Initiation Of Reperfusion Therapy Research Articles

Impact of a novel pre-hospital stroke notification programme on acute stroke care key performance indicators in Hong Kong: a multicentre prospective cohort study with historical controls.

Early identification and initiation of reperfusion therapy is essential for suspected acute ischaemic stroke. A pre-hospital stroke notification (PSN) protocol using FASE (facial drooping, arm weakness, speech difficulties, and eye palsy) was implemented to improve key performance indicators (KPIs) in acute stroke care delivery. We assessed KPIs and clinical outcomes before and after PSN implementation in Hong Kong. This prospective cohort study with historical controls was conducted in the Accident and Emergency Departments of four public hospitals in Hong Kong. Patients were screened using the PSN protocol between August 2021 and February 2022. Suspected stroke patients between August 2020 and February 2021 were included as historical controls. Door-to-needle (DTN) and door-to-computed tomography (DTC) times before and after PSN implementation were compared. Clinical outcomes including National Institutes of Health Stroke Scale score at 24 hours and modified Rankin Scale score at 3 months after intravenous recombinant tissue-type plasminogen activator (IV-rtPA) were also assessed. Among the 715 patients (266 PSN and 449 non-PSN) included, 50.8% of PSN patients and 37.7% of non-PSN patients had a DTC time within 25 minutes (P<0.001). For the 58 PSN and 134 non-PSN patients given IV-rtPA, median DTN times were 67 and 75.5 minutes, respectively (P=0.007). The percentage of patients with a DTN time within 60 minutes was higher in the PSN group than in the non-PSN group (37.9% vs 21.6%; P=0.019). No statistically significant differences in clinical outcomes were observed. Although the PSN protocol shortened DTC and DTN times, clinical outcomes did not significantly differ.

Stacking ensemble learning model to predict 6-month mortality in ischemic stroke patients

Patients with acute ischemic stroke can benefit from reperfusion therapy. Nevertheless, there are gray areas where initiation of reperfusion therapy is neither supported nor contraindicated by the current practice guidelines. In these situations, a prediction model for mortality can be beneficial in decision-making. This study aimed to develop a mortality prediction model for acute ischemic stroke patients not receiving reperfusion therapies using a stacking ensemble learning model. The model used an artificial neural network as an ensemble classifier. Seven base classifiers were K-nearest neighbors, support vector machine, extreme gradient boosting, random forest, naive Bayes, artificial neural network, and logistic regression algorithms. From the clinical data in the International Stroke Trial database, we selected a concise set of variables assessable at the presentation. The primary study outcome was all-cause mortality at 6 months. Our stacking ensemble model predicted 6-month mortality with acceptable performance in ischemic stroke patients not receiving reperfusion therapy. The area under the curve of receiver-operating characteristics, accuracy, sensitivity, and specificity of the stacking ensemble classifier on a put-aside validation set were 0.783 (95% confidence interval 0.758–0.808), 71.6% (69.3–74.2), 72.3% (69.2–76.4%), and 70.9% (68.9–74.3%), respectively.

The impact of a Danish stroke campaign: A cross-sectional study.

To investigate the impact of the Danish stroke campaign, 1year after initiation. The campaign ran in various media during 2019-2020. We performed a two-centre, repeated cross-sectional study in 2018 (before campaign) and again in 2020 based on data from structured interviews of patients and bystanders, medical records and the Danish Stroke Registry. Primary outcomes were patient delay and system delay. Patient delay is defined as the time from symptom onset until the first contact to a healthcare professional, whereas system delay is the time from this contact until arrival at the stroke centre. Secondary outcomes were primary emergency medical services (EMS) contact, arrival at a stroke centre within 3h of symptom onset, initiation of reperfusion therapy and knowledge of ≥2 core symptoms of stroke. We included 852 patients with stroke or transient ischemic attack. Patient delay and system delay were a median of 166min and 96min before the campaign and were non-significantly reduced by 16min (95% CI -128 to 97) and 7min (95% CI -21 to 6) in the second period. We found no significant differences in the clinical outcomes. The knowledge of ≥2 core symptoms increased from 22% to 30% (OR 1.63; 95% CI 1.15 to 2.30) in patients and from 53% to 65% (OR 1.81; 95% CI 1.24 to 2.64) in bystanders. Patient delay, system delay and clinical outcomes remained relatively unchanged. However, the knowledge of core symptoms had improved 1year after campaign initiation.

Vulnerability to cardiac arrest in patients with ST elevation myocardial infarction: Is it time or patient dependent? Results from a nationwide observational study.

Cardiac arrest is a common complication of ST elevation myocardial infarction and is associated with high mortality. We evaluated whether vulnerability to cardiac arrest follows a circadian rhythm and whether it is related to specific patient characteristics. A total of 24,164 ST elevation myocardial infarction patients who were admitted to 60 Belgian hospitals between 2008-2017 were analysed. The proportion of patients with cardiac arrest before initiation of reperfusion therapy was calculated for different time periods (hour of the day, months, seasons) and related to patient characteristics using stepwise logistic regression analysis. Cardiac arrest occurred in 10.8% of the ST elevation myocardial infarction patients at a median of 65 min (interquartile range 33-138 min) after onset of pain. ST elevation myocardial infarction patients with cardiac arrest showed a biphasic pattern with one peak in the morning and one peak in the late afternoon. Multivariate analysis identified the following independent factors associated with cardiac arrest: cardiogenic shock (odds ratio=28), left bundle branch block (odds ratio=3.7), short (<180 min) ischaemic period (odds ratio=2.2), post-meridiem daytime presentation (odds ratio=1.4), anterior infarction (odds ratio=1.3). Overall in-hospital mortality was 30% for cardiac arrest patients versus 3.7% for non-cardiac arrest patients (p<0.0001). In the present study population, cardiac arrest in ST elevation myocardial infarction showed an atypical circadian rhythm with not only a morning peak but also a second peak in the late afternoon, suggesting that cardiac arrest and ST elevation myocardial infarction triggers are, at least partially, different. In addition, specific patient characteristics, such as short ischaemic period, cardiogenic shock and left bundle branch block, increase the vulnerability to cardiac arrest.

Understanding the seriousness of a stroke is essential for appropriate help-seeking and early arrival at a stroke centre: A cross-sectional study of stroke patients and their bystanders.

Only a minority of patients with acute ischaemic stroke receive reperfusion treatment, primarily due to prehospital delay. We aimed to investigate predictors of a primary contact to the emergency medical services, arrival at stroke centre within 3 h of symptom onset and initiation of reperfusion therapy in patients with acute stroke. We conducted a cross-sectional study of consecutive patients with acute ischaemic stroke, intracerebral haemorrhage or transient ischaemic attack. Structured interviews of patients and bystanders were performed and combined with clinical information from the Danish Stroke Registry. Eligible patients were aged ≥18 years and were independent in activities of daily living before the stroke. We included 435 patients. Presence of a bystander at symptom onset and knowledge of ≥2 core symptoms of stroke were associated with a primary emergency medical services contact. Higher stroke severity and patients or bystanders perceiving the situation as very serious were associated with a primary emergency medical services contact (ORpatients 2.10; 95% CI 1.12-3.95 and ORbystanders 22.60; 95% CI 4.98-102.67), <3 h from onset to arrival (ORpatients 3.01; 95% CI 1.46-6.21 and ORbystanders 4.44; 95% CI 1.37-14.39) and initiation of reperfusion therapy (ORpatients 3.08; 95% CI 1.23-7.75 and ORbystanders 4.70; 95% CI 1.14-19.5).Conclusion: Having a bystander, knowledge of ≥2 core symptoms and understanding that stroke is a serious event are associated with appropriate help-seeking behaviour, shorter prehospital delay and higher chance of reperfusion therapy in acute stroke patients.

ELECTROCARDIOGRAPHIC SIGNS OF ACUTE MYOCARDIAL ISCHEMIA AS EQUIVALENTS OF ST ELEVATION MYOCARDIAL INFARCTION

Early initiation of reperfusion therapy remains to be crucial step of management for ST elevation myocardial infarction (STEMI), as elevation on a 12-lead electrocardiogram (ECG) is considered as a result of coronary occlusion or critical stenosis. At the same time, nearly 10 – 25 % of non-STEMI patients, according to coronary angiography, do have occlusion or critical stenosis of major epicardial vessel. Reperfusion delays in this case lead to worse outcomes. Although criteria for STEMI equivalents briefly mentioned in the current recommendations, data on those specific ECG patterns are lacking. By searching MEDLINE and EMBASE was conducted a structured review of non-STEMI patterns, connected with critical stenosis or occlusion, the sensitivity and specificity data was also provided. It is hard to overestimate the clinical significance of revealing high risk patients in the absence of classical STEMI in the emergency department or the pre-hospital setting.

Initial T wave morphology in the chest leads in patients presenting with anterior ST-segment elevation myocardial infarction and its correlation with spontaneous reperfusion of the left anterior descending coronary artery

Background: T wave inversion in leads with ST-segment elevation after reperfusion therapy is considered a sign of reperfusion. However, the significance of T wave inversion on presentation before the initiation of reperfusion therapy is unclear. Aim of the Work: The current study aimed to assess whether the initial T wave morphology in the electrocardiographic (ECG) at presentation can predict patency of the left anterior descending artery (LAD) in patients with acute anterior ST segment elevation myocardial infarction (STEMI) before undergoing primary percutaneous coronary interventions (PCIs). Methods: This study included ninety patients who presented to the emergency department with acute anterior ST-elevation MI. We excluded patients with bundle branch block, postcoronary artery bypass grafting patients, patients with paced rhythm, and patients who received thrombolytic therapy. The T wave morphology in the 2 leads with maximal ST-segment elevation on the presenting ECG was identified as one of the three morphologies, positive T waves (T+; initial positive deflection ≥0.5 mm above the isoelectric line), biphasic T waves (T+/−; where the T wave initially showed a positive deflection above the ST segment afterward followed by a negative deflection ≥0.5 mm below the isoelectric line), and negative T waves (T−; where the T wave initially showed a negative deflection ≥0.5 mm below the isoelectric line without showing any initial positive deflection). Then, according to the results of the initial angiography, patients were classified into spontaneous reperfusion (SR) (those with thrombolysis in MI [TIMI] II or TIMI III flow in the infarct-related artery [IRA] prior to intervention) or non-SR (those with TIMI 0 or TIMI I flow in the IRA prior to intervention). Results: Ninety consecutive patients (77 males and 13 females) presented by STEMI and treated by primary PCI at cath lab of Ainshams University Hospitals (a 24/7 tertiary referral center for primary PCI) between January 2015 and March 2016 were included in this study, of which 40 patients (44.4%) had positive T waves (T+), 34 patients (37.8%) had negative T waves (T−), and 16 patients (17.8%) had biphasic T waves (T+/−). Initial angiogram showed that 18 patients had SR and 72 patients had no SR. With regard to T wave morphology, negative T waves were significantly present in SR group (66.7% vs. 30.6%, P = 0.004), whereas positive T waves were predominantly present in non-SR (50% vs. 22.2%, P = 0.033). Conclusions: For SR of LAD in anterior STEMI patients, prior to primary PCI, T wave inversion had a good sensitivity of 66.7%, a specificity of 69.4%, and a good negative predictive value of 89.29%.

Efficacy of pharmacoinvasive percutaneous coronary intervention versus primary percutaneous coronary intervention in ST elevation myocardial infarction

Background ST-segment elevation myocardial infarction (STEMI) is mainly caused by complete occlusion of a coronary artery by a thrombus. Primary percutaneous coronary intervention requires transfer to an interventional cardiology center and this delays initiation of reperfusion therapy. A pharmacoinvasive strategy may alleviate the barriers in timely reperfusion of STEMI, especially in a developing country like Egypt. Aim The aim of the study was to assess the safety and efficacy of pharmacoinvasive strategy versus PPCI in STEMI patients at 3 months. Patients and methods A total of 200 patients were presenting with STEMI who were divided into two groups: group 1 included patients who underwent PPCI (n=160) and group 2 included patients who underwent pharmacoinvasive strategy as patients received thrombolytic therapy followed by scheduled coronary angiography and PCI within 24 h from the symptom onset (n=40). Primary end points were death, cardiogenic shock, reinfarction, repeated revascularization of the culprit artery, and congestive heart failure at the time of discharge or at follow-up till 3 months. Results In group 1, we found that about 28.1% of patients had infarct-related artery open and 71.9% were closed, while in group 2 there were 70.0% patients who had infarct-related artery open and 30.0% who had failed thrombolysis. There were 4.4% patients in group 1 and 75.0% patients in group 2 who were with bleeding complication especially at the access site. Complication was less frequent in group 1. Conclusion A pharmacoinvasive strategy resulted in outcomes that were comparable with PPCI at 3 months, suggesting it might be a viable option in Egypt. Larger studies are required to confirm these findings.

Temporal Trends in Mechanical Complications of Acute Myocardial Infarction in the Elderly

BackgroundReperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease. ObjectivesThis study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI. MethodsTrends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI. ResultsOverall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74). ConclusionsAlthough the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients.

Cardiac care in SAR helicopter paramedic practice: from mountainside to rehabilitation

Despite its decline in recent years, coronary heart disease remains the UKs single biggest killer. When someone suffers a heart attack on a mountainside in the UK, they often need a search and rescue (SAR) helicopter to provide them with timely emergency care and to transport them to a suitable hospital. The early diagnosis of an ST-elevation myocardial infarction (STEMI) from a 12-lead electrocardiogram facilitates timely initiation of reperfusion therapy, but obtaining one in the mountain rescue environment is challenging and sometimes impossible. Although primary percutaneous coronary intervention for STEMI patients is the treatment of choice, facilitating it renders the SAR aircraft unavailable for greater periods of time and requires the relevant, supporting infrastructure to be in place. The SAR paramedic must assess the suitability, validity and usability of clinical guidelines and pathways on a case-by-case basis, then integrate them into the demands of each particular SAR mission. Although cardiac rehabilitation has not traditionally been within the remit of the pre-hospital clinician, responding to the psychological needs of the heart-attack victim in the aircraft may be a significant determinant to their participation in rehabilitation programmes.

Impact of participation in randomized trials of reperfusion therapy on the time to reperfusion and hospital mortality in ST-segment elevation myocardial infarction: A single-centre cohort study.

There is uncertainty as to whether consenting and randomizing patients in randomized clinical trials (RCTs) in acute ST-segment elevation myocardial infarction (STEMI) delays reperfusion and increases mortality. The aim of this study was to determine whether participation of patients with STEMI in RCTs is associated with delay in implementation of reperfusion therapy and increased hospital mortality. A consecutive sample of 2523 patients, admitted within 6 hours of symptom onset without cardiogenic shock, was recruited from a single tertiary academic centre. They were categorized according to participation (n=392, 15.5%) or nonparticipation (n=2131, 84.5%) in RCTs of reperfusion therapy. Primary outcome was hospital mortality. Additional outcome was time from symptom onset to receipt of reperfusion therapy. Trial participants were more likely to receive fibrinolysis with a 37 min delay in comparison with patients not included in RCTs. Time from symptom onset to reperfusion (minutes) was longer for trial participants than nonparticipants (246 ± 85 vs 233 ± 93, p=0.01). Hospital mortality was 3.61% for nonparticipants. Expected mortality (based on risk modeling) for trial participants was 2.74% (p=0.014 vs nonparticipants). Observed mortality was 1.53% (p=0.034 vs nonparticipants; p=0.16 vs expected mortality). In a multivariable analysis using logistic regression, participation in a RCT was not an independent correlate of hospital mortality (odds ratio 0.54, 95% confidence interval 0.23-2.43, p=0.16). In this consecutive cohort, despite a longer delay to reperfusion, there was no indication that participation in a RCT, starting before initiation of reperfusion therapy, was associated with a detectable increase in risk of hospital mortality among patients with STEMI. These data suggest that it is possible to consent and randomize patients with STEMI into RCTs without jeopardizing their survival.

Usefulness of T Wave Inversion in Leads With ST Elevation on the Presenting Electrocardiogram to Predict Spontaneous Reperfusion in Patients With Anterior ST Elevation Acute Myocardial Infarction

Inversion of the T waves (T-) in electrocardiographic leads with ST-segment elevation after the initiation of reperfusion therapy is considered a sign of reperfusion. However, the significance of T- on presentation before the initiation of reperfusion therapy is unclear. The aim of this study was to assess whether T- on presentation predicts patency of the infarct-related artery in patients with acute ST-segment elevation myocardial infarctions (STEMIs) who undergo primary percutaneous interventions. The medical records, electrocardiograms, and angiographic findings of 209 consecutive patients who underwent emergent coronary angiography as part of primary percutaneous coronary intervention protocol activation for STEMI were reviewed. A total of 179 patients (86%) had positive T waves (T+), 16 (8%) had biphasic T waves (T+/-), and 14 (7%) had T-. Patency of the infarct-related artery (Thrombolysis In Myocardial Infarction [TIMI] flow grades 2 and 3) was seen in 64.3% of the patients in the T- group compared with only 31.2% in the T+/- group and 19.0% in the T+ group (p <0.001). Among patients with anterior STEMI, patency of the infarct-related artery was seen in all 7 patients in the T- group, compared with 50% of the 4 patients in the T+/- group and 10.1% of the 79 patients in the T+ group (p <0.001). There were no significant differences in TIMI flow grade among the groups in patients with nonanterior STEMIs (p= 0.985). In conclusion, T- in the leads with maximal ST-segment elevation on the presenting electrocardiogram was associated with higher prevalence of patency of the infarct-related artery before intervention (64.3%), especially in patients with anterior STEMIs (100%).

Early versus late ST-segment resolution and clinical outcomes after percutaneous coronary intervention for acute myocardial infarction.

Background. Absence of complete ST-segment resolution (STR) after percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) is a determinant of mortality. Traditionally, STR is determined on the coronary care unit (CCU) 60 to 90 minutes after the initiation of reperfusion therapy. We studied the prognostic value of STR immediately after PCI. Methods. We analysed 223 consecutive patients with STEMI and successful PCI. Continuous ECG data were collected during PCI and at 30 minutes after arrival on the CCU (mean time 81±17 minutes after reflow of the culprit artery). Patients were divided into three groups: patients with complete STR immediately after PCI ('early'), patients with complete and persistent STR at 30 minutes on the CCU, but not immediately after PCI ('late') and patients without STR. One-year follow-up was obtained for death and rehospitalisation for major adverse cardiac events. Cox proportional hazards regression was used to evaluate the association between STR and outcome. Results. Early STR occurred in 115 (52%) and late STR in 43 (19%) patients. Patients with early or late STR had a lower incidence of one-year cardiac death than those without STR (1.9 vs. 9.2%; p=0.02). In contrast, rehospitalisation occurred more frequently in patients with early or late STR (20.3 vs. 6.2%; p=0.009). As compared with patients without STR, early and late STR had a similar prognostic value (hazard ratios [95% confidence interval] for cardiac death 0.40 [0.08-2.03] and 0.25 [0.03-2.08]).Conclusions. We found no (major) change in prognostic value of STR during the 0 to 90 minutes time window after PCI. (Neth Heart J 2010;18:416-22.).

ST‐Segment Resolution Prior to Primary Percutaneous Coronary Intervention Is a Poor Indicator of Coronary Artery Patency in Patients with Acute Myocardial Infarction

The prognostic value of ST-segment resolution (STR) after initiation of reperfusion therapy has been established by various studies conducted in both the thrombolytic and mechanic reperfusion era. However, data regarding the value of STR immediately prior to primary percutaneous coronary intervention (PCI) to predict infarct-related artery (IRA) patency remain limited. We investigated whether STR prior to primary PCI is a reliable, noninvasive indicator of IRA patency in patients with ST-segment elevation myocardial infarction (STEMI). The study population consisted of STEMI patients who underwent primary PCI at our institution between 2000 and 2007. STR was analyzed in 12-lead electrocardiograms recorded at first medical contact and immediately prior to primary PCI and defined as complete (> or =70%), partial (70%- 30%), or absent (<30%). In 1253 patients with a complete data set, STR was inversely related to the probability of impaired preprocedural flow (P(for trend) < 0.001). Although the sensitivity of incomplete (<70%) STR to predict a Thrombolysis in Myocardial Infarction (TIMI) flow of <3 was 96%, the specificity was 23%, and the negative predictive value of incomplete STR to predict normal coronary flow was only 44%. This study establishes the correlation between STR prior to primary PCI and preprocedural TIMI flow in STEMI patients treated with primary PCI. However, the negative predictive value of incomplete STR for detection of TIMI-3 flow is only 44% and therefore should not be a criterion to refrain from immediate coronary angiography in STEMI patients.

Relation of Clinically Defined Spontaneous Reperfusion to Outcome in ST-Elevation Myocardial Infarction

In patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), a patent infarct-related artery on initial angiography was associated with better angiographic results and improved prognosis compared with patients without spontaneous reflow. Little is known about the prevalence, clinical course, and optimal management of patients presenting with clinical signs of spontaneous reperfusion (SR). The objective was to evaluate characteristics and clinical outcomes in patients with STEMI with clinical signs of SR. The study included 710 consecutive patients with STEMI eligible for reperfusion therapy who were followed up for 30 days. SR was defined as a >or=70% reduction in sum ST elevation and pain severity before initiation of reperfusion therapy. SR was observed in 155 patients (22%). Although almost all patients with STEMI without SR underwent primary reperfusion using primary PCI (398 of 555 patients; 72%) or thrombolysis (125 of 555; 23%), most patients with SR were initially treated conservatively, and primary PCI was performed in only 13 patients (8%). Although patients with SR had a higher incidence of recurrent in-hospital ischemia, they developed smaller myocardial infarctions and sustained less in-hospital cardiogenic shock, heart failure, and electrical complications and had lower 7- and 30-day mortality rates. On multivariate analysis, SR remained significantly associated with a lower incidence of the combined end point of 30-day mortality, congestive heart failure, and recurrent acute coronary syndrome. In conclusion, despite initial conservative therapy, the outcome of patients with SR was markedly better than for patients without SR who underwent primary reperfusion.

Acute anterior wall myocardial infarction entailing ST-segment elevation in lead V 3R, V 1 or aVR: electrocardiographic and angiographic correlations

Background The correlation between ST-segment elevation (ST↑) in lead V 3R (ST↑ V3R), lead V 1 (ST↑ V1), and lead aVR (ST↑ aVR) during anterior wall acute myocardial infarction (AMI) and the culprit lesion site in the left anterior descending (LAD) coronary artery and the nature of the conal branch of the right coronary artery has not been throughly described. Methods One hundred forty-two patients with first anterior wall AMI were included. The 15-lead electrocardiogram with the standard 12 leads plus leads V 3R through V 5R showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site in relation to the first septal perforator (S1) and the nature of the conal branch of the right coronary artery as determined by coronary angiography. Results ST-segment elevation in lead aVR, ST↑ V1 of at least 2 mm, and ST↑ V3R of at least 1 mm were more prevalent among patients with occlusions proximal to S1 than patients with occlusions distal to S1 (41.7% vs 4.9%, P < .01; 30.0% vs 7.3%, P < .01; and 91.7% vs 4.9%, P < .01, respectively). Of the 60 patients with occlusions proximal to S1, 20 patients had a small conal branch (18 patients with ST↑ aVR and 15 patients with ST↑ V1 ≥2 mm), and 24 patients had a large conal branch (all patients with non-ST↑ aVR and ST↑ V1 <2 mm; P < .01). The sensitivity of ST↑ V1 of more than 1 mm, of at least 2 mm, ST↑ V3R of at least 1.5 mm, and ST↑ aVR for detecting a small conal branch was 65.1%, 81.8%, 84.0%, and 90%, respectively; the specificity was 68.5%, 64%, 66.7%, and 64.9%, respectively. Conclusions In patients with anterior wall AMI, ST↑ V3R of at least 1 mm combined with ST↑ in leads V 2 through V 4 were strongly predictive of LAD occlusion proximal to S1; furthermore, ST↑ aVR and ST↑ V1 of at least 2 mm were found to be useful in identifying LAD occlusion proximal to S1. ST↑ aVR, ST↑ V3R of at least 1.5 mm, and ST↑ V1 of at least 2.0 mm were also associated with the presence of a small conal branch not reaching the intraventricular septum during anterior wall AMI.

Patient delay in responding to symptoms of possible heart attack: can we reduce time to care?

In Australia, many deaths and significant cardiac disability result from delayed response to symptoms of heart attack. Although delays due to transport and initiation of reperfusion therapy in hospital may contribute to late treatment, the major component of delay is the time patients take in deciding to seek help. A critical examination of campaigns to shorten patient delay concludes that they were based on a factual, short-term, non-targeted approach that included education and mass media strategies. They achieved equivocal results. One randomised controlled trial has been conducted. Although this showed an improved understanding of heart attack symptoms, it did not shorten pre-hospital delays. The implications of these findings are that future campaigns to shorten patient delay are likely to be more effective if they address the psychosocial and behavioural blocks to action, are ongoing rather than short term, and focus on people at highest risk, including those with known or high risk of coronary heart disease, those in rural locations, and Indigenous Australians. The National Heart Foundation of Australia proposes a comprehensive strategy to incorporate this approach into its future campaigns to reduce patient delay for suspected heart attack.

Factors influencing emergency department arrival time and in-hospital management of patients with acute myocardial infarction

Reperfusion of the infarct-related artery in the very first hour ("golden hour") of acute myocardial infarction (AMI) significantly reduces mortality rates. Several factors may delay the initiation of reperfusion therapy (ie, thrombolytic therapy or primary percutaneous transluminal coronary angioplasty [PCTA]), most of which are related to patients. A total of 520 patients with suspected AMI were evaluated in the emergency department of Dokuz Eylül University Hospital between March 1996 and October 1999. After inclusion criteria were applied, the study consisted of 178 patients with a history of AMI. Analyzed data that affected patients' arrival to the hospital were obtained from responses to a questionnaire. The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, Ill), version 11.0, was used for all statistical analyses. The mean "symptom onset-hospital arrival time" was 188+/-325 min for the entire study group. The median delay was 110 min (approximately 2 h). Only 39 (22%) patients arrived to the hospital within the first hour. The mean time needed for late responders (n=109, 74%) (hospital arrival later than 1 h after symptom onset) to arrive was 245-/+363 min. According to the results of this study, many patients with AMI who may be eligible for reperfusion therapy miss the "golden hour" because of late hospital arrival. Some groups of patients (ie, elderly, women, those with diabetes) were especially late in arriving. To reduce such delays, training programs may be advised to focus on these groups of patients. Arrival times to the hospital during AMI can be greatly improved by efficient public education programs targeted to these groups.

Mirror, mirror on the wall: the quest for the earliest marker of myocardial ischaemiaThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to ‘Serum deoxyribonuclease I activity can be used as a sensitive marker for detection of transient myocardial ischaemia induced by percutaneous coronary intervention'† by K. Arakawa et al., on page 2375 In patients with acute ST-segment elevation myocardial infarction (STEMI), the diagnosis and immediate initiation of reperfusion therapy is based on the standard 12-lead ECG. Owing to the fact that cardiac markers appear in the blood a substantial time after the onset of symptoms, cardiac markers are neither helpful for early diagnosis of patients with STEMI nor should results be awaited before initiation of recanalization therapy. Unfortunately, at least 40% of all patients with confirmed acute myocardial infarction (AMI) show no diagnostic ECG changes on admission.1 In these patients with suspected acute coronary syndrome (ACS), cardiac troponins have become the biochemical gold standard for classification, risk stratification, and guidance of therapy.1 Cardiac troponins owe their exclusive superiority to their cardiospecificity, which indicates myocardial necrosis, and to their higher sensitivity compared with creatine kinase. However, obviously myocardial necrosis is a prerequisite for appearance of troponins in the blood, and the inflicting event needs to have occurred a few hours earlier.2 Novel cardiac markers ideally should improve these limitations by appearing earlier in the blood in case of an AMI, or by allowing identification of myocardial ischaemia in advance, or even in the absence … *Corresponding author. Tel: +49 6221 56 8670. E-mail address : hugo_katus{at}med.uni-heidelberg.de

Prehospital evaluation in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention

In patients with ST-elevation myocardial infarction, fast initiation of reperfusion therapy is mandatory. It is well established that prehospital diagnosis results in earlier initiation of fibrinolysis, but there is limited evidence concerning the value of prehospital evaluation in patients treated with primary percutaneous coronary intervention (PCI). The present paper proposes various prehospital strategies that may be of relevance in treating the latter patients: (1) a substantial reduction in treatment delay may be achieved by prehospital diagnosis, especially if combined with rerouting of patients directly to interventional hospital; (2) use of telemedicine may allow a widespread implementation of a prehospital diagnostic program; (3) a rerouting strategy may result in prolonged transportation. In this setting, continuous real-time 1-lead ECG transmission from ambulance to hospital may allow physicians to support ambulance personnel in the treatment of arrhythmias during transportation; and (4) equipment used for prehospital ECG acquisition and transmission has built-in features for continuous ST-segment monitoring. It is hypothesized that continuous ST-segment monitoring performed in the prehospital phase and during primary PCI may provide important prognostic information, with the potential of triaging future pharmacological and interventional treatment at time of PCI.