Longer Total Ischemic Time Research Articles

Differences between sexes in STEMI treatment and outcomes with contemporary primary PCI.

Historically, differences in timely reperfusion and outcomes have been described in females who suffer ST-segment elevation myocardial infarction (STEMI). However, there have been improvements in the treatment of STEMI patients with contemporary Percutaneous Coronary Intervention (PCI) strategies. Comparisons between sexes were performed on STEMI patients treated with primary PCI over a 4-year period (January 1, 2017-December 31, 2020) from the Queensland Cardiac Outcomes Registry. Primary outcomes were 30-day and 1-year cardiovascular mortality. Secondary outcomes were STEMI performance measures. The total and direct effects of gender on mortality outcomes were estimated using logistic and multinomial logistic regression models. Overall, 2747 (76% male) were included. Females were on average older (65.9 vs. 61.9 years; p < 0.001), had longer total ischemic time (69 min vs. 52 min; p < 0.001) and less achievement of STEMI performance targets (<90 min) (50% vs. 58%; p < 0.001). There was no evidence for a total (odds ratio [OR] 1.3 (95% confidence interval [CI]: 0.8-2.2; p = 0.35) or direct (adjusted OR 1.2 (95% CI: 0.7-2.1; p = 0.58) effect of female sex on 30-day mortality. One-year mortality was higher in females (6.9% vs. 4.4%; p = 0.014) with total effect estimates consistent with increased risk of cardiovascular mortality (Incidence rate ratio [IRR]: 1.5; 95% CI: 1.0-2.3; p = 0.059) and noncardiovascular mortality (IRR: 2.1; 95% CI: 0.9-4.7; p = 0.077) in females. However, direct (adjusted) effect estimates of cardiovascular mortality (IRR: 1.0; 95% CI: 0.6-1.6; p = 0.94) indicated sex differences were explained by confounders and mediators. Small sex differences in STEMI performance measures still exist; however, with contemporary primary PCI strategies, sex is not associated with cardiovascular mortality at 30 days or 1 year.

The Role of QRS Complex and ST-Segment in Major Adverse Cardiovascular Events Prediction in Patients with ST Elevated Myocardial Infarction: A 6-Year Follow-Up Study.

as a relatively high number of ST-segment elevation myocardial infarction (STEMI) patients develop major adverse cardiovascular events (MACE) following percutaneous coronary intervention (PCI), our aim was to determine the significance, and possible predictive value of QRS complex width and ST-segment elevation. our patient sample included 200 PCI-treated STEMI patients, which were divided into two groups based on the following duration of symptoms: (I) less than 6 h, and (II) 6 to 12 h. For every patient, an ECG was performed at six different time points, patients were followed for up to six years for the occurrence of MACE. the mean age was 60.6 ± 11.39 years, and 142 (71%) were male. The 6-12 h group had significantly wider QRS complex, higher ST-segment elevation, lower prevalence of ST-segment resolution as well as MACE prevalence (p < 0.05). ECG parameters, QRS width, and magnitude of ST-segment elevation were proved to be independent significant predictors of MACE in all measured time points (p < 0.05). Even after controlling for biomarkers of myocardial injury, these ECG parameters remained statistically significant predictors of MACE (p < 0.05). our study highlights that wider QRS complex and a more pronounced ST-segment elevation are associated with longer total ischemic time and higher risk of long-term MACE.

Is the cardioprotective effect of pre-infarction angina blunted by age?

Abstract Funding Acknowledgements None. Background Pre-infarct angina (PIA) has been demonstrated to reduce infarct size and improve prognosis in ST-elevation myocardial infarction (STEMI). However, the effects of ischemic preconditioning with aging are still controversial. Purpose We aimed at comparing the effect of pre-infarction angina (PIA) on infarct size between two age groups. Methods We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. PIA was diagnosed if a patient had arm, jaw, or chest pain in the preceding eight days. Peak creatine kinase (CK) concentration was used as a surrogate of infarct size. Patients were divided into two groups, based on the median age: ≤62 years and &amp;gt;62 years. Multiple linear regression was used to identify independent predictors for infarct size that included total ischemic time and classic cardiovascular risk factors (hypertension, diabetes, dyslipidaemia, and smoking). Interaction between age and PIA was evaluated by 2-way factorial ANOVA. Results From the 1131 patients included in the study, 590 (52,2%) had ≤62 years and 541 (47,8%) had &amp;gt;62 years. Older patients were more often women (17.2% vs 8.6%, p&amp;lt;0.001) and had longer total ischemic time [4.6(3.0-9.0) vs 3.5(2.3-6.0) hours, p&amp;lt;0.001]. They also had higher prevalence of hypertension (32.8% vs 22.8%, p&amp;lt;0.001), diabetes (30.7% vs 18.7%, p&amp;lt;0.001) and were less likely to be smokers (26.9% vs 71.4%, p&amp;lt;0.001). The prevalence of PIA was similar across age groups (≤62Y 31.2% vs &amp;gt;62Y 32.0%, p=0.668). In older patients, PIA was associated with smaller infarct size [1.29(0.72-2.33) vs. 1.76(0.97-2.91) U/Lx103, p&amp;lt;0.001]. This difference was not observed for younger patients [1.72(0.95-3.40) vs. 1.81(0.94-3.37) U/Lx103, p=0.392]. There was no significant interaction between the existence of PIA and age on peak CK (p=0.280 for interaction) (Figure 1). In multivariate analysis, overall, PIA was associated with reduced peak CK (β=-0,320, p=0.011). On subgroup group analysis, PIA was a predictor of infarct size only in the older patients (β=-0,459, p=0.005), but not in the younger group (β=-0,182, p=0.394). Conclusion Older patients with PIA had significantly lower infarct size compared to patients in the same age group without PIA. After adjustment for risk factors and total ischemic time, PIA was a predictor of lower infarct size only for the older patients. These results suggest that the effect of pre-ischemic conditioning is not blunted by age, indicating that older patients should not be excluded from clinical trials investigation of cardioprotective strategies in STEMI patients.

Impact of Total Ischemic Time on No Reflow Phenomenon

Background: Ischemic heart disease, particularly ST-segment elevation myocardial infarction (STEMI), remains a major cause of morbidity and mortality globally. Despite advancements in primary percutaneous coronary intervention (PPCI), the no-reflow phenomenon, characterized by inadequate myocardial reperfusion despite successful vessel recanalization, continues to pose significant challenges, affecting clinical outcomes adversely. Objective: This study aims to investigate the relationship between total ischemic time and the incidence of the no-reflow phenomenon in STEMI patients undergoing PPCI, to identify potential strategies for improving therapeutic outcomes. Methods: Conducted at Hayatabad Medical Complex, Peshawar, this retrospective cohort study included 160 STEMI patients treated over eight months (February to October 2022). We collected data on demographic characteristics, clinical presentation, and outcomes. Inclusion criteria were patients over 18 years, undergoing PPCI within 12 hours of symptom onset, without prior MI, severe bleeding disorders, or previous significant revascularization. Statistical analysis was performed using SPSS 25.0, considering P ≤0.05 as statistically significant. Results: The average total ischemic time was significantly longer in patients experiencing no-reflow (Group I, 7.91 hours) compared to those with normal reperfusion (Group II, 3.41 hours) (P=0.001). Group I also showed higher rates of cardiogenic shock (17.6% vs. 6.8%, P=0.012) and reinfarction (11.8% vs. 2.9%, P=0.010). Mortality was significantly higher in Group I (5.8% vs. 1.9%, P=0.020). Conclusion: Longer total ischemic time is associated with an increased risk of the no-reflow phenomenon and poorer clinical outcomes in STEMI patients. Reducing ischemic time could be crucial in improving reperfusion success and reducing complications post-PPCI.

Early elevated donor-derived cell-free DNA levels in heart transplant recipients following precision-controlled cardiac transport system or ice-cooled organ transport.

Recent innovations in temperature-controlled cardiac transportation allow for static hypothermic preservation of transplant organs during transportation. We assessed differences in donor-derived cell-free DNA (dd-cfDNA) using the SherpaPak cardiac transport system (SCTS) and traditional ice transportation. Single-organ heart transplant recipients between January 2020 and January 2022 were included if they had dd-cfDNA measures ≤6weeks post-transplant along with the baseline biopsy at 6weeks as part of the surveillance protocol and no biopsy-confirmed rejection ≤90 days. Elevated dd-cfDNA ≥.20% were compared between groups using logistic regression including a subject effect. Of 65 hearts transplanted, 30 were transported with SCTS and 35 on ice. Recipient characteristics were similar between groups. Donors in the SCTS group were older (34vs. 40 years, p=.04) with a longer total ischemic time (171vs. 212 min, p=.002). Recipients in the SCTS group had a greater risk of elevated dd-cfDNA unadjusted and adjusted for donor age, and prolonged ischemic times>3.5h (Unadjusted odds ratio: 4.9, 95%-CI: 1.08-22.5, p=.039 and Adjusted odds ratio: 5.5, 95%-CI: 1.03-29.6, p=.046). Primary graft dysfunction rates and 1-year mortality were comparable between groups. Elevated dd-cfDNA in patients procured with SCTS may indicate that graft injury was not negated relative to ice transport. However, there were no clinical differences noted in short or long-term outcomes including mortality despite a longer ischemic time in the SCTS group.

IMPACT OF TOTAL ISCHEMIC TIME ON THE RECOVERY OF REGIONAL WALL MOTION ABNORMALITY AFTER STEMI IN PATIENTS UNDERGOING PCI

This study was designed to evaluate the impact of total ischemic time (TIT) on the recovery of regional wall motion abnormality (RWMA) in patients undergoing percutaneous coronary intervention (PCI) after ST-elevation myocardial infarction (STEMI). This was a single-center retrospective study of 155 patients with STEMI who underwent PCI at the Medical Teaching Institute-Hayatabad Medical Complex in Peshawar from May 3, 2022, to October 5, 2022. The primary outcome was the recovery of RWMA, as assessed by the wall motion score index (WMSI) at discharge. Longer TIT was associated with a decreased likelihood of recovery of RWMA (adjusted odds ratio [OR], 0.72; 95% confidence interval [CI], 0.59-0.89; P=0.002). Patients with TITs of 180 minutes or less were more likely to experience a decrease in WMSI (OR, 3.02; 95% CI, 1.36-6.71; P=0.007) if they were older, had an anterior myocardial infarction, and had higher baseline WMSI. Our study demonstrates that longer TIT is associated with a reduced likelihood of recovery of RWMA after STEMI in patients undergoing PCI. Timely reperfusion is crucial for improving myocardial function and optimizing clinical outcomes in these patients. Strategies to minimize TITs, such as pre-hospital activation of the catheterization laboratory, streamlined processes for door-to-balloon time, and advanced imaging techniques to guide revascularization, may improve outcomes in this patient population.

Impact of implantation time on early function of cardiac transplant.

Data on out-of-ice implantation ischemia in heart transplant are scarce. We examined implantation time's impact on allograft dysfunction. We conducted a single-site retrospective review of all primary adult heart transplants from June 2012 to August 2019 for implantation warm ischemic time (WIT), defined as first atrial stitch to aortic crossclamp removal. Univariate regression was used to assess the relationship of perioperative variables to primary graft dysfunction (PGD) and to pulmonary artery pulsatility index (PAPi) at postoperative hour 24. A threshold of p < .10 was set for the inclusion of covariates in multivariate regression. Secondary analyses evaluated for consistency among alternative criteria for allograft dysfunction. A post hoc subgroup analysis examined WIT effect in prolonged total ischemia of240 min or longer. Complete data were available for 201 patients. Baseline characteristics were similar between patients who did and did not have WIT documented. In univariate analysis, female gender, longer total ischemic time (TIT), longer bypass time, greater blood transfusions, and pretransplant intensive care unit (ICU) care were associated with PGD, whereas longer bypass time was associated with worse PAPi and pretransplant ICU care was associated with better PAPi. In multivariate analysis, longer bypass time predicted PGD, and worse PAPi and preoperative ICU admission predicted PGD and better PAPi. Results did not differ in secondary or subgroup analyses. This study is one of few examining the functional impact of cardiac implantation ischemia. Results suggest allograft implantation time alone may not impact postoperative graft function, which was driven by intraoperative bypass duration and by preoperative ICU care, instead.

Timing and outcomes of testicular torsion during the COVID-19 crisis

BackgroundDuring the COVID-19 crisis, there has been widespread reporting that non-COVID-19-related medical care has been delayed, even for emergent conditions. Testicular torsion is an emergent condition with higher risk of testicular loss with longer ischemic times. We sought to investigate whether patients with testicular torsion had longer time from symptom onset to initial presentation, longer total ischemic time, and higher rate of orchiectomy during the pandemic.Materials and methodsUsing billing data, we identified all patients age >1yo seen in our hospital from 1/1/2018 through 5/31/2020 who underwent emergent scrotal exploration for confirmed testicular torsion, comparing the COVID-19 crisis (3/1/2020–5/31/20) to the pre-COVID-19 period (1/1/2018–2/29/20). The primary outcome was time from symptom onset to initial presentation and secondary outcomes were ischemic time (time from symptom onset to entry of the OR) and orchiectomy rate. Parameters were compared with Mann–Whitney U and Fisher's exact tests; Poisson regression compared rates of torsion.ResultsOf 94 total cases, 77 occurred during the pre-COVID-19 period and 17 during the COVID-19 crisis. Median time from symptom onset to initial presentation was not significantly different (2.4 h [IQR 1.1 h–38.9] during COVID-19 vs. 5.6 h [IQR 1.6–16.9] during pre-COVID-19 period, p = 0.476). Time to presentation was >12 h in 5/17 patients (29%) during COVID-19 and 24/77 patients (31%) during pre-COVID-19 period (p = 1.00). Median ischemic time during COVID-19 was 7.5 h (IQR 4.7 h–45.5 h) compared to 9.4 h (IQR 5.4 h–22.5 h) during pre-COVID-19 period (p = 0.694). Incidence of orchiectomy in our center was 29% (5/17) during COVID-19 and 17% (13/77) during pre-COVID-19 period (p = 0.397). About half of patients were seen initially at outside facilities prior to arrival (47% [8/17] during COVID-19 vs. 49% [38/77] during pre-COVID-19 period, p = 1.00). The number of torsion case presentations per week to our facility increased from 0.7 cases/week in the pre-COVID-19 period to 1.3 cases/week during COVID-19 (p = 0.015); when comparing only the March 1 to May 31 calendar period, there were 0.6 cases/week during the pre-COVID-19 period and 1.3 cases/week during COVID-19 (p = 0.021).ConclusionTime to presentation, ischemic times, and orchiectomy rates for testicular torsion at our center were not significantly different during the COVID-19 period compared to the preceding 2 year period. The number of torsion case per week presenting to our facility increased significantly.Summary Table 1Comparison of patients, timing, and testicular outcomes among patients with testicular torsion before and during COVID-19 crisis.Summary Table 1OverallPre-COVIDCOVIDp-valuen947717Age, years (median [IQR]{range})14.38 [12.70, 15.87] {1.3–19.7}14.22 [12.64, 15.83]{1.3–19.7}15.24 [14.21, 16.01]{4.2–17.4}0.2950Time from symptom onset to presentation, hours (median [IQR]{range})5.38 [1.49, 18.38]{0.7, 148.0}5.58 [1.60, 16.85]{0.7, 81.3}2.40 [1.12, 38.92]{0.9, 148.0}0.4760Time from symptom onset to presentation > 6 h, n (%)43 (45.7)35 (45.5)8 (47.1)1.0000Time from symptom onset to presentation > 12 h, n (%)29 (30.9)24 (31.2)5 (29.4)1.0000Ischemic time, hours (Time from symptom onset to OR) (median [IQR]{range})9.19 [5.32, 26.02]{2.7, 152.2}9.40 [5.42, 22.52]{2.7, 86.3}7.52 [4.67, 45.45]{2.7, 152.2}0.6940Orchiectomy, n (%)18 (19.1)13 (16.9)5 (29.4)0.3970Presentation at OSH, n (%)46 (48.9)38 (49.4)8 (47.1)1.0000

COVID-19 et SCA ST+

The COVID-19 pandemic had an unexpected impact on cardiovascular emergencies, particularly STEMI. The France PCI registry and other studies around the world have highlighted a significant decrease in myocardial infarctions arriving at hospital. This decrease is mainly related to patients’ fear of coming to the hospital and being contaminated. Although the STEMI revascularisation time targets (<120min) are often difficult to achieve in normal times, they were almost impossible to achieve in periods of lockdown because of the many obstacles. Longer delays and longer total ischemic time have led to excess mortality, especially in the regions most affected by the epidemic. Recommendations for the management of STEMI during the COVID-19 period have thus been issued by the scientific societies. STEMI in patients with COVID-19 often have an uncommon clinical presentation, and the absence of coronary obstruction on angiography is frequent. Their prognosis is very poor. Only public information campaigns and an organisation adapted to the management of coronary emergencies during epidemics can try to limit their effects and avoid aggravating an already fragile health situation in the future.

TIME AND MORTALITY IN ST ELEVATION MYOCARDIAL INFARCTION: INSIGHTS FROM THE TOTAL TRIAL

The effect of thrombus aspiration in patients with ST elevation myocardial infarction (STEMI) may differ based on ischemic time. Patients with short ischemic times have greater viable myocardium and so may derive greater benefit from thrombus aspiration. We sought to determine the effect of thrombus aspiration on mortality in patients presenting with STEMI based on total ischemic time (duration of symptom onset to first medical device time) and first medical contact to first device time. The TOTAL trial was an international multicenter randomized trial of 10,732 patients comparing routine thrombus aspiration plus percutaneous coronary intervention (PCI) vs PCI alone in STEMI patients undergoing primary PCI within 12 hours of symptom onset. We performed a subgroup analysis for total ischemic time and first medical contact to device time for the primary outcome (Cardiovascular death [CV], Myocardial Infarction [MI], cardiogenic shock and heart failure) and CV mortality. In addition, we used a multi-variable analysis to determine the impact on CV mortality at 1 year for total ischemic time (6 hours) and first medical contact to device (120min). In this international multicenter trial, 64% of patients achieved a first medical contact to device time within 120 minutes and 41% within 90 minutes. In terms of total ischemic time, 87% of patients presented within 6 hours of symptom onset. For the randomized comparison of thrombus aspiration, there was no significant benefit on the primary outcome and for CV death irrespective of total ischemic time and medical contact to device time (Figure 1). CV Mortality was higher in patients with longer total ischemic time (2.5%, 3.5%, 5.2% for < 2 hours, 2-6 hours, >6 hours, P=0.0005). Similarly, CV mortality was higher in patients with longer first medical contact to device time (2.4%, 2.9%, 3.5%, 4.7% for 120 min, P= 0.0001). In a step-wise multivariable analysis, both total ischemic time (>3 hours, hazard ratio 1.34; 95% CI 1.09-1.66) and first medical contact to device time (>90 minutes, hazard ratio 1.45; 95% CI 1.16-1.82) were independent predictors of CV mortality at 1 year. Irrespective of first medical contact to device time and total ischemic time, thrombus aspiration was not beneficial for the primary outcome or CV death. In the current STEMI era, both total ischemic time and first medical contact to device times are important and are independent predictors of CV mortality.

Impact of Time Delay on Short Term Outcome of Primary Percutaneous Coronary Intervention (PCI) in Bangladeshi Population

Background: Now-a-days primary percutaneous coronary intervention (pPCI) is being increasingly done in our country as the treatment of acute ST elevation myocardial infarction (STEMI). Time until treatment is paramount in the management of STEMI. But the time delay to pPCI how much influencing the outcome in our setting is mostly unknown.So we evaluated the influence of total ischemic time on myocardial reperfusion and short term clinical outcome in patients with STEMI treated with primary PCI.&#x0D; Materials and methods: This prospective observational study was conducted from August 2016 to March 2017in the Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka. Forty-eight (48) acute STEMI patients were selected by purposive sampling based on inclusion and exclusion criteria dividing into two groups as early treatment group (group-A) in whom pain to pPCI time was &lt;6 hours and late treatment group (group-B) in whom pain to pPCI time was 6-12 hours. Angiographic (TIMI flow grade 3 &amp; MBG 3) &amp; short term clinical outcome (MACE, heart failure, major bleeding, minor bleeding, cardiogenic shock, significant arrhythmia, instent thrombosis) were observed and compared between these two groups.&#x0D; Results: The relationship between total ischemic time and 30-day mortality &amp; morbidity were assessed and compared with early and late pPCI group. The overall 30-day mortality rate was 4.2%, heart failure was 6.2%, cardiogenic shock was 4.2%, major bleeding was 2.1% and minor bleeding was 14.6%. Mortality and morbidity were higher in longer ischemic time group than shorter ischemic time group. In multivariate regression analysis, the factors independently influencing the adverse short term outcome were advance age (OR 1.51, 95% CI 1.105 to 4.101, p=0.03), hypertension (OR 2.44, 95% CI 1.102 to 4.281, p=0.02), diabetes mellitus (OR 2.51, 95% CI 1.200 to 4.987, p=0.02), anterior MI (OR 1.38, 95% CI 1.001 to 2.872, p=0.03), multivessel disease (OR 2.35, 95% CI 1.010 to 5.371, p=0.02), pain to door time (OR 1.66, CI 1.099 to 2.2.722, p=0.04), and total ischemic time (OR 2.67, 95% CI 1.122 to 5.784, p=0.02). Even after correction for predictive baseline and procedural variables of the univariate analysis, longer total ischemic time was the most significant independent predictor (OR 2.67, p=0.02) of short term adverse outcome of primary PCI. The current status of time delay in our country revealed symptom onset to door time was 5.6±2.4 hours, door to balloon time was 1.9±1.1 hours and total ischemic time was 7.3±2.6 hours.&#x0D; Conclusion: According to this study finding, there is prognostic implication of time delay in patients with STEMI undergoing primary PCI. Therefore, all efforts should be made to shorten total ischemic time, including reduction in patient related delays, to improve clinical outcome of STEMI patients.&#x0D; University Heart Journal Vol. 14, No. 2, Jul 2018; 77-82

Manual thrombus aspiration during primary percutaneous coronary intervention: Impact of total ischemic time

BackgroundThe benefit of manual thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) remains uncertain, and the effect of TA in relation to total ischemic time has not been evaluated. MethodsWe analyzed 5641 patients with ST-elevation myocardial infarction (STEMI) (<12h) from the Korea Acute Myocardial Infarction Registry undergoing primary PCI. Patients were divided into 2 groups: TA (n=1245) and PCI only (n=4396). Propensity-matched 12-month clinical outcome was compared between the groups according to different total ischemic times (≤2h, 2–4h, 4–6h, >6h). ResultsTwelve-month rates of death and major adverse cardiac events (MACE: composite of death, recurrent myocardial infarction, target-vessel revascularization, and coronary artery bypass grafting) were not different between TA and PCI only. After propensity matching (n=1162 for each group), there were no differences in the 12-month outcome between TA and PCI only, which was consistent across subgroups. In the propensity-matched cohort, the effect of TA on 12-month outcome showed a U-shaped relationship with longer total ischemic time: TA in patients with total ischemic time between 4 and 6h was associated with lower rates of death [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.24–1.19, p for interaction=0.01] and MACE (HR: 0.28, 95% CI: 0.12–0.66, p for interaction=0.01). ConclusionsManual TA during primary PCI was not associated with improved clinical outcome at 12 months. The impact of TA may become clinically relevant with longer total ischemic time, forming a U-shaped relationship.

Relationship of ischemic times and left atrial volume and function in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

Little is known about the impact of duration of ischemia on left atrial (LA) volumes and function during acute phase of myocardial infarction. We investigated the relationship of ischemic times, echocardiographic indices of diastolic function and LA volumes in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). A total of 433 consecutive STEMI patients underwent echocardiographic examination within 48 h of primary PCI, including the measurement of LA volumes and the ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/e'). Time intervals from onset of chest pain to hospital admission and reperfusion were collected and magnitude of Troponin I release was used to assess infarct size. Patients with LA volume index (LAVI) ≥28 ml/m(2) had longer total ischemic time (410 ± 347 vs. 303 ± 314 min, p = 0.007) and higher E/e' ratio (15 ± 5 vs. 10 ± 3, p < 0.001) than those with LAVI <28 ml/m(2), while the indices of LA function were similar between the study groups (p > 0.05, for all). Significant correlation was found between E/e' and LA volumes at all stages of LA filling and contraction (r = 0.363-0.434; p < 0.001, for all) while total ischemic time along with E/e' and restrictive filling pattern remained independent predictor of LA enlargement. Increased LA volume is associated with longer ischemic times and may be a sensitive marker of increased left ventricular filling pressures in STEMI patients treated with primary PCI.

Gender-specific time delays to primary PCI in STEMI: a consequence of the presentation or the management at the EMC centre?

Background: Women with ST elevation myocardial infarction (STEMI) tend to have longer treatment delays than men. This may partly be due to women delaying calling for help, difficulties for the Emergency Medical Communication (EMC) service in interpreting a different constellation of presenting symptoms than men, or gender-specific ambulance delays due to differences in the management by the EMC service. Methods and results: We studied the EMC audio logs and medical records of 244 consecutive STEMI patients (65 women and 179 men) who contacted a single EMC center directly. Patient demographics, clinical findings and outcome after primary PCI were similar for the two genders. More women than men reported chest discomfort and discomfort in other areas of the upper body as debuting symptoms. The combined effects of longer patients delay and system delay led to longer total ischemic time in women (total ischemic time 142 (180) minutes (median (interquartile range)) vs. 135 (83), women vs. men, p=0.024). Despite similar presentation, women had lower priority for emergent ambulance service (78.7% and 89.4% of women vs. men, p=0.035). Lower priority for ambulance service was associated with longer total ischemic time. Conclusion: Despite similar presentation and clinical findings, women with STEMI were given significantly lower priority for emergent ambulance service than men.

Improved outcomes in cadaveric renal allografts with pulsatile preservation.

Early immunologic and non-immunologic injury of renal allografts adversely affects long-term graft survival. Some degree of preservation injury is inevitable in cadaveric renal transplantation, and, with the reduction in early acute rejection, this non-immunologic injury has assumed a greater relative importance. Optimal graft preservation will maximize the chances of early graft function and long-term graft survival, but the best method of preservation pulsatile perfusion (PP) versus cold storage (CS) is debated. Primary cadaveric kidney recipients from January 1990 through December 1995 were evaluated. The effects of implantation warm ischemic time (WIT) ( < or = 20 min, 21-40 min, or > 40 min) and total ischemic time (TIT) ( < or > or = 20 h) on death-censored graft survival were compared between kidneys preserved by PP versus those preserved by CS. The effect of preservation method on delayed graft function (DGF) was also examined. There were 568 PP kidneys and 268 CS kidneys. Overall death-censored graft survival was not significantly different between groups, despite worse donor and recipient characteristics in the PP group. CS kidneys with an implantation WIT > 40 min had worse graft survival than those with < 40 min (p = 0.0004). Survival of PP kidneys and those transplanted into 2 DR-matched recipients was not affected by longer implantation WIT. Longer TIT did not impact survival. DGF was more likely after CS preservation (20.2% versus 8.8%, p = 0.001). Preservation with PP improves early graft function and lessens the adverse effect of increased warm ischemia in cadaveric renal transplantation. This method is likely associated with less preservation injury and/or increases the threshold for injury from other sources and is superior to CS.