilities.
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Affiliation(s)
- Jan Mannsverk
- 1 Department of Cardiology, University Hospital of North Norway, Norway
| | - Terje Steigen
- 1 Department of Cardiology, University Hospital of North Norway, Norway.,2 Cardiovascular Diseases Research Group, UiT The Arctic University of Norway, Norway
| | - Harald Wang
- 1 Department of Cardiology, University Hospital of North Norway, Norway
| | - Pål Morten Tande
- 1 Department of Cardiology, University Hospital of North Norway, Norway
| | | | | | - Ida Olsen Hokland
- 1 Department of Cardiology, University Hospital of North Norway, Norway
| | - Mads Gilbert
- 2 Cardiovascular Diseases Research Group, UiT The Arctic University of Norway, Norway.,3 Clinic of Emergency Medical Services, University Hospital of North Norway, Norway.,4 Anesthesia and Critical Care Research Group, UiT The Arctic University of Norway, Norway
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Paul A, George PV. Left ventricular global longitudinal strain following revascularization in acute ST elevation myocardial infarction - A comparison of primary angioplasty and Streptokinase-based pharmacoinvasive strategy. Indian Heart J 2017; 69:695-699. [PMID: 29174244 PMCID: PMC5717277 DOI: 10.1016/j.ihj.2017.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 04/09/2017] [Accepted: 04/17/2017] [Indexed: 01/18/2023] Open
Abstract
Objective Tenecteplase-based pharmacoinvasive percutaneous coronary intervention (PCI) has been shown to yield outcomes comparable to primary PCI in the setting of acute ST elevation myocardial infarction (STEMI). This study was designed to compare the efficacy of pharmacoinvasive PCI following successful thrombolysis with Streptokinase versus primary PCI in patients with STEMI. Methodology We conducted a prospective single center observational study in 120 patients with STEMI who underwent primary PCI (n = 60) and Streptokinase-based pharmacoinvasive PCI (n = 60). Patients with Killips class 3 or 4 at presentation, and those with evidence of failed fibrinolysis were excluded. The primary outcome was LV systolic function after angioplasty, as assessed by 2D global longitudinal strain (GLS) using speckle tracking echocardiography (STE), as well as 2D LVEF using Simpson's biplane method. Results LV systolic function after PCI was significantly lower in the pharmacoinvasive arm as compared to the primary PCI arm, both by 2D STE (GLS: −9% vs −11%; p = 0.03) and 2D Simpson's biplane method (LVEF: 40.7% vs 45.1%; p = 0.02). TIMI flow in the culprit vessel prior to angioplasty was better in the pharmacoinvasive arm indicating successful thrombolysis, whereas post angioplasty flow was not different. There was no in-hospital mortality in either group. There was a trend toward increased incidence of acute kidney injury in the pharmacoinvasive arm. Conclusion LV systolic function is significantly better after primary angioplasty as compared to pharmacoinvasive PCI following successful thrombolysis with Streptokinase.
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Affiliation(s)
- Amal Paul
- Department of Cardiology, Christian Medical College Vellore, Tamilnadu 632004, India.
| | - Paul V George
- Department of Cardiology, Christian Medical College Vellore, Tamilnadu 632004, India.
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Geng W, Zhang Q, Liu J, Tian X, Zhen L, Song D, Yang Y, Meng H, Wang Y, Chen J. A randomized study of prourokinase during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction. J Interv Cardiol 2017; 31:136-143. [PMID: 29171086 DOI: 10.1111/joic.12461] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/16/2017] [Accepted: 09/26/2017] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). METHODS Acute STEMI patients underwent primary PCI were randomly divided into two groups: intracoronary prourokinase (IP) group (n = 118) and control group (n = 112). During primary PCI, prourokinase or saline were injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and MACE occurred in the 6-months follow up were recorded. RESULTS No significant differences were observed between two groups with respect to baseline demographic, clinical, and angiographic characteristics (P > 0.05). In IP group, more patients had complete ST segment resolution (>70%) compared with control group (P < 0.05). Patients in IP group showed lower levels of serum CK, CK-MB and TnI, and a much higher myocardial blood flow (MBF) than those in control group (P < 0.05). No significant differences of TIMI major or minor bleeding complications were observed between the two groups (P > 0.05). At 6-months follow-up, there was a trend that patients in the IP group had a less chance to have MACE, though it was not statistically different (8.5% vs 12.5%, P > 0.05). CONCLUSIONS Intracoronary administration of prourokinase via balloon catheter during primary PCI effectively improved myocardial perfusion in STEMI patients.
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Affiliation(s)
- Wei Geng
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Qi Zhang
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Jingmin Liu
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Xiang Tian
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Libo Zhen
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Da Song
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Ying Yang
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Haiyun Meng
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Yafang Wang
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
| | - Jianjun Chen
- Department of Cardiology, Baoding First Central Hospital, Baoding, Hebei, China
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Russo JJ, Goodman SG, Cantor WJ, Ko DT, Bagai A, Tan MK, Di Mario C, Halvorsen S, Le May M, Fernandez-Avilés F, Scheller B, Armstrong PW, Borgia F, Piscione F, Sanchez PL, Yan AT. Does renal function affect the efficacy or safety of a pharmacoinvasive strategy in patients with ST-elevation myocardial infarction? A meta-analysis. Am Heart J 2017; 193:46-54. [PMID: 29129254 DOI: 10.1016/j.ahj.2017.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/30/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND The efficacy and safety of pharmacoinvasive strategy following fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to renal function have not been established. METHODS Using patient-level data from 4 randomized controlled trials, we examined the efficacy and safety of pharmacoinvasive versus standard treatment after fibrinolysis for STEMI. Patients were stratified based on the estimated glomerular filtration rate (eGFR) on presentation (<60 mL/min/1.73 m2 vs ≥60 mL/min/1.73 m2). The primary outcome was the composite of death or reinfarction at 30 days. RESULTS Of 2,029 patients, 457 (23%) had an eGFR<60 mL/min/1.73 m2. Patients with eGFR<60 mL/min/1.73 m2 were older and had higher Thrombolysis in Myocardial Infarction risk scores. Compared with patients with eGFR≥60 mL/min/1.73 m2, patients with renal dysfunction had higher rates of the primary outcome (5.3% vs 11.8%, respectively; P<.001). There was no significant heterogeneity in the treatment effect of pharmacoinvasive strategy on the primary outcome (P heterogeneity=.73) or the rate of death or reinfarction at 1 year (P heterogeneity=.64) in relation to eGFR. Patients with renal dysfunction had higher rates of in-hospital major bleeding compared with patients with eGFR ≥60 mL/min/1.73 m2 (7.7% vs 4.3%, respectively; P=.004); however, there was no difference in bleeding events between treatment arms in the overall cohort or in relation to eGFR (P heterogeneity=.67). CONCLUSIONS Renal impairment is associated with increased rates of adverse events in STEMI patients treated with fibrinolysis. However, the safety and efficacy of pharmacoinvasive strategy are preserved in patients with renal impairment on presentation.
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Affiliation(s)
- Juan J Russo
- Terrence Donnelly Heart Centre, Michael's Hospital, Toronto, Ontario; University of Toronto, Toronto, Ontario; University of Ottawa Heart Institute, Ottawa, Ontario
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, Michael's Hospital, Toronto, Ontario; University of Toronto, Toronto, Ontario; Canadian Heart Research Centre, Toronto, Ontario
| | - Warren J Cantor
- University of Toronto, Toronto, Ontario; Southlake Regional Health Centre, Newmarket, Ontario
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences (ICES), Sunnybrook Research Institute (SRI), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, Michael's Hospital, Toronto, Ontario; University of Toronto, Toronto, Ontario
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Ontario
| | - Carlo Di Mario
- NHLI Imperial College, London, UK, and University Hospital Careggi, Florence, Italy
| | | | - Michel Le May
- University of Ottawa Heart Institute, Ottawa, Ontario
| | | | - Bruno Scheller
- Innere Medizin III, Universitat des Saarlandes, Homburg, Germany
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta
| | | | - Federico Piscione
- Academic Hospital SS. Giovanni e Ruggi, University of Salerno, Salerno, Italy
| | | | - Andrew T Yan
- Terrence Donnelly Heart Centre, Michael's Hospital, Toronto, Ontario; University of Toronto, Toronto, Ontario.
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Dehghani P, Lavoie A, Lavi S, Crawford JJ, Harenberg S, Zimmermann RH, Booker J, Kelly S, Cantor WJ, Mehta SR, Bagai A, Goodman SG, Cheema AN. Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI. Am Heart J 2017; 192:105-112. [PMID: 28938956 DOI: 10.1016/j.ahj.2017.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/12/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Patients undergoing PCI early after fibrinolytic therapy are at high risk for both thrombotic and bleeding complications. We sought to assess the pharmacodynamic effects of ticagrelor versus clopidogrel in the fibrinolytic-treated STEMI patients undergoing early PCI. METHODS AND RESULTS Patients undergoing PCI within 24 hours of tenecteplase (TNK), aspirin, and clopidogrel for STEMI were randomized to receive additional clopidogrel 300 mg followed by 75 mg daily or ticagrelor 180 mg followed by 90 mg twice daily. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline) at 4 and 24 hours post-PCI. The primary end point was PRU ≤208 at 4 hours. A total of 140 patients (74 in ticagrelor and 66 in clopidogrel group) were enrolled. The mean PRU values at baseline were similar for the 2 groups (257.8±52.9 vs 259.5±56.7, P=.85, respectively). Post-PCI, patients on ticagrelor, compared to those on clopidogrel, had significantly lower PRU at 4 hours (78.7±88 vs 193.6±86.5, respectively, P<.001) and at 24 hours (34.5±35.0 and 153.5±75.5, respectively, P<.001). The primary end point was observed in 87.8% (n=65) in the ticagrelor-treated patients compared to 57.6% (n=38) of clopidogrel-treated patients, P<.001. CONCLUSION Fibrinolysis-treated STEMI patients who received clopidogrel and aspirin at the time of fibrinolysis and were undergoing early PCI frequently had PRU >208. In this high-risk population, ticagrelor provides more prompt and potent platelet inhibition compared with clopidogrel (Funded by Astra Zeneca; NCT01930591, https://clinicaltrials.gov/ct2/show/NCT01930591).
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada.
| | - Andrea Lavoie
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Shahar Lavi
- London Health Sciences, University of London, London, Ontario, Canada
| | - Jennifer J Crawford
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Sebastian Harenberg
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Rodney H Zimmermann
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Jeff Booker
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Sheila Kelly
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Asim N Cheema
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Khan AA, Williams T, Savage L, Stewart P, Ashraf A, Davies AJ, Faddy S, Attia J, Oldmeadow C, Bhagwandeen R, Fletcher PJ, Boyle AJ. Pre-hospital thrombolysis in ST-segment elevation myocardial infarction: a regional Australian experience. Med J Aust 2017; 205:121-5. [PMID: 27465767 DOI: 10.5694/mja15.01336] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 06/10/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The system of care in the Hunter New England Local Health District for patients with ST-segment elevation myocardial infarction (STEMI) foresees pre-hospital thrombolysis (PHT) administered by paramedics to patients more than 60 minutes from the cardiac catheterisation laboratory (CCL), and primary percutaneous coronary intervention (PCI) at the CCL for others. We assessed the safety and effectiveness of the pre-hospital diagnosis strategy, which allocates patients to PHT or primary PCI according to travel time to the CCL. DESIGN, SETTING AND PARTICIPANTS Prospective, non-randomised, consecutive, single-centre case series of STEMI patients diagnosed on the basis of a pre-hospital electrocardiogram (ECG), from August 2008 to August 2013. All patients were treated at the tertiary referral hospital (John Hunter Hospital, Newcastle). MAIN OUTCOME MEASURES The primary efficacy endpoint was all-cause mortality at 12 months; the primary safety endpoint was bleeding. RESULTS STEMI was diagnosed in 484 patients on the basis of pre-hospital ECG; 150 were administered PHT and 334 underwent primary PCI. The median time from first medical contact (FMC) to PHT was 35 minutes (IQR, 28-43 min) and to balloon inflation 130 minutes (IQR, 100-150 min). In the PHT group, 37 patients (27%) needed rescue PCI (median time, 4 h; IQR, 3-5 h). The 12-month all-cause mortality rate was 7.0% (PHT, 6.7%; PCI, 7.2%). The incidence of major bleeding (TIMI criteria) in the PHT group was 1.3%; no patients in the primary PCI group experienced major bleeding. CONCLUSION PHT can be delivered safely by paramedical staff in regional and rural Australia with good clinical outcomes.
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Affiliation(s)
| | | | | | | | - Asma Ashraf
- Hunter Medical Research Institute, University of Newcastle, Newcastle
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Coronary angiography after successful thrombolysis - Is the recommended time interval of 24h an important issue? Int J Cardiol 2016; 222:515-520. [PMID: 27509219 DOI: 10.1016/j.ijcard.2016.07.193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/28/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Percutaneous coronary intervention (PCI) is currently considered the gold-standard treatment of acute coronary syndromes with ST-segment elevation (STEMI). However, this is not the reality of many European centers, where thrombolysis is performed as primary therapy. AIMS To determine, in a STEMI population that performed successful fibrinolytic treatment, if the performance of coronary angiography after the first 24h was associated with more hospital complications, including higher mortality, compared with its performance in the recommended time. METHODS Retrospective study, including 1065 patients with STEMI, who performed successful thrombolysis. The population was divided in three groups: A, patients who didn't undergo coronary angiography after successful thrombolysis (n=278; 26.1%); B, patients who underwent coronary angiography in the first 24h after successful thrombolysis (n=127; 11.9%); and C, patients who underwent angiography after the first 24h (n=660; 62.0%). Groups were compared regarding their characteristics and in-hospital complications. RESULTS Groups B and C had more male patients and had younger patients than group A. Group A presented higher Killip classes at admission, more severe left ventricle dysfunction and a higher number of complications during hospitalization. Logistic regression revealed that: 1) the non-performance of coronary angiography after thrombolysis was an independent predictor of in-hospital mortality; and 2) the performance of angiography after the recommended time wasn't associated with higher mortality. CONCLUSIONS Coronary angiography after thrombolysis constitutes an important strategy, whose non-performance carries worse prognosis. The time interval currently recommended of 24h seems clinically acceptable; however, its realization outside the recommended time doesn't seem to lead to higher mortality.
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Radial versus femoral access for percutaneous coronary intervention in ST-elevation myocardial infarction patients treated with fibrinolysis: Results from the randomized routine early invasive clinical trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:295-301. [PMID: 27116940 DOI: 10.1016/j.carrev.2016.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/11/2016] [Accepted: 03/21/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND To investigate the relationship between arterial access site choice (radial versus femoral) and clinical outcomes among STEMI patients undergoing routine PCI after fibrinolysis. METHODS Patient-level data from trials of STEMI patients evaluating routine PCI after fibrinolysis were included. The primary endpoint was 30-day major bleeding; secondary endpoints included 30-day death and re-infarction. RESULTS 1891 patients underwent PCI (trans-radial n=338, trans-femoral n=1553). Trans-radial PCI patients were less likely to be >75years (2% vs. 8%, p=0.0001), heavier (median weight 82 [72-90] vs. 80 [70-90] kg, p=0.0013) and more likely in Killip class I at presentation (87% vs. 82%, p=0.03). At 30days, trans-radial PCI was associated with a similar unadjusted risk for major bleeding (3.7% vs. 1.2%, Odds Ratio [OR] 0.43 [95% CI 0.13-1.48], p=0.18), mortality (3.4% vs. 1.2%, OR 0.34 [0.09-1.28], p=0.11) and re-infarction (3.9% vs. 4.7%, OR 1.25 [0.60-2.58], p=0.56). In multivariable analysis, radial access was associated with similar estimates for bleeding and death/reinfarction risk. CONCLUSIONS In STEMI patients treated with fibrinolysis and undergoing an early routine invasive strategy, radial compared to femoral PCI is chosen in younger, less ill patients and is independently associated with similar risk of bleeding, re-infarction, and mortality. SUMMARY This study evaluated the relationship between arterial access choice (radial versus femoral) and in-hospital and 30-day outcomes in patients undergoing routine PCI after fibrinolysis for STEMI. We included patient-level data from trials evaluating a strategy of routine PCI after fibrinolysis for STEMI. Of 1891 patients undergoing PCI, trans-radial access (n=338) was chosen in younger, lower risk patients. At 30days, trans-radial access was associated with a similar unadjusted and adjusted risk of major bleeding, re-infarction and mortality.
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O'Connor RE, Al Ali AS, Brady WJ, Ghaemmaghami CA, Menon V, Welsford M, Shuster M. Part 9: Acute Coronary Syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S483-500. [PMID: 26472997 DOI: 10.1161/cir.0000000000000263] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Nikolaou N, Arntz H, Bellou A, Beygui F, Bossaert L, Cariou A. Das initiale Management des akuten Koronarsyndroms. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Liu F, Guo Q, Xie G, Zhang H, Wu Y, Yang L. Percutaneous Coronary Intervention after Fibrinolysis for ST-Segment Elevation Myocardial Infarction Patients: An Updated Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0141855. [PMID: 26523834 PMCID: PMC4629904 DOI: 10.1371/journal.pone.0141855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/14/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI), fibrinolysis and the combination of both methods are current therapeutic options for patients with ST-segment elevation myocardial infarction (STEMI). METHODS We searched PubMed, EMBASE, Google scholar and Cochrane Controlled Trials Register for randomized controlled trials (RCTs) evaluating the efficacy and safety of PCI after fibrinolysis within 24 hours, which was compared with primary PCI alone and ischemia-guided or delayed PCI. Meta-analysis was conducted using Review Manager 5.30 following the methods described by the Cochrane library. RESULTS A total of 16 studies including 10,034 patients were enrolled. As compared with primary PCI alone group, the short-term mortality (5.8% vs 4.5%, RR 1.29, 95% confidence interval [CI] 1.00-1.65) and re-infarction rate (4.1% vs 2.7%, RR 1.46, 95%CI 1.05-2.03) were higher in the immediate PCI group (median/mean time ≤ 2 h after fibrinolysis). However, the short-term mortality and re-infarction rate showed no statistically significant differences in the early PCI group (2-24 hours after fibrinolysis). The rate of major bleeding events was higher both in the immediate PCI (6.3% vs 4.4%, RR 1.43, 95%CI 1.11-1.85) and the early PCI group (6.4% vs 4.4%, RR 1.46, 95%CI 1.03-2.06) as compared with primary PCI alone group. As compared with ischemia-guided or delayed PCI, early PCI was associated with significantly reduced re-infarction (2.4% vs 4.0%, RR 0.61, 95%CI 0.41-0.92) and recurrent ischemia (1.5% vs 5.3%, RR 0.29, 95%CI 0.12-0.70) at short-term. And the reduced re-infarction rate was also observed at long-term. CONCLUSIONS Early PCI after fibrinolysis, with a relatively broader time for PCI preparation, can bring the similar effects with primary PCI alone and is better than ischemia-guided or delayed PCI in STEMI patients with symptom onset < 12 h who cannot receive timely PCI. However, immediate PCI after fibrinolysis is detrimental.
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Affiliation(s)
- Feng Liu
- Department of Postgraduate, Third Military Medical University, Chongqing, China
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Qinglong Guo
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Guoqiang Xie
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Han Zhang
- Department of Postgraduate, Second Military Medical University, Shanghai, China
| | - Yaxi Wu
- Department of Cardiology, Kunming General Hospital of Chengdu Military Area, Yunnan, China
- Department of Postgraduate, Kunming Medical University, Yunnan, China
| | - Lixia Yang
- Department of Cardiology, Kunming General Hospital of Chengdu Military Area, Yunnan, China
- * E-mail:
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Nikolaou NI, Arntz HR, Bellou A, Beygui F, Bossaert LL, Cariou A, Danchin N. European Resuscitation Council Guidelines for Resuscitation 2015 Section 8. Initial management of acute coronary syndromes. Resuscitation 2015; 95:264-77. [DOI: 10.1016/j.resuscitation.2015.07.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Nikolaou NI, Welsford M, Beygui F, Bossaert L, Ghaemmaghami C, Nonogi H, O’Connor RE, Pichel DR, Scott T, Walters DL, Woolfrey KG, Ali AS, Ching CK, Longeway M, Patocka C, Roule V, Salzberg S, Seto AV. Part 5: Acute coronary syndromes. Resuscitation 2015; 95:e121-46. [DOI: 10.1016/j.resuscitation.2015.07.043] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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Arriaga-Nava R, Valencia-Sánchez JS, Rosas-Peralta M, Garrido-Garduño M, Calderón-Abbo M. [Prehospital thrombolysis: A national perspective. Pharmaco-invasive strategy for early reperfusion of STEMI in Mexico]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 85:307-17. [PMID: 26256256 DOI: 10.1016/j.acmx.2015.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 06/16/2015] [Accepted: 06/23/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To review the existing evidence on the role of prehospital thrombolysis in patients with ST-segment elevation acute myocardial infarction (STEMI) as part of a strategy of cutting edge to reduce the time of coronary reperfusion and as a consequence improves both the survival and function. METHODS We used the technique of exploration-reduction-evaluation-analysis and synthesis of related studies, with an overview of current recommendations, data from controlled clinical trials and from the national and international registries about the different strategies for STEMI reperfusion. In total, we examined 186 references on prehospital thrombolysis, 130 references in times door-treatment, 139 references in STEMI management and national and international registries as well as 135 references on rescue and primary percutaneous coronary intervention for STEMI. Finally the 48 references that were more relevant and informative were retained. CONCLUSION The «time» factor is crucial in the success of early reperfusion in STEMI especially if thrombolysis is applied correctly during the prehospital time. The primary percutaneous coronary intervention is contingent upon its feasibility before 120 min from the onset of symptoms. In our midst to internationally, thrombolysis continues to be a strategy with great impact on their expectations of life and function of patients. Telecommunication systems should be incorporate in real time to the priority needs of catastrophic diseases such as STEMI where life is depending on time.
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Affiliation(s)
- Roberto Arriaga-Nava
- División Médica, Hospital de Cardiología, Unidad Médica de Alta Especialidad, Centro Médico Nacional Siglo XXI, México, D. F., México
| | - Jesús-Salvador Valencia-Sánchez
- Dirección de Enseñanza e Investigación, Hospital de Cardiología, Unidad Médica de Alta Especialidad, Centro Médico Nacional Siglo XXI, México, D. F., México
| | - Martin Rosas-Peralta
- Investigación en Salud, Hospital de Cardiología, Unidad Médica de Alta Especialidad, Centro Médico Nacional Siglo XXI, México, D. F., México; Academia Nacional de Medicina de México, A. C., México, D. F., México.
| | - Martin Garrido-Garduño
- División Médica, Hospital de Cardiología, Unidad Médica de Alta Especialidad, Centro Médico Nacional Siglo XXI, México, D. F., México
| | - Moisés Calderón-Abbo
- Dirección General, Hospital de Cardiología, Unidad Médica de Alta Especialidad, Centro Médico Nacional Siglo XXI, México, D. F., México
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Abdel-Qadir H, Yan AT, Tan M, Borgia F, Piscione F, Di Mario C, Halvorsen S, Cantor WJ, Westerhout CM, Scheller B, Le May MR, Fernandez-Aviles F, Sánchez PL, Lee DS, Goodman SG. Consistency of benefit from an early invasive strategy after fibrinolysis: a patient-level meta-analysis. Heart 2015; 101:1554-61. [DOI: 10.1136/heartjnl-2015-307815] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/18/2015] [Indexed: 12/22/2022] Open
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Ranasinghe I, Barzi F, Brieger D, Gallagher M. Long-term mortality following interhospital transfer for acute myocardial infarction. Heart 2015; 101:1032-40. [PMID: 25736049 DOI: 10.1136/heartjnl-2014-306966] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/01/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Interhospital transfer of patients admitted with an acute myocardial infarction for specialised care is common and costly. However, the long-term mortality of transferred patients compared with patients solely treated at the presenting hospital has not been evaluated. Here, we assess the long-term mortality of patients who undergo interhospital transfer during their acute myocardial infarction admission. METHODS We evaluated 40 482 patients with a ICD10-AM diagnosis of acute myocardial infarction admitted to hospitals in New South Wales, Australia, from 2004 to 2008, of whom 10 107 (25%) were transferred. We compared in-hospital and mortality up to 5.5 years postdischarge among transferred and non-transferred patients. We created a 1:1 propensity score matched cohort (n=16 854; 8427 per group) to account for selection bias. RESULTS In the matched cohort, transferred patients were more likely to undergo revascularisation (55.6% vs 13.7%, RR 4.05; 95% CI 3.83 to 4.29) and had lower mortality at 30 days (3.5% vs 5.7%, HR 0.60; 95% CI 0.52 to 0.70), 1 year (7.5% vs 12.6%, HR 0.58; 95% CI 0.52 to 0.64) and at the end of follow-up (15.3% vs 22.5%, HR 0.65; 95% CI 0.61 to 0.70) than patients treated in presenting hospitals. With the exception of transfers originating from revascularisation capable hospitals, these findings were consistent across a range of subgroups, including patients of all ages, ST-elevation myocardial infarction and non ST-elevation myocardial infarction patients, and transfers originating from hospitals in regional and major city areas. Sensitivity analyses showed that these findings are unlikely to be due to survival bias or to confounding by unmeasured variables. CONCLUSIONS Patients hospitalised for an acute myocardial infarction who are transferred to one or more hospitals for specialised care have higher rates of coronary revascularisation and experience lower long-term mortality.
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Affiliation(s)
- Isuru Ranasinghe
- The University of Adelaide, Adelaide, Australia The George Institute for Global Health, Sydney, Australia
| | - Federica Barzi
- The George Institute for Global Health, Sydney, Australia University of Sydney, Sydney, Australia
| | - David Brieger
- The George Institute for Global Health, Sydney, Australia Concord Repatriation & General Hospital, Sydney, Australia
| | - Martin Gallagher
- The George Institute for Global Health, Sydney, Australia University of Sydney, Sydney, Australia Concord Repatriation & General Hospital, Sydney, Australia
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Gershlick AH, Westerhout CM, Armstrong PW, Huber K, Halvorsen S, Steg PG, Ostojic M, Goldstein P, Carvalho AC, Van de Werf F, Wilcox RG. Impact of a pharmacoinvasive strategy when delays to primary PCI are prolonged. Heart 2015; 101:692-8. [DOI: 10.1136/heartjnl-2014-306686] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 01/25/2015] [Indexed: 02/01/2023] Open
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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47
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Madan M, Halvorsen S, Di Mario C, Tan M, Westerhout CM, Cantor WJ, Le May MR, Borgia F, Piscione F, Scheller B, Armstrong PW, Fernandez-Aviles F, Sanchez PL, Graham JJ, Yan AT, Goodman SG. Relationship Between Time to Invasive Assessment and Clinical Outcomes of Patients Undergoing an Early Invasive Strategy After Fibrinolysis for ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2015; 8:166-174. [DOI: 10.1016/j.jcin.2014.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/10/2014] [Accepted: 09/24/2014] [Indexed: 12/22/2022]
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48
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Elbarouni B, Cantor WJ, Ducas J, Borgundvaag B, Džavík V, Heffernan M, Buller CE, Langer A, Goodman SG, Yan AT. Efficacy of an early invasive strategy after fibrinolysis in ST-elevation myocardial infarction relative to the extent of coronary artery disease. Can J Cardiol 2014; 30:1555-61. [PMID: 25475460 DOI: 10.1016/j.cjca.2014.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A strategy of early transfer for coronary angiography and intervention is superior to a standard approach of delayed coronary angiography after fibrinolysis for ST-elevation myocardial infarction (STEMI). STEMI patients with lesions in noninfarct-related arteries have a worse prognosis compared with patients with single vessel disease. This study aimed to assess whether the benefits of an early invasive strategy differ in patients with single vessel and multivessel disease. METHODS The Trial of Routine ANgioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomized STEMI patients receiving fibrinolysis to a strategy of early transfer and coronary angiography vs a standard approach. In this post hoc analysis, we stratified 992 patients into 2 groups according to the presence or absence of multivessel disease. We compared the 2 groups in terms of baseline characteristics, in-hospital management, and patient outcomes, and tested for treatment heterogeneity. RESULTS Multivessel disease was present in 369 (37%) patients. Patients with multivessel disease had a greater rate of the primary composite end point of in-hospital death, recurrence of infarction, recurrent ischemia, shock, or heart failure at 30 days (18.2% vs 10.8%; P < 0.001). An early invasive strategy was efficacious in both groups for the primary outcome. In multivariable analysis adjusting for Global Registry of Acute Coronary Events (GRACE) risk score, there was no significant treatment heterogeneity (all P interaction > 0.40) for the primary end point, or death/recurrence of infarction at 6 months and 1 year. CONCLUSIONS Multivessel disease is present in a significant proportion of STEMI patients treated with fibrinolysis and is associated with worse outcomes. A strategy of early transfer and coronary intervention after fibrinolysis was beneficial regardless of the presence or absence of multivessel disease.
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Affiliation(s)
- Basem Elbarouni
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, Newmarket, University of Toronto, Toronto, Ontario, Canada
| | - John Ducas
- St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Christopher E Buller
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anatoly Langer
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Andrew T Yan
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Routine invasive management early after fibrinolysis: relationship between baseline risk and treatment effects in a pooled patient-level analysis of 7 randomized controlled trials. Am Heart J 2014; 168:757-65. [PMID: 25440805 DOI: 10.1016/j.ahj.2014.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 07/31/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND The efficacy of a routine invasive strategy early after fibrinolysis in relation to baseline risk status is unclear. We sought to characterize the interaction between patient risk and treatment with routine invasive strategy early after fibrinolysis for ST-segment elevation myocardial infarction. METHODS We pooled 2,974 patients from 7 randomized trials of fibrinolysis-treated patients with ST-segment elevation myocardial infarction comparing a routine early invasive strategy with a standard approach of percutaneous coronary intervention (PCI) guided by recurrent ischemia or need for rescue. Cox proportional hazards regression was used to examine the interaction between baseline patient risk classified by Thrombolysis in Myocardial Infarction risk score (low/intermediate: ≤ 5 [n = 2,697] vs high: > 5 [n = 277]) and treatment with routine early invasive strategy. RESULTS Time to PCI after fibrinolysis was longer among patients randomized to standard treatment compared with routine early invasive strategy in the low/intermediate-risk strata (median 11.4 vs 3.5 hours), but was only marginally different between the 2 groups in the high-risk strata (median 4.1 vs 3.5 hours). There was a significant interaction between treatment assignment and risk status for the composite of 30-day death or reinfarction (P = .01). Compared with standard treatment, routine early invasive strategy was associated with lower 30-day death/reinfarction in the low/intermediate-risk stratum (7.5% vs 4.0%, P < .001), but not in the high-risk stratum (14.9% vs 19.6%, P = .45). CONCLUSIONS Although clearly beneficial among the larger subgroup of patients at low/intermediate risk, the benefit of a routine early invasive strategy was not evident in the smaller subgroup of higher-risk patients in the context of an increased requirement for urgent PCI in the comparative standard treatment arm.
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3291] [Impact Index Per Article: 329.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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