Time Of First Medical Contact Research Articles

Recognition and diagnosis of acute type A aortic dissection in a large Belgian referral center – can we do better?

Background: Acute type A aortic dissection (ATAAD) has a poor prognosis unless promptly diagnosed and surgically treated. As ATAAD is relatively rare and clinical presentation may mimic other pathologies, diagnosis can be challenging. Objectives: The aim of this study is to evaluate the difficulties in diagnosing ATAAD. Methods: A monocentric, retrospective analysis was conducted of all patients undergoing surgical repair for acute type A aortic dissection in our hospital (a large Belgian referral center) between the 1st of January 2016 and the 31st of December 2020. Data were collected regarding patient’s demographics i.e. age and gender, time of first medical contact, referral from other hospitals, presenting symptoms, initial diagnosis, inappropriate antiplatelet or antithrombotic therapy, time to the correct diagnosis, time to initiate surgical repair, and one- year mortality. Results: Thirty-three patients were included. We found that a correct initial diagnosis was only made in twelve percent of patients with ATAAD. In twenty-one percent of patients, misdiagnoses led to inappropriate administration of antiplatelet or antithrombotic drugs pre-operatively. There was a difference in time from first medical contact to initiation of surgical repair between referred and non-referred patients. This time interval tended to be shorter in the latter group. Conclusions: The main finding of this analysis is the delayed diagnosis of ATAAD in the majority of patients. This trend is slightly higher in patients referred from other hospitals. To improve outcome in ATAAD, efforts should be made to increase awareness for the presenting symptoms, and appropriate diagnostic imaging should be performed in a timely manner.

Patient delay in patients with st-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Snedkermester Sophus Jacobsen og hustru Astrid Jacobsens fond Background/Introduction Rapid revascularisation therapy (primary percutaneous intervention (PCI)) is widely established as the most important factor in preventing myocardial damage after ST-Elevation Myocardial Infarction (STEMI)(1,2). Current ESC (European Society of Cardiology) guidelines recommends fast revascularisation therapy within 120 minutes of symptom onset(3). Despite this, previous studies have shown patient delay times above 120 minutes in more than 50% of patients(2,4). Reducing patient delay is therefore an important factor in the endeavour of decreasing myocardial damage and for prediction of outcome following STEMI. However, most knowledge on this field originates from registry-based studies(4). Previous studies conducted in Denmark, rely on data from danish quality databases containing data such as delay times, cardiac risk factors and procedure specific information. The few studies on this field using patient reported data, have focused on subpopulations or sex differences(5). Purpose The purpose of this study was to investigate the patient reported delay in STEMI patients and to compare the registered delay times to the physician reported delay in databases. Methods This single center study includes interviews of 129 patients hospitalized for STEMI between April and October 2021. The patients participated in semi-structured patient interviews conducted within 30 days of hospitalization. The main focus of the interviews was time of symptom onset and time of first medical contact, but other factors such as symptom presentation and perception, lifestyle choices and care seeking behaviour were also investigated. The patient reported delay times were then compared with the delay time registered in danish quality databases, using descriptive analysis and double-sided T-test. Results 148 patients were included to the study. Upon contact, 19 were lost to follow up. 16 patients had missing delay times in the database. The final study cohort consisted of 113 patients (93 men and 20 women) aged 30-94 years (mean: 62,7 years). We observed that on average patient reported delay times were 5 hours longer than the physician reported delay times in the databases, P=0.0080. The disagreement in delay times ranged from -25 hours to 159 hours. Conclusions We found a substantially longer delay time when comparing patient reported delay times with physician reported delay times. This is of high clinical importance in relation to proper prediction of outcomes, and to ensure the aiming of future information campaigns to populations most at need. As quality measures in this field relies on database registrations, it is imperative to address this discrepancy in order to improve patient delay times.

Cardiac Fibrosis Is a Risk Factor for Severe COVID-19.

Increased left ventricular fibrosis has been reported in patients hospitalized with coronavirus disease 2019 (COVID-19). It is unclear whether this fibrosis is a consequence of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection or a risk factor for severe disease progression. We observed increased fibrosis in the left ventricular myocardium of deceased COVID-19 patients, compared with matched controls. We also detected increased mRNA levels of soluble interleukin-1 receptor-like 1 (sIL1-RL1) and transforming growth factor β1 (TGF-β1) in the left ventricular myocardium of deceased COVID-19 patients. Biochemical analysis of blood sampled from patients admitted to the emergency department (ED) with COVID-19 revealed highly elevated levels of TGF-β1 mRNA in these patients compared to controls. Left ventricular strain measured by echocardiography as a marker of pre-existing cardiac fibrosis correlated strongly with blood TGF-β1 mRNA levels and predicted disease severity in COVID-19 patients. In the left ventricular myocardium and lungs of COVID-19 patients, we found increased neuropilin-1 (NRP-1) RNA levels, which correlated strongly with the prevalence of pulmonary SARS-CoV-2 nucleocapsid. Cardiac and pulmonary fibrosis may therefore predispose these patients to increased cellular viral entry in the lung, which may explain the worse clinical outcome observed in our cohort. Our study demonstrates that patients at risk of clinical deterioration can be identified early by echocardiographic strain analysis and quantification of blood TGF-β1 mRNA performed at the time of first medical contact.

Outcomes of Radial Versus Femoral Approach in Patients with St Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Abstract Aim of the work To compare transradial and transfemoral approaches in 1ry and rescue PCI for STEMI. Methods This prospective observational study was done at Alexandria University Hospital and International Cardiac Center from January 2020 to August 2020 by recruiting every patient had met our inclusion criteria (the third universal definition of MI) admitted to the coronary care unit after doing primary or rescue PCI 200 patients were involved. Exclusion criteria were (Thrombophilia and thrombocytopenia, known hematological abnormalities, and patients with known sever peripheral vascular disease. Randomization made by a computer-generated program into two equal parallel groups that were randomly assigned to either Radial access approach or femoral access approach for primary or rescue PCI. Chest pain to time of first medical contact (FMC), and the procedural time were computed. Coronary angiography and PCI procedure were described including materials used and the intra-procedure complications. MACE (Major Adverse Cardiac Events) or other hemodynamic complications were documented. All the patients were contacted for follow up to 6 months after the procedure by interviewing with the patients via telephone or the responsible physician to determine the outcomes procedure. Results The distribution of demographic variables and risk factors were similar among 200 patients in the radial and femoral groups. There had been significant differences between the groups concerning the primary end point MACE after 6 months in favor of radial group patients with p value (0.004), there was significant deference between the two studied groups concerning the total bleeding complication with higher risk in femoral group 11% compared to radial group 3% with P value (0.02). Despite the nearly equal mean time from pain to FMC (9.01 hours in radial group and 9.2 hours in femoral group), the total procedural time was significantly longer in radial group compared to femoral group with (p value 0.037). However the rate of non-culprit vessel revascularsation was significantly higher in radial group 17% compared to 6% in femoral group with p value of (0.015). In-hospital stay was significantly shorter in the radial group patients P value (0.02). Conclusion Transradial approach is safe, and effective with a high procedural success rate as the transfemoral approach but with lower risk for bleeding vascular complications and other access site complications as hematoma especially for patients where aggressive antiplatelet and anticoagulation therapy is needed, or patients who are expected to suffer from access site complications as those who need rescue PCI. Transradial approach has major additional advantages of decreasing the incidence of MACE compared to transfemoral approach. Transradial approach has another advantages of decreasing the in hospital stay.

Impact of the COVID-19 pandemic on ST - elevation myocardial infarction management in a reference center of northern Peru

To evaluate the impact of the COVID-19 pandemic on the ST-Elevation myocardial infarction (STEMI) management in a reference center of northern Peru. Observational, analytical, retrospective cohort-type study, derivated from the Acute Coronary Syndrome registry of the Almanzor Aguinaga Asenjo National Hospital. The characteristics of the patients with STEMI and their 30-day outcomes were compared in 02 cohorts according to the time of medical care: prior to the pandemic or during the pandemic. During the COVID-19 pandemic, hospitalizations for STEMI decreased by 53%, there was a greater use of fibrinolysis to the detriment of primary angioplasty, with increases in the time of first medical contact (100 vs. 240 minutes, p = 0.006) and ischemic time to percutaneous coronary intervention (900 vs. 2880 minutes, p <0.001). This generated a higher frequency of post-infarction heart failure (21.1% vs. 46.7%, p = 0.002) and a lower left ventricular ejection fraction at discharge (49.2 +/- 8.6 vs 44.8 +/- 9.3, p = 0.009), without an increase in in-hospital cardiovascular mortality. The COVID-19 has had a negative impact on the treatment of patients with STEMI. We found less hospitalizations, prolonged reperfusion times, and higher frequency of post-infarction heart failure and lower left ventricular ejection fraction at discharge.

Rationale and design of the OPTIMAL-REPERFUSION trial: A prospective randomized multi-center clinical trial comparing different fibrinolysis-transfer percutaneous coronary intervention strategies in acute ST-segment elevation myocardial infarction.

Primary percutaneous coronary intervention (PPCI), the preferred reperfusion strategy for all acute ST‐segment elevation myocardial infarction (STEMI) patients, is not universally available in clinical practice. Pharmacoinvasive strategy has been proposed as a therapeutic option in patients with STEMI when timely PPCI is not feasible. However, pharmacoinvasive strategy has potential delay between clinical patency and complete myocardial perfusion. The optimal reperfusion strategy for STEMI patients with anticipated PPCI delay according to current practice is uncertain. OPTIMAL‐REPERFUSION is an investigator‐initiated, prospective, multicenter, randomized, open‐label, superiority trial with blinded evaluation of outcomes. A total of 632 STEMI patients presenting within 6 hours after symptom onset and with an expected time of first medical contact to percutaneous coronary intervention (PCI) ≥120 minute will be randomized to a reduced‐dose facilitated PCI strategy (reduced‐dose fibrinolysis combined with simultaneous transfer for immediate invasive therapy with a time interval between fibrinolysis to PCI < 3 hours) or to standard pharmacoinvasive treatment. The primary endpoint is the composite of death, reinfarction, refractory ischemia, congestive heart failure, or cardiogenic shock at 30‐days. Enrollment of the first patient is planned in March 2021. The recruitment is anticipated to last for 12 to 18 months and to complete in September 2023 with 1 year follow‐up. The OPTIMAL‐REPERFUSION trial will help determine whether reduced‐dose facilitated PCI strategy improves clinical outcomes in patients with STEMI and anticipated PPCI delay. This study is registered with the ClinicalTrials.gov (NCT04752345).

Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry.

The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region. Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; P<0.0001). Differences were greatest for transfers under 50 km (13.7% vs. 44.7%; P<0.0001) and for primary transfers (22.4% vs. 49.6%; P<0.0001). The median time from first medical contact to primary percutaneous coronary intervention and from symptom onset to primary percutaneous coronary intervention (total ischaemic time) were significantly higher in the helicopter transport group than in the ground transport group (respectively, 137 vs. 103 minutes; P<0.0001 and 261 vs. 195 minutes; P<0.0001). There was no significant difference in inhospital mortality between the helicopter and ground transport groups (6.9% vs. 6.6%; P=0.88). Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.

Stent-Save a Life! Argentina Initiative

Introduction: The Stent-Save a Life! (SSL) initiative is a European program that seeks to improve the access of patients withST-segment elevation acute myocardial infarction (STEMI) to reperfusion therapies based on clinical guideline recommendations,thus reducing morbidity and mortality.Objective: The aim of this study was to describe the results of the first three years of the SSL Argentina initiativeMethods: Initially, a mapping was carried out to analyze the local situation and then the Door-to- Balloon Program (DBP) wasdeveloped as a continuous improvement process for centers with primary percutaneous coronary intervention (pPCI) capability.Results: From March 2016 to March 2018, 3,041 patients with STEMI were treated in 38 centers participating in this program.In 20% of cases (n=610) patients had their first medical contact with the emergency medical services. After excluding 184 patients(6%) without coronary lesions, reperfusion therapy was performed in 93% of cases, mainly by pPCI (95%). Total ischemictime was 117 minutes, with differences according to the time of first medical contact. Overall in-hospital mortality was 7%.Conclusions: The lack of a “reperfusion culture” was the common barrier of public and private centers that motivated thedevelopment of the DBP. The identification of critical points that prevent treatment on time, together with enhancement ofin-hospital organization, represent the first step to improve the care of these patients. The integrated work of all the involvedparties is necessary to develop care networks adapted to the local reality of each center and region.

Circulating levels of selenium-binding protein 1 (SELENBP1) are associated with risk for major adverse cardiac events and death

ObjectiveSelenium-binding protein 1 (SELENBP1) is an intracellular protein with variable expression in response to cellular stress. As the selenium (Se) status is affected by inflammation and hypoxia, we hypothesized that SELENBP1 contributes to disease-specific Se metabolism. To test this hypothesis, a quantitative assay was developed and used to monitor SELENBP1 in patients with acute coronary syndrome (ACS). Materials and methodsSELENBP1 was expressed, antibodies were generated and a luminometric immuno assay (LIA) was established and characterized. Serum samples were collected from controls (n = 37) and patients (n = 85) admitted to the Chest Pain Unit with suspected ACS. Blood samples were available from time of first medical contact in the ambulance, at admission to hospital, and after 2, 4, 6 and 12–36 h. ResultsCirculating SELENBP1 was close to limit of detection in healthy controls and elevated in patients with suspected ACS. SELENBP1 was unrelated to other biomarkers of myocardial damage such as troponin T or aspartate aminotransferase. Serum SELENBP1 enabled a categorization of patients on first medical contact as either high-risk or low-risk for major adverse cardiac events (MACE) or death, when using 0.8 nmol/l as threshold. The odds-ratios (OR) for MACE and death were OR = 11 (95% CI: 2–49, p = 0.0022) and OR = 12 (2–74, p = 0.014), respectively. ConclusionsUntil now, SELENBP1 was mainly considered as an intracellular protein involved in Se metabolism and redox control. Our data indicate that SELENBP1 constitutes a circulating biomarker for cardiac events categorizing patients with suspected ACS at first medical contact into high-risk or low-risk for MACE and death, independent from and complimentary to current biomarkers.

Variable diagnostic accuracy in reading ECGs in a nurse-led primary PCI pathway

Background The Electrocardiogram (ECG) remains as the crucial tool to diagnose acute ST-elevation myocardial infarction (STEMI). Activation of the cardiac catheterization team to perform Primary Percutaneous Coronary Intervention (PPCI) largely depends on the interpretation of the ECG at the time of first medical contact with the patient. In Northern Ireland, if the referrer decides that the ECG shows a STEMI they would then transmit the ECG to a designated Coronary Care Nurse who then decides whether to activate the PPCI pathway or to transfer the patient to the nearest Emergency Department (ED). Objective We sought to ascertain the impact, ECG based decisions have on the PPCI pathway and specifically on clinical outcomes. Methods ECG and clinical data were retrospectively reviewed for consecutive patients referred to the PPCI pathway over an 8-month period as part of a continuous audit. Patients were either accepted or turned down for PPCI by the Nurse. All ECGs were retrospectively adjudicated upon with a final diagnosis made by a senior Coronary Care nurse and Interventional Cardiologist. ECG interpretation was evaluated in the referrer group, the ECG machine, and the nurse activator. Results A total of 344 patients were referred to the PPCI pathway over the 8-month period. 114 (33%) were accepted for PPCI. All accepted patients met diagnostic ECG criteria with 97/114 (85%) having a final diagnosis of STEMI. 230 referrals (67%) were turned down for PPCI, predominantly on the basis of lack of diagnostic criteria. All turndowns were considered appropriate. Paramedics were the main referrers 205/344 (60%) with the remainder from ED. The ECG machine suggested an ischaemic diagnosis in 95/97 (Sensitivity=98%) of patients with STEMI and 103/198 (1-Specificity=52%, Specificity=48%) of the turndown cases (patients with a final diagnosis of ACS/angina were excluded from the turndown group when calculating machine specificity). Of those referred for PPCI, 66% of the ED referrals were turned down. Of those referred by Paramedics for PPCI 67% were turned down. The STEMI group were significantly younger that the turndown group (63 ± 12 vs. 68 ± 17, p Conclusions ECG interpretation by referrers in this nurse-led primary PCI pathway is sub-optimal. The high rate of false positives in ECG machine diagnoses in the turndown group could be an influencing factor in the human-decision making. There is a need to find ways to improve ECG interpretation, particularly in a time critical PPCI pathway.

Contemporary use of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction referred to primary percutaneous coronary interventions in Poland: Data from ORPKI national registry

According to guidelines, it is recommended to give P2Y12 inhibitors (preferably ticagrelor or prasugrel) at the time of first medical contact in patients with STEMI. However, in real life antiplatelet treatment strategies are different among countries. We analyzed data on antiplatelet treatment in STEMI patients included into Polish ORPKI national registry. A total of 23,139 STEMI patients from 153 invasive cardiology centers were reported in ORPKI registry between September 2015 and August 2016. Finally 19,437 patients from 122 centers (immediate PCI in 94%) were included into the analysis (lack of ticagrelor or prasugrel usage reported in 31 centers). The dominant P2Y12 inhibitor was clopidogrel (69%) with a high rate of precathlab administration (51.3%). Ticagrelor was administered in 10.1% of patients (2.3% during precathlab phase) and prasugrel in 1.1% (0.4% precathlab). The periprocedural switch from clopidogrel to newer generation oral P2Y12 inhibitors was rare (to ticagrelor: 2%; to prasugrel: 0.15%). Analysis of data from top 10 centers with the highest rate of newer generation P2Y12 inhibitors usage (1295 patients) revealed ticagrelor administration in 43.1% (prasugrel in 3%). During precathlab phase higher proportion of ticagrelor instead of clopidogrel (ticagrelor 17.9%, clopidogrel 29.8%) and higher rate of periprocedural switch from clopidogrel to ticagrelor (11.9%) was found comparing to all centers data (p < 0.001 for all). The strategy of precathlab administration of P2Y12 inhibitors applies to about half of STEMI patients in Poland. Generally, ticagrelor or prasugrel use is low, and not equally distributed among centers. In centers with high usage, ticagrelor is main newer generation P2Y12 inhibitor for precathlab and periprocedural administration.

Cardiovascular complications in nonreperfused acute ST segment elevation myocardial infarction

BACKGROUND: Cardiovascular diseases are currently the leading cause of death in industrialized countries. Among them, coronary artery disease is the most prevalent manifestation and is associated with high morbidity and mortality worldwide. In Mexico, ischemic heart disease is the leading cause of death in older than 60s and the second cause in the general population. OBJECTIVE: To evaluate cardiovascular complications in patients with acute ST segment elevation myocardial infarction who did not receive acute reperfusion therapy. MATERIAL AND METHOD: Descriptive, cross-sectional, retrospective study in which 35 medical files of patients with acute ST segment elevation myocardial infarction without reperfusion treatment who were admitted to the Hospital Central Militar from january 1st to december 31st in 2013. Cardiovascular complications and their association with clinical variables were quantified, as well as the quantification of time in the care system. RESULTS: The complications were: heart failure 68.2%, arrhythmias 17.1% and death 17.1%. Variables associated with a higher proportion of total cardiovascular complications and heart failure were age ? 65 years, location of extensive anterior infarction, and TIMI risk score ? 7. Variables such as type 2 diabetes, location of extensive anterior infarct, TIMI risk score ? 7, Killip &gt; 2 and arrhythmias were associated with a higher proportion of deaths. Patients who underwent late angioplasty with adequate indication had a lower proportion of deaths. The patient-first medical contact time had a median of 8 hours, the first medical-diagnostic contact time had a median of 11.5 hours and the diagnostic-admission time to the hospital had a median of 3 hours. CONCLUSIONS: All patients admitted for acute myocardial infarction with ST segment elevation without reperfusion therapy had at least one cardiovascular risk factor and a characteristic symptom of acute coronary syndrome at the time of first medical contact.

Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital.

BackgroundsST-elevation myocardial infarction (STEMI) guidelines recommend reperfusion by primary percutaneous coronary intervention (PCI) ≤ 90 min from time of first medical contact (FMC). This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service (EMS) STEMI field triage protocol.MethodsSixty STEMI patients directly transported by EMS from three rural counties (Nassau, Camden and Charlton Counties) within a 50-mile radius of University of Florida Health-Jacksonville (UFHJ) from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements: (1) a cooperative agreement between each of the rural emergency medical service (EMS) agency and UFHJ; (2) performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and (3) direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device (FMC2D), door-to-device (D2D), and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio (OR) of achieving FMC2D times was calculated.ResultsFMC2D times were shorter for in-state STEMIs (81 ± 17 vs. 87 ± 19 min), but D2D times were similar (37 ± 18 vs. 39 ± 21 min). FMC2D ≤ 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs (OR = 4.4, 95% CI: 1.24–15.57; P = 0.018). FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D ≤ 120 min.ConclusionsGuideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time ≤ 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.

IPhone ECG monitoring — the gateway to the new paradigm of STEMI therapy

iPhone ECG monitoring — the gateway to the new paradigm of STEMI therapy

Abstract 89: Penn State Hershey: 4-Year Experience in Mild Therapeutic Hypothermia Program---Lessons Learned

Introduction: Mild Therapeutic Hypothermia (MTH) improves neurological outcomes in patients (pts) following sudden cardiac arrest with return of spontaneous circulation (SCA-ROSC). The Penn State Hershey Medical Center assembled a multispecialty team and formalized a MTH program in October 2007. Indications were expanded to include pts presenting with cerebrovascular trauma (CVT) and stroke in addition to SCA-ROSC. Methods: A multidisciplinary team of nurses and physicians (Emergency Medicine, Interventional Cardiology and Neurology) along with EMS (Life Lion) reviewed the scientific literature and created educational programs that were provided to the critical care units in the hospital. An electronic order set was created to standardize protocol. Life Lion provided education to Emergency Medicine programs at regional hospitals. Results: From October 1, 2007-March 29, 2011, 149 pts were enrolled in the MTH program (97 men, mean age 61.4 yr; 52 women, mean age 58.0 yr). 100 pts were enrolled for SCA; 1 pt enrolled following ICD failure; 5 pts enrolled post-CABG (cooling with ECMO); and 43 pts were enrolled following CVT/stroke. SCA-ROSC ranged from 5-45 min. Cardiac rhythm at the time of first medical contact (FMC) was as follows: VFib/VT:58 pts; asystole/PEA:42 pts; NSR:49 pts. Time to cooling (target 33°C) ranged from 2.5 - 10 hours with 3 pts receiving pre-hospital cooling. 64 pts (43%) survived to hospital discharge. 85 pts died (57%). Pittsburgh cerebral-performance category (CPC) level I-II was observed in 54.7% (n=35); CPC Level III-V was observed in 35.9% (n=23). 21 pts were discharged to a rehab facility. Of pts with FMC rhythm VFib/VT (n=56) there were 26 deaths (survival rate 53.6%). Of pts with FMC rhythm Asystole/PEA (n=39) there were 31 deaths (survival rate 20.5%). Conclusion: The MTH program was successfully implemented at our institution in pts presenting with SCA-ROSC and CVT/stroke. Pts with FMC cardiac rhythm of VFib/VT demonstrated better survival and neurological outcomes with MTH as compared to pts with FMC cardiac rhythm of asystole/PEA. Elements that have contributed to the success of our program include: a multidisciplinary approach; nursing leadership with an educational focus; and standardization of medical order sets.

Relationship between therapeutic time intervals and intermediate term left ventricular systolic function in patients treated with facilitated percutaneous coronary intervention for acute myocardial infarction

The concept of initiating fibrinolytic therapy in patients who cannot undergo immediate percutaneous coronary intervention (PCI) in the setting of acute ST-segment-elevation myocardial infarction (STEMI) has been proposed as a strategy to improve outcomes. However, evidence supporting the use of this strategy is not conclusive, and the results of recent randomized controlled trials are apparently contradictory. Probably, the time points of administration of the adjunctive thrombolytics and antiplatelet agents and the time loss until coronary intervention have a major influence on the discrepancy of outcomes in different trials. Therefore, the relationship between therapeutic time intervals and outcome in patients treated with facilitated PCI has been analyzed. In this single center retrospective study, 131 patients with STEMI were treated with a combined pharmaco-mechanical reperfusion strategy using half-dose r-tPA combined with a glycoprotein (GP) IIb/IIIa antagonist prior to PCI. Specific time points were recorded for each patient, including the time of symptom onset, the time of first medical contact, the start of intravenous thrombolysis, the time of administration of the GP IIb/IIIa antagonist and the start of coronary intervention. We then examined the relationship between the time delay from symptom onset to the initiation of various steps of treatment and the residual myocardial damage as expressed by the severity of both global and regional myocardial dysfunction calculated from a left ventriculography study performed 3 months later. The median time from symptom onset to the first medical contact, with 25th and 75th percentiles in parentheses, was 1.25 h (0.75, 3), from symptom onset to initiation of thrombolytic therapy 2.25 h (1.25, 3), to initiation of GP IIb/ IIIa inhibitor therapy 3.5 h (2, 5.69), and to the start of coronary intervention 4.81 h (2.85, 7.91). The time between symptom onset and initiation of both thrombolytic therapy and coronary intervention was significantly related to the global ejection fraction and to the extent of regional hypokinesia at the 3-month follow-up (p<0.05). The time to the initiation of GP IIb/IIIa inhibitors was only significantly related to the global ejection fraction (p<0.05), while the time to the first medical contact did not show a similar relationship (p>0.05). Furthermore, we observed a significant relationship between the infarct-related artery (IRA) patency at the initial angiogram and the residual regional myocardial damage at follow-up; normokinesia at follow-up was found in 61.3% of patients with an initially patent IRA and in 41.2% of patients with an initially occluded IRA, whereas severe hypokinesia was found in 13.8% and 37.3%, respectively (p<0.05). In patients with STEMI treated with a facilitated PCI strategy using half dose r-tPA in combination with a glycoprotein IIb/IIIa receptor blocker, the 3-month global and regional residual myocardial dysfunction is significantly related to the time elapsed between the onset of symptoms and the start of both fibrinolytic therapy and coronary intervention.