The impact of time to thrombolytic treatment on outcome in patients with acute myocardial infarction. For the CORE investigators (Collaborative Organisation for RheothRx Evaluation)

Development and evolution of nuclear cardiology and cardiac PET in Canada

Gated radionuclide angiography and myocardial perfusion imaging were developed in the United States and Europe in the 1970's and soon adopted in Canadian centers. Much of the early development of nuclear cardiology in Canada was in Toronto, Ontario and was quickly followed by new programs across the country. Clinical research in Canada contributed to the further development of nuclear cardiology and cardiac PET. The Canadian Nuclear Cardiology Society (CNCS) was formed in 1995 and became the Canadian Society of Cardiovascular Nuclear and CT Imaging (CNCT) in 2014. The CNCS had a major role in education and advocacy for cardiovascular nuclear medicine testing. The CNCS established the Dr Robert Burns Lecture and CNCT named the Canadian Society of Cardiovascular Nuclear and CT Imaging Annual Achievement Award for Dr Michael Freeman in memoriam of these two outstanding Canadian leaders in nuclear cardiology. The future of nuclear cardiology in Canada is exciting with the expanding use of SPECT imaging to include Tc-99m-pyrophosphate for diagnosis of transthyretin cardiac amyloidosis and the ongoing introduction of cardiac PET imaging.

Step-down units are cost-effective alternatives to coronary care units with non-inferior outcomes in the management of ST-elevation myocardial infarction patients after successful primary percutaneous coronary intervention

Percutaneous coronary interventions (PCIs) within a door-to-balloon timing of 90 min have greatly decreased mortality and morbidity of ST-elevation myocardial infarction (STEMI) patients. Post-PCI, they are routinely transferred into the coronary care unit (CCU) regardless of the severity of their condition, resulting in frequent CCU overcrowding. This study assesses the feasibility of step-down units (SDUs) as an alternative to CCUs in the management of STEMI patients after successful PCI, to alleviate CCU overcrowding. Criteria of assessment include in-hospital complications, length of stay, cost-effectiveness, and patient outcomes up to a year after discharge from hospital. A retrospective case-control study was done using data of 294 adult STEMI patients admitted to the emergency departments of two training and research hospitals and successfully underwent primary PCI from 1 January 2014 to 31 December 2015. Patients were followed up for a year post-discharge. Student t test and χ² test were done as univariate analysis to check for statistical significance of p < 0.05. Further regression analysis was done with respect to primary outcomes to adjust for major confounders. Patients managed in the SDU incurred significantly lower inpatient costs (p = 0.0003). No significant differences were found between the CCU and SDU patients in terms of patient characteristics, PCI characteristics, in-hospital complications, length of stay, and patient outcomes up to a year after discharge. The SDU is a viable cost-effective option for managing STEMI patients after successful primary PCI to avoid CCU overcrowding, with non-inferior patient outcomes as compared to the CCU.

Prevalence and Predictors of Delay in Seeking Emergency Care in Patients Who Call 9-1-1 for Chest Pain

BACKGROUND

Delay in seeking medical treatment for suspected acute coronary syndrome can lead to negative patient outcomes.

OBJECTIVE

Our aim was to evaluate the prevalence and predictors of delay in seeking care in high-risk chest pain patients with or without acute coronary syndrome (ACS).

METHODS

This was a secondary analysis of an observational cohort study of patients transported by Emergency Medical Services for a chief complaint of chest pain. Important demographic and clinical characteristics were extracted from electronic health records. Two independent reviewers adjudicated the presence of ACS. Logistic regression was used to model the predictors of delay in seeking care.

RESULTS

The final sample included 743 patients (99% non-Hispanic). Overall, 24% presented > 12 h from onset of symptoms. Among those with ACS (n = 115), 14% presented > 12 h after onset of symptoms. Race, smoking, diabetes, and related symptoms were associated with delayed seeking behavior. In multivariate analysis, non-Caucasian race (black or others) was the only independent predictor of > 12 h delay in seeking care (odds ratio 1.4; 95% confidence interval 1.0-1.9).

CONCLUSIONS

One in four patients with chest pain, including 14% of those with ACS, wait more than 12 h before seeking care. Compared to non-blacks, black patients are 40% more likely to delay seeking care > 12 h.

Cardiac Muscle Membrane Stabilization in Myocardial Reperfusion Injury

The phospholipid bilayer membrane that surrounds each cell in the body represents the first and last line of defense for preserving overall cell viability. In several forms of cardiac and skeletal muscle disease, deficits in the integrity of the muscle membrane play a central role in disease pathogenesis. In Duchenne muscular dystrophy, an inherited and uniformly fatal disease of progressive muscle deterioration, muscle membrane instability is the primary cause of disease, including significant heart disease, for which there is no cure or highly effective treatment. Further, in multiple clinical forms of myocardial ischemia-reperfusion injury, the cardiac sarcolemma is damaged and this plays a key role in disease etiology. In this review, cardiac muscle membrane stability is addressed, with a focus on synthetic block copolymers as a unique chemical-based approach to stabilize damaged muscle membranes. Recent advances using clinically relevant small and large animal models of heart disease are discussed. In addition, mechanistic insights into the copolymer-muscle membrane interface, featuring atomistic, molecular, and physiological structure-function approaches are highlighted. Collectively, muscle membrane instability contributes significantly to morbidity and mortality in prominent acquired and inherited heart diseases. In this context, chemical-based muscle membrane stabilizers provide a novel therapeutic approach for a myriad of heart diseases wherein the integrity of the cardiac muscle membrane is at risk.

Efficacy and Safety of Tenectaplase versus Streptokinase in Treating ST-Elevation Myocardial Infarction Patients in Hong Kong: A Four-Year Retrospective Review in Queen Elizabeth Hospital

Objective

Data were lacking in comparing tenectaplase (TNK) and streptokinase (SK) in treating Chinese ST elevation myocardial infarction (STEMI) patients. We sought to compare these 2 types of thrombolytics in our locality.

Methods

We analysed 196 STEMI patients who received either TNK or SK in our hospital from 2007 to 2011. We compared the mortality and other outcomes of these 2 groups of patients.

Results

In-hospital mortality has no significant difference between the TNK and the SK groups (8.9% vs 5.3%, p=0.322). Door-to-needle time was shorter in the TNK group (31±10 vs 25±7, p<0.001). Hypotension after drug administration was more common in the SK group than in the TNK group (21.1% vs. 3.0%, p<0.001).

Conclusion

TNK is at least as safe as SK in treating STEMI patients, with the advantage of shorter door-to-needle time and less frequent hypotensive effect. (Hong Kong j.emerg.med. 2013;20:359-363)

Patterns of ST segment resolution after guidewire passage and thrombus aspiration in primary percutaneous coronary intervention (PPCI) for acute myocardial infarction

Background

ST segment elevation allows the rapid identification of patients with acute myocardial infarction who benefit from emergency reperfusion. Primary percutaneous coronary intervention (PPCI) has emerged as the preferred perfusion strategy for patients presenting with ST segment elevation myocardial infarction (STEMI).

Methods and results

We studied the effects of the simple passage of an angioplasty guidewire followed by mechanical thrombus aspiration on the ST segment displacement in 289 patients presenting with acute STEMI. Simple guidewire passage led to a statistically significant fall in the mean ST elevation from 5.9 to 4.9 mm (p<0.001), but the mean ST displacement after subsequent mechanical thrombus aspiration was 4.8 mm, not statistically significantly different from guidewire passage. When compared with simple guidewire passage, thrombus aspiration resulted in more patients achieving more than 50% ST resolution (21.8% vs 15.2%, p=0.009), but a higher proportion had a worsening of ST elevation compared to baseline (19.7% vs 13.5%, p=0.041).

Conclusions

Mechanical thrombus aspiration in acute STEMI did not improve the mean ST resolution compared with simple guidewire passage. Thrombus aspiration increased the proportion achieving 50% resolution but also increased the proportion who had a worsening of ST elevation. These data may help explain some of the uncertainties surrounding the routine use of thrombus aspiration in STEMI and potentially supports the use of ‘time to angioplasty guidewire passage’ as one of the ways to judge the promptness of PPCI services.

Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Background

In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥ 2 h.

Methods

A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

Results

The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

Conclusions

Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0271-x) contains supplementary material, which is available to authorized users.

Therapy in ST-elevation myocardial infarction: reperfusion strategies, pharmacology and stent selection

OPINION STATEMENT

The estimated annual incidence of new and recurrent myocardial infarction (MI) in the U.S. is 715,000 events. Primary percutaneous coronary intervention (PCI) is the reperfusion strategy of choice in most patients with acute ST-elevation myocardial infarction (STEMI). Recent advances in percutaneous techniques and devices, including manual aspiration catheters and newer generation drug eluting stents and pharmacologic therapies, such as novel antiplatelets and anticoagulants have led to significant improvements in the acute and long-term outcomes for these patients. Implementation of community-wide systems directed to shorten treatment times tied to closely monitored quality improvement processes have led to further advances in STEMI care. Recent data suggests that transradial access for primary PCI is associated with improved outcomes. This contemporary review discusses the strategies for reperfusion, pharmacological therapy and stent selection process involved in STEMI.

Efficacy of early invasive management post-fibrinolysis in men versus women with ST-elevation myocardial infarction: a subgroup analysis from Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)

BACKGROUND

The TRANSFER-AMI study demonstrated that early routine percutaneous coronary intervention post-fibrinolysis (pharmacoinvasive strategy) is superior to conservative management for ST-elevation myocardial infarction. However, it is not clear whether treatment efficacy differs between men and women.

METHODS

In this pre-specified subgroup analysis, we compared the efficacy of a pharmacoinvasive strategy in men versus women with acute ST-elevation myocardial infarction who were randomized to a pharmacoinvasive versus standard management following fibrinolysis. The primary end point was a composite of death, recurrent myocardial infarction, recurrent ischemia, heart failure and shock at 30 days. We tested for treatment heterogeneity between men and women using the Breslow-Day test. We also performed multivariable analysis adjusting for GRACE risk score and its interaction with treatment assignment, and evaluated for death/recurrent myocardial reinfarction as a secondary outcome.

RESULTS

Of the 1059 patients, 843 were men and 216 were women. Compared to men, women were older, had worse Killip class, higher GRACE risk score, and higher rates of death and death/myocardial reinfarction at 30 days. The primary end point did not differ significantly between men and women (13.4% vs 16.7%, P = .22). Compared to standard treatment, a pharmacoinvasive strategy was associated with a lower rate of the primary end point in men (17.5% vs 9.4%, respectively, P < .001), but not in women (16.2% vs 17.1%, P = .86). There was a trend toward an interaction between treatment assignment and sex for the composite primary end point (P = .06). After adjustment for the significant interaction between GRACE risk score and treatment (P < .001), there was no significant interaction between sex and treatment for all the end points (all P > .40).

CONCLUSION

The borderline heterogeneity in treatment efficacy of a pharmacoinvasive strategy in men versus women was no longer evident after adjustment for the difference in baseline risk. This suggests that sex per se was not an important determinant of the efficacy of a pharmacoinvasive strategy. Owing to the small number of women in this trial, further study in this area is needed.

Time to treatment and three-year mortality after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction-a DANish Trial in Acute Myocardial Infarction-2 (DANAMI-2) substudy

In patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (pPCI), early reperfusion is believed to improve left ventricular systolic function and reduce mortality; however, long-term (>1 year) data are sparse. In the DANish Trial in Acute Myocardial Infarction-2 (DANAMI-2) study, 686 patients with ST-segment elevation myocardial infarction were treated with pPCI. Long-term mortality was obtained during 3 years of follow-up. We classified the patients according to the symptom-to-balloon time (<3, 3 to 5, and > or =5 hours). The groups were compared using a Cox proportional hazards regression model adjusted for confounding factors. The left ventricular systolic ejection fraction was estimated by echocardiography before discharge. Coronary flow was evaluated using the Thrombolysis In Myocardial Infarction score. Mortality did not differ between the 2 earliest symptom-to-balloon groups, and they were therefore combined into 1 group in the analysis of survival. Mortality was significantly increased for patients with a symptom-to-balloon time > or =5 hours (hazard ratio 2.36, 95% confidence interval 1.51 to 3.67, p <0.001), a difference that remained significant after controlling for confounding factors (adjusted hazard ratio 2.44, 95% confidence interval 1.31 to 4.54, p = 0.007). The symptom-to-balloon time was inversely associated with a left ventricular systolic ejection fraction of < or =40% (19.7% vs 22.8% vs 33.1%, p = 0.036), with the latter a major predictor of 3-year mortality in this cohort (hazard ratio 6.02, 95% confidence interval 3.68 to 9.85, p <0.001). A shorter symptom-to-balloon time was associated with greater rates of Thrombolysis In Myocardial Infarction 3 flow after pPCI (86.5% vs 80.9% vs 75.7%, p = 0.002). In conclusion, a shorter symptom-to-balloon time was associated with improved coronary flow, an increased likelihood of subsequent left ventricular systolic ejection fraction >40%, and greater 3-year survival in patients with ST-segment elevation myocardial infarction treated with pPCI.

Effect of Supersaturated Oxygen Delivery on Infarct Size After Percutaneous Coronary Intervention in Acute Myocardial Infarction

Background— Myocardial salvage is often suboptimal after percutaneous coronary intervention in ST-segment elevation myocardial infarction. Posthoc subgroup analysis from a previous trial (AMIHOT I) suggested that intracoronary delivery of supersaturated oxygen (SSO 2 ) may reduce infarct size in patients with large ST-segment elevation myocardial infarction treated early.

Methods and Results— A prospective, multicenter trial was performed in which 301 patients with anterior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention within 6 hours of symptom onset were randomized to a 90-minute intracoronary SSO 2 infusion in the left anterior descending artery infarct territory (n=222) or control (n=79). The primary efficacy measure was infarct size in the intention-to-treat population (powered for superiority), and the primary safety measure was composite major adverse cardiovascular events at 30 days in the intention-to-treat and per-protocol populations (powered for noninferiority), with Bayesian hierarchical modeling used to allow partial pooling of evidence from AMIHOT I. Among 281 randomized patients with tc-99m-sestamibi single-photon emission computed tomography data in AMIHOT II, median (interquartile range) infarct size was 26.5% (8.5%, 44%) with control compared with 20% (6%, 37%) after SSO 2 . The pooled adjusted infarct size was 25% (7%, 42%) with control compared with 18.5% (3.5%, 34.5%) after SSO 2 ( P Wilcoxon =0.02; Bayesian posterior probability of superiority, 96.9%). The Bayesian pooled 30-day mean (�SE) rates of major adverse cardiovascular events were 5.0�1.4% for control and 5.9�1.4% for SSO 2 by intention-to-treat, and 5.1�1.5% for control and 4.7�1.5% for SSO 2 by per-protocol analysis (posterior probability of noninferiority, 99.5% and 99.9%, respectively).

Conclusions— Among patients with anterior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention within 6 hours of symptom onset, infusion of SSO 2 into the left anterior descending artery infarct territory results in a significant reduction in infarct size with noninferior rates of major adverse cardiovascular events at 30 days.

Clinical Trial Registration— clinicaltrials.gov Identifier: NCT00175058

Survival of patients receiving fibrinolytic therapy for acute ST-segment elevation myocardial infarction in a developing country - patient characteristics and predictors of mortality

There is paucity of outcomes data on patients receiving fibrinolytic therapy (FT) for acute ST-elevation myocardial infarction (STEMI) in Indo-Asians. We conducted this study to determine survival as well as correlates of mortality in this population. Hospital charts of 230 patients receiving FT for acute STEMI between January 2002 and December 2004 were reviewed. Primary outcome variable was total mortality. Cox proportional hazards regression models were constructed. At a median follow-up of 717 days, 13.5% died, majority (23) during the in-hospital period. Multivariate predictors of mortality included (adjusted hazards ratio [HR], 95% confidence interval [CI]) age (HR 1.06, 95% CI 1.01-1.13), ejection fraction (HR 0.93, 95% CI 0.89-0.97), admission white cell count (HR 1.02, 95% CI 1.01-1.04) and change in ST-segment elevation (HR 0.96, 95% CI 0.92-0.99). We conclude that patients receiving FT for acute STEMI in Pakistan are a relatively high-risk group with a 10% in-hospital mortality and high frequency of recurrent events. Comparison data with primary angioplasty as an alternative strategy are needed.

The effect of health care provider consultation on acute coronary syndrome care-seeking delay

PROBLEM

The time required for health care provider (HCP) consultation during acute coronary syndrome (ACS) has not been systematically studied. This study seeks to understand who calls an HCP and the duration of HCP evaluation during ACS.

METHODS

Interviews were conducted with 1102 hospitalized patients with ACS in Columbus, Ohio. At discharge, diagnoses were acute myocardial infarction (560), unstable angina (214), cardiac disease (122), and noncardiac emergencies (206).

RESULTS

Among the 1102 patients studied, 40.9% (451) contacted an HCP. Situational factors were more important than demographic factors in accounting for medical evaluation phase incidence and duration. Advice from HCPs to call the emergency medical services or travel to the emergency department reduced medical evaluation phase duration. The median total time duration was 6 hours for HCP consulters and 1 hour 30 minutes for nonconsulters (P < .001). Patients foregoing HCP consultation experienced significantly greater hemodynamic instability than patients contacting an HCP. Calling an HCP significantly (P < .001) reduced emergency medical services use.

CONCLUSIONS

Consulting an HCP during ACS extended total time duration from symptom onset to emergency department arrival. In general, patients calling an HCP experienced a less severe ACS event than patients not contacting an HCP. There is a need for an epidemiologic study of calls to HCPs to develop a protocol for ACS call management.

Impact of time to treatment on myocardial reperfusion and infarct size with primary percutaneous coronary intervention for acute myocardial infarction (from the EMERALD Trial)

The impact of time to treatment on outcomes after primary percutaneous coronary intervention (PCI) is controversial, and there are few data about time to treatment and infarct size. The EMERALD trial randomly assigned 501 high-risk patients with ST-elevation myocardial infarction undergoing primary PCI to stenting with or without GuardWire (Medtronic, Santa Rosa, California) distal protection. Infarct size using sestamibi imaging at 5 to 14 days and clinical outcomes were examined by time to treatment. There were no differences in outcomes between distal protection and control patients. Shorter time to reperfusion (<2 vs 2 to 3 vs >3 to 4 vs >4 hours) was associated with smaller infarct size (2% vs 9% vs 12% vs 11%, p=0.026), trends for better myocardial blush (p=0.08), and lower 6-month mortality rates (0% vs 0% vs 2.4% vs 5.3%, p=0.06). Incremental delays in reperfusion after 2 hours had little impact on infarct size. Shorter time to reperfusion impacted on infarct size in patients with anterior infarction (0% vs 17% vs 20.5% vs 30.5%, p=0.026), but not nonanterior infarction (3% vs 7% vs 7.5% vs 10%, p=0.23, p=0.022 for interaction). In conclusion, very early reperfusion with primary PCI is associated with smaller infarct size and has a much greater impact in anterior versus nonanterior infarction. Incremental delays in reperfusion after 2 hours have less effect on infarct size. These data have implications regarding the triage of patients for primary PCI.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency

BACKGROUND

Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices.

METHODS

Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%).

RESULTS

Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25-0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37-0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66-0.99 when comparing low to high SES).

CONCLUSION

In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.

Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials

BACKGROUND

Quick administration of intravenous recombinant tissue plasminogen activator (rt-PA) after stroke improved outcomes in previous trials. We aimed to analyse combined data for individual patients to confirm the importance of rapid treatment.

METHODS

We pooled common data elements from six randomised placebo-controlled trials of intravenous rt-PA. Using multivariable logistic regression we assessed the relation of the interval from stroke onset to start of treatment (OTT) on favourable 3-month outcome and on the occurrence of clinically relevant parenchymal haemorrhage.

FINDINGS

Treatment was started within 360 min of onset of stroke in 2775 patients randomly allocated to rt-PA or placebo. Median age was 68 years, median baseline National Institute of Health Stroke Scale (NIHSS) 11, and median OTT 243 min. Odds of a favourable 3-month outcome increased as OTT decreased (p=0.005). Odds were 2.8 (95% CI 1.8-4.5) for 0-90 min, 1.6 (1.1-2.2) for 91-180 min, 1.4 (1.1-1.9) for 181-270 min, and 1.2 (0.9-1.5) for 271-360 min in favour of the rt-PA group. The hazard ratio for death adjusted for baseline NIHSS was not different from 1.0 for the 0-90, 91-180, and 181-270 min intervals; for 271-360 min it was 1.45 (1.02-2.07). Haemorrhage was seen in 82 (5.9%) rt-PA patients and 15 (1.1%) controls (p<0.0001). Haemorrhage was not associated with OTT but was with rt-PA treatment (p=0.0001) and age (p=0.0002).

INTERPRETATION

The sooner that rt-PA is given to stroke patients, the greater the benefit, especially if started within 90 min. Our results suggest a potential benefit beyond 3 h, but this potential might come with some risks.

Hospital performance with myocardial reperfusion therapy: are hospitals capable of meeting established guidelines?

OBJECTIVES

To determine whether hospitals are capable of delivering myocardial reperfusion therapy in a manner consistent with the American College of Cardiology/American Heart Association guidelines. DATA SOURCE AND STUDY SETTING: Data from the National Registry of Myocardial Infarction (NRMI)-2 and NRMI-3 were used. NRMI is an observational study, sponsored by Genentech, conducted from June 1994 through June 2000 and involving 1876 hospitals and 1,310,030 patients across the United States. The protocol calls for collecting data on all patients with a diagnosis of acute myocardial infarction. The setting was community and tertiary hospitals in the United States.

STUDY DESIGN

This observational study used process capability analysis.

PRINCIPAL FINDINGS

Overall, no hospital was deemed capable of delivering myocardial reperfusion therapy consistent with the American College of Cardiology/American Heart Association guidelines. The highest thrombolytic and angioplasty CPUs were 0.44 and 0.52, respectively-well below the traditional value of 1.0 signifying minimum capability. In addition, among the hospitals examined, there remained a wide degree of variability in process capability, ranging from -0.69 to 0.52.

CONCLUSIONS

Myocardial reperfusion therapy performance measurement systems relying solely on mean time-to-reperfusion conceal true process performance, thereby obscuring quality improvement opportunities and strategies for improvement. Health care providers, purchasers, regulators, and other organizations interested in measuring and improving health care quality are encouraged to incorporate process capability analysis into their myocardial reperfusion therapy performance measurement and quality management systems.

[Impact of a public-directed media campaign on emergency call to a mobile intensive care units center for acute chest pain]

Cardiovascular diseases represent the second highest cause of mortality among the 25-65 age group in the Nord-Pas-de-Calais region. The Monica study clearly showed that in 1996 the average length of time between a casualty showing the first signs of a coronary and the commencement of treatment was 3 h 30 in northern region of France compared with an average of 2 hours for the rest of the country. Many factors play a part: lack of knowledge of the symptoms, ignorance of the benefits of making an early call to the ambulance, lack of awareness of the french emergency services- centre 15 and its role, absence of any structured network for coronary emergencies. Given these observations, an extensive regional informative campaign is being launched for the first time in France, which will involve all relevant health professionals. The 2 aims of this campaign are to encourage people to call centre 15 directly and as quickly as possible after noticing the first coronary symptoms, and to encourage general practitioners (GPs) to "prescribe calling centre 15". The impact of this campaign has been estimated using the descriptive analysis of the relationship between the number of calls made to centre 15 by the general public and doctors and the number of successful prehospital interventions by the mobile emergency unit of Lille in cases of coronaries and thrombosis. The results of 3 telephone surveys of 1200 people carried out by the emergency services and 2 surveys carried out by a private company were also used for this evaluation. The analysis of this data provides a wealth of arguments in favour of the effectiveness of the campaign. On one hand this is due to the quality of its contents, which we compared to a similar campaign and on the other hand it is due to its lengthy duration.

Improved prognosis of patients presenting with clinical markers of spontaneous reperfusion during acute myocardial infarction

OBJECTIVE

To describe the clinical features, management, and prognosis of patients presenting with clinical markers of spontaneous reperfusion (SR) during acute myocardial infarction (AMI).

DESIGN

Cohort study.

SETTING

National registry of 26 coronary care units.

PATIENTS

2382 consecutive patients with AMI.

MAIN OUTCOME MEASURES

Patient characteristics, management, and mortality.

RESULTS

The incidence of SR was 4% of patients (n = 98) compared with thrombolytic treatment (n = 1163, 49%), primary angioplasty (n = 102, 4%), and non-reperfusion (n = 1019, 43%). SR patients were more likely to develop less or no myocardial damage as indicated by a higher percentage of non-Q wave AMI (58% v 32%, 47%, and 44%, respectively, p < 0.0001), aborted AMI (25% v 9%, 8%, and 12%, p < 0.001), and lower peak creatine kinase (503 v 1384, 1519, and 751 IU, p < 0.0001). SR patients, however, were more likely to develop recurrent ischaemic events (35% v 17%, 12%, and 16%, respectively; p < 0.001) and subsequently were more likely to be referred to coronary angiography (67%), angioplasty (41%), or bypass surgery (16%, p < 0.001). Mortality at 30 days (1% v 8%, 7%, and 13%, respectively, p < 0.0001) and one year (6% v 11%, 12%, and 19%, p < 0.0001) was significantly lower for SR patients than for the other subgroups. By multivariate analysis, SR remained a strong determinant of 30 day survival (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.01 to 0.74). At one year, the association between SR and survival decreased (OR 0.49, 95% CI 0.18 to 1.13).

CONCLUSIONS

Clinical markers of SR are associated with greater myocardial salvage and favourable prognosis. The vulnerability of SR patients to recurrent ischaemic events suggests that they need close surveillance and may benefit from early intervention.

Shur-clens: an agent to remove silicone gel after breast implant rupture

Removal of silicone gel from surrounding tissues after implant rupture is difficult. Local inflammation, infection, and silicone granulomas warrant thorough removal of the silicone gel. Shur-Clens (20% solution of the surfactant poloxamer 188), povidone-iodine, and saline are agents that are used to aid in the removal of silicone gel from tissue. The purpose of this study was to compare the efficacy of silicone gel removal by these three agents in vitro. Shur-Clens, povidone-iodine, and saline were compared as solvents for silicone gel. Four weight increments of silicone gel (0.02 g, 0.04 g, 0.06 g, and 0.08 g) were placed on glass slides. These slides were placed in separate beakers containing 40 ml test solution. The slides were soaked for 1 minute with gentle agitation. The slides were removed, rinsed gently with de-ionized water, and placed in a vacuum desiccator to dry. The slides were weighed to determine the amount of silicone removed after soaking in the solution. Analysis of variance was used to determine the significance between the three solvents. The percentages of silicone gel removed for the four weight increments (0.02 g, 0.04 g, 0.06 g, and 0.08 g) in saline were 5.6%, 2.9%, 2.1%, and 5.8%, respectively. In povidone-iodine solution, the percentages were 18.9%, 25.4%, 28.8%, and 51.9%. In Shur-Clens, the percentages were 31.3%, 43.0%, 63.5%, and 79.9%. The greater percentage of silicone gel removed by Shur-Clens was significant compared with the other solutions (p < or = 0.05). Shur-Clens was shown to be a more effective solvent for removal of silicone gel in vitro. This enhanced efficacy is a result of the fact that Shur-Clens contains 20% of the surfactant poloxamer 188. The authors' clinical experience with 7 patients who underwent ruptured silicone breast implant removal demonstrated the superiority of Shur-Clens. Shur-Clens is a surfactant cleanser that is widely available, is inexpensive, and has a good safety profile. They propose the use of Shur-Clens to clean silicone gel spillage to decrease local complications resulting from residual silicone gel.

A new performance indicator for acute myocardial infarction

OBJECTIVE

To develop a performance indicator for acute myocardial infarction which would reliably measure success of treatment and which might provide an alternative to case fatality as an audited outcome.

DESIGN

A two year audit of all cases of acute myocardial infarction and resuscitated cases of out of hospital cardiac arrest from coronary heart disease in patients under 75 years of age. Behaviour of patients in calling for help, performance of the ambulance services in treating out of hospital arrest, and of the hospitals in providing resuscitation and thrombolytic treatment are audited separately.

SETTING

Four district general hospitals. AUDITED INTERVENTIONS: Resuscitation from cardiac arrest and thrombolytic treatment.

MAIN OUTCOME MEASURES

Hospital case fatality and lives saved/1000 patients treated.

RESULTS

Overall, the lives of 83/1000 patients were saved (95% confidence interval 70 to 96). Of these, 29 (35%) were saved by out of hospital resuscitation and 38 (46%) by in hospital resuscitation from cardiac arrest. It was estimated that 16 lives (19%) were saved by thrombolytic treatment. There were no significant differences in case fatality among the hospitals.

CONCLUSIONS

Lives saved/1000 patients treated is an easily measurable index and assesses performance of the ambulance service as well as of the hospital. Because it is relatively insensitive to diagnostic definitions, it may provide a robust alternative to case fatality as a performance indicator.