Guideline-based Protocol Research Articles

Contemporary Management of Cardiac Implantable Electronic Device Infection: The American College of Cardiology COGNITO Survey

BackgroundCardiac implantable electronic devices (CIEDs) infection remains a serious complication, causing increased morbidity and mortality. Early recognition and escalation to definitive therapy including extraction of the infected device often pose challenges. ObjectivesThe purpose of this study was to assess U.S.-based physicians current practices in diagnosing and managing CIED infections and explore potential extraction barriers. MethodsAn observational survey was performed by the American College of Cardiology including U.S. physicians managing CIEDs from February to March 2022. Sampling techniques and screener questions determined eligibility. The survey featured questions on knowledge and experience with CIED infection patients and case scenarios. ResultsOf 387 physicians completing the survey (20% response rate), 49% indicated familiarity with current guidelines regarding CIED infection. Electrophysiologists (EPs) (91%) were more familiar with these guidelines, compared to non-EP cardiologists (29%) and primary care physicians (23%). Only 30% of physicians specified that their institution had guideline-based protocols in place for managing patients with CIED infection. When presented with pocket infection cases, approximately 89% of EPs and 50% of non-EP cardiologists would follow guideline recommendation to do complete CIED system removal, while 70% of primary care physicians did not recommend guideline-directed treatment. ConclusionsThere are gaps in familiarity of guidelines as well as the knowledge in practical management of CIED infection with non-extracting physicians. Most institutions lack a definite pathway. Addressing discrepancies, including guideline education and streamlining care or referral pathways, will be a key factor to bridging the gap and improving CIED infection patient outcomes.

Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases

IntroductionA multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and...

Abstract 10348: Contemporary Management of Cardiac Implantable Electronic Device Infection: A Survey of American College of Cardiology Members and Primary Care Physicians (COGNITO Study)

Introduction: Cardiac implantable electronic devices (CIED) infection remains a serious complication associated with CIEDs. Complete extraction is a Class I recommendation for CIED infections, but a recent US Medicare analysis has demonstrated that there is a lack of guideline adherence with only 1 in 5 patients with a CIED infection undergoing extraction. Objective: To assess the current practice of US-based physicians related to the diagnosis and management of CIED infections and explore potential barriers to extraction. Methods: ACC performed a survey, based on a previous multinational EHRA/ESC needs assessment, to collect data from a mix of US physicians that may encounter CIED patients with complications. The survey timeframe was Feb 11 - Mar 10, 2022. Sampling techniques and screener questions were used to determine eligibility. The survey included questions based on knowledge and experience with CIED infection patients and multiple case scenarios. Results: The response rate was 20%, with a total of 387 physicians completing the survey. Less than half of clinicians polled (49%) indicated that they were familiar with the current HRS/AHA/EHRA/ESC guidelines regarding CIED infection. EPs (91%) were more familiar with these guidelines, compared to non-EP cardiologists (29%) and PCPs (23%). All EPs surveyed have had experience managing patients with CIEDs and nearly all (98%) have implanted these devices. Only two-thirds of non-EP cardiologists have experience with these patients. Only 30% of physicians specified that their institution had guideline-based protocols in place for managing patients with CIED infection. When presented with pocket infection cases, close to 50% of non-EP cardiologists and 70% of PCPs did not recommend guideline directed treatment. Conclusions: There are gaps in familiarity of guidelines as well as practical management of CIED infection with several non-extracting physician groups. Additionally, there is a lack of care pathways and other mechanisms in place for the management of CIED infection patients at most institutions. Addressing discrepancies, including guideline education and streamlining care/referral pathways, will be a key factor to bridging the gap and improving CIED infection patient outcomes.

PD35-04 THE EFFECT OF PELVIC RADIATION DOSE ON INCIDENCE OF URETEROENTERIC STRICTURE

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (PD35)1 Sep 2021PD35-04 THE EFFECT OF PELVIC RADIATION DOSE ON INCIDENCE OF URETEROENTERIC STRICTURE Mei Tuong, Andrew Winkelman, Clinton Yeaman, Perri Nelson, Chandler Morris, Kara Romano, Tracey Krupski, and Sumit Isharwal Mei TuongMei Tuong More articles by this author , Andrew WinkelmanAndrew Winkelman More articles by this author , Clinton YeamanClinton Yeaman More articles by this author , Perri NelsonPerri Nelson More articles by this author , Chandler MorrisChandler Morris More articles by this author , Kara RomanoKara Romano More articles by this author , Tracey KrupskiTracey Krupski More articles by this author , and Sumit IsharwalSumit Isharwal More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002039.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior radiation therapy is a known risk factor for ureteroenteric stricture (UES) development following urinary diversion. We aimed to determine whether cancer radiation delivered dose impacts development of UES after urinary diversion. METHODS: An IRB approved cystectomy database was utilized to identify UES in patients treated with prior pelvic radiation who underwent radical cystectomy or pelvic exenteration and urinary diversion at a single academic center between 2016 and 2020. UES was confirmed by endoscopic diagnosis or imaging. Radiation dose delivered was extrapolated based upon current cancer guideline-based protocols. A Kaplan-Meier survival curve in addition to Cox Proportional-Hazards Model was used to compare UES rates between radiation treated cancers. RESULTS: 65 patients had a history of radiation prior to extirpative surgery in our cohort of 215 patients; 15 (23%) of these patients developed UES as compared to our institutional rate of 5.3%. The rate of UES development by cancer radiation dose is as follows: cervical cancer (target dose 85 Gy) 4/8 patients (50%), colorectal cancer (target dose 50 Gy) 3/11 patients (27%), urologic cancer (target dose 45-50 Gy) 7/39 patients (18%), and non-cervical gynecologic cancer (45-50 Gy) 1/7 patients (14%).Initial Kaplan-Meier estimation demonstrated radiation treated cervical cancer had a statistically significant higher probability of developing UES compared with other radiation treated cancers (p=0.046) (Figure 1). Cervical cancer also had a statistically significant UES hazard ratio (HR) of 3.6 (95% CI 1.04-12.2, p=0.04) compared to urologic cancers.Colorectal and non-cervical gynecologic cancers did not statistically significantly differ in UES HR when compared to urologic cancers (p=0.3, p>0.9). CONCLUSIONS: This contemporary series confirms that there is a high rate of UES, 23%, after urinary diversion in previously radiated patients in spite of our knowledge of this risk factor. The higher pelvic radiation dose given with cervical cancer appears to be associated with an increased risk of UES after urinary diversion compared with other radiation treated cancers. This knowledge of developing UES in radiation treated cancers is important for patient counseling. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e589-e589 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mei Tuong More articles by this author Andrew Winkelman More articles by this author Clinton Yeaman More articles by this author Perri Nelson More articles by this author Chandler Morris More articles by this author Kara Romano More articles by this author Tracey Krupski More articles by this author Sumit Isharwal More articles by this author Expand All Advertisement Loading ...

Impact of a telemedicine-guided, population-based, STEMI network on reperfusion strategy, efficiency, and outcomes: Impact of telemedicine on STEMI management.

A telemedicine-guided strategy increases the access to and efficiency of ST-elevation myocardial infarction (STEMI) networks resulting in increased access to, and reduced disparities in, acute myocardial infarction (AMI) care between rural and urban areas. The Latin America Telemedicine Infarct Network (LATIN) was developed for poor and remote regions in Brazil and Colombia that lacked coordinated AMI systems of care. It strategically connects small clinics and primary care health centres (spokes) to hubs with 24/7 percutaneous coronary intervention (PCI) capability. Experts at three remote sites provide urgent electrocardiogram (ECG) diagnosis and tele-consultation for the entire network. Data from the busiest LATIN site, the Santa Marcelina Hospital in Sao Paolo, Brazil, were compared with health statistics from Sistema Unico de Saude (Brazilian Public Health System - SUS). A total of 192 centres were networked using standardised and guideline-based protocols for AMI care. Overall, 313,897 patients were remotely screened, 3,572 AMI diagnosed (1.1%), and 1,636 AMI urgently reperfused (45.8%), mainly by primary PCI (n=1,351; 83%). In conclusion, a comparison between a pre-LATIN cohort from SUS (1,015) and a LATIN cohort from Santa Marcelina Hospital (1,247) revealed increased reperfusion with PCI (65.52% vs 75.2%), increased cost ($2,037.12 vs $2,246.40, p<0.005), a statistically significant reduction in PCI mortality (8.5% vs 4.3% p<0.01) and a non-significant reduction in mortality overall amongst all treatment pathways (9.69% vs 9.43%, p=0.931).

Abstract P180: Protocolized Selection for Telestroke Activation in The Extended Window for Thrombectomy

Background: The advent of biomarker-driven identification of candidates for acute therapies in the 4.5-24-hour time window has resulted in an increase in the number of telestroke consults with low yield for acute intervention. While the use of the Vision Aphasia Neglect (VAN) score and a National Institutes of Health Stroke Scale (NIHSS) cutoff score of ≥6 may help identify patients with Large Vessel Occlusions (LVO), there are no guideline-based protocols for using these scales as a decision point for telestroke activation. Method: We selected 5 spoke sites from an academic hub-and-spoke model telestroke network for inclusion in our study. In the extended window (4.5-24 hours), telestroke consultants assisted with appropriate selection for hospital transfers for mechanical thrombectomy (MT) with the goals of maximizing retention at the spoke sites. All sites were able to obtain computed tomography angiography (CTA) head and neck onsite. In the extended window, the following protocols were followed at the sites for telestroke activation: Sites A - B: NIHSS ≥6; Site C: NIHSS ≥6 and/or VAN positive; Sites D - E any acute-onset, focal neurological symptoms within 24 hours of symptom onset. Descriptive statistics were used. Results: Between July 2019 and February 2020, there were 1,114 telestroke consults with 351 (32%) extended window activations. In the extended window, the number of activations for NIHSS≥6 was less than a third of the total activations and the rate of transfer for MT was low across the sites regardless of whether the sites had adopted a protocolized activation (Table). However, 80% of all transfers had an NIHSS ≥6. Conclusion: In an academic telestroke network, protocols for selecting “high-yield” consults in the extended thrombectomy window did not lead to less telestroke activation or a higher yield for MT. More studies are needed to determine if this is due to the applied scales or whether targeted educational interventions at the sites would improve selection.

Articles That May Change Your Practice: Traumatic Brain Injury Revisited

Traumatic brain injury (TBI) is a burden to the health care system worldwide, with more than 60 million new cases annually. Aside from mortality attributed to TBI, those who survive often end up with permanent disabilities and mental illness that impact their quality of life. Traditionally, there has not been much evidence that prehospital interventions can positively impact a patient's outcome. In addition, there is a lack of evidence that demonstrates any benefits of guideline-based protocol. Essentially, the best option has always been to transfer to a neurosurgery facility as quickly as possible, either by air or land.

P575Merging technologies to provide Mexico an innovative nationwide AMI management network

Abstract Background “Cόdigo Infarto”, the vast patient-centric, app-based, educational crusade of the Mexican Society of Interventional Cardiology (SOCIME) has been combined with the Latin America Telemedicine Infarct Network (LATIN) to create a comprehensive, national AMI program for Mexico. Purpose To demonstrate the benefits of amalgamating educational initiatives of national cardiology societies with a global telemedicine program for improving AMI management. Methods “Cόdigo Infarto” App connects patients to a network of several hundred cardiologists and 250 Primary PCI-capable labs. LATIN provides the partnership with its robust telemedicine platform, a hub-spoke strategy that supports patient's access to appropriate medical management. Remotely located experts, in Colombia, provide urgent EKG diagnosis via tele-consultation to the entire LATIN Mexico network. They activate ambulance dispatch and implement guideline-based protocols. Results Numerous “Cόdigo Infarto” sites have incorporated LATIN to provide a simple and accelerated management of AMI patients. Currently, the partnership (7 hubs, 78 spokes) has screened 19,886 patients. A total of 359 STEMI cases (1.8%) have been diagnosed; 118 patients (33%) were urgently reperfused, Primary PCI was performed in 74% of the latter cases. D2B time was 41 min. Reasons for the lack of treatment include delayed presentation, lack of ICU beds and insurance denials. Currently, these constraints are being methodically probed. Updated results will be available at time of presentation. Conclusions The synergy of the AMI initiative for Mexico provides a template for similar initiatives in developing countries.

Myocardial infarction patients referred to the primary care physician after 1‑year treatment according to aguideline-based protocol have agood prognosis.

IntroductionIdentifying ST-elevation myocardial infarction (STEMI) patients who can be referred back to the general practitioner (GP) can improve patient-tailored care. However, the long-term prognosis of patients who are returned to the care of their GP is unknown. Therefore, the aim of this study was to assess the long-term prognosis of patients referred back to the GP after treatment in accordance with a 1-year institutional guideline-based protocol.MethodsAll consecutive patients treated between February 2004 up to May 2013 who completed the 1‑year institutional MISSION! Myocardial Infarction (MI) follow-up and who were referred to the GP were evaluated. After 1 year of protocolised monitoring, asymptomatic patients with a left ventricular ejection fraction >45% on echocardiography were referred to the GP. Long-term prognosis was assessed with Kaplan-Meier curves and Cox proportional hazards analysis was used to identify independent predictors for 5‑year all-cause mortality and major adverse cardiovascular events (MACE).ResultsIn total, 922 STEMI patients were included in this study. Mean age was 61.6 ± 11.7 years and 74.4% were male. Median follow-up duration after the 1‑year MISSION! MI follow-up was 4.55 years (interquartile range [IQR] 2.28–5.00). The event-free survival was 93.2%. After multivariable analysis, age, not using an angiotensin-converting enzyme (ACE) inhibitor/angiotensin-II (AT2) antagonist and impaired left ventricular function remained statistically significant predictors for 5‑year all-cause mortality. Kaplan-Meier curves revealed that 80.3% remained event-free for MACE after 5 years. Multivariable predictors for MACE were current smoking and a mitral regurgitation grade ≥2.ConclusionSTEMI patients who are referred back to their GP have an excellent prognosis after being treated according to the 1‑year institutional MISSION! MI protocol.

How tandem gait stumbled into the neurological exam: a review.

Tandem gait testing is an integral part of the neurological exam. It is informative in a wide variety of disorders ranging from cerebellar disease to vestibular and peripheral neuropathies, parkinsonism, and other neurodegenerative conditions. We discuss the history and development of tandem gait testing as well as its technique, utility, and limitations in the assessment of neurological conditions. Tandem gait has emerged as a tool in the assessment of cerebellar disease, Huntington disease, idiopathic Parkinson's disease, atypical parkinsonism, peripheral neuropathies, and vestibulopathies. Its origin can be deduced from experimental observation and clinical experience as far back as the early nineteenth century. Despite the long history and ubiquitous performance of tandem gait testing, there is no standardized, guideline-based protocol to model for more homogenous research and clinical practices. Such a protocol should be developed using historical texts and manuscripts as well as the consensus of the medical research community. With standard protocols, further studies could define the sensitivity of abnormal tandem gait testing in cerebellar disorders, more diffuse neurodegeneration, and peripheral pathologies. Tandem gait can be a useful marker of dysfunction in neurologic conditions whose pathologies extend beyond the vermis or vestibulocerebellar module to include interconnected networks throughout the nervous system.

Implementation of a Regional Telephone Cardiopulmonary Resuscitation Program and Outcomes After Out-of-Hospital Cardiac Arrest.

Bystander cardiopulmonary resuscitation (CPR) significantly improves survival from out-of-hospital cardiac arrest but is provided in less than half of events on average. Telephone CPR (TCPR) can significantly increase bystander CPR rates and improve clinical outcomes. To investigate the effect of a TCPR bundle of care on TCPR process measures and outcomes. A prospective, before-after, observational study of adult patients with out-of-hospital cardiac arrest not receiving bystander CPR before the 9-1-1 call between October 1, 2010, and September 30, 2013. A TCPR program, including guideline-based protocols, telecommunicator training, data collection, and feedback, in 2 regional dispatch centers servicing metropolitan Phoenix, Arizona. Audio recordings of out-of-hospital cardiac arrest calls were audited and linked with emergency medical services and hospital outcome data. Survival to hospital discharge and functional outcome at hospital discharge. There were 2334 out-of-hospital cardiac arrests (798 phase 1 [P1] and 1536 phase 2 [P2]) in the study group; 64% (1499) were male, and the median age was 63 years (age range, 9-101 years; interquartile range, 51-75 years). Provision of TCPR increased from 43.5% in P1 to 52.8% in P2 (P < .001), yielding an increase of 9.3% (95% CI, 4.9%-13.8%). The median time to first chest compression decreased from 256 seconds in P1 to 212 seconds in P2 (P < .001). All rhythm survival was significantly higher in P2 (184 of 1536 [12.0%]) compared with P1 (73 of 798 [9.1%]), with an adjusted odds ratio (aOR) of 1.47 (95% CI, 1.08-2.02; P = .02) in a logistic regression model and an adjusted difference in absolute survival rates (adjusted rate difference) of 3.1% (95% CI, 1.5%-4.9%). Survival for patients with a shockable initial rhythm significantly improved in P2 (107 of 306 [35.0%]) compared with P1 (42 of 170 [24.7%]), with an aOR of 1.70 (95% CI, 1.09-2.65; P = .02) and an adjusted rate difference of 9.6% (95% CI, 4.8%-14.4%). The rate of favorable functional outcome was significantly higher in P2 (127 of 1536 [8.3%]; 95% CI, 6.9%-9.8%) than in P1 (45 of 798 [5.6%]; 95% CI, 4.1%-7.5%), with an aOR of 1.68 (95% CI, 1.13-2.48; P = .01) and an adjusted rate difference of 2.7% (95% CI, 1.3%-4.4%). Implementation of a guideline-based TCPR bundle of care was independently associated with significant improvements in the provision and timeliness of TCPR, survival to hospital discharge, and survival with favorable functional outcome.

Abstract 14288: Implementation of a Multidimensional Bundle for Dispatcher Telephone CPR in a Horizontal Dispatch System is Associated With Increased Bystander CPR and Good Neurological Survival From Out-of-Hospital Cardiac Arrest

Background: The resuscitation guidelines indicate pre-arrival dispatcher-assisted telephone CPR (DATCPR) instructions and measurement to increase the proportion of bystander CPR (BCPR), however the impact of those guidelines on survival is not well known. Objective: To describe the impact of a comprehensive bundle of DATCPR on BCPR and survival from OHCA in a horizontal computerized-aided dispatch (CAD) system. Methods: A centralize CAD system in a metropolitan EMS is studied. Routinely in system the time from call to ambulance dispatch should be within 60 seconds. The audio recordings of confirmed OHCAs were reviewed using a standardized format linked with EMS and hospital process and outcome data. The proportions of BCPR and survival six months after implementation (P1) of a bundle that included guideline-based protocol changes, staff training, computerized audit, feedback to providers and leadership rebuilt are compared with that of the same month period in the prior year as control group (P0), using regression analysis for statistics. Results: There were 1437 OHCAs [665 P0, 772 P1; 64% male, median age 62 (IQR: 47-74)](Table 1). The rate of BCPR went from 20.6% in P0 to 35.0% in P1 (p&lt;0.001). Outcome of ROSC (return to spontaneous circulation) upon hospital arrival was significantly higher in P1 (10.4%) compared to P0 (6.6% p=0.037), as was good neurological outcome (CPC 1or2: 5.5% in P1 vs. 2.6% in P0 p=0.029). Survival to hospital discharge was higher in P1 (8.3%, vs. P0: 6.4%) but not statistically significant. After adjusting for witnessed arrest, shockable rhythms, age, sex, and pre-hospital time intervals, good neurological outcome were still significantly higher in P1 vs. P0 [adjusted odds ratios: 2.1 (95% 1.1-4.4)]. Conclusions: The implementation of a comprehensive bundle of DATCPR in a metropolitan horizontal dispatch system was associated with significant improvements in the rates of BCPR and good neurologic outcome after OHCA.

Venous Thromboembolism Prophylaxis on a Cardiology In-Patient Unit: A Surprising Result?

To determine whether a guideline-based protocol improves compliance with venous thromboembolism (VTE) prophylaxis guidelines, 10 single-day audits of a cardiology inpatient unit were performed. All patients at high risk for VTE were included (n = 420; male/female = 282/138; median age, 66 ± 14 years). Before the protocol, 36% of patients were not receiving VTE prophylaxis; after the protocol, 26% did not receive prophylaxis (P = 0.024). In conclusion, there is a high rate of noncompliance with accepted guidelines for the prevention of VTE. The introduction of a guideline-based protocol significantly increased compliance, but a substantial proportion of patients still did not receive VTE prophylaxis despite meriting such therapy.

Abstract 1: Statewide Implementation of a Standardized Prearrival Telephone CPR Program Is Associated with Increased Bystander CPR and Survival from Out-of-Hospital Cardiac Arrest

Background: Bystander CPR (BCPR) increases survival from OHCA yet is provided in a minority of cases. The AHA has promulgated guidelines on the provision of pre-arrival Telephone CPR (TCPR) instructions and measurement to increase the proportion of BCPR; however, the impact of those guidelines on survival is unknown. Objective: To describe the impact of a comprehensive bundle of 9-1-1 TCPR protocol, training, data collection, and feedback on BCPR and survival from OHCA across the state of Arizona. Methods: 9-1-1 audio recordings of confirmed OHCAs and suspected OHCAs (10/2010-6/2013) in 7 large 9-1-1 centers were reviewed using a standardized time-stamp methodology linked with EMS and hospital process and outcome data. There were 2343 pre-implementation cases (P1) and 2291 cases post-implementation of a bundle of care (P2) that included staff training and guideline-based protocol changes, data collection and feedback to providers. Univariate and multivariable analyses were used to assess outcomes between P1 and P2. Results: There were 2532 OHCAs [1232 P1, 1300 P2; 64% male, median age 62 (IQR: 47-74)]. 83% of cases were identified in P1 compared with 89% in P2 (p&lt;0.001). The rate of telephone-assisted BCPR went from 44% in P1 to 62% in P2 (p&lt;0.001). Time to beginning TCPR instructions decreased from a median of 144 sec (P1) to 126 in P2 (p&lt;0.001). Time to first chest compression also decreased (P1: 178; P2: 155; p&lt;0.001). Outcome data are currently available for 64% of confirmed OHCAs (1630 patient outcomes with 1619 neuro outcomes). Survival was significantly higher in P2 (11.2%) compared to P1 (7.9%; p=0.023), as was good neuro outcome (CPC-1 or 2: 7.7% P2 vs. 4.8% P1 p=0.018). After adjusting for witnessed arrest, shockable rhythms, age, and sex, both survival and good neuro outcome were still significantly higher in P2 vs. P1 [adjusted odds ratios: survival = 1.5 (95% 1.1-2.1); good neuro outcome = 1.7 (95% 1.1-2.6)]. Conclusion: The implementation of a comprehensive statewide TCPR bundle was associated with significant improvements in the rates of telephone-assisted BCPR, survival and good neurologic outcome after OHCA.

Value of platelet pharmacogenetics in common clinical practice of patients with ST-segment elevation myocardial infarction

BackgroundAntiplatelet drug resistance is a well-known problem, causing recurrent cardiovascular events. Multiple genetic polymorphisms have been related to antiplatelet resistance by several large trials, however data from common clinical practice is limited. We examined the influence of previously described polymorphisms, related to aspirin and clopidogrel resistance, on treatment outcome in a real life unselected population of patients presenting with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention. Methods and resultsThis cohort study consisted of 1327 patients with STEMI. Patients were treated according to a standardized guideline-based protocol. Nine polymorphisms, COX1 (−842A>G), P2Y1 (893C>T), GPIa (807C>T), GPIIIa (PlA1/A2), CYP2C19 (*2, *3 and *17), ABCB1 (3435T>C) and PON1 (576A>G), were genotyped. During 1year of follow up the primary endpoint, a composite of cardiac death or recurrent myocardial infarction, was reached in 86 patients. The COX1 and CYP2C19*2 polymorphisms were associated with the primary endpoint, HR 2.55 (95% CI 1.48–4.40), P=0.001 and HR 2.03 (1.34–3.09) P=0.001, respectively. The combined analysis demonstrated a 2.5-fold increased risk for individuals with ≥2 risk alleles, P=6.9×10–9. The association of COX1 was driven by mortality related events whereas that of CYP2C19*2 was mainly attributed to myocardial infarction and stent thrombosis. ConclusionIn this unselected, real life population of STEMI patient on dual-antiplatelet therapy, the polymorphisms COX1 –842A>G and CYP2C19*2 were determinants of thrombotic complications during follow-up. We show that in a clinical setting, testing for these polymorphisms could be of value in the identification of STEMI patients at risk for recurrent cardiovascular events.

Primary prevention of sudden cardiac death after acute myocardial infarction: lessons from Leiden

Several important conclusions can be drawn from the interesting observations made in this issue by the Leiden group in relation to patients with acute myocardial infarction (AMI) treated using a guideline-based protocol.1 First, left ventricular function can be preserved using an evidence-based protocol to manage AMI; second, with preservation of left ventricular function, the proportion of post-MI patients fulfilling criteria for implantable cardioverter defibrillator (ICD) implantation is small; and third, that relatively few of those patients who received ICDs receive appropriate ICD therapy delivery during follow-up. This last observation brings into question the current guidelines for the selection of patients for ICD implantation as primary prophylaxis against sudden cardiac death and should prompt a review of the evidence on which these guidelines are based. The MISSION! protocol for the management of AMI combines a strategy for early percutaneous coronary intervention with rigorous attention to prescription of appropriate drug therapy and modification of risk factors, with rehabilitation, and out patient follow-up.2 Performance indicators related to each of these have been described throughout. Significant improvement in several of these indicators has been achieved in comparison with a historical cohort, with a significant reduction in length of hospital stay.2 Atary et al .1 describe the outcome in 799 patients treated according to this protocol. Of these, 6% died within 3 months of the index event, mostly of progressive heart failure. The … *Corresponding author. Tel: +44 191 2137543; fax: +44 191 223 1400, Email: janet.mccomb{at}nuth.nhs.uk

A contemporary protocol to assist primary care physicians in the treatment of panic and generalized anxiety disorders

Anxiety disorders are prevalent in primary care practice and generate a significant excess of morbidity, health services utilization, and health care expenditures. Complexities in delivering effective care for such disorders have led to stepped collaborative care models that involve nonphysician care managers following guideline-based protocols under the direction of patients’ primary care physicians and a medical specialist. With the goal of aiding colleagues attempting to improve the primary care for panic and generalized anxiety disorders, we detail the collaborative care strategy for treatment of these conditions used by our National Institute of Mental Health (NIMH)-funded clinical trial in which a telephone-based care manager performs timely, patient-specific clinical and case management tasks. We illustrate the clinical considerations underlying the steps taken to implement and then sustain our care manager intervention at four geographically dispersed primary care practices linked by a common electronic medical record system and the modifications made as we encountered clinical situations common to typical practice settings. This report serves to familiarize physicians contemplating use of a similar strategy for improving the quality of primary care for an anxiety disorder or any other chronic mental health condition.