Early Catheterization Research Articles

Early Cardiac Catheterization Laboratory Activation by Paramedics for Patients with ST-segment Elevation Myocardial Infarction on Prehospital 12-Lead Electrocardiograms

Background. Prompt reperfusion in ST-segment elevation myocardial infarction (STEMI) saves lives. Although studies have shown that paramedics can reliably interpret STEMI on prehospital 12-lead electrocardiograms (p12ECGs), prehospital activation of the cardiac catheterization laboratory by emergency medical services (EMS) has not yet gained widespread acceptance. Objective. To quantify the potential reduction in time to percutaneous coronary intervention (PCI) by early prehospital activation of the cardiac catheterization laboratory in STEMI. Methods. This prospective, observational study enrolled all patients diagnosed with STEMI by paramedics in a mid-sized regional EMS system. Patients were enrolled if: 1) the paramedic interpreted STEMI on the p12ECG, 2) the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) score was 75%% or greater, and 3) the patient was transported to either of two area PCI centers. Data recorded included the time of initial EMS “STEMI alert” from the scene, time of arrival at the emergency department (ED), and time of actual catheterization laboratory activation by the ED physician, all using synchronized clocks. The primary outcome measure was the time difference between the STEMI alert and the actual activation (i.e., potential time savings). The false-positive rate (patients incorrectly diagnosed with STEMI by paramedics) was also calculated and compared with a locally accepted false-positive rate of 10%%. Results. Twelve patients were enrolled prior to early termination of the study. The mean and median potential time reductions were 15 and 11 minutes, respectively (range 7–29 minutes). There was one false STEMI alert (8.3%% false-positive rate) for a patient with a right bundle branch block who subsequently had a non–ST-segment elevation myocardial infarction. The study was terminated when our cardiologists adopted a prehospital catheterization laboratory activation protocol based on our initial data. Conclusion. Important reductions in time to reperfusion seem possible by activation of the catheterization laboratory by EMS from the scene, with an acceptably low false-positive rate in this small sample. This type of clinical research can inform multidisciplinary policies and bring about meaningful clinical practice changes.

Establishing Coronary Patency: A Key to Optimal Post Resuscitation Care

The formalizing post resuscitation care to include therapeutic hypothermia and cardiac angiography with percutaneous coronary intervention when needed could significantly improve survival following cardiac arrest. Any sudden death patient suspected to have a cardiac origin for their cardiac arrest should be considered for early catheterization and subsequent percutaneous coronary intervention (PCI) if a culprit lesion can be identified. Successful PCI improves survival to hospital discharge and cerebral performance category in patients with or without ST elevation. Current ‘report carding’ methodology needs to be changed regarding those resuscitated from cardiac arrest (patients with cardiac arrest not including them in any statistical reporting on PCI mortality report cards).

2009 Dickinson W. Richards Memorial Lecture—Improving Survival From Out-of-Hospital Cardiac Arrest

A renewed understanding of resuscitation physiology has led to several bold new approaches to basic life support (BLS) and advanced cardiovascular life support (ACLS), as well as a recognition that aggressive postresuscitation care can have a major impact on long-term outcome. Concepts initially tested in basic and translational resuscitation research laboratories have within the past several years been piloted in a number of rural and urban communities. Several of these newer approaches to BLS, ACLS, and postresuscitation care have dramatically increased historical survival rates around the world. These include the following: Hands-only BLS CPR . The survival rate for witnessed ventricular fibrillation in Tokyo increased from 11% to 19% when lay bystander rescuers performed chest compression– only or “hands-only” BLS as compared with chest compressions and mouth-to-mouth breathing. The American Heart Association endorsed “hands-only” BLS for encouraging more bystander CPR in March 2008. New ACLS algorithm emphasizing uninterrupted chest compressions . The initial report of the use of this newly revised ACLS approach came from rural Wisconsin. The rate of 1-year survival from witnessed ventricular fibrillation cardiac arrest tripled, from 15% to 48%. A follow-up report 3 years later showed a persistent benefit, with a 3-year survival rate of 40%. In Phoenix, Arizona, introduction of this revised ALCS algorithm increased the rate of survival to hospital discharge with ventricular fibrillation cardiac arrest from 12% to 28%. Postresuscitation care . Postresucitation care is the next great opportunity to improve long-term outcome among victims of out-of-hospital cardiac arrest. In Norway, the rate of 1-year survival among those resuscitated from out-of-hospital cardiac arrest increased from 26% to 56% after formalization of the postresuscitation care, with emphasis on providing mild therapeutic hypothermia and early catheterization and percutaneous coronary intervention where indicated. Case series reported in the literature suggest this approach can produce long-term survival rates of 70% among those initially resuscitated, with 80% of such long-term survivors being neurologically intact. The near future holds more real promise for improving the outcome of those suffering cardiac arrest than ever before. Now is the time to move forward and provide improved care to all victims of sudden cardiac death.

Abstract 4864: Electrocardiographic and Angiographic Correlations in Patients With Left Bundle Branch Block With Suspected Myocardial Infarction Undergoing Urgent Coronary Angiography

Background: The purpose of this study is to determine the accuracy of the Sgarbosa criteria to identify the presence of acute Myocardial Infarction (MI) diagnosed by biomarkers and to predict coronary occlusions in patients with new or presumed new Left Bundle Branch Block (LBBB) and suspected acute MI. Methods: We retrospectively reviewed the records of 1322 consecutive patients presenting to our institution with suspected acute transmural MI who underwent urgent coronary angiography between 2004 and 2008. Results: Thirty four patients (2.6%) had LBBB. Results of Sgarbosa criteria versus presence of an occluded coronary artery and troponin status are shown in the table below. Conclusions: In our cohort of patients 26 out of 34 (76%) patients had MI as determined by elevated tropnin levels. Sgarbosa criteria, when applied with the weighted score of >/=2, could detect patients of myocardial infarction with a sensitivity of 62%, specificity of 63%, positive predictive value of 76% and negative predictive value of 23%. When the same criteria were applied to detect occlusion of any coronary artery the sensitivity was found to be 50% with a specificity of 32%, positive predictive value of 29% and negative predictive value of 54%. In conclusion, the incidence of MI among the patients of new or presumed new LBBB is high at 76%. The overall usefulness of Sgarbosa criteria to diagnose MI and occluded coronaries (which are most likely to benefit from early revascularization) in patients with LBBB is moderate but the negative predictive value is very low. Hence patients with new or presumed new LBBB with suspected myocardial infarction should get the benefit of early catheterization if clinically justified. Occluded Coronary Artery and Troponin Status

Completion Angiography After Cardiac Surgery for Congenital Heart Disease: Complementing the Intraoperative Imaging Modalities

Residual structural pathology after cardiac surgery for congenital heart disease may complicate postoperative recovery. Completion angiograms obtained in the operating room may facilitate early detection and therapy of residual structural abnormalities. Our objective here is to report our institutional experience performing completion angiograms after cardiopulmonary bypass surgery. Between October 2007 and August 2008, 31 patients underwent completion angiograms after 32 cardiac surgical procedures. The median age was 7.5 months (range, 50 days to 31.2 years) and the median weight was 6.5 kg (range, 3.1-153 kg). Type of procedure, angiographic findings, and therapeutic decision were retrospectively reviewed. Procedures (proc) evaluated through completion angiography included comprehensive stage II or Glenn (n = 13), aortic arch reconstruction/conduit (n = 3), repair/palliation of tetralogy of Fallot or pulmonary atresia with ventricular septal defect (n = 4), PVR or conduit replacement (n = 5), and others (n = 7). Unexpected pathology was identified in 18 of 32 (56.3%) proc, which included left pulmonary artery (LPA) stenoses (n = 15), right pulmonary artery (RPA) stenoses (n = 11), and stenosis impairing coronary blood flow (after DKS; n = 1). In 9 of 32 (28.1%) proc, findings may have led to a change in therapeutic management. This included surgical revision (n = 1), 'Hybrid' therapy in the same setting (n = 2: LPA stent, 1; RPA balloon, 1), early catheterization within 3 months (n = 4), and change in medical management (n = 2: change in anticoagulation, 1; early CT, 1). Complications related to completion angiography were seen in only a single procedure (LPA staining). In conclusion, completion angiograms using a dedicated Hybrid cardiac operating suite may aid in early diagnosis and therapy of postsurgical abnormalities. They complement other methods of intraoperative imaging and may reduce the potential need for early surgical or transcatheter reintervention.

Overcoming barriers to developing seamless ST-segment elevation myocardial infarction care systems in the United States: recommendations from a comprehensive Prehospital 12-lead Electrocardiogram Working Group

Background Reducing time to reperfusion treatment for patients with ST-segment elevation myocardial infarction (STEMI) improves patient outcomes. Few medical systems consistently meet current benchmarks regarding timely access to treatment. Studies have widely demonstrated that prehospital 12-lead electrocardiography can facilitate early catheterization laboratory activation and is the most effective means of decreasing patients' time to treatment. Methods We gathered experts to examine the barriers to implementation of prehospital 12-lead electrocardiographic monitoring and transmission to in-hospital cardiologists in creating seamless STEMI care systems (STEMI-CS) and propose multidisciplinary approaches to overcoming these barriers. Results and Conclusions Physicians, hospital systems, and emergency medical services often lack coordination of care delivery and receive fragmented funding and oversight. Clinical and regulatory guidelines do not emphasize local solutions to achieving clinical benchmarks, do not target incentives at all components of the STEMI-CS, and underemphasize risk-based approaches to protecting patient health. Integration of the multiple complex components involved in STEMI-CS is essential to improving care delivery.

Quality of Care and Length of Hospital Stay Among Patients With Stroke

The relationship between quality of care and economic outcome measures, including length of stay (LOS), among patients with stroke remains to be clarified. To determine whether quality of care is associated with LOS among patients with stroke. In this population-based follow-up study, we included 2636 patients with stroke who had been admitted to dedicated stroke units in Aarhus County, Denmark, from 2003 to 2005. Quality of care was measured as fulfillment of 12 criteria: early admission to a stroke unit, early antiplatelet therapy, early anticoagulant therapy, early computed tomography/magnetic resonance imaging scan, early water swallowing test, early mobilization, early intermittent catheterization, early deep venous thromboembolism prophylaxis, early assessment by a physiotherapist and an occupational therapist, and early assessment of nutritional and constipation risk. Data were analyzed by linear regression clustered at the stroke units by multilevel modeling. Median LOS was 13 days (25th and 75th percentiles: 7, 33). Meeting each quality of care criteria was associated with shorter LOS. Adjusted relative LOS ranged from 0.67 (95% confidence interval (CI): 0.61-0.73) to 0.87 (95% CI: 0.81-0.93). The association between meeting more quality of care criteria and LOS followed a dose-response effect, that is, patients who fulfilled between 75% and 100% of the quality of care criteria were hospitalized about one-half as long as patients who fulfilled between 0% and 24% of the criteria (adjusted relative LOS: 0.53, 95% CI: 0.48-0.59). Higher quality of care during the early phase of stroke was associated with shorter LOS among patients with stroke.

Transcatheter aortic valve implantation in the operating room: early experience

Aortic stenosis is the most common valvular heart disease in the Western world and the proportion of patients unsuitable for conventional surgery is increasing as a result of aging and comorbidities. We report our early experience with transcatheter aortic valve implantation in high-risk patients with severe symptomatic aortic stenosis. Transcatheter Edwards-SAPIEN valve implantation was attempted in 22 patients (80 +/- 5 years) in whom surgical risk was deemed excessive because of older age, poor left ventricular function, comorbidities, or all. A retrograde transarterial approach was used in 15 cases. In seven cases, valve implantation was performed by transapical approach because of aortic or iliac artery tortuosity, or both, and stenosis. All procedures were performed without cardiopulmonary bypass. Rapid ventricular pacing was used to reduce cardiac output while delivering balloon-expandable prosthesis. One patient died because of aortic dissection during early catheterization maneuvers. In the remaining patients, procedural success was achieved in all cases. Successful valve replacement was associated with an increase in transthoracic echocardiographic valve area from 0.65 +/- 0.14 to 2.2 +/- 0.4 cm2 and significant improvement in clinical condition. During the course of this experience, we encountered three (13.6%) cases of vascular complications related to transcatheter aortic valve implantation procedures. The present study confirms the excellent hemodynamic performances of the transcatheter-implanted aortic prosthesis, with both transarterial and transapical approaches, in inoperable candidates with end-stage aortic stenosis. With progressive improvement in patient selection, techniques, equipment, and operator endovascular skills, vascular complications can decline further.

Hemodynamic variables during stress testing can predict referral to early catheterization but failed to show a prognostic impact on emerging cardiac events in patients aged 70 years and older undergoing exercise 99mTc-sestamibi myocardial perfusion scintigraphy

The aim of the present study was to evaluate the prognostic value of hemodynamic variables during ergometric stress testing for (99m)Tc-sestamibi myocardial perfusion scintigraphy (MPS) as compared to several patient-related variables and MPS results with regard to referral to early coronary angiography (<3 months after MPS; CA) as well as cardiac event (CE) free survival in a study population aged > or =70 years. About 90 patients aged > or =70 years (74.5 +/- 3.6 years) who underwent ergometric stress/rest MPS were included in this study. About 19 hemodynamic variables during stress testing were assessed. Semiquantitative visual interpretation of MPS images were performed and Summed-Stress-(SSS), Summed-Difference-, and Summed-Rest-Scores were calculated. Emerging CE comprised myocardial revascularization and -infarction as well as cardiac-related death. Multivariate logistic regression analyses were performed for evaluation of independent prognostic impact of hemodynamic-, MPS- and clinical-variables with regard to referral to early catheterization as well as emerging CE. Kaplan-Meier survival- and log rank analyses were calculated for assessment of CE free survival. History of CAD (Odds ratio; OR: 99.3), low rest heart rate (OR: 14.9) and low peak systolic blood pressure (OR: 15.4) during ergometric stress testing as well as pathological SSS (OR: 48.4) were significantly associated with referral to CA. History of ischemic ECG (OR: 4.7) and pathological SSS (OR: 3.7) independently predicted emerging CE and were associated with a lower CE free survival. In patients aged > or =70 years, CA is independently predicted by clinical variables, pathological results of MPS and hemodynamic variables. In contrast, hemodynamic response to stress testing failed to show any predictive impact on emerging CE.

Cardiac catheterization is underutilized after in-hospital cardiac arrest

Indications for immediate cardiac catheterization in cardiac arrest survivors without ST elevation myocardial infarction (STEMI) are uncertain as electrocardiographic and clinical criteria may be challenging to interpret in this population. We sought to evaluate rates of early catheterization after in-hospital ventricular fibrillation (VF) arrest and the association with survival. Using a billing database we retrospectively identified cases with an ICD-9 code of cardiac arrest (427.5) or VF (427.41). Discharge summaries were reviewed to identify in-hospital VF arrests. Rates of catheterization on the day of arrest were determined by identifying billing charges. Unadjusted analyses were performed using Chi-square, and adjusted analyses were performed using logistic regression. One hundred and ten in-hospital VF arrest survivors were included in the analysis. Cardiac catheterization was performed immediately or within 1 day of arrest in 27% (30/110) of patients and of these patients, 57% (17/30) successfully received percutaneous coronary intervention. Of those who received cardiac catheterization the indication for the procedure was STEMI or new left bundle branch block (LBBB) in 43% (13/30). Therefore, in the absence of standard ECG data suggesting acute myocardial infarction, 57% (17/30) received angiography. Patients receiving cardiac catheterization were more likely to survive than those who did not receive catheterization (80% vs. 54%, p<.05). In patients receiving cardiac catheterization, more than half received this procedure for indications other than STEMI or new LBBB. Cardiac catheterization was associated with improved survival. Future recommendations need to be established to guide clinicians on which arrest survivors might benefit from immediate catheterization.

Abstract 5577: Short-Term Outcomes of STEMI and NSTEMI in Patients with Chronic Kidney Disease: A Report from the National Cardiovascular Data ACTION Registry

Chronic kidney disease (CKD) is a risk factor for myocardial infarction (MI) and death. However, the relationship between severity of CKD and contemporary hospital-based management and outcomes across the spectrum of MI (STEMI and NSTEMI) has not been well-documented. The study population was drawn from the ACTION Registry, a nation-wide sample of STEMI (n=19,481) and NSTEMI (n=30,462) patients admitted to 274 hospitals in the United States between January 1 and December 31, 2007. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation and categorized as ≥60, 30 to &lt;60, 15 to &lt;30 and eGFR&lt;15 mL/min/1.73m 2 or dialysis. Use of acute (first 24 hours) therapies and early (first 48 hours) cardiac catheterization as well as in-hospital major bleeds, and death were compared across CKD stages in models adjusted for demographics, CVD history and prior procedures, and risk factors. Overall, 30.5% and 42.9% of patients with STEMI and NSTEMI, respectively, had CKD Stage III or greater (eGFR&lt;60 ml/min/1.73m 2 or dialysis). Regardless of MI type, patients with CKD were less likely to receive acute evidence-based therapies including aspirin, beta-blockers or clopidogrel or to undergo early invasive care and were more likely to experience a major bleed or death (Table ). There were 1030 deaths among those presenting with STEMI, and 1223 among those with NSTEMI. There was a greater relative increase in death for patients with STEMI with advancing CKD stage than was seen in NSTEMI (P interaction &lt;0.0001 for each stage). A large proportion of patients presenting with STEMI or NSTEMI have CKD. Further efforts to address treatment gaps in the management of MI in the presence of CKD are needed to improve outcomes in this high-risk population. Table- Multivariable adjusted odds ratios and 95% confidence intervals of outcomes based on CKD stage

Some Old and Some New Statistical Tools for Outcomes Research

Outcomes research “seeks to understand the end results of particular health care practices and interventions”1 to inform the development of clinical practice guidelines, evaluate the quality of medical care, and foster effective interventions to improve the quality of care.2 Although randomized trial designs have been used to assess quality of care and to identify effective interventions in the real world,3,4 the empirical basis of outcomes research largely rests on data collected in the observational setting (eg, in the routine setting of everyday practice). With more emphasis placed on increasing the value of health care in terms of lives saved and morbidity avoided, outcomes researchers are making unprecedented demands of observational databases. This is evidenced by the increasing number of and participation in national registries. These include the National Cardiac Data Registry of the American College of Cardiology; the Implantable Cardioverter Defibrillator Registry launched jointly by the American College of Cardiology and the Heart Rhythm Society; the National Cardiac Surgery Database of the Society of Thoracic Surgeons; and the Interagency Registry of Mechanically Assisted Circulatory Support Devices funded by the National Heart, Lung, and Blood Institute, the Centers for Medicare and Medicaid Services, and others. Empirical analyses of these databases require statistical tools that can handle the complexity of the data: observational, sometimes hierarchical, often with multiple outcomes, and always with some missing data. The purpose of the present article is to review key statistical methods important to outcomes research and to introduce newer methodology. The article describes 4 methodological issues commonly present when observational data are analyzed; summarizes the primary assumptions associated with strategies to handle these common problems; demonstrates methods to assess the plausibility of the assumptions associated with each strategy; and illustrates these concepts using examples from cardiovascular outcomes research. Although the intent of the …

Tailored antithrombotic therapy for acute coronary syndromes

Acute coronary syndromes usually result from thrombotic occlusion of a coronary artery at the site of atherosclerotic plaque disruption. The mainstay of treatment is the use of antiplatelet and antithrombotic therapy to maintain patency of the artery. In patients with non-ST segment elevation acute coronary syndromes, antithrombotic therapy followed by coronary revascularization (when feasible in patients with high-risk features) is the optimal management strategy. In the patient with ST elevation acute coronary syndromes who receives a fibrinolytic agent antithrombotic agents, are also important to prevent reocclusion. Bleeding complications of antithrombotic therapy are associated with a substantial increase in adverse short- and long-term outcomes. Hence, the selection of the most appropriate antithrombotic agent aims to minimize both ischemic and hemorrhagic complications. Factors that are associated with increased bleeding risk and need to be considered when selecting an antithrombotic agent include decreased renal function, short time to invasive procedure (<24 h), and the overall bleeding risk. For patients who will undergo later cardiac catheterization and are not at high bleeding risk, either enoxaparin or fondaparinux are acceptable choices. For patients who are likely to undergo early catheterization or have an increased bleeding risk, either fondaparinux or unfractionated heparin are the optimal choice. Patients with severe impairment of renal function should receive unfractionated heparin

A clinical evaluation of the StarClose device in patients who are ambulated early post-diagnostic catheterization procedure

A clinical evaluation of the StarClose device in patients who are ambulated early post-diagnostic catheterization procedure

Traumatisme de l'urètre antérieur : diagnostic et traitement

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).

B-natriuretic Peptide: A Helpful Clinical Marker After Norwood I

Amplified cardiac B-natriuretic peptide (BNP) expression results from ventricular volume or pressure overload. Clinicians have used BNP levels when evaluating cardiac performance in patients with varied clinical conditions. We report a case in which BNP levels helped guide early catheterization intervention in a patient after stage 1 Norwood palliation.

Recombinant Nematode Anticoagulant Protein c2 in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: The ANTHEM–TIMI-32 Trial

We sought to evaluate the safety and efficacy of recombinant nematode anticoagulant protein c2 (rNAPc2) in patients with non-ST-segment elevation acute coronary syndrome (nSTE-ACS). Recombinant NAPc2 is a potent inhibitor of the tissue factor/factor VIIa complex that has the potential to reduce ischemic complications mediated by thrombin generation. A total of 203 patients were randomized 4:1 to double-blinded intravenous rNAPc2 or placebo every 48 h for a total of 1 to 3 doses in 8 ascending panels (1.5 to 10 microg/kg). All patients received aspirin, unfractionated heparin (UFH), or enoxaparin and early catheterization; clopidogrel and glycoprotein IIb/IIIa blockers were encouraged. Two subsequent open-label panels evaluated 10 mug/kg rNAPc2 with half-dose UFH (n = 26) and no UFH (n = 26). The primary end point was the rate of major plus minor bleeding. Pharmacokinetics, pharmacodynamics, continuous electrocardiography, and clinical events were assessed. Recombinant NAPc2 did not significantly increase major plus minor bleeding (3.7% vs. 2.5%; p = NS) despite increasing the international normalized ratio in a dose-related fashion (trend p < or = 0.0001). Higher-dose rNAPc2 (> or =7.5 microg/kg) suppressed prothrombin fragment F1.2 generation compared with placebo and reduced ischemia by >50% compared to placebo and lower-dose rNAPc2. Thrombotic bailout requiring open-label anticoagulant occurred in 5 of 26 patients treated without UFH, but none in the half-dose UFH group (19% vs. 0%; p = 0.051). In patients with nSTE-ACS managed with standard antithrombotics and an early invasive approach, additional proximal inhibition of the coagulation cascade with rNAPc2 was well tolerated. rNAPc2 doses > or =7.5 microg/kg suppressed F1.2 and reduced ischemia, though some heparin may be necessary to avoid procedure-related thrombus formation. (Anticoagulation With rNAPc2 to Eliminate MACE/TIMI 32; http://www.clinicaltrial.gov/ct/show/NCT00116012?order=1; NCT00116012).

Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study

The ICTUS trial was a study that compared an early invasive with a selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome (nSTE-ACS). The study reported no difference between the strategies for frequency of death, myocardial infarction, or rehospitalisation after 1 year. We did a follow-up study to assess the effects of these treatment strategies after 4 years. 1200 patients with nSTE-ACS and an elevated cardiac troponin were enrolled from 42 hospitals in the Netherlands. Patients were randomly assigned either to an early invasive strategy, including early routine catheterisation and revascularisation where appropriate, or to a more selective invasive strategy, where catheterisation was done if the patient had refractory angina or recurrent ischaemia. The main endpoints for the current follow-up study were death, recurrent myocardial infarction, or rehospitalisation for anginal symptoms within 3 years after randomisation, and cardiovascular mortality and all-cause mortality within 4 years. Analysis was by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN82153174. The in-hospital revascularisation rate was 76% in the early invasive group and 40% in the selective invasive group. After 3 years, the cumulative rate for the combined endpoint was 30.0% in the early invasive group compared with 26.0% in the selective invasive group (hazard ratio 1.21; 95% CI 0.97-1.50; p=0.09). Myocardial infarction was more frequent in the early invasive strategy group (106 [18.3%] vs 69 [12.3%]; HR 1.61; 1.19-2.18; p=0.002). Rates of death or spontaneous myocardial infarction were not different (76 [14.3%] patients in the early invasive and 63 [11.2%] patients in the selective invasive strategy [HR 1.19; 0.86-1.67; p=0.30]). No difference in all-cause mortality (7.9%vs 7.7%; p=0.62) or cardiovascular mortality (4.5%vs 5.0%; p=0.97) was seen within 4 years. Long-term follow-up of the ICTUS trial suggests that an early invasive strategy might not be better than a more selective invasive strategy in patients with nSTE-ACS and an elevated cardiac troponin, and implementation of either strategy might be acceptable in these patients.

Transhepatic vascular access for diagnostic and interventional procedures: Techniques, outcome, and complications

Early or multiple cardiac catheterizations may result in occlusion of the femoral veins prohibiting their use. The internal jugular or sub-clavian approach may be an appropriate alternative. However, these approaches may not be suitable in patients with surgical interruption of the superior vena cava. In other patients, they may not allow easy access to certain areas of the heart. The transhepatic approach is an important alternative route for performing cardiac catheterization and interventions. Depending on the planned procedure, it may be the preferred route to perform the cardiac catheterization even in the presence of patent femoral veins. The indications, technical details and potential complications of this approach are discussed.

Bleeding complications in patients with acute coronary syndrome undergoing early invasive management can be reduced with radial access, smaller sheath sizes, and timely sheath removal

Our objective was to analyze the impact of arterial access site, sheath size, timing of sheath removal, and use of access site closure devices on high-risk patients with acute coronary syndromes (ACS). In the SYNERGY trial, 9,978 patients with ACS were randomly assigned to receive enoxaparin or unfractionated heparin. This analysis includes 9,404 patients for whom sheath access information was obtained for the first PCI procedure or diagnostic catheterization. Comparisons of baseline, angiographic, and procedural characteristics were carried out according to access site and sheath size. Overall, 9,404 (94%) patients underwent angiography at a median of 21 hr (25th and 75th percentiles: 5, 42) and 4,687 (50%) underwent PCI at a median of 23 hr (6,49) of enrollment. The access site was femoral for 94.9% of cases, radial for 4.4%, and brachial for 0.7%. Radial access was associated with fewer transfusions than femoral access (0.9% vs. 4.8%, P=0.007). For femoral access, the rates of noncoronary artery bypass grafting (CABG)-related TIMI major bleeding by sheath size was 1.5% for 4 or 5 French (Fr), 1.6% for 6 Fr, 3.3% for 7 Fr, and 3.8% for >or=8 Fr (P<0.0001). After adjustment for baseline characteristics, femoral access site, larger sheath size, and delayed sheath removal were independent predictors of need for transfusion. Smaller sheaths, radial access, and timely sheath removal may mitigate the bleeding risk associated with potent antithrombotic/platelet therapy and early catheterization.