Patients Underwent Emergency Coronary Angiography Research Articles

Door‐to‐balloon times are reduced in ST‐elevation myocardial infarction by emergency physician activation of the cardiac catheterisation laboratory and immediate patient transfer

To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door-to-balloon (DTB) times for patients with suspected ST-elevation myocardial infarction (STEMI). A quasi-experimental before-and-after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary-care hospital, Western Australia. Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door-to-activation time, activation-to-balloon time and false-positive activations of the CCL. Two hundred and thirty-four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door-to-activation time from 28 to 15 minutes (P = 0.002) and median activation-to-balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38). ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

Field Triage Reduces the Incidence and Mortality of Ischaemic Cardiogenic Shock in Patients with Acute Myocardial Infarction

reduce door to balloon (DTB) time in STEMI. Shorter DTB times are associated with reduced mortality. The main barrier to implementing ED CCL activation is concern of inappropriate activation of the CCL. Aim:Tocompare falsepositive ratesof suspectedSTEMI patients undergoing emergency coronary angiography by cardiology verses senior ED activation of the CCL. Methods: All patients undergoing emergency cardiac catheterisation forSTEMI from2007 to2009wereanalysed. Falsepositive rateswere comparedbefore andafter implementing a protocol enabling independent ED activation of the CCL (2007–2008 vs. 2009). Some patient characteristics required ED to communicate with cardiology prior to CCL activation (elderly, borderline ECG changes, out of hospital arrest, LBBB, significant co-morbidities). Patient files, ECGs, coronary angiograms and left ventriculograms were reviewed in all patients undergoing emergency angiography without percutaneous coronary intervention to determine diagnosis, management and cause of the false positive cases. Results: Cardiology 2008–2009 (n= 150) ED 2009 (n= 84) Primary PCI 118 (79%) 70(83%) Medical management 11 (7%) 4 (5%) Surgery 3 (2%) 1 (1) False positive 18 (12%) 9 (11%) (NS) Causes of false positives: Chest pain of unclear cause with either early repolarisation of ST segments or LBBB (63%, 7/27). Takotsubo cardiomyopathy (22%, 6/27), myo/pericarditis (11%, 3/27) and pulmonary embolism (5%, 1/27). Conclusion: False positive rates in patients undergoing emergency angiography for suspected STEMI is not increasedwithacontrolledsystemofemergencyphysician activation of the cardiac catheterisation laboratory. doi:10.1016/j.hlc.2010.06.975

False Positive Rates in Patients Undergoing Emergency Coronary Angiography for Suspected STEMI is Not Increased with Emergency Physician Activation of The Cardiac Catheterisation Laboratory

False Positive Rates in Patients Undergoing Emergency Coronary Angiography for Suspected STEMI is Not Increased with Emergency Physician Activation of The Cardiac Catheterisation Laboratory

Rescue angioplasty after failed fibrinolysis foracute myocardial infarction: Predictors of a failed procedure and 1‐year mortality

Rescue angioplasty (rPCI) for failed fibrinolysis is associated with a low mortality if successful, but a high mortality if it fails. The latter may reflect a high-risk group or harm in some patients. Predictors of success or failure of rPCI may aid selection of patients to be treated. Unselected patients referred for rPCI from March 1994 to March 2005 were studied to determine the predictors of a failed procedure and 1-year mortality. Of 440 patients undergoing emergency coronary angiography for failed fibrinolysis (1-year mortality 18%), 101 had thrombolysis in myocardial infarction flow grade (TFG) 3 in the infarct-related vessel. rPCI was attempted in 318 of 339 patients with <TFG 3 flow, but not in 21 patients (angiography-produced TFG 3 [n = 7] or unsuitable anatomy [n = 14]). Of the rPCI cohort, 77% had a successful procedure (no in-lab death or emergency coronary artery bypass grafting and TFG 3 in the infarct-related vessel); rPCI failed in 23%. One-year mortality rates for successful and failed rPCI were 14 and 43%, respectively. Patients with failed rPCI were older and more likely to be diabetic, have anterior MI, be interhospital transfers, be in cardiogenic shock, and less likely to be a current smoker. Shock was the only independent predictor of failed rPCI. Age group >75 years, shock, and final TFG < 3 were independent predictors of 1-year mortality. Cardiogenic shock is an independent predictor of a failed rPCI. Age group >75 years and shock were the only independent clinical predictors of 1-year mortality. These clinical variables may help in selecting patients for either a strategy of rescue angioplasty after failed fibrinolysis, or in selecting specific patients who might do better with a policy of primary angioplasty.

Tako-tsubo-like transient left ventricular dysfunction—A new cause of diastolic heart failure

A 49-year-old women presented with severe chest pain typical of myocardial infarction with vomiting and sweating during emotional stress (funeral). The initial ECG revealed normal sinus rhythmwith STelevation in leadsV1–V3,T-wave inverted in I, aVL, V5–V6 (Fig. 1-1). Admission Troponin I (1.4 ng/ml — normalb0.1 ng/ml) and creatinine kinase-MB (5.4 ng/ml, normalb3.6 ng/ml) level were positive. Other laboratory tests were normal. The patient underwent emergency coronary angiography which revealed normal coronary arteries (Fig. 2-1, 2). However contrast left ventriculography demonstrated typical view of tako-tsubo cardiomyopathy with markedly reduced left ventricular ejection fraction (Fig. 2-3). This observation was confirmed in transthoracic echo. Subsequent echocardiography performed 4 days after admission revealed a normal ejection fraction of 55% with grossly normal wall motion but with a relaxation abnormality. No valvular and right ventricular dysfunctions were observed in those examinations. The patient remained clinically and hemodynamically stable during 6 days of hospitalization and was discharged home (ECG at discharge — Fig. 1-2). Discharged medications included an aspirin, beta-blocker, calcium channel antagonist and statin. After 1 month patient had signs of heart failure and the transthoracic echo showed preserved left ventricular function with normal ejection fraction (Fig. 3-1, 2) and impaired

Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction

Stress-induced myocardial stunning is defined as a syndrome of acute chest pain, ST-T changes on the ECG and transient left ventricular apical wall motion abnormalities mimicking acute myocardial infarction but with surprisingly normal coronary angiography findings. The aim of this retrospective study is to assess the prevalence of stress-induced myocardial stunning among patients undergoing urgent coronary angiography for suspected acute myocardial infarction. During a four-year period (2002–2005), a total of 5876 patients underwent urgent coronary angiography for suspected acute myocardial infarction at three tertiary centers. Four patients fulfilled the diagnostic criteria for stress-induced myocardial stunning. Thus, the cath-lab prevalence of stress-induced myocardial stunning (i.e. among patients undergoing urgent coronary angiography for suspected acute myocardial infarction) was estimated as 1 per 1469 ST-elevation coronary angiograms (i.e. 0.07%) The estimated annual population incidence of this rare disorder was calculated as 0.00006%. Stress-induced myocardial stunning is an extremely rare syndrome among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.

Not So Mural Thrombus

A 64-year-old man with type 2 diabetes mellitus was admitted to our emergency department for a 12-hour history of waxing and waning chest pain. During the first hour of observation, he complained about a new episode of chest pain accompanied by ST elevation in leads V2 and V3. The patient underwent emergency coronary angiography that showed 80% stenosis of the proximal left anterior descending artery with subocclusive thrombotic lesion …

Síndrome da disfunção apical reversível (Takotsubo)

The patient was a male with myasthenia gravis, hospitalized with acute respiratory failure due to decompensation of the underlying disease. He evolved with findings suggestive of acute myocardial infarction, with electrocardiographic and enzymatic alterations compatible with that diagnosis. The patient underwent emergency coronary angiography, which showed no severe coronary obstruction, although his left ventricle had significant systolic dysfunction with characteristic alterations, on ventriculography, of the syndrome described as transient ventricular dysfunction or Takotsubo syndrome. On evolution, complete recovery of the electrocardiographic alterations and systolic ventricular function assessed on echocardiography occurred, confirming the syndrome.

Prognostic Value of I-123 Metaiodobenzylguanidine Imaging in Vasospastic Angina Without Significant Coronary Stenosis

Myocardial imaging is widely used to detect coronary artery disease and to assess its prognosis. In vasospastic angina (VA), cardiac imaging can provide information on disease activity, which is related to cardiac events. The aim of this study was to clarify whether exercise thallium-201 imaging (Tl-SPECT) and 123I-metaiodobenzylguanidine imaging (MIBG) have prognostic value for patients with VA, but without significant coronary artery stenosis. One hundred and 5 patients who showed acetylcholine-induced coronary spasm, normal left ventricular function and no significant stenosis (<50%) underwent both symptom-limited Tl-SPECT and MIBG within 1 month. All patients were prescribed calcium antagonist during the follow-up period (mean 4.7 years). Exercise-induced ischemia was detected by Tl-SPECT in 53 patients and multivessel coronary spasm by coronary angiography in 33 patients. During the follow-up period, 1 patient died suddenly and another died of acute myocardial infarction (MI). Two patients developed nonfatal acute MI and 7 patients underwent emergency coronary angiography because of unstable angina. According to the baseline characteristics, VA with cardiac events showed a significantly higher heart-to-mediastinum ratio (H/M ratio) and a significantly lower MIBG washout rate than those without cardiac events (p<0.03 and p<0.02, respectively). Among 8 clinical variables, including coronary risk factors, exercise parameters and exercise-induced ischemia on Tl-SPECT and the MIBG delayed H/M ratio and washout rate, univariate Cox proportional hazard regression analysis showed that the high H/M ratio and reduced washout rate of MIBG were significant predictors of future cardiac events (relative risk (RR) =4, confidence interval (CI) =1.21-13.29, p<0.02 for H/M ratio and RR 0.92, CI 0.85-0.99, p<0.02 for washout rate). However, exercise-induced ischemia did not show any statistical significance. By multivariate Cox proportional hazard regression analysis, a reduced MIBG washout rate was the only significant predictor of future cardiac events (odds ratio =0.90, CI =0.82-1.00, p<0.04). MIBG imaging can identify high-risk patients, even among those with VA who were previously regarded as low risk. This result strongly supports the idea that cardiac sympathetic dysfunction contributes to coronary artery spasm leading to cardiac events.