ST-elevation Myocardial Infarction Guidelines Research Articles

Type of evidence supporting ACC/AHA and ESC clinical practice guidelines for acute coronary syndrome.

The aim of clinical practice guidelines for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) is to assist healthcare professionals in clinical decision-making. We evaluated the type of studies supporting these guidelines and their recommendations. All references and recommendations in the 2013 and 2014 ACC/AHA and 2017 and 2020 (ESC clinical guidelines for STEMI and NSTE-ACS were reviewed. References were classified into meta-analyses, randomised, non-randomised, and other types (e.g., position papers, reviews). Recommendations were classified according to class and their level of evidence (LOE). We retrieved 2128 non-duplicated references: 8.4% were meta-analyses, 26.2% randomised studies, 44.7% non-randomised studies, and 20.7% 'other' papers. Meta-analyses were based on randomised data in 78% of cases and used individual-patient data in 20.2%. Compared to non-randomised studies, randomised studies were more frequently multicentre (85.5% vs. 65.5%) and international (58.2% vs. 28.5%). The type of studies supporting recommendations varied as per the LOE of the recommendation. For LOE-A recommendations, the breakdown of supporting recommendations was: 18.5% meta-analyses, 56.6% randomised studies, 16.6% non-randomised studies and 8.3% 'other' papers; for LOE-B this breakdown was 9%, 39.8%, 38.2%, and 12.9%; and for LOE-C; 4.6%, 19.3%, 30.3%, and 45.9%. The references supporting the ACC/AHA and ESC guidelines on STEMI and NSTE-ACS consisted of non-randomised studies in ~ 45% of cases, with less than a third of the references consisting of meta-analyses and randomised studies. The type of studies supporting guideline recommendations varied widely by the LOE of the recommendation.

The impact of cross-jurisdictional patient flows on ascertainment of hospitalisations and cardiac procedures for ST-segment-elevation myocardial infarction in an Australian population.

The patient journey for residents of New South Wales (NSW) Australia with ST-elevation myocardial infarction (STEMI) often involves transfer between hospitals and these can include stays in hospitals in other jurisdictions. To estimate the change in enumeration of STEMI hospitalisations and time to subsequent cardiac procedures for NSW residents using cross-jurisdictional linkage of administrative health data. Records for NSW residents aged 20 years and over admitted to hospitals in NSW and four adjacent jurisdictions (Australian Capital Territory, Queensland, South Australia, and Victoria) between 1 July 2013 and 30 June 2018 with a principal diagnosis of STEMI were linked with records of the Australian Government Medicare Benefits Schedule (MBS). The number of STEMI hospitalisations, and rates of angiography, percutaneous coronary intervention and coronary artery bypass graft were compared for residents of different local health districts within NSW with and without inclusion of cross-jurisdictional data. Inclusion of cross-jurisdictional hospital and MBS data increased the enumeration of STEMI hospitalisations for NSW residents by 8% (from 15,420 to 16,659) and procedure rates from 85.6% to 88.2%. For NSW residents who lived adjacent to a jurisdictional border, hospitalisation counts increased by up to 210% and procedure rates by up to 70 percentage points. Cross-jurisdictional linked hospital data is essential to understand patient journeys of NSW residents who live in border areas and to evaluate adherence to treatment guidelines for STEMI. MBS data are useful where hospital data are not available and for procedures that may be conducted in out-patient settings.

Abstract 14896: Air Embolism and St Elevation Myocardial Infarction: A Systematic Review

Introduction: Air embolism has rarely been associated with ST- elevation myocardial infarction (STEMI). Limited data exists on the risks, management and outcomes of this phenotype of STEMI to guide clinicians. Method: We queried EMbase, PubMed and Cochrane database for cases of air embolism associated with STEMI to better understand this association, its complications and outcomes. Results: We identified thirty-six cases of systemic air embolism events associated with STEMI. A mean age of fifty-nine with male predominance was identified. Patent foramen ovale was identified in 22%. Periprocedural air emboli occurred 66% (24/36) and miscellaneous causes including scuba diving and positive pressure ventilation accounted for 33% (12/36). Six patients reported chest pain, eleven developed shock and four suffered cardiac arrest. Neurological symptoms were reported in eighteen patients (50%). ST elevations were noted in all cases. CT angiography detected air bubbles in ten patients and seven were detected via cardiac catheterization. Transthoracic echocardiography detected air bubbles in a ventricular cavity in seven patients, and thirteen had air bubbles demonstrated on CT brain. Hyperbaric oxygen was delivered to eleven patients, nine of whom also received high flow oxygen. Seven were placed in Trendelenburg position and two had catheter aspiration of air bubbles. All patients received supportive treatment. Thirteen (36%) patients died. Conclusion: Patients with periprocedural STEMI and unexplained neurological symptoms should have air embolism considered in the differential. If identified, patients should be treated as per STEMI guidelines along with early delivery of 100% oxygen, in hyperbaric setting if available. If patient is hemodynamically unstable for catheterization, CT and echocardiographic imaging are reasonable alternatives to establish the diagnosis.

Factors associated with poor clinical outcomes of ST-elevation myocardial infarction in patients with door-to-balloon time

BackgroundRecent guidelines for ST-elevation myocardial infarction (STEMI) recommended the door-to-balloon time (DTBT) <90 minutes. However, some patients could have poor clinical outcomes in spite of DTBT <90 minutes, which suggest the importance of therapeutic targets except DTBT. The purpose of this study was to find factors associated with poor clinical outcomes in STEMI patients with DTBT <90 minutes.MethodsThis retrospective study included 383 STEMI patients with DTBT <90 minutes. The primary endpoint was the major adverse cardiac events (MACE) defined as the composite of all-cause death, acute myocardial infarction, and acute heart failure requiring hospitalization.ResultThe median follow-up duration was 281 days, and the cumulative incidence of MACE was 16.2%. In the multivariate Cox hazard model, low body mass index (< 20 kg/m2) (vs. >20 kg/m2: HR 2.80, 95% CI 1.39–5.64, p = 0.004), history of previous myocardial infarction (HR 2.39, 95% CI 1.06–5.37, p = 0.04), and Killip class 3 or 4 (vs. Killip class 1 or 2: HR 2.39, 95% CI 1.30–4.40, p = 0.005) were significantly associated with MACE. In another multivariate Cox hazard model, flow worsening during percutaneous coronary intervention (PCI) (HR 3.24, 95% CI 1.79–5.86, p<0.001) and use of mechanical support (HR 3.15, 95% CI 1.71–5.79, p<0.001) were significantly associated with MACE, whereas radial approach (HR 0.54, 95% CI 0.32–0.92, p = 0.02) was inversely associated with MACE.ConclusionLow body mass index, Killip class 3/4, history of previous myocardial infarction, use of mechanical support, and flow worsening were significantly associated with MACE, whereas radial-access was inversely associated with MACE. It is important to avoid flow worsening during primary PCI even when appropriate DTBT was achieved.

Reperfusion of ST-Segment-Elevation Myocardial Infarction in the COVID-19 Era: Business as Usual?

Reperfusion of ST-Segment-Elevation Myocardial Infarction in the COVID-19 Era: Business as Usual?

Barriers and facilitators to implementing coronary care networks in South Africa: a qualitative study

ST-elevation myocardial infarction (STEMI) is on the rise in sub-Saharan Africa. South Africa consistently fails to deliver timely reperfusion to these patients, possibly due to under-developed coronary care networks (CCN). To determine the current perceived state of CCNs, to determine the barriers to optimising CCNs and to suggest facilitators to optimising CCNs within the South African context. A qualitative descriptive approach was employed, by performing two structured in-depth and two focus group interviews (n=4 and 5, respectively), inviting a purposely heterogeneous sample of 11 paramedics (n=4), doctors (n=5), and nurses (n=2) working within different settings in South African CCNs. Recorded interviews were transcribed verbatim and subjected to content analysis. Participants described an under-resourced, unprioritised and fragmented CCN with significant variation in performance. Barriers to CCN optimisation resided in recognition and diagnosis of STEMI, transport and treatment decisions, and delays. Participants suggested that thrombolysing all STEMI patients could facilitate earlier reperfusion and that pre-hospital thrombolysis should be considered. Participants highlighted the need for regionalised STEMI guidelines, and the need for further research. Numerous barriers were highlighted. Healthcare policy-makers should prioritise the development of CCNs that is underpinned by evidence and that is contextualised to each specific region within the South African health care system.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry.

The Acute Cardiac Care Association (ACCA)-European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI. Between 1 January 2015 and 31 March 2018, a total of 11462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients' outcomes. Patients will be followed for 1 year after admission. The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Arandomised, investigator-initiated, clinical trial of the effects of fentanyl on P2Y12-receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: rationale and design of the Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME3) trial.

BackgroundFast and accurate platelet inhibition is an important therapeutic goal in the acute treatment of patients with ST-elevation myocardial infarction (STEMI). Platelet inhibitory effects induced by oral P2Y12-receptor antagonists are delayed in STEMI patients undergoing primary percutaneous coronary intervention (PCI) due to haemodynamic changes and delayed gastro-intestinal absorption. Concomitant use of opioids, although recommended in the American College of Cardiology/American Heart Association and European Society of Cardiology STEMI guidelines, further delays gastro-intestinal absorption. To date, trials investigating alternative analgesics in STEMI patients have been scarce. This trial aims to assess the feasibility of a novel drug strategy for treatment of STEMI patients with crushed ticagrelor in combination with paracetamol (acetaminophen) instead of opioids.HypothesisSTEMI patients who are pre-treated with crushed ticagrelor and paracetamol have a higher level of platelet inhibition after primary PCI than patients pre-treated with crushed ticagrelor and fentanyl.Study designThe Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial is a randomised controlled trial designed to examine whether administration of paracetamol instead of fentanyl can optimise platelet inhibition in STEMI patients who are pre-treated with crushed ticagrelor in the ambulance. One hundred and ninety patients with STEMI will be randomised (1:1 fashion) to intravenous (IV) fentanyl or IV paracetamol. The primary endpoint is the level of platelet reactivity units measured immediately after primary PCI.SummaryThe ON-TIME 3 trial (NCT03400267) aims to achieve optimal platelet inhibition and pain relief in STEMI patients receiving crushed ticagrelor in the ambulance by investigating IV fentanyl and IV paracetamol as analgesics.

AVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion

BackgroundIdentification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression. MethodsSTEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression. ResultsEmergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001). ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

Integrating the results of the CULPRIT-SHOCK trial in the 2017 ESC ST-elevation myocardial infarction guidelines: viewpoint of the task force.

Holger Thiele was the PI of the CULPRIT-SHOCK trial, which was funded the European Union 7th Framework Program (FP7/2007-2013) and by the German Heart Research Foundation and the German Cardiac Society.

Expert Consensus Document on Management of ST-Elevation Myocardial Infarction: Adaptation of 2012 ESC Guidelines.

In 2012, the European Society of Cardiology (ESC) guidelines provided recommendations on the management of ST-elevation myocardial infarction (STEMI). The recommendation from these guidelines is restricted to the European subcontinent. To adapt the updated recommendations for Indian subset of STEMI patients, a panel of experts in the management of STEMI provided their expert opinions. This document provides expert consensus on adapting 2012 ESC STEMI guidelines recommendations in Indian setting. Document also discussed “India-specific” relevant literature to support the consensus opinions provided in the management of STEMI.

Trends and Clinical Outcomes in Patients Undergoing Primary Percutaneous Revascularisation for ST-Elevation Myocardial Infarction: A Single Centre Experience

Primary percutaneous coronary intervention (PPCI) is the preferred therapy for patients presenting with ST-elevation myocardial infarction (STEMI). We reviewed patients undergoing PCI for STEMI over a 6-year period to evaluate changes in procedural characteristics and clinical outcomes given recent changes to STEMI guidelines. All patients presenting to the Alfred Hospital, a tertiary referral hospital, between 1 January 2010 and 31 December 2015 undergoing PCI for STEMI were identified. Detailed review of their procedure reports was performed and 30-day and 12-month clinical outcomes were recorded including major adverse cardiac events (MACE). There was a total of 445 patients aged 60.6±12.4 years with 369 (82.9%) male. There was a significant increase in radial access use over the 6-year period 0/49 (0%) in 2010 vs 56/113 (49.6%) in 2015 (p<0.01). There was a significant reduction in the use of IIb/IIIa receptor antagonists during the period 29/49 (59%) in 2010 vs 24/113 (21%) in 2015 (p<0.01) and use of aspiration thrombectomy 15/49 (31%) in 2010 vs 19/113 (17%) in 2015 (p<0.01). There was no significant reduction in major bleeding over this period with 2/49 (4%) in 2010 vs 5/108 (5%) in 2015 (p=0.32). Thirty-day and 12-month mortality was also unchanged. Between 2010 and 2015 there has been a significant increase in the use of radial access and a reduction in the use of glycoprotein IIb/IIIa antagonists and aspiration thrombectomy in patients undergoing PPCI. This was not associated with changes in major bleeding or 30-day or 12-month mortality.

Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review.

Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.

LO05: In patients presenting to the ED with STEMI, is the provision of morphine associated with worse patient outcomes?

Introduction: ST-elevation myocardial infarction (STEMI) presenting to the ED is a significant health burden. The provision of IV morphine with doses titrated to provide comfort is recommended in the AHA STEMI Guidelines, yet there is limited evidence of safety in this setting. The primary objective of this study was to measure potential harm associated with the provision of IV morphine in STEMI patients presenting to the ED. Methods: This was a two centre retrospective chart review from an urban, inner city, academic ED with an annual census of 85,000 visits, and an affiliated community hospital with 35,000 annual visits. Consecutive patients from April 2009 to January 2015 presenting to the 2 EDs with a diagnosis of STEMI were identified in the ED database. Eight trained research assistants, blinded to the study hypothesis, used standardized data collection templates. The primary investigator double collected 20% of all data to ensure completeness and accuracy. Results: We included 311 patients with STEMI (124 received morphine [M]; 187 no morphine [nM]). The ages of the two groups were similar (mean 64 yrs [M] &amp;amp; 67 yrs [nM]; median 63 yrs [M] &amp;amp; 66 yrs [nM]; IQR 45-81 [M] and 45.5-86.5 [nM]); as were the proportion of female patients (21.0% [M] &amp;amp; 23.5% [nM]. The pre-STEMI Charlson comorbidity scores (mean 2.6), median time to first ECG (11 min [M] &amp;amp; 16 min [nM]), and mean time-to-needle for PCI (96.8 min [M] &amp;amp; 92.0 min [nM]) were similar between groups. The mean CCU length of stay (LOS) (9.3 days vs 6.3 days) and hospital LOS (7.4 days vs 4.6 days) were longer for patients receiving morphine than those not receiving morphine. Rates of congestive heart failure, acute kidney injury and cardiac arrest in hospital were unchanged between the groups. Unadjusted mortality was similar (10.5% [M] vs 13.3% [nM]) between groups. Binary logistic regression controlling for age, Charlson score, first and peak troponin values demonstrated an association between receiving morphine in the ED and an increased risk of death at 30 days (OR 8.1; 95% CI 7.1.-9.1). Conclusion: The provision of morphine to patients with STEMI in the ED may be associated with increased CCU and hospital LOS. When controlling for age, pre-STEMI Charlson score, first and peak troponin values, receiving morphine was associated with an increased risk of death at 30 days. Further research to elucidate this association is warranted.

Improving door-to-needle times for patients presenting with ST-elevation myocardial infarction at a rural district general hospital.

Acute coronary syndrome is a common condition with a major global impact on healthcare resources and expenditure. International guidelines are clear in specifying that patients with acute ST-elevation myocardial infarction (STEMI) should receive urgent coronary reperfusion with either primary percutaneous coronary intervention (PCI) or thrombolysis. Although PCI is the gold standard in the treatment of STEMI, this is not always achievable in a rural hospital with no cardiac catheterization service. Consequently, local recommendations on STEMI management exist to promote timely administration of thrombolysis within 30 minutes of patient arrival. However, translating updated clinical policy into practice is a challenging and complex task that requires a multi-faceted approach with sustained engagement from local stakeholders.Whilst working at a district general hospital in New Zealand, we noted a high incidence of patients presenting with STEMI receiving thrombolytic therapy outside the recommended 30 minutes door-to-needle time. Although final treatment was often only delayed by 5-10 minutes, we were concerned by the seemingly inconsistent management of these patients, often leading to unnecessary delays in the initiation of rapid reperfusion therapy.We therefore championed a newly updated clinical guideline and promoted an early STEMI recognition and treatment algorithm in our hospital to raise awareness amongst staff and improve door-to-needle times. We introduced a number of simple low-cost interventions that included educational sessions for junior doctors and cardiac nursing staff, as well as posters and training on the use of a remote electronic ECG interpretation system to streamline out-of-hours management.Overall, we found there to a be a steady improvement in door-to-needle times at our hospital, with 74% of patients receiving appropriate care within 30 minutes, compared to 43% prior to our interventions. This also translated to better patient outcomes.This project forms part of an ongoing process to instigate quality improvements in the management of STEMI within rural institutions. Whilst we have demonstrated improved utilisation of a local STEMI guideline and streamlining of out-of-hours services, the key challenge remains to ensure that momentum of this project continues and forms a platform for sustainable clinical improvement in the long term.

Pre-hospital management, procedural performance and outcomes for primary percutaneous coronary intervention in ST-elevation myocardial infarction in the Netherlands: Insights from the Dutch cohort of the APPOSITION-III trial.

AimThe aim of this study was to achieve useful insights into pre-hospital management and procedural performance for ST-elevation myocardial infarction (STEMI) in the Netherlands by extrapolating patient characteristics, and procedural and clinical outcomes of the Dutch patient cohort from the APPOSITION-III trial.MethodsThis is a retrospective analysis from the APPOSITION-III trial with respect to the geographical borders of STEMI management. The APPOSITION-III trial was a European registry for the use of the STENTYS self-expandable stent in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). 965 Patients were enrolled mainly in the Netherlands (n = 420, 43.5 % of the overall study population), Germany (n = 165) and France (n = 131). The data from the Dutch cohort were compared with both the overall study population, and the French and German cohorts, respectively, as well as the European Society of Cardiology (ESC) STEMI guidelines.ResultsIn this trial there was a wide inter-country variation on symptom-to-balloon time, 165 minutes (120–318) in the Netherlands, 270 minutes (180–650) in Germany and 360 minutes (120–480) in France, respectively. In general, a preload of dual antiplatelet therapy (DAPT) combined with heparin was more often performed in the Dutch and French cohort than in the German cohort. DAPT at discharge was high across the whole APPOSITION-III population. No important differences were seen between the different groups according to the endpoints major adverse cardiac event and stent thrombosis.ConclusionIn the Dutch cohort of an European multicentre STEMI study (APPOSITION-III trial), the performance in terms of symptom-to-balloon time, and pre-, peri- and post-procedural medical treatment is in line with the recommendations of ESC STEMI guidelines.

Drug Treatment of STEMI in the Elderly: Focus on Fibrinolytic Therapy and Insights from the STREAM Trial.

Elderly patients constitute a large and growing proportion of ST-elevation myocardial infarction (STEMI) patients, yet they have been under-represented or even excluded from reperfusion trials. Despite evidence that fibrinolysis improves outcomes irrespective of age, many elderly STEMI patients still remain undertreated or subject to major delays to primary percutaneous coronary intervention (PCI). The fear of an excessive risk of intracranial hemorrhage (ICH) in these patients can lead to avoidance of potentially life-saving reperfusion treatment, despite the fact that current STEMI guidelines do not exclude the elderly from a pharmaco-invasive strategy. Age-specific dose reductions have been succesfully made to antithrombotic drugs such as clopidogrel and enoxaparin as an adjunct to fibrinolysis, but until recently no dose adjustments for elderly patients have been applied to the fibrinolytic agents. In the pharmaco-invasive STREAM trial, halving the bolus of tenecteplase for patients aged >75years because of an unacceptably high ICH rate in the elderly was associated with a more favorable safety/efficacy profile. Whether a pharmaco-invasive strategy including half-dose tenecteplase, age- and weight-adjusted enoxaparin, and a tailored P2Y12 inhibitor followed by routine angiography represents a safe and efficacious alternative reperfusion therapy for elderly patients remains to be prospectively assessed in a clinical trial in this age group.

Study of markers of inflammation as predictors and prognosticators of acute coronary syndrome in patients with acute chest pain

Background: The role of inflammation in the pathogenesis of acute coronary syndrome (ACS) is established, however use of inflammatory markers as predictors for future short-term cardiovascular events in patients of acute coronary syndrome. Objective: To assess whether inflammatory markers C-reactive protein (hs-CRP), total leucocyte count (TLC) and serum albumin can correlate with the diagnosis of ACS in patients with acute chest pain and to see whether these markers can be used to predict short-term cardiovascular events in patients of ACS. Methods: All Patients presenting within 12 hours of the onset of central non traumatic chest pain were enrolled and investigated, the diagnosis of ACS was made as per JACC 2004 guidelines for ST-elevation myocardial infarction, unstable angina and non-ST elevation myocardial infarction. All patients received routine institutional care and treatment as per diagnosis blinded to CRP, albumin, and total leucocyte count (TLC). The independent predictors of ACS and predictors of adverse events in 30 days was evaluated using multivariate analysis. Results: one forty nine patients of ≥ 18 years (88 male, 61 female) which were included in the study, the diagnosis of non-ischemic chest pain (NICP)were in 30 (20%) and ACS in 119 (80%) patients. TLC and hs-CRP levels were higher (11576±3083, 14.04±6.17) in patients with ACS compared to NICP (5596±1370, 2.39±1.55) with significant P-value (&lt;0.001). Significantly high hs-CRP level (19.95±6.46), TLC (15630±3522) and low serum albumin (3.45±0.31) were there in patients in whom adverse cardiovascular events occurred. Conclusion: Leucocyte count and hs-CRP level are the independent predictors of ACS in patients presenting to the emergency department with chest pain suggestive of ACS. High hs-CRP, TLC, neutrophil count and low serum albumin, lymphocyte count are independent predictors of adverse short-term cardiovascular events.Health Renaissance 2014;12(2): pp: 99-105

Evaluation of transfer parameters in patients admitted to our hospital with ST-elevation myocardial infarction

Acute coronary syndrom (ACS) is a common disease that causes severe morbidity and mortality. The most important aspect of ST-elevation myocardial infarction (STEMI) as a subgroup of ACS treatment is the rapid reperfusion of arteries. Successful results depend not only on the experience of the center but also on the rapidity in which reperfusion is achieved. In our study, the transfer parameters were evaluated in patients who were admitted to our hospital with STEMI. Two hundred consecutive patients (160 males, 40 females) who underwent primary percutaneous coronary intervention (PCI) for acute STEMI between January 2011 and March 2013 were included in our study. Transfer parameters of symptom-to-reperfusion treatment, clinical characteristics, and laboratory parameters were recorded. Thirty-six patients were admitted to our hospital with ambulances; 70 patients were admitted to centers without PCI capability, with a mean transfer time to our hospital of 73.9±12.5 min. Median pain-to-first medical contact time was 105 min (range: 5-600 min), and average first medical contact-to-balloon time was 115.5 min (range: 20-414 min). Total pain-to-balloon time in females was significantly higher than males (246 min [range: 70-840 min], 195 min [range: 45-684 min], respectively, p=0.032). Mean pain-to-balloon time was significantly lower in patients delivered to the hospital by ambulance than in patients admitted to emergency departments independently (185 min [range: 45-439 min], 248 min [range: 65-840 min], respectively, p=0.017). In this study, our hospital door-to-balloon time was found compatible with the target specified in the European Society of Cardiology and American College of Cardiology STEMI guidelines; however, first medical contact-to-balloon time was found to be above that advised by the current guidelines.

What Do Guidelines Say We Should Do in Patients with ST Elevation Myocardial Infarction?

Clinical statements and guidelines dynamically regenerate with rapidly growing new evidence and regulate our daily clinical practice. On the other hand, our obedience on traditional experiences might lead us to manage patients inappropriately. Recently published guidelines on ST elevation myocardial infarction (STEMI) by the European Society of Cardiology (ESC) and American College of Cardiology (ACC) have altered and changed many previously accurate managements. The aim of this review is to evaluate the recommendations of the new STEMI guidelines and the inappropriate management practices we perform in our daily practice. (JAEM 2014; 13: 199-203)