Primary Coronary Angioplasty Research Articles

Evolution of in-hospital management in ST Segment Elevation Myocardial Infarction in Portuguese hospitals over the years

Abstract Objectives To assess the evolution of in-hospital management of ST Segment Elevation Myocardial Infarction (STEMI) over the years in Portuguese hospitals and its impact on in-hospital complications and mortality Methods A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of acute coronary syndrome since 2002 until 2019 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical data, revascularization strategy, medication during hospitalization. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess tendencies in categorical variables, and Kruskal-Wallis tests were used to assess tendencies in numerical variables. A p-value <0.05 was considered statistically significant. Results During the study, a total of 24425 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years. We report a progressive increase in patients treated with aspirin, P2Y12 inhibitors (from 22.2% to 97.6% – p<0.001), beta blockers 62.% to 72.4% – p<0.001), ACE inhibitors (68.9% to 78.2% – p<0.001) and statins (72.1% to 88.4% – p<0.001), a progressive decrease in GP 2a3b inhibitors (20.9 to 14.6% – p<0.001), enoxaparin (55.2% to 29.9% – p<0.001), nitrates (82.7% to 16.1% – p<0.001), calcium channel blockers (5.0% to 3.1% – p<0.001) and inotropes (12.0% to 5.6% – p<0.001). There was an increase of the use primary coronary angioplasty (36.4% to 73.2% – p<0.001), and of drug eluting stents (0% to 70.1% – p<0.001) a decrease in the use of fibrinolysis (75.7% to 1.6% – p<0.001), bare metal stents (88.1% to 0.3% – p<0.001) and intra-aortic balloon pump (1.8% to 0% – p=0.009), but not in invasive mechanical ventilation (2.5% to 1.9% – p=0.142). Less patients had moderate to severely impaired left ventricle ejection fraction (28.8% to 14.9% – p<0.001), and there was a significant reduction in almost all in-hospital complications: re-infarction (2.0% to 1.0% – p<0.001); heart failure (36.2% to 9.9% – p<0.001); cardiogenic shock (10.8% to 3.9% – p<0.001); AV block (5.8% to 2.5% – p<0.001); mechanical complications (2.8% to 0.4% – p<0.001); stroke (1.3% to 0.4% – p<0.001); in-hospital mortality (9.9% to 3.8% – p<0.001); as well as length of stay ([4–10] days to [3–6] days – p<0.001). Exceptions were and increase in major bleeding (0.9% to 1.8% – p<0.001) and resuscitated cardiac arrest (3.9% to 4.5%, p=0.001). Conclusion In 17 years, we report a progressive evolution of the in-hospital treatment of STEMI patients in Portuguese hospitals, with a higher prescription of guideline recommended medications, use of invasive reperfusion techniques and last generation stents, resulting in a lower rate of in-hospital complications and mortality. In-hospital outcomes over the years Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Registo Nacional de Síndromes Coronárias Agudas - Sociedade Portuguesa de Cardiologia

Correlation of ‘R’ wave peak time with no reflow in patients undergoing primary coronary angioplasty

Correlation of ‘R’ wave peak time with no reflow in patients undergoing primary coronary angioplasty

Mechanical Dispersion as a powerful echocardiographic predictor of outcomes after Myocardial Infarction

Abstract Introduction Several studies have addressed the importance of transthoracic echocardiography (TTE) in risk prediction of subsequent adverse events after ST elevation myocardial infarction (STEMI). While several traditional echo parameters have a well-established prognostic value, data derived from 2D-Speckle Tracking Echocardiography (2DSTE) needs further investigation. Objectives To determine if 2DSTE parameters provide additional information beyond conventional echocardiography to predict long-term adverse outcomes in patients admitted with STEMI Methods Retrospective, single-center study, that included all patients without previous cardiovascular events admitted with STEMI (who underwent primary coronary angioplasty) between 2015 and 2017. Patients with poor acoustic windows, severe valvular disease, irregular heart rhythm, and those who died during hospital stay were excluded. We reviewed all pre-discharge TTE to assess conventional parameters of LV systolic and diastolic function and data obtained by 2DSTE: global longitudinal strain (GLS) and peak strain dispersion (PSD), an index that is the standard deviation from time to peak strain of all segments over the entire cardiac cycle. Demographic and clinical data was obtained through electronic hospital records. Minimum follow-up was 2 years. The primary endpoint was a composite of all-cause mortality and cardiovascular re-admission at follow-up. Survival analysis was used to determine independent predictors of the primary endpoint. Results 377 patients were included, mean age 62±13 years, 72% male. Mean LVEF was 50±10% with 19% of patients having LVEF <40%. Mean indexed left atrium volume (LAVi) was 33±10 ml/m2, mean GLS was −14±4%, and PSD was 60±22 msec. Average follow-up was 36±11 months, with a combined endpoint of mortality and hospitalization of 27% (n=102) Univariate analysis of echocardiographic variables revealed an association between heart rate, LVEF, indexed LV end-systolic volume, indexed stroke volume, LAVi, GLS and PSD with the endpoint. However, on multivariate analysis only LAVi [HR 1.030 (95% CI 1.009 - 1.051), p-value = 0.005] and PSD [HR 1.011 (95% CI 1.002 - 1.020), p-value = 0.012] remained independent predictors of the primary endpoint. We determined that a PSD value higher than 52 msec has a sensitivity of 76% and a negative predictive value of 83% for mortality and hospitalization, and that this cut-off point discriminates patients at a higher risk of events in Kaplan-Meier Survival analysis with a Log-Rank p-value=0.001. Conclusion PSD derived by longitudinal strain analysis is a promising prognostic predictor after STEMI. PSD outperformed conventional echocardiographic parameters in the risk stratification of STEMI patients at discharge. Kaplan-Meier Survival Curves Funding Acknowledgement Type of funding source: None

Primary percutaneous coronary angioplasty in octogenarians and over. The experience of a high-volume hub center

Primary coronary angioplasty (PCI) is the reference treatment for acute ST-elevation myocardial infarction (STEMI), but elderly patients (>80 years) are underrepresented in clinical trials that support the guideline recommendations. The aim of this study was to assess in-hospital and 1-year total mortality of octogenarians and over treated with primary PCI at a large referral center. Single-center analysis of all consecutive patients with STEMI aged ≥80 years treated with primary PCI between 2010 and 2016. Patients were divided into three age groups: 80-84 years, 85-89 years, and ≥90 years. For each group, clinical and procedural data, in-hospital and 1-year mortality were analyzed. During the study period, 2127 patients were treated with primary PCI, 463 of them (22%) were aged ≥80 years (mean 85 ± 3 years). Of these, 51% were aged ≥80 and ≤84 years, 32% were aged ≥85 and ≤89 years, and 17% were aged ≥90 years. An increase of female gender prevalence and a decrease of risk factor prevalence as well as PCI success were observed with ageing. In-hospital and 1-year total death rates increased with age as well, mainly after 85 years. Primary PCI for STEMI among octogenarians and over is feasible and has good procedural results. Nevertheless, in-hospital and 1-year total mortality is high, with a marked deterioration after 85 years of age, when it doubles. Considering population demographics, specific studies in this very elderly population are needed to improve treatment and outcomes.

Clinical and angiographic predictors in primary percutaneous intervention

Percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction with ST segment elevation (STEMI) is the standard treatment according to the current European Society of Cardiology Guidelines. Certain aspects of therapy remain under debate, as periodic changes in the guidelines are enabled by new and thorough research. Objectives – We aimed to evaluate clinical and angiographic prognostic factors in patients presenting with acute STEMI treated with primary PCI. Methods – Demographical, clinical and procedural parameters were retrospectively analysed for 303 consecutive STEMI patients successfully treated with primary PCI. Short-term and long-term outcomes were evaluated. Results – Mean follow-up period was 18 ± 12 months. The studied endpoints were mortality, major adverse cardiac events (MACEs) and left ventricular ejection fraction (LVEF). At admission TIMI fl ow 0 or 1 was found in 233 (76.9%) of patients and was associated with increased mortality and MACE. Of the studied population, 232 (76.6%) patients had MBG 0 and 52 (17.2%) of patients had MBG 1. In these subgroups of patients mortality was higher than in those with MBG of 2 or 3 (p < 0.05). An increase in TIMI fl ow and MBG score of at least 2 points after successful reperfusion was correlated with decreased mortality and improvement in the LVEF (p < 0.05). 46 (15.2%) of patients presented with atrial fibrillation while 277 (91.4 %) of patients presented with hypertension at admission. These clinical characteristics were associated with negative survival in STEMI patients (p < 0.05). Conclusion – TIMI fl ow grade and MBG were strong predictors for mortality and cardiovascular events in STEMI patients undergoing primary coronary artery angioplasty. Atrial fibrillation and presence of hypertension predict survival in STEMI patients treated with primary PCI.

Adverse Events in Primary Percutaneous Coronary Angioplasty With Drug-Eluting Stents Compared With Drug-Coated Balloons: A Retrospective Outlook.

ObjectiveTo compare drug-eluting stents (DES) with drug-coated balloons (DCBs) in terms of major adverse cardiovascular and cerebrovascular events (MACCE) in patients who have undergone primary percutaneous coronary intervention (PPCI).MethodologyOut of 210 angioplasties in six months, 80 patients were included; 40 in DES and 40 in DCB, respectively. All had a successful PPCI. It was defined as the achievement of thrombolysis in myocardial infarction (TIMI) grade II/III with <20% residual stenosis for the DES and TIMI grade II/III with <30% residual stenosis for the DCB. Any subsequent MACCE during the ensuing six months were assessed from emergency/outpatient records during their subsequent hospital visits, hospital registry, and telephonic interviews.ResultsThe mean age in the DES group was 54.83 + 8.72 years while it was 56.8 + 8.9 years in the DCB group. The left anterior descending artery (LAD) was the culprit artery in the majority of the cases in both groups. The mean diameter of DES and DCB was 3.17 + 0.38 mm and 2.75 + 0.53 mm, respectively. Overall, 15 adverse events were seen in the DES group and 16 in the DCB group. The difference was insignificant (P-value = ≥ 0.999). There were nine hospitalizations due to chest pain in the DES group and eight in the DCB group. Total vessel revascularization (TVR) was seen in two patients in the DES group and three patients in the DCB group. None of the patients suffered a stroke. All variables of MACCE were non-significant (P-value = ≥ 0.999).ConclusionDCB appears to be non-inferior to DES in PPCI at a median follow-up of six months.

The comparison of revalcularization outcomes in acute coronary syndrom following primary coronary angioplasty

Purpose. To compare clinical and morphofunctional outcomes of revascularization in patients after primary coronary angioplasty with different degree of coronary arteries damage and type of myocardial infarction.&#x0D; Material and methods. The research involved 258 patients after myocardial infarction who underwent coronary balloon angioplasty with stenting infarct-related artery. By electrocardiographic and angiographic picture all patients were divided into 4 groups: Q-wave myocardial infarction and without Q-wave myocardial infarction with single-vessel and multivessel disease.&#x0D; Results. The study found that the patients with non Q-wave myocardial infarction and single-vessel disease had no adverse clinical outcomes during a year. The wall motion index and the ejection fraction almost recovered completely (wall motion index varied from 1.18 0.02 to 1.05 0.02 and ejection fraction from 57.4 0.5% to 63.3 0.6%; р 0.001). All the patients with Q-wave myocardial infarction revealed similar clinical outcomes and morphofunctional characteristics. The group of patients with non Q-wave and multivessel disease had the highest rate of adverse clinical outcomes with progressing left-ventricular disfunction according to echocardiography (wall motion index varied from 1.15 0.01 to 1.19 0.04 and ejection fraction from 53.9 0.5% to 55.1 0.6%; р 0.001).&#x0D; Conclusion. The degree of coronary arteries damage in the patients with Q myocardial infarction did not influence postinfarction remodeling and long-term cardiac outcomes. The patients with non-Q myocardial infarction and single-vessel disease had fewer signs of postinfarction remodeling and complications in postinfarction period. The worst prognosis was revealed by patients with similar forms of myocardial infarction and multivessel disease.

Lo sviluppo di una partnership tra Aziende Sanitarie: l’integrazione dei laboratori di Emodinamica tra l’Azienda Ospedaliera Universitaria San Luigi Gonzaga di Orbassano e l’Azienda Sanitaria Locale Torino 3

The healthcare sector is among the most complex ones where partnerships and interdependencies between different hospitals can achieve real technical and managerial operational models aimed at optimizing resources. However, the construction of this type of interdependence is not simple to implement, making it necessary to integrate at different organizational and professional levels. The aim of this work is to present the integration process and results achieved during the first 3 years of experience after a synergic integration of the interventional cath lab units of the San Luigi Gonzaga University Hospital, Orbassano and the Infermi Hospital Local Health Unit TO 3, Rivoli. Starting from March 2016, data concerning number and type of procedures as well as the distribution of workloads of each operator in the two cath labs were recorded and monitored. Moreover, numbers of urgent procedures performed as well as the door-to-balloon time in case of primary angioplasty were recorded. Compared to the first 12 months of non-integrated activity, the number of procedures remained constant with an overall trend of activity increase (total procedures: +2.6% from 2016 to 2017; +8.7% from 2017 to 2018). No statistically significant differences were found in the average door-to-balloon time, either by stratifying by period (year 2015 vs 2016 vs 2017 vs 2017 vs 2018) or by single institution. All ST-elevation myocardial infarctions were treated at the arrival site, displacing the medical availability team. The mortality rate and the number of complications were not different compared to the trend recorded in previous years. The implementation of joint programs with an exchange of expertise between operators has allowed the rapid development of skills necessary for the execution of structural heart procedures not previously performed in one of the operating centers. The model of an integrated cath lab unit represents an example of a partnership between two hospitals, which allows a synergistic growth of professional skills, even facing daily logistical challenges. The integration has made it possible to expand the number and type of procedures performed as well to join the on-call equipe without impacting on the door-to-balloon time in case of primary coronary angioplasty.

CRT-100.54 Impact of Early Complete Myocardial Revascularization on Remote Global Mortality in Acute Myocardial Infarction

The approach of patients with acute myocardial infarction with SST maintains controversy especially in the treatment of patients who present with multiple vessel involvement. To evaluate the clinical and procedural characteristics of primary coronary angioplasty in the global population and

The impact of oral nicorandil pre-treatment on ST resolution and clinical outcome of patients with acute ST-segment elevation myocardial infarction undergoing primary coronary angioplasty: A randomized placebo controlled trial.

Introduction: Literature has shown the effects of intravenous/intracoronary nicorandil on increased myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) treated with mechanical reperfusion. However, the possible cardioprotective effect of oral nicorandil on the clinical outcome prior to primary coronary angioplasty is not well documented. Our aim was to assess the effect of oral nicorandil on primary percutaneous coronary intervention (PPCI). Methods: A total of 240 patients with acute STEMI undergoing PPCI were randomly assigned to oral nicorandil (Intervention, n=116) and placebo (Control, n=124) groups. The intervention group received 20 mg oral nicorandil at the emergency department and another 20 mg oral nicorandil in the catheterization laboratory just before the procedure. The control group received matched placebo. Our primary outcome was ST-segment resolution ≥50% one hour after primary angioplasty. Secondary outcome was in-hospital major adverse cardiovascular events (MACE), defined as a composite of death, ventricular arrhythmia, heart failure and stroke. Results: In the patients of intervention and control groups, the occurrence of ST-segment resolution ≥ 50% were 68.1% and 62.9% respectively, (P =0.27). In-hospital MACE occurred less frequently in the intervention group, compared to placebo group (11.2% vs. 22.5%, P =0.012). Conclusion: Although the administration of oral nicorandil before primary coronary angioplasty did not improve ST-segment resolution in patients with acute STEMI, its promoting effects was remarkable on in-hospital clinical outcomes. Clinical Registration: IRCT20140512017666N1

Our first encounter with a COVID-19 patient in cardiology ward: Lessons learned

COVID-19 is an ongoing global pandemic caused by a betacoronavirus named SARS-CoV-2. Within few months after the first index case is identified in Wuhan city of China, it attained a global pandemic status due to its unique epidemiology and pathophysiology. It typically presents with signs and symptoms of viral pneumonia. Patients with cardiac disease are at increased risk of COVID disease and create a diagnostic dilemma in differentiating from respiratory illnesses for the cardiologists. Furthermore, ST-segment changes in electrocardiogram and troponin elevation which form a key diagnostic point in the diagnosis of acute coronary syndromes are frequently seen in COVID-19 patients. This is a matter of utmost concern as the diagnostic dilemma caused may lead to many patients who may not have epicardial coronary artery disease that may be taken up for invasive angiography. Moreover, the prejudice caused by the COVID-19 is leading to fewer admissions for acute coronary syndromes and fewer primary percutaneous transluminal coronary angioplasty leading to inappropriate management of deserving patients with genuine acute coronary syndromes. These patients form a very important chunk of population as on the one hand, they are more likely to spread the infection if they are improperly triaged, and on the other hand, they are less likely to receive proper guideline-directed treatment of cardiovascular syndromes increasing the mortality from primary cardiac pathology. The following case highlights the above-mentioned issues faced in triaging and treating a patient who presented a diagnostic dilemma. Our patient a 53-year-old lady who is a known case of chronic coronary syndrome with effort-induced angina on exertion for the last 4 months on medical management presented to the emergency department, after being rejected admission by three hospitals, with features of chest pain at rest 5 days prior to admission associated with dyspnea and nonproductive cough along with elevated troponin and ST elevation. She was initially diagnosed as acute coronary syndrome with acute heart failure and was taken up to the cardiology ward where a proper clinical examination suggesting right middle lobe localized crackles and chest X-ray findings prompted the suspicion of COVID-19, testing for which by a viral RNA-based test came as positive. This case illustrated the unique challenge posed by the COVID-19 for the cardiologist and the importance of clinical examination and a high index of suspicion needed along with prompt isolation of any suspected case. She was shifted to the COVID ward from where she was discharged after 5 weeks.

Study of primary angioplasty in hospital not having onsite cardiac catheterization facility

Objectives: The aim of this study is to evaluate the appropriateness of use and quality as well as outcomes of primary angioplasty for acute myocardial infarction (MI) in a single center without percutaneous coronary intervention (PCI) capability. Background: Primary percutaneous transluminal coronary angioplasty (PTCA) increases the rates of patency of the infarcted artery, improves survival rates, and reduces the rates of reinfarction and strokes as compared to thrombolysis. Methods: This is a hospital-based prospective study involving 77 patients. Primary PTCA was done by emergency transfer to PCI center at earliest. Results: Male patients outnumbered females (77% vs. 22%). Patients in the age group of 45–69 years constituted around 70.0% of the total ST-elevation MI patients. Majority of the patients (90%) presented with chest pain. During coronary angiography, it was found that the major culprit coronary was the right coronary (42.85%) followed by the left anterior descending artery (36.36%). A majority of the patients in the study group were found to have single-vessel disease (57.14%), and only five of the patients had triple-vessel disease (06.49%). Glycoprotein IIb/IIIa inhibitors were given to 41 patients (53.24%) as an adjuvant therapy. Conclusion: Primary angioplasty is very appropriate and feasible with a good outcome for the management of patients with acute ST-elevation MI even in a center where the facility of cardiac catheterization is not available. Our patients with acute ST-elevation myocardial infarction who were shifted to a center having cardiac catheterization laboratory and subsequently managed with primary angioplasty showed good response and outcome in terms of mortality and morbidity over a follow-up of 1 year.

Contrast-induced encephalopathy after primary percutaneous coronary angioplasty mimicking a subarachnoid hemorrhage

Contrast-induced encephalopathy (CIE) is a rare temporary phenomenon after intravenous injection of contrast media. The prognosis is generally good. Neurological symptoms develop within hours and resolve spontaneously over days. Global syndromes such as confusion can also be seen with cortical and subcortical deficits. There is a good correlation between the volume of contrast extravasation and clinical picture. In addition, this extravasation can be confused with intracranial hemorrhage in the early stage with imaging. In this case, we presented a 62-year-old male patient who developed CIE after coronary angioplasty mimicking subarachnoid hemorrhage and spontaneously recovered on the 2nd day of the event.

1928P - Antecedent of cancer and mortality after the first ST segment elevation acute myocardial infarction treated with primary coronary angioplasty. A prospective cohort study

BackgroundST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both are highly incident and prevalent. We sought to investigate if a previous diagnosis of cancer influences the outcome of patients with STEMI treated with primary coronary angioplasty. MethodsWe included 917 patients in a prospective cohort observational study, 53 of them (5.8%) cancer survivors. The primary end-point was total mortality. ResultsOut of the 53 patients with history of cancer, all which have been included in the analysis, 12 (23.0%) were treated with chemotherapy, 38 (72.0%) with radiotherapy and 12 (23.0%) had surgical treatment. Cancer locations were: breast cancer in 10 patients (18.9%), gastrointestinal tract in 11 (20.8%), prostate in 10 (18.9%), urologic in 7 (13.2%), hematologic malignancies in 5 (9.4%), respiratory tract in 5 (9.4%) and other locations in 3 (5.7%). One hundred patients died during a median follow-up of 643 days (interquartile range 258 to 1015 days), 88 (10.2%) in patients without cancer and 12 (22.6%) in patients with cancer, being this difference significant (log-rank test=8.4, p=0.004). Cancer patients were older: 73.4 (11.5) vs 65.2 (13.8) years (p<0.001), with a lower prevalence of previous stroke: 1.1% vs 2.2%, p=0.002. The hemoglobin concentration was also lower: 13.4 (2.1) vs 14.4 (1.7) g/L, p=0.001. No significant differences were found in the data gleaned from the primary angioplasty, although a trend towards a lower use of coronary stents in cancer survivors was noted (p=0.061). Cancer was associated with a high probability of death, HR=2.37 (95% confidence interval 1.30 to 4.34), p=0.005. When confounding variables were included in a multivariate Cox regression model, this association was no longer significant: HR=1.63 (0.84-3.18), p=0.150. ConclusionsWe failed to demonstrate a survival advantage of patients with ST-segment myocardial infarction treated with primary coronary angioplasty when patients did not have a previous cancer. The finding of a difference in crude mortality rate can be explained by the baseline differences between both groups. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

P6220The non-invasive coronary flow reserve predicts exercise capacity in patients undergoing cardiac rehabilitation

Abstract Background The benefit of exercise on peripheral muscles is established but the exact role of the coronary microcirculation in exercise capacity after cardiac rehabilitation (CR) is unclear. Objective: Our aim was to test the relationship between non-invasive coronary flow reserve (CFR) and exercise capacity in patients undergoing CR after acute myocardial infarction (AMI). Methods CFR was performed by transthoracic Doppler echocardiography in the left anterior descending artery 24 h after angioplasty (CFR1) and after 20 sessions of CR program (at 4±1 months) (CFR2) in 60 consecutive patients (57±11 years, 30% women) with an anterior AMI successfully treated by primary coronary angioplasty. CFR was performed in a modified parasternal view using intravenous adenosine infusion (0.14 mg/kg/min within 2 minutes). CR program consisted of a half hour of fractioned exercise added of a half hour session of general gymnastics and body building. To test the exercise capacity, symptom limited exercise echocardiography was performed just after the CFR2, in a semi-supine position, starting at 25 watts, with 20–25 watts increments of workload every two minutes. Results CFR was measured successfully in all patients, and CFR2 was significantly higher than CFR1 (2.9±0.65 vs 1.9±0.4, p&lt;0.001). Though CFR1 was correlated to left ventricular systolic function and its improvement at follow-up (all, p&lt;0.01), CFR2 was independently related to exercise capacity (mean workload 100±30 watts, percent maximal heart rate 83±12%, no ischemia, no new wall motion abnormalities in all tests) after adjusting for age, sex, and body mass index (r=0.6, p&lt;0.01). Conclusion CFR predicts exercise capacity in patients undergoing a CR program after AMI. The improvement of CFR contributes to cardiac performance.

Leczenie wstrząsu kardiogennego wikłającego zawał serca — nadal więcej pytań niż jednoznacznych odpowiedzi

Cardiogenic shock is usually caused by a severe myocardium injury resulting in stroke volume and cardiac output decrease. As a consequence, hypotension and coronary and peripherial hypoperfusion may occur. The mortality in patients with cardiogenic shock is high, and exceeds 40%. Despite the advances in intervention cardiology in the last 20 years, no significant mortality reduction has been observed. Although urgent coronary revascularisation is considered to play a pivotal role in survival improvement in patients with cardiogenic shock, there is no consuensus in terms of revascularisation strategy, including primary coronary angioplasty ( i.e. complete revascularisation vs. revascularisation limited to the infarct-related artery). Current guidelines do not recommend routine use of an intra-aortic balloon pump in patients with CS. However, such a simple and widely available therapy may improve the survival rate in some groups of patients. This is particularly important because there is as yet no evidence for survival improvement in patients with CS treated with more advanced methods of percutaneous mechanical circulatory support, not to mention the limited availability of these methods in everyday clinical practice.

Determining Patient Characteristics Leading to Worse Outcomes with Long Term Milrinone Therapy

Background Milrinone is an inotrope used in patients with end-stage heart failure awaiting mechanical support, heart transplant or as palliative therapy. Numerous studies have evaluated adverse events and mortality associated with milrinone use, which have shown to be associated with higher mortality rates and arrhythmias. Despite the homogeneous prevalence of these adverse effects, the association of their development with the duration of treatment remains debatable. Additionally, emerging smaller studies have described relative safety of long term milrinone use. In light of such discrepancy, no specific factors have been identified to account for the difference in onset and prevalence of milrinone associated deleterious effects. We sought to determine underlying patient characteristics that would influence worse outcomes with milrinone Methods We conducted a single-center retrospective study reviewing all patients on outpatient milrinone therapy at St. Francis Hospital with a mean follow up of 36 months. Results In total, 10 patients were identified of which 4 patients were deceased. These 4 patients were on milrinone for a mean of 11.5 months. The attributes of the survivors compared to deceased showed: age at start of therapy 67.5 vs 79; female gender 66% vs 33%; non-ischemic cardiomyopathy 33% vs 50%; atrial fibrillation/flutter 50% vs 25%; hyperlipidemia 66% vs 50%; anemia 83% vs 75%; presence of CRT 66% vs 25% and ICD 16% vs 0%; sodium 136 vs 140mEq; chloride 101.5 vs 104.5mEq; potassium 4.07 vs 4.23mEq; and creatinine 1.3 vs 1.8 mg/dL. Conversely, deceased patients were more likely to have diabetes (50% vs 16%), hypertension (100% vs 83%), chronic kidney disease (75% vs 66%), peripheral vascular disease (25% vs 0%), coronary artery disease (75% vs 33%), higher pulmonary artery pressures (54 vs 50.5mmHg) and history of coronary intervention with primary coronary angioplasty or coronary bypass surgery (50% vs 16%). Conclusion Males were more likely to have died if they were placed on milrinone at a later age. Ischemic risk factors appear to be more deleterious. These trends exhibit potential patient characteristics that may predict worse outcomes on long term milrinone. Larger studies are needed to assess statistical significance of these findings.

Dlaczego bardziej chorzy rezygnują z szansy na wyzdrowienie? Paradoks podejmowania decyzji o udziale w rehabilitacji kardiologicznej

Introduction. Coronary heart disease is the leading cause of death in industrialised countries. Cardiac rehabilitation allows improvement of functioning after acute coronary syndrome (ACS). It is important to identify the factors that have an impact upon treatment and rehabilitation decisions. We aimed to assess the impact of the clinical characteristics of ACS pts upon the decision to participate in an early inpatient cardiac rehabilitation programme (ICR). Material and methods. 137 patients after ACS (70% ST-elevation myocardial infarction) treated with primary percutaneous coronary angioplasty were enrolled in the study. Quality of life questionnaire (EuroQol-5D with Visual Analogue Scale) and depression score (Beck Depression Inventory) was collected at discharge from cardiology department (5 ± 2 days after ACS). All patients were asked to participate in a three-week-long ICR programme. Depending on approval or refusal, the patients were divided into two subgroups. Results. The group without ICR had lower median values of red blood count, haemoglobin and haematocrit compared to the rehabilitation group. The objectors had higher total cholesterol, low-density lipoproteins cholesterol, and Gensini score (40 ± 22.6 vs. 35 ± 24.3, p = 0.02). There was a strong trend towards a lower median depression level in the ICR group compared to controls (8 ± 8.8 vs. 12 ± 8.5, p = 0.06). No other statistically significant differences were identified between the groups. Conclusions. Patients who refuse cardiac rehabilitation had a worse clinical profile compared to those who accepted ICR. A higher depression score was a borderline significant predictor of refusing ICR. Paradoxically, sicker patients are less willing to take part in rehabilitation and require more encouragement as part of their individualised treatment.

Climate changes and ST-elevation myocardial infarction treated with primary percutaneous coronary angioplasty

BackgroundThe impact of seasonal changes on the incidence of acute myocardial infarction has been incompletely appraised, especially in the modern era of primary percutaneous coronary intervention (PPCI). We aimed to appraise the overall and season-specific impact of climate changes on the daily rate of PCCI. MethodsDetails on PPCI and climate changes were retrospectively collected in three high-volume Italian institutions with different geographical features. The association between rate of PPCI and temperature, atmospheric pressure (ATM), humidity and rainfall was appraised with Poisson models, with overall analyses and according to season of the year. ResultsDetails on 6880 days with a total of 4132 PPCI were collected. Overall adjusted analysis showed that higher minimum atmospheric pressure 3 days before PPCI were associated with lower risk (regression coefficient = 0.999 [95% confidence interval 0.998–1.000], p = 0.030). Focusing on season, in Winter PPCI rates were increased by lower same day mean temperature (0.973 [0.956–0.990], p = 0.002) and lower rainfall (0.980 [0.960–1.000], p = 0.049). Conversely, in Spring greater changes in atmospheric pressure 3 days before PPCI were associated with increased risk (1.023 [1.002–1.045], p = 0.032), with similar effects in Summer for minimum temperature on the same day (1.022 [1.001–1.044], p = 0.040). ConclusionsClimate has a significant impact on the risk of PPCI in the current era, with a complex interplay according to season. Higher risk risk is expected with lower minimum atmospheric pressure in the preceding days, lower rainfall in Winter, greater changes in atmospheric pressure in Spring, and higher temperatures in Summer. These findings have important implications for prevention strategies.

Prehospital ECG transmission results in shorter door-to-wire time for STEMI patients in a remote mountainous region

BackgroundPre-hospital triage with ECG-transmission may reduce time to reperfusion in patients with ST-elevation acute myocardial infarction (STEMI). Less, however, is known on potential benefit of ECG-transmission triage in mountain areas, with complex orography. MethodsPatients admitted for STEMI and primary coronary angioplasty (pPCI) in a mountain area served by a single cathlab and triaged with ECG-transmission were enrolled in the study and compared with controls: patients' demographics and time to coronary wire were recorded. ResultsForty-seven consecutive patients were enrolled in the study: 23 patients following ECG transmission and 24 STEMI patients who presented directly to the Emergency Department. At multivariable regression analysis, pre-hospital ECG-transmission electrocardiogram was an independent predictor of shorter time-to-wire (beta −0.34, p < 0.05). In case of transport times >30 min, ECG-transmission triage achieved time-to-wire times 20% shorter. Excluding unreducible transport time, avoidable delay was reduced by 38% in the whole population, by 48% in case of peripheral areas (transport time > 30 min from cathlab) and elderly (>80 years) patients (p < 0.05 in all cases). ConclusionsPre-hospital triage with ECG-transmission is associated with shorter ischemic time even in mountain areas with a complex orography profile. The benefit is greater in elderly patients and remote areas.