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Rashedi S, Greason CM, Sadeghipour P, Talasaz AH, O'Donoghue ML, Jimenez D, Monreal M, Anderson CD, Elkind MSV, Kreuziger LMB, Lang IM, Goldhaber SZ, Konstantinides SV, Piazza G, Krumholz HM, Braunwald E, Bikdeli B. Fibrinolytic Agents in Thromboembolic Diseases: Historical Perspectives and Approved Indications. Semin Thromb Hemost 2024; 50:773-789. [PMID: 38428841 DOI: 10.1055/s-0044-1781451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Fibrinolytic agents catalyze the conversion of the inactive proenzyme plasminogen into the active protease plasmin, degrading fibrin within the thrombus and recanalizing occluded vessels. The history of these medications dates to the discovery of the first fibrinolytic compound, streptokinase, from bacterial cultures in 1933. Over time, researchers identified two other plasminogen activators in human samples, namely urokinase and tissue plasminogen activator (tPA). Subsequently, tPA was cloned using recombinant DNA methods to produce alteplase. Several additional derivatives of tPA, such as tenecteplase and reteplase, were developed to extend the plasma half-life of tPA. Over the past decades, fibrinolytic medications have been widely used to manage patients with venous and arterial thromboembolic events. Currently, alteplase is approved by the U.S. Food and Drug Administration (FDA) for use in patients with pulmonary embolism with hemodynamic compromise, ST-segment elevation myocardial infarction (STEMI), acute ischemic stroke, and central venous access device occlusion. Reteplase and tenecteplase have also received FDA approval for treating patients with STEMI. This review provides an overview of the historical background related to fibrinolytic agents and briefly summarizes their approved indications across various thromboembolic diseases.
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Affiliation(s)
- Sina Rashedi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Christie M Greason
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, Virginia
- Department of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York
- Department of Pharmacy, New York-Presbyterian Hospital Columbia University Medical Center, New York, New York
| | - Michelle L O'Donoghue
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
- Universidad Catolica de Murcia, Murcia, Spain
| | - Christopher D Anderson
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, Massachusetts
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Lisa M Baumann Kreuziger
- Medical College of Wisconsin, Milwaukee, Wisconsin
- Blood Research Institute, Versiti, Milwaukee, Wisconsin
| | - Irene M Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Eugene Braunwald
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
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Saeed EN, Faeq AK. Impact of primary percutaneous coronary intervention on ST-segment elevation myocardial infarction patients: A comprehensive analysis. World J Exp Med 2024; 14:88541. [PMID: 38590300 PMCID: PMC10999064 DOI: 10.5493/wjem.v14.i1.88541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/08/2024] [Accepted: 02/02/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Myocardial infarction, particularly ST-segment elevation myocardial infarction (STEMI), is a key global mortality cause. Our study investigated predictors of mortality in 96 STEMI patients undergoing primary percutaneous coronary intervention at Erbil Cardiac Center. Multiple factors were identified influencing in-hospital mortality. Significantly, time from symptom onset to hospital arrival emerged as a decisive factor. Consequently, our study hypothesis is: "Reducing time from symptom onset to hospital arrival significantly improves STEMI prognosis." AIM To determine the key factors influencing mortality rates in STEMI patients. METHODS We studied 96 consecutive STEMI patients undergoing primary percutaneous coronary intervention (PPCI) at the Erbil Cardiac Center. Their clinical histories were compiled, and coronary evaluations were performed via angiography on admission. Data included comorbid conditions, onset of cardiogenic shock, complications during PPCI, and more. Post-discharge, one-month follow-up assessments were completed. Statistical significance was set at P < 0.05. RESULTS Our results unearthed several significant findings. The in-hospital and 30-d mortality rates among the 96 STEMI patients were 11.2% and 2.3% respectively. On the investigation of independent predictors of in-hospital mortality, we identified atypical presentation, onset of cardiogenic shock, presence of chronic kidney disease, Thrombolysis In Myocardial Infarction grades 0/1/2, triple vessel disease, ventricular tachycardia/ventricular fibrillation, coronary dissection, and the no-reflow phenomenon. Specifically, the recorded average time from symptom onset to hospital arrival amongst patients who did not survive was significantly longer (6.92 ± 3.86 h) compared to those who survived (3.61 ± 1.67 h), P < 0.001. These findings underscore the critical role of timely intervention in improving the survival outcomes of STEMI patients. CONCLUSION Our results affirm that early hospital arrival after symptom onset significantly improves survival rates in STEMI patients, highlighting the critical need for prompt intervention.
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Affiliation(s)
- Eza Nawzad Saeed
- Department of Medicine, Hawler Medical University, Erbil 44001, Kurdistan, Iraq
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Bosch L, Rittersma SZH, van der Worp BH, Kraaijeveld AO, Vlachojannis G, van der Harst P, Voskuil M. The value of computed tomography for head trauma in patients presenting with out-of-hospital cardiac arrest before emergency percutaneous coronary intervention. Neth Heart J 2024; 32:125-129. [PMID: 37615827 PMCID: PMC10883901 DOI: 10.1007/s12471-023-01807-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 08/25/2023] Open
Abstract
INTRODUCTION Out-of-hospital cardiac arrest (OHCA) caused by an ST-elevation myocardial infarction (STEMI) is often accompanied by a sudden loss of consciousness that may cause the patient to collapse with resulting head trauma, leading to a suspicion of possible intracranial haemorrhage. To rule out intracranial haemorrhage before emergency percutaneous coronary intervention (PCI), emergency computed tomography (CT) of the head might be useful but also causes a delay in percutaneous STEMI treatment. METHODS The medical records of all adult patients that presented with OHCA to the emergency department (ED) of the University Medical Centre Utrecht (UMCU), the Netherlands between 16 February 2020 and 16 February 2022 were reviewed. RESULTS A total of 263 patients presented to the ED with an OHCA; 50 presented with a STEMI requiring emergency PCI. Thirty-nine (78%) patients with a STEMI were immediately referred to the catheterisation laboratory and 11 (22%) STEMI patients underwent a CT scan prior to emergency angiography; in no case was PCI deferred on the basis of the CT findings. The dominant indication for CT of the head was collapse, reported by 10 patients and resulting in a visible traumatic head injury in 7 patients. In none of the patients was intracranial haemorrhage detected. However, there was a delay between presentation to the ED and arrival at the catheterisation laboratory in patients who underwent CT of the head (mean 63 ± 25 min) before emergency PCI compared to patients without a CT scan (mean 37 ± 21 min). CONCLUSION CT of the head did not result in a diagnosis of intracranial haemorrhage or deferral of PCI but did delay PCI treatment for STEMI in patients presenting with OHCA.
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Affiliation(s)
- Lena Bosch
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Saskia Z H Rittersma
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bart H van der Worp
- Department of Neurology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Adriaan O Kraaijeveld
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - George Vlachojannis
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Boytsov SA, Shakhnovich RM, Tereschenko SN, Erlikh AD, Pevsner DV, Gulyan RG, Rytova YK, Dmitrieva NY, Voznyuk YM, Musikhina NA, Nazarova OA, Pogorelova NA, Sanabasova GK, Sviridova AV, Sukhareva IV, Filinova AS, Shylko YV, Shirikova GA. [Features of the Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction According to the Russian Registry of Acute Myocardial Infarction - REGION-IM]. KARDIOLOGIIA 2024; 64:3-17. [PMID: 38462799 DOI: 10.18087/cardio.2024.2.n2601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/24/2023] [Indexed: 03/12/2024]
Abstract
AIM Based on data from the Russian REGION-IM registry, to study the features of reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI) in real-life clinical practice. MATERIAL AND METHODS REGION-IM is a multicenter prospective observational study. The observational period is divided into 3 stages: during the stay in the hospital and at 6 and 12 months after inclusion in the registry. The patient's records contain demographic and history data; information about the present case of MI, including the time of the first symptom onset, first contact with medical personnel, and admission to the hospital; coronary angiography (CAG) data, percutaneous coronary intervention (PCI) data, and information about the thrombolytic therapy (TLT). RESULTS Reperfusion therapy was performed in 88.9 % of patients with STEMI. Primary PCI (pPCI) was performed in 60.6 % of patients. The median time from the onset of symptoms to pPCI was 315 minutes [195; 720]. The median time from ECG to pPCI was 110 minutes [84;150]. Isolated TLT was performed in 7.4 %, pharmaco-invasive treatment tactics were used only in 20.9 % of cases. The median time from ECG to TLT (prehospital and in-hospital) was 30 minutes [10; 59], whereas the median time from ECG to prehospital TLT was 18 minutes [10; 39], and in 63 % of patients, TLT was performed more than 10 minutes after diagnosis. PCI followed TLT in 73 % of patients. CONCLUSION The frequency of reperfusion therapy for STEMI in the Russian Federation has increased considerably in recent years. The high frequency of pPCI is noteworthy, but the timing of pPCI does not always comply with clinical guidelines. The results of this registry confirm the high demand for pharmaco-invasive strategies in real-life clinical practice. Taking into account geographical and logistical features, implementing timely myocardial reperfusion requires prehospital TLT. However, the TLT frequency in the Russian Federation is still insufficient despite its proven maximum effectiveness in the shortest possible time from the detection of acute MI.
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Affiliation(s)
- S A Boytsov
- Chazov National Medical Research Center of Cardiology
| | | | | | - A D Erlikh
- Pirogov Russian National Research Medical University
| | - D V Pevsner
- Chazov National Medical Research Center of Cardiology
| | - R G Gulyan
- Chazov National Medical Research Center of Cardiology
| | - Yu K Rytova
- Chazov National Medical Research Center of Cardiology
| | | | | | - N A Musikhina
- Tyumen Cardiology Research Center, Tomsk National Research Center
| | | | | | | | | | - I V Sukhareva
- Khanty-Mansiysk-Yugra District Cardiology Center for Diagnostics and Cardiovascular Surgery
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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: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Lapostolle F, Petrovic T, Moiteaux B, Loyeau A, Boche T, Kadji Kalabang R, Le Bail G, Lamhaut L, Lafay M, Dupas F, Scannavino M, Benamer H, Bataille S, Lambert Y. Evolution of REperfusion Strategies and impact on mortality in Old and Very OLD STEMI patients. The RESOVOLD-e-MUST study. Age Ageing 2024; 53:afad215. [PMID: 38167925 PMCID: PMC10762506 DOI: 10.1093/ageing/afad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development. METHODS Setting: Greater Paris Area (Ile-de-France). DATA Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h). PARAMETERS Demographic, decision to perform reperfusion and outcome (in-hospital mortality). PRIMARY ENDPOINT Reperfusion decision rate by decade over age 70. SECONDARY ENDPOINT Outcome. RESULTS We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years. CONCLUSION the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age.
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Affiliation(s)
- Frédéric Lapostolle
- SAMU 93, UF Recherche-Enseignement-Qualité, Avicenne Hospital-APHP, Bobigny, France
- Université Paris 13, INSERM Unit 942, Sorbonne Paris Cité, Bobigny, France
| | - Tomislav Petrovic
- SAMU 93, UF Recherche-Enseignement-Qualité, Avicenne Hospital-APHP, Bobigny, France
- Université Paris 13, INSERM Unit 942, Sorbonne Paris Cité, Bobigny, France
| | | | | | - Thévy Boche
- SAMU 94, Mondor Hospital-APHP, Créteil, France
| | | | | | | | - Marina Lafay
- SAMU 91, Sud Francilien Hospital, Corbeil-Essonnes, France
| | | | | | - Hakim Benamer
- Cardiology Department, Institut Cardiovasculaire Paris Sud (ICPS), Massy, France
| | | | - Yves Lambert
- SAMU 78, Versailles Hospital, Le Chesnay, France
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Stopyra JP, Snavely AC, Ashburn NP, Supples MW, Miller CD, Mahler SA. Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction. Acad Emerg Med 2023; 30:1101-1109. [PMID: 37567785 PMCID: PMC10830062 DOI: 10.1111/acem.14787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients. METHODS We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death. RESULTS Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%). CONCLUSIONS Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael W. Supples
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Chadwick D. Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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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: 707] [Impact Index Per Article: 707.0] [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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Ward MJ, Nikpay S, Shermeyer A, Nallamothu BK, Rokos I, Self WH, Hsia RY. Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California. JAMA Netw Open 2023; 6:e2317831. [PMID: 37294567 PMCID: PMC10257096 DOI: 10.1001/jamanetworkopen.2023.17831] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/26/2023] [Indexed: 06/10/2023] Open
Abstract
Importance Insurance status has been associated with whether patients with ST-segment elevation myocardial infarction (STEMI) presenting to emergency departments are transferred to other facilities, but whether the facility's percutaneous coronary intervention capabilities mediate this association is unknown. Objective To examine whether uninsured patients with STEMI were more likely than patients with insurance to experience interfacility transfer. Design, Setting, and Participants This observational cohort study compared patients with STEMI with and without insurance who presented to California emergency departments between January 1, 2010, and December 31, 2019, using the Patient Discharge Database and Emergency Department Discharge Database from the California Department of Health Care Access and Information. Statistical analyses were completed in April 2023. Exposures Primary exposures were lack of insurance and facility percutaneous coronary intervention capabilities. Main Outcomes and Measures The primary outcome was transfer status from the presenting emergency department of a percutaneous coronary intervention-capable hospital, defined as a facility performing 36 percutaneous coronary interventions per year. Multivariable logistic regression models with multiple robustness checks were performed to determine the association of insurance status with the odds of transfer. Results This study included 135 358 patients with STEMI, of whom 32 841 patients (24.2%) were transferred (mean [SD] age, 64 [14] years; 10 100 women [30.8%]; 2542 Asian individuals [7.7%]; 2053 Black individuals [6.3%]; 8285 Hispanic individuals [25.2%]; 18 650 White individuals [56.8%]). After adjusting for time trends, patient factors, and transferring hospital characteristics (including percutaneous coronary intervention capabilities), patients who were uninsured had lower odds of experiencing interfacility transfer than those with insurance (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98; P = .01). Conclusions and Relevance After accounting for a facility's percutaneous coronary intervention capabilities, lack of insurance was associated with lower odds of emergency department transfer for patients with STEMI. These findings warrant further investigation to understand the characteristics of facilities and outcomes for uninsured patients with STEMI.
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Affiliation(s)
- Michael J. Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Andrew Shermeyer
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Brahmajee K. Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ivan Rokos
- Department of Emergency Medicine, UCLA-Olive View, Los Angeles, California
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco
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Pineda A, Savary D, Vromant A, Lapostolle F. Benefit-risk balance of fibrinolytic therapy in ST-elevation myocardial infarction as evaluated by physicians. Eur J Emerg Med 2023; 30:216-218. [PMID: 37103903 DOI: 10.1097/mej.0000000000001020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Affiliation(s)
- Alexandre Pineda
- SAMU 93 - UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny
| | - Dominique Savary
- SAMU 49 - Urgences adultes, Centre Hospitalier Universitaire, Angers
| | | | - Frédéric Lapostolle
- SAMU 93 - UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Bobigny
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Caullery B, Ellouze T, Descotes-Genon V, Rias S, Fluttaz A, Belle L. [Impact of out-of-hospital presentation remote areas of patients with myocardial infarction with ST segment elevation : From the Nord-Alpin Emergency Network [RENAU]]. Ann Cardiol Angeiol (Paris) 2023; 72:16-24. [PMID: 36528422 DOI: 10.1016/j.ancard.2022.11.001] [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: 10/27/2022] [Revised: 10/30/2022] [Accepted: 11/04/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND European guidelines order management of patients with ST-segment elevation myocardial infarction (STEMI) less than 12 hours. They encourage healthcare networks to rapid coronary reperfusion strategy depending on the distance of the patient from the PCI center. OBJECTIVE To determine impact of out-of-hospital presentation of patients with STEMI in remote areas within the framework of a care network, and to define the degree of compliance with local recommendations, and its prognostic impact. METHOD Over three years (2017-2019), from the RESURCOR prospective register, 310 patients with STEMI less than 12 hours were out-of hospital managed and transferred to Metrolpole Savoie Hospital in Chambéry. Depending on the "door in to PCI center" time, patients are divided into 2 groups: "Local area" for a time ≤ 60 min and "Remote area" for a time > 60 min. RESULTS 51 patients were in the "Local area" group and 259 patients in the "Remote area" group with an average age of 63.36 years, without significant difference between the two groups. We noted more men, smokers and a higher heart rate in the "Local area" group (p = 0.015; p = 0.005 and p = 0.035 respectively). The median "call-EMS care" delay was similar at 24 min in each group. Seventy-five patients (29%) in the "Remote area" group had fibrinolysis versus only one patient in the "Local area" group (p < 0.001). Among them, 42 patients (56%) had rescue PCI, in 40% with 90 min of fibrinolytic administration. The presence of a primary care physicians "PCP" was reported in 39 cases of the "remote area" group. PCP intervention increased the rate of bolus of fibrinolytics within 10 min from STEMI diagnosis (69.2% vs 21.8%, p < 0.001), increased the rate of bolus treatment within 10 min from STEMI diagnosis within 10 min (60% vs 16% p < 0.001) and reduced the rate of rescue PCI (44.4% vs 62.5%, p = 0.035). Total ischemia time was significantly shorter in the "Local area" group (144 min vs 175 min, p = 0.005). No significant difference concerning the in-hospital outcomes was found between 2 groups. Concerning compliance with local recommendations in the "remote area" group, among those eligible for thrombolysis, 135 patients (64,2 %) had an inappropriate primary PCI (error in estimated time from STEMI diagnosis to PCI-mediated reperfusion (< 1 h)), which was associated with a higher rate of serious arrhythmias (11.1% vs 2.7% respectively, p = 0.035). Regardless of the group, if the strategy was primary PCI 22% of patients had angiography within 60 minutes after STEMI diagnosis. CONCLUSION In this work, the temporal distance from the PCI room does not seem to be responsible for a more pejorative in-hospital outcomes, unlike the proportion of inappropriate primary PCI which increase serious arrhythmias.
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Affiliation(s)
- Benoit Caullery
- Département de cardiologie, centre hospitalo-universitaire de Grenoble, CS 10217, Grenoble CEDEX 09, 38043, France.
| | - Tarek Ellouze
- Service de cardiologie du centre hospitalier métropole Savoie, Chambéry, France; Faculté de médecine de Sfax, Tunisie
| | | | - Stéphane Rias
- Service de cardiologie du centre hospitalier métropole Savoie, Chambéry, France
| | - Arnaud Fluttaz
- Service de cardiologie du centre hospitalier métropole Savoie, Chambéry, France
| | - Loic Belle
- Service de cardiologie du centre hospitalier d'Annecy, France. Responsable médical du Réseau Nord Alpin des Urgences
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Trerayapiwat K, Jinatongthai P, Vathesatogkit P, Sritara P, Paengsai N, Dilokthornsakul P, Nathisuwan S, Le LM, Chaiyakunapruk N. Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 26:100503. [PMID: 35789828 PMCID: PMC9250039 DOI: 10.1016/j.lanwpc.2022.100503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Due to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown. METHODS Cost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed. FINDINGS From the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK. INTERPRETATION In a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase. FUNDING None.
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Affiliation(s)
- Krittimeth Trerayapiwat
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Peerawat Jinatongthai
- Pharmacy practice division, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Ninutcha Paengsai
- National Health Security Office (NHSO), Fund Management Unit, Bangkok, Thailand
| | - Piyameth Dilokthornsakul
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Lan My Le
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, United States of America
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13
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Verreault-Julien L, Rinfret S. Prolonged Reperfusion Delays During the COVID-19 Pandemic: Is Faster Always Better? Can J Cardiol 2022; 38:723-725. [PMID: 35288293 PMCID: PMC8916828 DOI: 10.1016/j.cjca.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022] Open
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14
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Li K, Zhang B, Zheng B, Zhang Y, Huo Y. Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy. Front Cardiovasc Med 2022; 9:813325. [PMID: 35369319 PMCID: PMC8970601 DOI: 10.3389/fcvm.2022.813325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background Pharmaco-invasive therapy (PIT), combining thrombolysis and percutaneous coronary intervention, was a potential complement for primary percutaneous coronary intervention (pPCI), while bleeding risk was still a concern. Objectives This study aims to compare the efficacy and safety outcomes of PIT and pPCI. Methods A systematic search for randomized controlled trials (RCTs) and observational studies were conducted on Pubmed, Embase, Cochrane library, and Scopus. RCTs and observational studies were all collected and respectively analyzed, and combined pooled analysis was also presented. The primary efficacy outcome was short-term all-cause mortality within 30 days, including in-hospital period. The primary safety outcome was 30-day trial-defined major bleeding events. Results A total of 26,597 patients from 5 RCTs and 12 observational studies were included. There was no significant difference in short-term mortality [RCTs: risk ratio (RR): 1.14, 95% CI: 0.67–1.93, I2 = 0%, p = 0.64; combined results: odds ratio (OR): 1.09, 95% CI: 0.93–1.29, I2 = 0%, p = 0.30] and 30-day major bleeding events (RCTs: RR: 0.44, 95% CI: 0.07–2.93, I2 = 0%, p = 0.39; combined results: OR: 1.01, 95% CI: 0.53–1.92, I2 = 0%, p = 0.98). However, pPCI reduced risk of in-hospital major bleeding events, stroke and intracranial bleeding, but increased risk of in-hospital heart failure and 30-day heart failure in combined analysis of RCTs and observational studies, despite no significant difference in analysis of RCTs. Conclusion Pharmaco-invasive therapy could be an important complement for pPCI in real-world clinical practice under specific conditions, but studies aiming at optimizing thrombolysis and its combination of mandatory coronary angiography are also warranted.
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Affiliation(s)
- Kaiyin Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bin Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First hospital, Beijing, China
- *Correspondence: Bo Zheng,
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First hospital, Beijing, China
- Yan Zhang,
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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15
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Mahadevan K, Sharma D, Walker C, Maznyczka A, Hobson A, Strike P, Griffiths H, Dana A. Impact of paramedic education on door-to-balloon times and appropriate use of the primary PCI pathway in ST-elevation myocardial infarction. BMJ Open 2022; 12:e046231. [PMID: 35210332 PMCID: PMC8883211 DOI: 10.1136/bmjopen-2020-046231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Evidence supports improved outcomes and reduced mortality with rapid reperfusion through primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). UK national audit data (Myocardial Ischaemia National Audit Project [MINAP]) demonstrates minor improvements in door-to-balloon times (DTB) of <90 min but increasing call-to-balloon times (CTB). We evaluate the effect of a regional Cardiologist delivered paramedic education programme (PEP) on DTB times and appropriate use of the PPCI pathway. METHODS This was a prospective single-centre study of patients with STEMI brought directly to hospital via ambulance services. Data sources included ambulance charts, in-patient notes, British Cardiovascular Interventional Society (BCIS) database and local MINAP data. All DTB breaches were investigated. A local PEP was implemented with focus on ECG interpretation, STEMI diagnosis and appropriate use of the PPCI pathway. Non-parametric Wilcoxon rank test was used for comparisons of DTB and CTB times between direct versus ED-associated cath lab transfer. RESULTS A total of 728 patients with STEMI were admitted directly to our centre via ambulance, 66% (n=484) directly to the Catheterisation Laboratory (Cath Lab) and 34% (n=244) via the Emergency Department (ED). There was a significant increase in median DTB, 83 vs 37 min (p<0.001) and median CTB 144 vs 97.5 min (p<0.001) when transfer to the Cath Lab occurred via the ED versus direct transfer. The PEP increased direct cath lab transfers (52%-85%) and generated annual reductions in median DTB times, with sustained improvement seen throughout the 7-year study period. CONCLUSIONS Paramedic education increases direct transfer of STEMI patients to the Cath Lab, and reduces DTB times. This is an effective and reproducible intervention to facilitate timely reperfusion in STEMI.
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Affiliation(s)
- Kalaivani Mahadevan
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Hospitals Health and Social Services Trust, Londonderry, UK
| | - Christopher Walker
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Annette Maznyczka
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Alex Hobson
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip Strike
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Huw Griffiths
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ali Dana
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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16
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Oleynikov VE, Matskeplishvili S, Shigotarova E, Kulyutsin A, Burko N. Diagnosis of coronary artery rethrombosis after effective systemic thrombolytic therapy in patients with ST-segment elevation myocardial infarction. J Investig Med 2022; 70:892-898. [PMID: 35046117 DOI: 10.1136/jim-2021-001945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/04/2022]
Abstract
The aim of the study was to evaluate the diagnostic significance of ST-segment re-elevation episodes registered with telemetric ECG monitoring in patients with ST-segment elevation myocardial infarction (STEMI) treated with thrombolytic therapy (TLT). The study included 117 patients with STEMI following effective TLT. The elective coronary angiography followed by percutaneous coronary interventions was performed in the interval from 3 to 24 hours after a successful systemic TLT. Before and after cardiac catheterization, the telemetric ECG monitoring was performed using AstroCard Telemetry system (Meditec, Russia). During the study, two groups of patients were formed. Group 1 included 85 patients (72.6%) without new ST-segment deviations on telemetry. 77 patients (90.6%) had no recurrent coronary artery thrombosis at angiography. Eight patients (9.4%) from group 1 were diagnosed with thrombosis of the infarct-related coronary artery. Group 2 included 32 patients (27.4%) who underwent TLT and then had ST-segment re-elevation episodes of 1 mV or more in the infarct-related leads, lasting for at least 1 minute. In group 2, in 27 of 32 patients (84.4%), thrombosis of the infarct-related coronary artery was confirmed (p<0.01 compared with group 1). In 71.9% cases, the recurrent ischemic episodes were asymptomatic ('painless myocardial ischemia') (p<0.01). Thus, in patients with STEMI and successful TLT, re-elevation of ST-segment during remote ECG monitoring is strongly related to angiographically documented coronary artery thrombotic reocclusion. The absence of chest pain during recurrent myocardial ischemia requires continuous ECG telemetry to select patients for the rescue percutaneous coronary interventions at an earlier stage.
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Affiliation(s)
| | - Simon Matskeplishvili
- Cardiology Department, Lomonosov Moscow State University Clinic, Moscow, Russian Federation
| | | | - Alexey Kulyutsin
- Therapy Department, Penza State University, Penza, Russian Federation
| | - Nadezhda Burko
- Therapy Department, Penza State University, Penza, Russian Federation
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17
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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 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 596] [Impact Index Per Article: 298.0] [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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18
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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 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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19
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The use of reperfusion therapy in transition countries without fully applicable pharmacoinvasive strategy. VOJNOSANIT PREGL 2022. [DOI: 10.2298/vsp190118090k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. The pharmacoinvasive (PI) therapy is a recommended strategy in patients (pts) with ST elevation myocardial infarction (STEMI) unable to undergo timely primary percutaneous coronary intervention (p-PCI). The aim of the study was to find out the cohorts of pts who are not treated by any reperfusion therapy (RT) as well to determine the outcome of the pts treated with RT in a transition country without fully applicable PI therapy. Methods. The study analyzed data from the Hospital National Registry for Acute Coronary Syndrome of Serbia (HORACS). Results. The significant predictors of the withdrawing of the application of any RT in the model [c 75.6%, SE 0.004, 95% CI 0.748?0.761)] were a ge ( ? 6 5 years), heart failure (Killip II-IV), diabetes mellitus, and the time to first medical contact (FMC) (> 360 min). In patients without RT, mortality was 15.7%, in pts treated with fibrinolytic therapy (FT) was 10.5%, and in pts treated with pPCI, it was 6.2% (p < 0.000). Within 3 hours to FMC, higher in-hospital mortality was in FT pts (FT 8.7% vs p-PCI 4.3%). FT treated patients were older, had more comorbidities and heart failure (HF). However, after propensity score matching, in order to ad-just the differences among the pts, the mortality rate remained higher in FT pts but not statistically significantly higher than in p-PCI pts (FT 8.8% vs p-PCI 6.4%). Conclusion. The balance of the best cost-benefit strategies for better use of RT is difficult to achieve in transition countries. The possibility for timely p-PCI and PI therapy is especially not applicable in high-risk patients, older pts, pts with HF, and those with diabetes mellitus.
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20
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Bosmans S, Sluyts Y, Lysens de Oliveira E Silva-Van Acker J, Van Caenegem O, Sinnaeve PR, Dubois P, Vranckx P, Gevaert S, Coussement P, Beauloye C, Evrard P, Argacha JF, De Raedt H, Wouters K, Claeys MJ. Adherence to quality indicators for ST-elevation myocardial infarction and its relation to mortality: a hospital network analysis from the Belgian STEMI database. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:601-607. [PMID: 32941605 DOI: 10.1093/ehjqcco/qcaa067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/24/2020] [Indexed: 06/11/2023]
Abstract
AIMS To assess the adherence to established quality indicators (QIs) for ST-elevation myocardial infarction (STEMI) at the hospital-network level and its relation to outcome. METHODS AND RESULTS The data of 7774 STEMI patients admitted to 32 STEMI networks during the period 2014-18 were extracted from the Belgian STEMI database. Five QIs [primary percutaneous coronary intervention use, diagnosis-to-balloon time (DiaTB) <90 min, door-to-balloon time (DoTB) <60 min, P2Y12 inhibitor and statin prescription at discharge, and a composite QI score ranging from 0 to 10] were correlated with in-hospital mortality adjusted for differences in baseline risk profile (TIMI risk score). The median composite QI score was 6.5 [interquartile range (IQR) 6-8]. The most important gaps in quality adherence were related to time delays: the recommended DiaTB and DoTB times across the different networks were achieved in 68% (IQR 53-71) and 67% (IQR 50-78), respectively. Quality adherence was better in networks taking care of more high-risk STEMI patients. The median in-hospital mortality among the STEMI networks was 6.4% (IQR 4.1-7.9%). There was a significant independent inverse correlation between the composite QI score and in-hospital mortality (partial correlation coefficient: -0.45, P = 0.013). Stepwise regression analysis revealed that among the individual QIs, prolonged DiaTB was the most important independent outcome predictor. CONCLUSION Among established STEMI networks, the time delay between diagnosis and treatment was the most variable and the most relevant prognostic QI, underscoring the importance of assessing quality of care throughout the whole network.
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Affiliation(s)
- Sara Bosmans
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - Yasmine Sluyts
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | | | | | - Peter R Sinnaeve
- Department of Cardiology, UZ Leuven, Ottignies-Louvain-la-Neuve, Belgium
| | | | - Pascal Vranckx
- Department of Cardiology, Virga Jesse Hasselt, Hasselt, Belgium
| | | | | | | | - Patrick Evrard
- Department of Intensive Care, UCL Mont-Godinne, Mont-Godinne, Belgium
| | | | | | - Kristien Wouters
- Clinical Trial Center (CTC), CRC Antwerp, Antwerp University Hospital, University of Antwerp, Antwerpen, Belgium
| | - Marc J Claeys
- Department of Cardiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
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21
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Sultan EZM, Elberry AA, Rabea H, Mahmoud HB. Safety and Efficacy of Pharmaco-invasive Approach Using Streptokinase Compared With Primary Percutaneous Coronary Angiography. Crit Pathw Cardiol 2021; 20:149-154. [PMID: 33337729 DOI: 10.1097/hpc.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fibrin-specific fibrinolytics are preferred when they used in STEMI patients (pharmaco-invasive approach). However, streptokinase is still the most common used thrombolytic agent in Egypt because of its cheaper cost. METHODS 266 STEMI patients were randomly assigned to undergo PPCI or pharmacoinvasive (using streptokinase). Primary end point (death, shock, congestive heart failure, or reinfarction up to 30 d) and secondary end point (ischemic stroke, intracranial hemorrhage, or nonintracranial bleeding) were followed for 30 days after reperfusion. In pharmaco-invasive arm, urgent coronary angiography was performed in case of failed reperfusion. Based on the reperfusion time from symptoms onset, patients in both arms were divided into; early (≤3 hrs) and late reperfusion (>3 hrs). RESULTS No statistical significant difference regarding left ventricular ejection fraction, end diastolic and end systolic diameter in both arms. Early PPCI (≤3 hrs) had highest ejection fraction values (56.9 ± 7.5). Myocardial wall preservation was best achieved in early pharmaco-invasive (≤3 hrs).There was no statistical significant difference in TIMI flow results between all subgroups (early and late of both arms) (P = 0.750). Suction devices and IV Eptifibatide were less frequently used in the pharmaco-invasive comparing to PPCI arm; (P = 0.000 and P = 0.006) subsequently. No statistical significant difference regarding complication incidence in both arms (P = 0.518). Radial access was more commonly used in the pharmaco-invasive arm (P = 0.015). CONCLUSION Utilizing streptokinase in early re-perfused patients by PI approach (≤3 hrs) seems safe and efficient when PPCI delay (>120 min from symptom onset) is the other option.
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Affiliation(s)
- El-Zahraa M Sultan
- From the Cardiology Department, Beni-Suef University Hospital, Beni-Suef, Egypt
| | - Ahmed A Elberry
- Pharmacology Department, Faculty of Medicine, Beni-Suef University Hospital, Beni-Suef, Egypt
| | - Hoda Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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22
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Abstract
The role of air medical and land-based critical care transport services is not always clear amongst traditional emergency medical service providers or hospital-based health care practitioners. Some of this is historical, when air medical services were in their infancy and their role within the broader health care system was limited. Despite their evolution within the regionalized health care system, some myths remain regarding air medical services in Canada. The goal is to clarify several commonly held but erroneous beliefs regarding the role, impact, and practices in air medical transport.
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23
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Mously H, Shah N, Zuzek Z, Alshaghdali I, Karim A, Jaswaney R, Filby SJ, Simon DI, Shishehbor MH, Forouzandeh F. Door-to-balloon Time for ST-elevation MI in the Coronavirus Disease 2019 Era. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In patients presenting with ST-elevation MI, prompt primary coronary intervention is the preferred treatment modality. Several studies have described improved outcomes in patients with door-to-balloon (D2B) and symptom onset-to-balloon (OTB) times of less than 2 hours, but the specific implications of the coronavirus disease 2019 (COVID-19) pandemic on D2B and OTB times are not well-known. This review aims to evaluate the impact of COVID-19 on D2B time and elucidate both the factors that delay D2B time and strategies to improve D2B time in the contemporary era. The search was directed to identify articles discussing the significance of D2B times before and during COVID-19, from the initialization of the database to December 1, 2020. The majority of studies found that onset-of-symptom to hospital arrival time increased in the COVID-19 era, whereas D2B time and mortality were unchanged in some studies and increased in others.
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Affiliation(s)
- Haytham Mously
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Nischay Shah
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Zachary Zuzek
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Ibrahim Alshaghdali
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Adham Karim
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Rahul Jaswaney
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Steven J Filby
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Daniel I Simon
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
| | - Farshad Forouzandeh
- Harrington Heart and Vascular Institute and Case Western Reserve University, Cleveland, OH
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Solís-Marquínez MN, Rondán-Murillo JJ, Pérez-Otero M, Vegas-Valle JM, Lozano Martínez-Luengas Í, Morís-de la Tassa J. Impact of creating a haemodynamics room, a coronary unit and a primary angioplasty programme on the prognosis of acute coronary syndrome in a district hospital. Rev Clin Esp 2021; 221:187-197. [PMID: 32113647 DOI: 10.1016/j.rce.2019.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/11/2019] [Accepted: 11/20/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program METHODS: We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432). RESULTS There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021). CONCLUSIONS With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events and mortality.
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Affiliation(s)
- M N Solís-Marquínez
- Servicio de Medicina Interna, Hospital Universitario de Cabueñes, Gijón, España.
| | - J J Rondán-Murillo
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, España
| | - M Pérez-Otero
- Servicio de Urgencias, Hospital Universitario Central de Asturias, Oviedo, España
| | - J M Vegas-Valle
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, España
| | | | - J Morís-de la Tassa
- Servicio de Medicina Interna, Hospital Universitario de Cabueñes, Gijón, España; Facultad de Medicina y Ciencias de la Salud, Universidad de Oviedo, Oviedo, España
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Vallabhajosyula S, Verghese D, Bell MR, Murphree DH, Cheungpasitporn W, Miller PE, Dunlay SM, Prasad A, Sandhu GS, Gulati R, Singh M, Lerman A, Gersh BJ, Holmes DR, Barsness GW. Fibrinolysis vs. primary percutaneous coronary intervention for ST-segment elevation myocardial infarction cardiogenic shock. ESC Heart Fail 2021; 8:2025-2035. [PMID: 33704924 PMCID: PMC8120407 DOI: 10.1002/ehf2.13281] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/27/2021] [Accepted: 02/12/2021] [Indexed: 12/29/2022] Open
Abstract
AIMS There are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI). METHODS Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status. RESULTS During 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs. CONCLUSIONS The use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA,Division of Pulmonary and Critical Care Medicine, Department of MedicineMayo ClinicRochesterMNUSA,Center for Clinical and Translational ScienceMayo Clinic Graduate School of Biomedical SciencesRochesterMNUSA,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of MedicineEmory University School of Medicine1364 Clifton Road NEAtlantaGA30322USA,Department of MedicineAmita Health Saint Joseph HospitalChicagoILUSA
| | - Dhiran Verghese
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of MedicineEmory University School of Medicine1364 Clifton Road NEAtlantaGA30322USA,Department of MedicineAmita Health Saint Joseph HospitalChicagoILUSA
| | - Malcolm R. Bell
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - Wisit Cheungpasitporn
- Division of Nephrology, Department of MedicineUniversity of Mississippi School of MedicineJacksonMSUSA
| | - Paul Elliott Miller
- Division of Cardiovascular Medicine, Department of MedicineYale University School of MedicineNew HavenCTUSA
| | - Shannon M. Dunlay
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA,Department of Health Sciences ResearchMayo ClinicRochesterMNUSA
| | - Abhiram Prasad
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - Rajiv Gulati
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Mandeep Singh
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | - Amir Lerman
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
| | | | - David R. Holmes
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
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Assessment of Transportation by Air for Patients with Acute ST-Elevation Myocardial Infarction from Non-PCI Centers. Healthcare (Basel) 2021; 9:healthcare9030299. [PMID: 33800429 PMCID: PMC8000528 DOI: 10.3390/healthcare9030299] [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] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/20/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the delays that can potentially occur in the emergency transfer of patients with ST-elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) centers. We conducted a retrospective study using the medical reports pertaining to 97 patients who presented to the Emergency Department of the Emergency County Hospital of Galati during the year of 2018 with the diagnosis of STEMI and meeting eligibility criteria for PCI, thus warranting transfer to a hospital with PCI facilities. The pick-up time of patients diagnosed with acute myocardial infarction from the emergency department by the transfer crew is significantly shorter (p < 0.05) than those transferred by air, regardless of the PCI center to which the transfer was performed, Iasi or Bucharest, when compared to the time required to process the patients transferred by land to the same PCI centers. The results of the study shows that the helicopter use for transferring acute myocardial infarction patients to a PCI center must be considered, given the distance between non-PCI and PCI centers is over 200 km.
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Impact of creating a hemodynamics room, a coronary care unit, and a primary angioplasty program on the prognosis of acute coronary syndrome in a district hospital. Rev Clin Esp 2021; 221:187-197. [PMID: 33998497 DOI: 10.1016/j.rceng.2019.11.017] [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: 10/18/2019] [Accepted: 11/20/2019] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program. METHODS We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432). RESULTS There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021). CONCLUSIONS With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events, and mortality.
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Aria S, Clugston R. Re-Thrombolysis of a Reoccluded STEMI in a Remote Patient. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Araiza-Garaygordobil D, Gopar-Nieto R, Cabello-López A, Martinez-Amezcua P, Eid-Lidt G, Baeza-Herrera LA, Gonzalez-Pacheco H, Briseño-De la Cruz JL, Sierra-Lara Martinez D, Mendoza-García S, Altamirano-Castillo A, Arias-Mendoza A. Pharmacoinvasive Strategy vs Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Study in Mexico City. CJC Open 2020; 3:409-418. [PMID: 34027343 PMCID: PMC8129473 DOI: 10.1016/j.cjco.2020.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 12/22/2022] Open
Abstract
Background A low proportion of patients with ST-elevation myocardial infarction (STEMI) in low- to middle-income countries receive reperfusion therapy. Although primary percutaneous coronary intervention (PCI) is the method of choice, a pharmacoinvasive strategy (PIs) is reasonable when primary PCI cannot be delivered on a timely basis. The aim of our study was to assess the efficacy and safety of a PIs compared with primary PCI in a real-world setting. Methods This was a prospective registry that included patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary composite end point was the occurrence of cardiovascular death, cardiogenic shock, recurrent myocardial infarction, or congestive heart failure at 30 days according to the reperfusion strategy used. The key safety end point was major bleeding (Bleeding Academic Research Consortium [BARC] score 3-5) at 30 days. Results We included 579 patients with STEMI, 49.7% underwent primary PCI and 50.2% received PIs. Those who received a PIs approach were more likely to present with Killip class > 1 and to have a history of diabetes but were less likely to have a previous cardiovascular disease diagnosis. No statistically significant difference was shown in the primary composite end point according to reperfusion strategy (hazard ratio for PIs, 0.76; 95% confidence interval, 0.48-1.21; P = 0.24). Major bleeding was not different among groups (hazard ratio for PIs, 0.92; 95% confidence interval, 0.45-1.86; P = 0.81). Two patients in the PIs group (0.6%) and no patients in the PCI group had intracranial bleeding (P = 0.15). Conclusions In this prospective real-world registry, major cardiovascular outcomes and bleeding were not different among patients who underwent a PIs or primary PCI. The study suggests that a PIs is an effective and safe option for patients with STEMI when access to primary PCI is limited.
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Affiliation(s)
- Diego Araiza-Garaygordobil
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
| | - Rodrigo Gopar-Nieto
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
| | - Alejandro Cabello-López
- Occupational Health Research Unit, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, México
| | - Pablo Martinez-Amezcua
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Guering Eid-Lidt
- Department of Interventional Cardiology, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
| | - Luis A Baeza-Herrera
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
| | - Héctor Gonzalez-Pacheco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
| | | | | | - Salvador Mendoza-García
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
| | | | - Alexandra Arias-Mendoza
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez," Mexico City, México
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Desfechos clínicos de pacientes após uso de terapia fibrinolítica pré-hospitalar: revisão sistemática. ACTA PAUL ENFERM 2020. [DOI: 10.37689/acta-ape/2020ar00946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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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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Birnbaum Y, Levine GN, French J, Kaski JC, Atar D, Alam M, Hasdai D, Jneid H, Uretsky BF. Inferior ST-Elevation Myocardial Infarction Presenting When Urgent Primary Percutaneous Coronary Intervention Is Unavailable: Should We Adhere to Current Guidelines? Cardiovasc Drugs Ther 2020; 34:865-870. [PMID: 32671603 PMCID: PMC7360897 DOI: 10.1007/s10557-020-07039-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 01/09/2023]
Abstract
The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital without pPCI capacity, and it is anticipated that pPCI cannot be performed within 120 min of first medical contact, fibrinolytic therapy is indicated (if there are no contraindications) (class I indication, level of evidence A). Our review of the pertinent literature shows that the current recommendation for inferior STEMI is based on the level of evidence lower than A. We can consider level B even C, supporting the recommendation for fibrinolytic therapy if pPCI is not available for inferior STEMI.
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Affiliation(s)
- Yochai Birnbaum
- The Department of Medicine, The Section of Cardiology, Baylor College of Medicine, One Baylor Plaza, MS BCM620, Houston, TX, 77030, USA.
| | - Glenn N Levine
- The Department of Medicine, The Section of Cardiology, Baylor College of Medicine, One Baylor Plaza, MS BCM620, Houston, TX, 77030, USA.,The Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - John French
- Department of Cardiology, Liverpool Hospital, Universities of New South Wales & Western Sydney, Sydney, Australia
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway, and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Mahboob Alam
- The Department of Medicine, The Section of Cardiology, Baylor College of Medicine, One Baylor Plaza, MS BCM620, Houston, TX, 77030, USA
| | - David Hasdai
- Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | - Hani Jneid
- The Department of Medicine, The Section of Cardiology, Baylor College of Medicine, One Baylor Plaza, MS BCM620, Houston, TX, 77030, USA.,The Section of Cardiology, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Barry F Uretsky
- Central Arkansas Veterans Health System and the University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 4027] [Impact Index Per Article: 1006.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Kazi DS, Martin LM, Litmanovich D, Pinto DS, Clerkin KJ, Zimetbaum PJ, Dudzinski DM. Case 18-2020: A 73-Year-Old Man with Hypoxemic Respiratory Failure and Cardiac Dysfunction. N Engl J Med 2020; 382:2354-2364. [PMID: 32521138 DOI: 10.1056/nejmcpc2002417] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Dhruv S Kazi
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
| | - Lila M Martin
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
| | - Diana Litmanovich
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
| | - Duane S Pinto
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
| | - Kevin J Clerkin
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
| | - Peter J Zimetbaum
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
| | - David M Dudzinski
- From the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z.) and Radiology (D.L.), Beth Israel Deaconess Medical Center, the Departments of Medicine (D.S.K., L.M.M., D.S.P., P.J.Z., D.M.D.) and Radiology (D.L.), Harvard Medical School, and the Department of Medicine, Massachusetts General Hospital (D.M.D.) - all in Boston; and the Department of Medicine, New York Presbyterian-Columbia University Medical Center, and the Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons - both in New York (K.J.C.)
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Mishra A, Prajapati J, Dubey G, Patel I, Mahla M, Bishnoi S, Pandey V. Characteristics of ST-elevation myocardial infarction with failed thrombolysis. Asian Cardiovasc Thorac Ann 2020; 28:266-272. [PMID: 32493040 DOI: 10.1177/0218492320932074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fibrinolytic therapy is an important reperfusion strategy, especially when primary percutaneous coronary interventions cannot be offered to ST-elevation myocardial infarction patients. Given that failed reperfusion after fibrinolytic therapy is common, it is pragmatic that the predictors, outcomes, and angiographic profiles of patients with failed thrombolysis are carefully scrutinized. METHODS We prospectively studied clinical variables and outcomes over 30 months in 243 ST-elevation myocardial infarction patients who received fibrinolytics as primary treatment. Logistic regression analysis was used to identify predictors of failed thrombolysis. RESULTS Failed thrombolysis occurred in 38.68% of patients with a mean window period of 6.58 ± 1.42 h, and 55.32% of patients with failed thrombolysis had Killip class >I on presentation. Risk factors such as diabetes mellitus (55.32%), dyslipidemia (60.64%) and obesity (77.66%) were frequently associated with failed thrombolysis; 73.40% of patients with failed thrombolysis had Thrombolysis in Myocardial Infarction flow grade 0/1 in the infarct-related artery, and 58.51% of such patients needed a rescue percutaneous coronary intervention. The mean Thrombolysis in Myocardial Infarction risk score was 5.46 ± 2.77 in failed thrombolysis patients, with mortality of 4.25% at the 6-month follow-up. CONCLUSION Non-resolution of presenting symptoms and ST changes on electrocardiography at 90 min served as the earliest indicators of failed thrombolysis, with a significant angiographic correlation. Clinical variables such as delayed presentation (>6 h), dyspnea, Killip class >I, cardiogenic shock, Thrombolysis in Myocardial Infarction score, and conventional risk factors including diabetes mellitus, dyslipidemia, and obesity represented cluster of predictors of failed thrombolysis.
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Affiliation(s)
- Ashish Mishra
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Jayesh Prajapati
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Gajendra Dubey
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Iva Patel
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Mukesh Mahla
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Suresh Bishnoi
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
| | - Vimlesh Pandey
- UN Mehta Institute of Cardiology and Research Centre, Ahmedabad, Gujarat, India
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Mujtaba SF, Khan MN, Sohail H, Sial JA, Karim M, Saghir T, Abbas K, Ahmed M, Qamar N. Outcome at Six Months After Primary Percutaneous Coronary Interventions Performed at a Rural Satellite Center of Sindh Province of Pakistan. Cureus 2020; 12:e8345. [PMID: 32617219 PMCID: PMC7325348 DOI: 10.7759/cureus.8345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 05/28/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction Primary percutaneous coronary intervention (PPCI) is now a well-established treatment of acute ST-elevation myocardial infarction (STEMI). For the first time in Pakistan, various off-site satellite centers are established to perform PPCI 24-hours. Our population mainly resides in the rural area with low literacy rate and poor socioeconomic conditions. The majority of the patients who are presented in the satellite center had either never received any long-term treatment plan or were non-compliant to their medication. The objective of this study was to determine the outcome of patients at six months who underwent primary PCI at a rural satellite center of Sindh, Pakistan. Methods This study was conducted at Larkana satellite center of National Institute of Cardiovascular Diseases, Karachi. Patients who underwent PPCI for STEMI from October 2017 to March 2018 were enrolled in the study. In case of death of the patient, data were obtained from the attendant of the deceased. Patients, on follow-up visits, were interrogated for post-procedure symptoms. Results A total of 271 patients were enrolled in the study. The mean age ± standard deviation of patients was 54.84 ± 10.64 years. The most common culprit artery was left anterior descending (LAD) artery with 161 (59.4%) patients, followed by right coronary artery (RCA) with 98 (36.2%) patients. Only 41 (15%) patients had a three-vessel disease, while 141 (52%) patients had single-vessel disease. On follow-up, 70 (25.8%) patients complained of chest pain grade II, 20 (7.4%) complained of shortness of breath (SOB) grade II, 44 (16.2%) complained of vertigo, and 16 (5.9%) complained of nonspecific weakness. The mortality rate of 6.3% (17) was observed after six months of PPCI. The mortality rate was found to be lower for patients with LAD disease (p = 0.036) and higher among patients with RCA as the culprit artery (p = 0.045). The mortality rate was significantly associated with the number of diseased vessels and the type of stent deployed. Conclusion Primary PCI, at a rural satellite center, has an overall positive outcome. Steps should be taken to provide free medication along with encouragement towards compliance of dual antiplatelet medication. Furthermore, the facility for subsequent procedures should be provided at the same set-up.
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Affiliation(s)
- Syed F Mujtaba
- Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Muhammad N Khan
- Interventional Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Hina Sohail
- Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Jawaid A Sial
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Musa Karim
- Statistics, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Tahir Saghir
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Kiran Abbas
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
- Medicine and Surgery, Sindh Medical College, Karachi, PAK
| | - Moiz Ahmed
- Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
- Medicine and Surgery, Sindh Medical College, Karachi, PAK
| | - Nadeem Qamar
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
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Decision to deploy coronary reperfusion is not affected by the volume of ST-segment elevation myocardial infarction patients managed by prehospital emergency medical teams. Eur J Emerg Med 2020; 26:423-427. [PMID: 30648976 DOI: 10.1097/mej.0000000000000586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Mortality in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with the volume of activity of percutaneous coronary intervention (PCI) facilities. This observational study investigated whether the coronary reperfusion-decision rate is associated with the volume of activity in a prehospital emergency setting. METHODS Prospectively collected data for the period 2003-2013 were extracted from a regional registry of all STEMI patients handled by eight dispatch centers (SAMUs) in and around Paris [41 mobile ICU (MICUs)]. A possible association between volume of activity (number of STEMIs) and coronary reperfusion-decision rate, and subsidiarily between volume of activity and choice of technique (fibrinolysis vs. primary PCI), were investigated. Explanatory factors (patient age, sex, delay between pain onset and first medical contact, and access to a PCI facility) were analyzed in a multivariate analysis. RESULTS Overall, 18 162 patients; male/female 3.5/1; median age 62 (52-72) years were included in the analysis. The median number of STEMIs per MICU was 339 (IQ 220-508) and that of reperfusion-decisions was 94% (91-95). There was no association between the decision rate and the number of STEMIs (P = 0.1). However, the decision rate was associated with age, sex, delay, and access to a PCI facility (P < 0.0001) in a highly significant way. Fibrinolysis was a more frequent option for low-volume (remoter PCI facilities) than high-volume MICUs (30 vs. 16%). CONCLUSION The decision of coronary reperfusion in a prehospital emergency setting depended on patient characteristics, delay between pain onset and first medical contact, and access to a PCI facility, but not on volume of activity. Promoting fibrinolysis use in underserved areas might help increase the reperfusion-decision rate.
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Rój J, Jankowiak M. Assessment of Equity in Access to Percutaneous Coronary Intervention (PCI) Centres in Poland. Healthcare (Basel) 2020; 8:E71. [PMID: 32225113 PMCID: PMC7348863 DOI: 10.3390/healthcare8020071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/15/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
The purpose of this study is to analyse the disparities in the distribution of percutaneous coronary intervention (PCI) centres in Poland and the impact of eventual inequities on access to the invasive treatment of acute myocardial infarctions (AMI). To examine the distribution of PCI centres against population size and geographic size in Poland, the Gini coefficient calculated based on the Lorenz Curve was engaged. In addition, the regression function was employed to estimate the impact of distribution of PCI centres on access to invasive procedures (coronarographies and primary percutaneous coronary intervention). Data were collected from the public statistical system and Polish National Health Fund database for the year 2018. The relation and the level of equity was measured based on the aggregated data at a district (voivodeship) level. The results of the Gini coefficient analysis show that the distribution of invasive cardiology units measured against population size is more equitable than when measured against geographic size. In addition, the regression analysis shows the moderate size of the positive correlation between number of PCI centres per 100,000 population and the number of all categories of the invasive treatment of AMI per 100,000 population, and the lack of similar correlation in case of the number of PCI centres expressed per 1000 km2, which could be evidence of an insufficiency of PCI centres in areas where the concentration of PCI centres per 100,000 population is lower. The main implication for policy makers that results from this research is the need for a correction of PCI centres distribution per 100,000 inhabitants to ensure better access to invasive procedures.
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Affiliation(s)
- Justyna Rój
- Department of Operational Research, The Poznań University of Economics and Business, Al. Niepodległości 10, Poznań 61-875, Poland
| | - Maciej Jankowiak
- Department of Medical Law, Organisation and Healthcare Management, Poznań University of Medical Sciences, ul. Przybyszewskiego 39, Poznań 60-356, Poland;
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Efficacy and Safety of Pharmacoinvasive Strategy Compared to Primary Percutaneous Coronary Intervention in the Management of ST-Segment Elevation Myocardial Infarction: A Prospective Country-Wide Registry. Ann Glob Health 2020; 86:13. [PMID: 32064231 PMCID: PMC7006601 DOI: 10.5334/aogh.2632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: A pharmacoinvasive reperfusion strategy is recommended for ST-elevation myocardial infarction (STEMI) patients when primary percutaneous coronary intervention (PCI) cannot be achieved in a timely fashion. This is based on a limited number of trials. The effectiveness of this strategy in the real-world is unclear. Objectives: To compare the effectiveness of pharmacoinvasive strategy versus primary PCI using a nationwide prospective registry of STEMI patients. Methods: We examined 936 STEMI patients from the reperfusion in ST-elevation myocardial infarction in Kuwait (REPERFUSE Kuwait) registry who underwent either primary PCI or pharmacoinvasive reperfusion. A composite outcome was measured based on death, congestive heart failure, reinfarction or stroke prospectively ascertained during hospital stay and up to one-year follow-up. The association between reperfusion strategy and the composite outcome was assessed using multivariate regression and Poisson proportional hazard model. Results: Compared to the pharmacoinvasive group, those undergoing primary PCI had higher Killip class on presentation and required more blood transfusions during hospitalization. There was no significant difference between primary PCI and pharmacoinvasive strategy with regards to the incidence of the composite outcome during the in-hospital period (RR = 1.0; 95% CI 0.98–1.02; p = 0.96) after adjustment for possible confounders. Over one-year follow-up, the survival of the two groups was not different (p = 0.66). The incidence of major bleeding was similar in both groups. Conclusion: STEMI patients treated with a pharmacoinvasive strategy have comparable outcomes to those treated with primary PCI with no increased risk of major bleeding. These real-world data support the use of a pharmacoinvasive strategy when primary PCI cannot be achieved in a timely fashion.
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Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in Patients ≥70 Years of Age. Am J Cardiol 2020; 125:1-10. [PMID: 31685213 DOI: 10.1016/j.amjcard.2019.09.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 11/20/2022]
Abstract
The benefit-risk ratio of a pharmacoinvasive strategy (PI) in patients ≥70 years of age with ST-segment elevation myocardial infarction (STEMI) remains uncertain resulting in its limited use in this population. This study compared efficacy and safety of PI with primary percutaneous coronary intervention (pPCI). Data from 2,841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either PI (n = 269) or pPCI (n = 2,572), were analyzed. The primary end point was in-hospital major adverse cardiovascular events (MACE) defined as the composite of all-cause mortality, nonfatal MI, stroke, and definite stent thrombosis. Secondary end points included all-cause death, major bleeding, net adverse clinical events, and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the PI (n = 247) and pPCI (n = 958) groups, (11.3% vs 9.0%, respectively, odds ratio 1.25, 95% confidence interval 0.81 to 1.94; p = 0.31). Secondary end points were comparable between groups at the exception of a lower rate of development of Killip class III or IV heart failure after PI. The rate of intracranial hemorrhage was significantly higher in the PI group (2.3% vs 0.0%, p = 0.03). In conclusion, the present study demonstrated no difference regarding in-hospital MACE following PI or pPCI in STEMI patients ≥70 years of age. An adequately-powered randomized trial is needed to precisely define the role of PI in this high-risk subgroup.
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Maroja F, Caixeta A, Poyares D, Tufik S, de Paola A, Castro L, Storti L, Burke P, Cintra F. Impact of severe OSA on pharmacoinvasive treatment in ST elevation myocardial infarction patients. Sleep Breath 2019; 24:1357-1363. [PMID: 31792908 DOI: 10.1007/s11325-019-01975-4] [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: 06/06/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The negative association between obstructive sleep apnea (OSA) and adverse cardiovascular outcomes in patients undergoing percutaneous coronary intervention (PCI) is well documented. However, little is known about the influence of OSA on fibrinolytic therapy. The aim of this study was to evaluate the impact of severe OSA on pharmacoinvasive treatment in ST elevation myocardial infarction (STEMI) patients. METHODS We enrolled consecutive STEMI patients without previous vascular disease, heart failure, or OSA diagnosis. All patients underwent either a pharmacoinvasive therapy or primary PCI. Syntax score (SS) was calculated for all patients, and a full bedside polysomnography was performed in the first 72 h of admission. In-hospital events and 30 days readmissions were analyzed. RESULTS The sample included 116 patients, 87 men. Patients with severe OSA were older (p = 0.01), had higher neck and abdominal circumferences (p < 0.01), and had higher BMI (p < 0.01). They also had lower reperfusion rates post-fibrinolysis (20 vs. 65%; p = 0.001), higher SS (20.2 ± 11.2 vs. 14.6 ± 10.6; p = 0.03), lower left ventricle ejection fraction (45 ± 8 vs. 51 ± 10%; p = 0.02), and a higher incidence of atrial arrhythmias (4 vs. 21%; p = 0.02). STEMI patients with severe OSA presented with threefold increase in the risk for at least one adverse outcome. Regression analysis showed that both severe OSA and hypertension were independent predictors of higher SS. CONCLUSION Severe OSA was associated with a poor outcome after pharmacoinvasive treatment in STEMI patients.
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Affiliation(s)
- Fabrizio Maroja
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Adriano Caixeta
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil.,Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Dalva Poyares
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Sergio Tufik
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Angelo de Paola
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Laura Castro
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Luciana Storti
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Patrick Burke
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil
| | - Fatima Cintra
- Medicine Department, Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, Brazil.
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Bhandari M, Vishwakarma P, Sethi R, Pradhan A. Stroke Complicating Acute ST Elevation Myocardial Infarction-Current Concepts. Int J Angiol 2019; 28:226-230. [PMID: 31787820 PMCID: PMC6882668 DOI: 10.1055/s-0039-1695049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Myocardial infarction (MI) is one of the leading causes of mortality today both in developed and developing countries alike. Advancement in the pharmacotherapy and revascularization techniques has resulted in drastic improvement in survival. Most of the complications of MI can be managed adequately resulting in reduced mortality from MI in the recent years. However, mortality from stroke following acute MI remains high even today. Here, we discuss the incidence, risk factors, and management of stroke following acute ST elevation MI.
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Affiliation(s)
- Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow, India
| | | | - Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow, India
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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: 106] [Impact Index Per Article: 21.2] [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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Scholz KH, Maier SKG, Maier LS, Lengenfelder B, Jacobshagen C, Jung J, Fleischmann C, Werner GS, Olbrich HG, Ott R, Mudra H, Seidl K, Schulze PC, Weiss C, Haimerl J, Friede T, Meyer T. Impact of treatment delay on mortality in ST-segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT-STEMI trial. Eur Heart J 2019; 39:1065-1074. [PMID: 29452351 PMCID: PMC6018916 DOI: 10.1093/eurheartj/ehy004] [Citation(s) in RCA: 235] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 01/18/2018] [Indexed: 01/06/2023] Open
Abstract
Aims The aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without haemodynamic instability. Methods and results Using data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n = 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). For patients treated within 60 to 180 min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P < 0.0001). Conclusions In patients with CS, the time elapsing from the first medical contact to primary PCI is a strong predictor of an adverse outcome. This patient group benefitted most from immediate PCI treatment, hence special efforts to shorten contact-to-balloon time should be applied in particular to these high-risk STEMI patients. Clinical Trial Registration NCT00794001. ![]()
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Affiliation(s)
- Karl Heinrich Scholz
- Department of Cardiology, Medizinische Klinik I, St. Bernward Hospital, Treibestraße 9, 31134 Hildesheim, Germany
| | - Sebastian K G Maier
- Department of Cardiology, Medizinische Klinik II, Klinikum Straubing and Comprehensive Heart Failure Center Würzburg, Würzburg, St.-Elisabeth-Straße 23, 94315 Straubing, Germany
| | - Lars S Maier
- Department of Cardiology, Universitätsklinikum Regensburg, Klinik und Poliklinik für Innere Medizin II, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Björn Lengenfelder
- Department of Cardiology, Universitätsklinikum Würzburg and Comprehensive Heart Failure Center Würzburg, Medizinische Klinik und Poliklinik I, Oberdürrbacher Straße 6, 97080 Würzburg, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, Heart Center, University of Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany
| | - Jens Jung
- Department of Cardiology, Medizinische Klinik I, Klinikum Worms, Gabriel-von-Seidl-Straße 81, 67550 Worms, Germany
| | - Claus Fleischmann
- Department of Cardiology, Klinikum Wolfsburg, Medizinische Klinik I, Sauerbruchstraße 7, 38440 Wolfsburg, Germany
| | - Gerald S Werner
- Department of Cardiology, Medizinische Klinik I, Klinikum Darmstadt, Grafenstraße 9, 64283 Darmstadt, Germany
| | - Hans G Olbrich
- Department of Cardiology, Asklepios Klinik Langen, Röntgenstraße 20, 63225 Langen, Germany
| | - Rainer Ott
- Department of Cardiology, HELIOS Klinikum Krefeld, Medizinische Klinik I, Lutherplatz 40, 47805 Krefeld, Germany
| | - Harald Mudra
- Department of Cardiology, Klinikum Neuperlach, Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, Oskar-Maria-Graf-Ring 51, 81737 München, Germany
| | - Karlheinz Seidl
- Department of Cardiology, Klinikum Ingolstadt, Medizinische Klinik I und IV, Krumenauerstraße 25, 85049 Ingolstadt, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Am Klinikum 1, 07740 Jena, Germany
| | - Christian Weiss
- Department of Cardiology, Klinikum Lüneburg, Bögelstraße 1, 21339 Lüneburg, Germany
| | - Josef Haimerl
- Department of Cardiology, Krankenhaus Landshut-Achdorf, Medizinische Klinik I, Achdorfer Weg 3, 84036 Landshut, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, University of Göttingen, and DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Thomas Meyer
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Göttingen, University of Göttingen, and DZHK, partner site Göttingen, Waldweg 33, 37073 Göttingen, Germany
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Pharmacoinvasive Approach with Streptokinase in Low to Intermediate Risk ST-Elevation Myocardial Infarction Patients: Insights from the Tamil Nadu-STEMI Initiative. Am J Cardiovasc Drugs 2019; 19:517-519. [PMID: 30798503 DOI: 10.1007/s40256-019-00327-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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One-Month Clinical Outcomes of ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention at a High-volume Cardiac Tertiary Center: Routine Hours Versus Off-hours. Crit Pathw Cardiol 2019; 19:33-36. [PMID: 31478947 DOI: 10.1097/hpc.0000000000000195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI). We aimed to compare 1-month major adverse cardiac events (MACE) of patients undergoing primary PCI between 2 routine-hour and off-hour working shifts. In this cross-sectional study, 1791 STEMI patients were retrospectively evaluated who underwent primary PCI. The patients were classified into 2 groups of routine and off-hour according to the PCI start time and date [495 patients (27.7%) in routine-hour group; 1296 patients (72.3%) in off-hour group]. Cardiovascular risk factor, angiographic, procedural data, door-to-device time, and 1-month follow-up data of patients were compared between 2 groups. There was a statistical difference in door-to-device time between routine-hour and off-hour group [55 minutes (40-100 minutes) in off-hour group vs. 49 minutes (35-73 minutes) in routine-hour group; P ≤ 0.001]. However, most of the patients in both groups had door-to-device time ≤60 minutes. The frequency of 1-month MACE was 8.5% in off-hour group and 6.9% in routine-hour group (P = 0.260). After adjustment for possible confounders, the procedure result, in-hospital death, and 1-month MACE were not significantly different between both study groups. We found that STEMI patients treated with primary angioplasty during off-hour shifts had similar 1-month clinical outcomes to routine-hour shifts. Considering the high number of patients requiring primary PCI during off-hours, the importance of early revascularization in acute myocardial infarction, and the comparable clinical outcomes and procedural success, full-time provision of primary PCI services seems to be beneficial.
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Ferreira AS, Costa J, Braga CG, Marques J. Impacto na mortalidade da admissão direta versus transferência inter‐hospitalar nos doentes com enfarte agudo do miocárdio com elevação do segmento ST submetidos a intervenção coronária percutânea primária. Rev Port Cardiol 2019; 38:621-631. [DOI: 10.1016/j.repc.2019.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 01/16/2019] [Accepted: 02/03/2019] [Indexed: 01/10/2023] Open
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Impact on mortality of direct admission versus interhospital transfer in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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New European Society of Cardiology guidelines for the management of patients with ST-elevation myocardial infarction: effect on physician's compliance and patient's outcome. Eur J Emerg Med 2019; 26:380-381. [PMID: 31460965 DOI: 10.1097/mej.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ali M, Lange SA, Wittlinger T, Lehnert G, Behrend S, Ziadeh B, Ali K, Sakellaropoulos S, Ganchev G, Rigopoulos AG, Noutsias M. RETRACTED ARTICLE: Direct transfer of STEMI patients to cardiac catheterization laboratory : Prognostic relevance for in-hospital mortality. Herz 2019; 44:460. [PMID: 29350253 DOI: 10.1007/s00059-017-4673-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Affiliation(s)
- M Ali
- Department of Cardiology, AsklepiosHarzklinik Goslar, KöslinerStraße 12, 38642, Goslar, Germany.
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany.
| | - S A Lange
- Department of Cardiology, AsklepiosHarzklinik Goslar, KöslinerStraße 12, 38642, Goslar, Germany
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Heart Centre Lübeck, Lübeck, Germany
| | - T Wittlinger
- Department of Cardiology, AsklepiosHarzklinik Goslar, KöslinerStraße 12, 38642, Goslar, Germany
| | - G Lehnert
- Department of Cardiology, AsklepiosHarzklinik Goslar, KöslinerStraße 12, 38642, Goslar, Germany
| | - S Behrend
- Department of Cardiology, AsklepiosHarzklinik Goslar, KöslinerStraße 12, 38642, Goslar, Germany
| | - B Ziadeh
- Department of Cardiology, AsklepiosHarzklinik Goslar, KöslinerStraße 12, 38642, Goslar, Germany
| | - K Ali
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - S Sakellaropoulos
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - G Ganchev
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - A G Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
| | - M Noutsias
- Mid-German Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany
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