Uncomplicated ST-elevation Myocardial Infarction Research Articles

Proposal for initial management of uncomplicated ST elevation myocardial infarction in centers without percutaneous coronary intervention capacity in Peru

ST-segment elevation myocardial infarction (STEMI) is a clinical entity whose adequate treatment will depend on its prompt recognition, accurate diagnosis, and management in reperfusion networks. The first contact with these patients is generally done in centers without reperfusion capacity, attended by non-cardiologist doctors, and in centers far from hospitals with greater resolution capacity, something that is well known in our country. This manuscript proposes a strategy for the diagnosis and treatment of STEMI in centers without percutaneous coronary intervention capacity of the public health system in Peru, emphasizing not losing sight of electrocardiographic patterns compatible with coronary artery occlusion, adequate fibrinolysis and management of its complications, the treatment of infarction in special populations and highlighting the importance of the pharmacoinvasive strategy as the main form of reperfusion treatment in our country.

Abstract 17879: Assessing the Safety of an Early Repatriation Strategy for Uncomplicated ST-Elevation Myocardial Patients After Primary Percutaneous Intervention

Introduction: Repatriation of patients with ST-elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) is common in Canadian regional health care programs. However, the safety of early repatriation after PPCI in uncomplicated STEMI patients remains unknown. We aimed to compare the outcomes between uncomplicated STEMI patients repatriated early (transfer to home hospital ≤4hrs of PPCI completion) vs. those who remained at the PPCI-hospital until discharge. Methods: We performed a retrospective, cohort study examining consecutive, uncomplicated STEMI patients treated with PPCI between 2016-2018 in the Fraser Health Authority. Patients were designated as uncomplicated if there was no evidence of cardiogenic shock, prolonged cardiac arrest or congestive heart failure requiring mechanical ventilation. Outcomes of interest included discharge with guideline-based medical therapy (GBMT) and a composite of 1-year major cardiovascular events. Results: A total of 787 patients were included for analysis, with 62% (n=492) being repatriated early. Early repatriated patients were similar in age and baseline characteristics when compared with those discharged from the PPCI-based hospital. Interestingly, early repatriated patients were more likely to be discharged on GBMT (89% vs. 83%, p=0.015) In multivariate analysis, early repatriation was not associated with worsened 1-year cardiovascular outcomes (OR 1.05, 95% CI 0.6782,1.6521, p=0.80). Independent predictors of 1-year major cardiovascular outcomes included hypertension (OR 1.75, 95% CI 1.0918-2.8349, p=0.02) and discharge with GBMT (OR 0.49, 95% CI 0.2831-0.8465, p=0.01). Amongst the subset of early repatriated patients, primary treatment by cardiologist vs internist did not result in differences in 1-year outcomes (10% vs. 8%, p=0.23) or discharge with GBM (87% vs. 83%, p=0.09). Conclusions: Early repatriation of uncomplicated STEMI patients after PPCI was associated with outcomes similar to those having ongoing care at the PPCI-based hospital. Therefore, early repatriation serves as a safe treatment strategy for regional STEMI programs and may be particularly relevant for PPCI centres with limited bed capacity.

Length of stay and 30 day mortality in patients suffering an uncomplicated ST-elevation myocardial infarction treated with primary percutaneous coronary intervention in New York State

We studied the duration of hospitalization and clinical outcome of patients with an uncomplicated STEMI (ST-elevation myocardial infarction) treated with primary percutaneous coronary intervention (PCI) in New York State between 2007 and 2009. Among the 4,939 such patients, 1,818 were discharged after 2 nights, and 1,922 were discharged after 3 nights. There were no deaths on the day after discharge among patients discharged after 2 nights. There was also no significant difference in 30-day mortality or readmission between patients discharged after 2 and 3 nights. In conclusion, 24-hour mortality was very low in patients with an uncomplicated STEMI discharged after 2 nights in the hospital, based on physician judgment. Thirty-day mortality is also low and similar to that of patients discharged after 3 nights in the hospital.

Risk Factors, Clinical Features of the Course of Myocardial Infarction and Treatment of Young Patients Based on Two Hospital Registries

Aim.To identify specific risk factors and features of the course of myocardial infarction (MI) in young patients.Material and methods.The study design is based on a comparison of observation data for patients of different ages from the Russian RECORD-3 registry (n=2359) and the registry of acute coronary syndrome of the Kemerovo city in 2015 (n=1343). The clinical and anamnestic portrait was determined, the frequency of hospital complications and the “hard” endpoints were evaluated.Results.Young patients with myocardial infarction (MI) according to RECORD-3 are more often male smokers (p=0.001) with a heredity in cardiovascular pathology (p=0.034), who have an uncomplicated STEMI upon admission to the hospital, and are sent for coronary angiography with stenting (p=0.001), without prescribing statins in the primary and secondary prevention (p=0.050 and p=0.016, respectively). There were no differences with other age groups by endpoints a year later; during the current hospitalization, young patients less often died (p=0.001) or had a relapse of MI (p=0.011). Young patients with MI from Kemerovo were also mostly male smokers (p=0.001), who more often had a history of chronic kidney disease, chronic heart failure, and lipid metabolism disorders (p=0.001), who admitted to the hospital with uncomplicated STEMI, actively undergoing thrombolytic therapy and endovascular diagnosis and treatment (p=0.001). However, it should be noted that these patients were less likely to receive aspirin (p=0.015), dual antiplatelet therapy (p=0.003), angiotensin converting enzyme (ACE) inhibitors (p=0.040) and statins (p=0.001). Moreover, in young patients with MI, deficiency of high density lipoproteins (p=0.005) was more often found in the absence of very high values of low density lipoproteins (p=0.001). Among the complications of inpatient treatment, it should be noted a tendency to bleeding (p=0.001). One year after referent MI a high proportion of repeated non-fatal MI (p=0.005) and deaths (p=0.001) were observed. A comparison of the registries showed that young patients from Kemerovo were more likely to have STEMI (p=0.032), they were more likely to have stenting (p=0.004), they were more often diagnosed with chronic renal and heart failure (p=0.001), and more often ACE inhibitors was prescribed (p=0.017), and MI during hospitalization was more often complicated by bleeding (p=0.003).Conclusion.From 1.7 to 2.4% of all MI occurs in young patients. The most frequent version of the debut is STEMI. The leading factors of cardiovascular risk in such patients are the male gender, active smoking, a hereditary history of cardiovascular diseases, low cholesterol of high density lipoproteins with insufficient statins prevention. In young patients of the Kemerovo registry, chronic heart failure and chronic kidney disease were more often observed, and ACE inhibitors were prescribed, hospitalization was often accompanied by bleeding. In a young age differences in the frequency and structure of outcomes in one year after referent MI were not found when comparing registries.

Abstract 108: Contemporary Timing and Etiology of Mortality in ST-Elevation Myocardial Infarction

Background: Acute treatment of ST-elevation myocardial infarction (STEMI) has focused on early reperfusion, prompt defibrillation, and appropriate mechanical support to mitigate short-term mortality. Long-term patterns of death in a contemporary population are not well described. Methods: We reviewed consecutive cases of STEMI treated with percutaneous coronary intervention (PCI) at our center between January 1, 2011, and December 31, 2016, and divided patients into two groups: uncomplicated STEMI (US) and complicated STEMI (CS). CS was defined by presence of cardiac arrest or cardiogenic shock, ascertained from first-medical-contact to device time for PCI. We assessed for differences in characteristics and short- and long-term mortality between the groups. Results: We identified 1,272 patients with STEMI; 214 of which were CS (16.8%). Those with CS were significantly more likely to have heart failure (22.9% vs 11.3%, p<0.001), kidney disease (38.2% vs. 21.0%, p<0.001), cerebrovascular disease (18.7% vs 11.0%, p=0.003), peripheral vascular disease (16.8% vs 7.9%, p<0.001), and left main or left anterior descending culprit vessel (51.9% vs. 40.3%, p<0.002). Total in-hospital mortality was 5.0% (63 patients), with 19.6% (42/214) and 2.0% (21/1058) of those with CS and US respectively (p<0.001). Among 1209 of patients that survived to hospital discharge, total long-term mortality was 10% (121 patients) of which 18.0% (31/172) had CS and 8.7% (90/1037) had US (p=0.001) over mean follow-up of 3.1±1.9 years. Of those, 52% and 50%, respectively, were from non-cardiovascular etiologies (Figure) including malignancy (13% vs. 22%), infection (22% vs. 19%), or other causes (17% vs. 9.0%). Conclusion: Despite advances in the in-hospital care of patients with STEMI, there remains a significant risk of long-term mortality for both patients with uncomplicated and complicated STEMI. A substantial proportion of overall STEMI mortality now occurs after hospital discharge predominantly due to non-cardiovascular causes. Systems of care to mitigate this long-term risk are needed.

Improving Care Pathways for Acute Coronary Syndrome: Patients Undergoing Percutaneous Coronary Intervention

Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS <3 days and TFI with LOS <3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that >$300 million could be saved if prevalence of the TRI with LOS <3 days and TFI with LOS <3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes.

P5488Temporal trends and prognostic impact of hospital length of three or less days in uncomplicated myocardial infarction after primary percutaneous coronary intervention in Spain

Abstract Introduction and objectives There is scarce data on the safety of hospital stay length in uncomplicated ST- elevation myocardial infarction (STEMI). We studied the trends of the hospital stay and the safety of short (≤3 days) vs. long hospital stay, in Spain. Methods Using data from the Minimum Basic Data set of Spanish taxpayer-funded health system. We identified patients with uncomplicated STEMI undergoing coronary angioplasty and who were discharged alive. The mean length of stay was calculated by multilevel Poisson regression with mixed-effects, including patients from 2003–15. The effect of short stay on cardiac diseases readmissions at 30 days and 1 year was evaluated by multilevel logistic regression, including patients from 2003–14. Thirty-day and 1-year cardiac diseases risk-standardized readmissions and mortality rates (RSRRs and RSMRs), respectively, were also compared. Results The adjusted mean length of stay was significantly reduced (incidence rate ratio &lt;1; p&lt;0.001) for each year since 2003. The percentage of short stay increased from 14.3% in 2003 to 19.5% in 2015 (p&lt;0.001). In none of the specified models short stay was statistically significant (p&gt;0.05). The RSRRs at 30 days and 1 year as well as RSMRs at 30 days, did not differ significantly between groups. 1-year RSMRs was significantly higher in the short stay group, although probably without clinical significance (0.103% vs. 0.109%, p&lt;0.001). See Table. Diff mean of RSRRs and RSMRs at 30 days &amp; 1 year Stay length N Mean Standard deviation p-value RSRRs at 30-day ≤3 days 6,486 2.541 0.74 0.20 &gt;3 days 31,651 2.554 0.72 RSRRs at 1 year ≤3 days 6,486 5.306 1.22 0.42 &gt;3 days 31,651 5.292 1.14 RSMRs at 30-day ≤3 days 6,486 0.109 0.04 &lt;0.001 &gt;3 days 31,651 0.103 0.03 RSMRs at 1 year ≤3 days 6,486 0.429 0.13 0.25 &gt;3 days 31,651 0.427 0.13 RSRRs = risk-standardized readmission rates; RSMRs = risk-standardized readmission mortality rates. Conclusions In Spain, short hospital stay increased significantly from 2003 to 2015 and seems a safety option in uncomplicated STEMI patients.

Current perspectives on location of monitoring and length of stay following PPCI for ST elevation myocardial infarction.

There is marked variability in location of care and hospital length of stay after primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI). We performed a literature review on non-critical care monitoring and early discharge following primary percutaneous coronary intervention and describe a framework for implementation in the real world. The medical literature was searched from 1 January 1988 to 31 April 2019 using PubMed and Cochrane Central Register of Controlled Trials. Randomized clinical trials, observational studies and guideline statements were included. Available data suggest that carefully selected low-risk STEMI patients identified using Zwolle or CADILLAC risk stratification scores after primary percutaneous coronary intervention may be considered for discharge after 48 hours of hospital care. There was no increase in major adverse cardiac events, medication non-compliance or hospital readmission with this treatment strategy. There are limited data on non-critical monitoring of uncomplicated STEMI patients; however, given the low adverse events rate, this strategy is likely to be safe in selected patients and may facilitate reduced length of stay and reduce resource utilization. Available evidence supports the safety of early discharge after 48 hours of care and omission of critical care monitoring in carefully selected patients following primary percutaneous coronary intervention. Early risk stratification and structured discharge planning are imperative. Adoption of this treatment strategy could reduce hospital costs, resource utilization and enhance patient satisfaction without affecting outcomes.

Percutaneous Coronary Intervention Outcomes Following Out-of-Hospital Cardiac Arrest For Patients With and Without ST-Elevation Myocardial Infarction

Background: Outcomes after out-of-hospital cardiac arrest (OHCA) remain poor, and percutaneous coronary intervention (PCI) may have prognostic benefit in patients with a culprit coronary lesion. We aimed to describe outcomes among patients undergoing PCI following OHCA and the effect of ST-elevation myocardial infarction on outcome. Methods: Data were prospectively collected on 1,047 consecutive PCI procedures following OHCA at six Victorian public hospitals from 2005 to 2017. Patients were divided into those with STEMI (OHCA-S) and those without (OHCA-NS). Outcomes were compared against patients with STEMI only without OHCA (n = 9,694). Results: OHCA-S patients were younger and the treated lesion was more commonly occluded at time of PCI (63% vs 22%, p < 0.001). GP-IIb/IIIa antagonists, thrombus aspiration and intra-aortic balloon pump insertion were more frequently used for OHCA-S (p < 0.01). Cardiogenic shock (CS) was present in 47% of OHCA-S and 29% of OHCA-NS (p < 0.001). 30-day mortality was 34% for the OHCA-S and 18% for the OHCA-NS group. However, OHCA-S and OHCA-NS had similar long-term outcomes to the STEMI only group if they survived to 30-days. Multivariable predictors for 30-day mortality after PCI for OHCA were diabetes, impaired renal or LV function, and CS.Tabled 1OHCA w STEMIOHCA w/out STEMIn = 840n = 207p-value30-Day Mortality, n (%)282 (33.6)37 (17.9)<0.00112-Month Mortality, n (%)292 (34.8)38 (18.4)<0.001NDI-Linked Mortality, n(%)344 (41.3)53 (25.6)<0.001NDI Follow-up (days), mean ± SD1,082 ± 11981,221 ± 11030.12 Open table in a new tab Conclusions: PCI following OHCA has a high 30-day mortality, with worse outcomes among patients with STEMI. Beyond 30-days, long-term outcomes are similar to uncomplicated STEMI cohorts.

Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting

Standard admission order sets have become ubiquitous across hospitals to promote adherence to practice guidelines and increase ordering efficiency.1 2 This standardisation arose in part out of a need to...

Upper endoscopy in patients with acute ST-elevation myocardial infarction (STEMI) and postthrombolysis upper gastrointestinal bleeding – results, therapeutic utility

Abstract Upper endoscopy is the “golden standard” for the diagnosis of upper gastrointestinal bleeding (UGB); it appreciates the persistence of bleeding in more than 90% of cases, it reveals the UGB lesion, gives prognostic information about re-bleeding risk and offers the possibility of endoscopic haemostasis. Uncomplicated STEMI by itself is not a contraindication for upper endoscopy [1,2]. The aim of our study was to observe the haemorrhagic lesions in STEMI patients with postthrombolysis UGB and to evaluate the safety and therapeutic utility of upper endoscopy in this category of patients. We performed upper endoscopy in STEMI patients with postthrombolytic UGB during a period of 4 years (1st of Jan 2008 - 31st of Dec 2011). Patients with systolic blood pressure (SBP) &lt;100 mmHg, with Killip class&gt;1, with unstable ECG and/or with severe associated conditions (respiratory distress, cerebrovascular stroke, consciousness disorders) were withdrawn from undergoing upper endoscopy, as well as patients who refused the investigation. During studied period, 618 STEMI patients underwent pharmacological coronary reperfusion. Postthrombolysis UGB occurred in 42 of them (6.79%). We could perform upper endoscopy in 30 patients (71.43%), the rest of 12 (28.57%) being withdrawn from endoscopy (6 patients with Killip class&gt;1, 4 patients with systolic blood pressure&lt;100mmHg, 2 patients refused the investigation). Incriminated haemorrhagic lesions were: erosive gastroduodenitis in 20 cases (66.67%) and duodenal ulcer in 10 cases (33.33%). As about therapeutic utility, amongst 30 patients investigated just 4 needed endoscopic treatment (haemoclips used in Forrest IB patients with duodenal ulcers). Endoscopy was a safe investigation in STEMI patients with postthrombolysis UGB. Erosive gastroduodenitis was incriminated as the source of bleeding in most of the cases. As it concerns the therapeutic utility of UE in STEMI patients with UGB, 13.33% of bleeding patients benefited from endoscopic treatment (mechanical haemmostasis).

Abstract 137: Efficacy and Cost Savings Realized through Validation of a Tool to Identify Low Risk STEMI Patients not Requiring CCU Care

Introduction In the early 1960s, the creation of Cardiac Care Units (CCUs) led to a 50% reduction in the in-hospital mortality of acute myocardial infarction (AMI). Prompt application of closed chest cardiac resuscitation and external defibrillation -- then new technologies -- served to reduce the consequences of the event. Over the ensuing four decades, therapeutic advances in the treatment of AMI (e.g. prompt reperfusion strategies) have favorably altered its natural history, potentially obviating the need for CCU care. Since such care is expensive, identification of a low risk cohort of patients in whom this care is not necessary could allow substantial improvements in the cost of cardiac care. Hypothesis Existing risk models can be used to accurately identify low risk STEMI patients who do not require CCU care after primary PCI. Methods We performed a retrospective chart review of all STEMI cases from 2010 at Carolinas Medical Center. We then assessed them using the TIMI STEMI risk score and a risk assessment algorithm for uncomplicated STEMI developed at Brigham and Women's Hospital (BWH). The BWH STEMI Care Redesign defines low risk STEMI patients as those who are promptly revascularized via successful single vessel PCI with (1) no evidence of ongoing ischemia, (2) EF&gt;40%, (3) absence of CHF, hemodynamic or electrical instability, and (4) who are awake without need of respiratory support. Cost data (fixed and variable) from Quality Advisor™, a product by Premier, was abstracted for each STEMI case, examining specific resources used in CCU and non-CCU units. Results Among 310 consecutive STEMI patients, in-hospital mortality was 3.9%. The BWH risk score identified 46.4% of these patients as low-risk. Among these patients, in-hospital mortality was 0%. Only one of these 144 low-risk patients required subsequent CCU care. None required CPR or defibrillation after revascularization. The TIMI STEMI risk score &lt;2 classified 26.1% of the patients as low-risk. Among these patients, in-hospital mortality was 0%. However, 3.7% of these "low-risk" patients had ventricular arrhythmias or respiratory decompensation during or shortly after PCI. None of the 3.7% were classified as "low-risk" by the BWH model. CCU care added $723 in fixed costs and $340 in variable costs per hospital day. Conclusion The BWH model, but not the TIMI STEMI risk score, accurately predicted a sizable cohort of STEMI patients at very low risk of in-hospital death and complications. These patients may be appropriate for admission to non-CCU level care immediately following primary PCI. Doing so would be projected to yield a cost savings of &gt;$1000 per patient.

High-concentration versus titrated oxygen therapy in ST-elevation myocardial infarction: A pilot randomized controlled trial

The optimal approach to oxygen therapy in ST-elevation myocardial infarction (STEMI) is uncertain. A randomized controlled trial was undertaken in which 136 patients presenting with their first STEMI uncomplicated by cardiogenic shock or marked hypoxia were randomized to receive high-concentration (6 L/min via medium concentration mask) or titrated oxygen (to achieve oxygen saturation 93%-96%) for 6 hours after presentation. The main outcome variables were 30-day mortality and infarct size assessed by troponin T level at 72 hours. Secondary outcomes included a meta-analysis of mortality data from this study and previous randomized controlled trials, and infarct size was assessed by magnetic resonance imaging at 4 to 6 weeks. There were 1 of 68 and 2 of 68 deaths in the high-concentration and titrated oxygen groups, respectively; a meta-analysis including these data with those from the 2 previous studies showed an odds ratio for mortality of high-concentration oxygen compared with room air or titrated oxygen of 2.2 (95% CI 0.8-6.0). There was no significant difference between high-concentration versus titrated oxygen in troponin T (ratio of mean levels 0.74, 95% CI 0.50-1.1, P = .14), infarct mass (mean difference -0.8 g, 95% CI -7.6 to 6.1, P = .82), or percent infarct mass (mean difference -0.6%, 95% CI -5.6 to 4.5, P = .83). This study found no evidence of benefit or harm from high-concentration compared with titrated oxygen in initially uncomplicated STEMI. However, our estimates have wide CIs, and as a result, large randomized controlled trials are required to resolve the clinical uncertainty.

Beyond the unmeasured anions: the clinics

We thank Dr Berend for his kind suggestions. Beyond the discussion and comparison between different types of fruits, the aim of our investigation was to assess, on a clinical ground, the prognostic values of base excess in uncomplicated ST elevation myocardial infarction. Two considerations arises from this. Firstly, despite the universal controversy on the diagnostic power of different methodological approaches for the evaluation of acid–base disorders [1, 2] (diagnostic target), the assessment of acidosis also retains a prognostic significance in different clinical settings [3–5] (prognostic target). In this context, recently, in acute myocardial infarction, anion gap (though its ‘‘diagnostic’’ limits) proved to provide important incremental information for initial risk stratification. In agreement with these findings, and despite the scarcity of data on acute cardiac patients on this topic, we documented that the presence of low base excess was an independent predictor for intra-ICCU complications (represented by acute pulmonary edema and arrhythmias) in uncomplicated ST elevation myocardial infarction submitted to percutaneous interventions. Secondly, the available literature dealing with the diagnostic significance of ‘‘acid–base parameters’’ stems mainly from studies in critically ill patients. A recent growing body of evidence [3–5] strongly supports the notion that HCO3, base excess and anion gap (corrected for hypoalbuminemia, when needed) remain the most appropriate for clinical usage. In our investigation we enrolled consecutive uncomplicated STEMI patients, mirroring the real world scenario. These patients do not show hypoalbuminemia and hence anion gap correction is not necessary. In our opinion, the strength of our investigation is represented by the fact that easily available parameters (such as base excess) proved to help clinicians in optimizing risk stratification in the early phase of STEMI patients, even if uncomplicated. Like Dr Berend, we agree that Cl/Na deserves further studies in a larger cohort of patients in order to better clarify its clinical significance since it is a very feasible parameter, and that is what we have expressed in the section ‘‘limit of the study’’. We are very grateful for the suggestions and challenges posed by Dr Berend. Yet we are convinced that in the dialectic reasoning on acid–base evaluation, the clinical significance of parameters should also be taken into account, bearing in mind the recent evidence.

Acid–base imbalance in uncomplicated ST-elevation myocardial infarction: the clinical role of tissue acidosis

Little information is available on acid-base imbalance in uncomplicated ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI). We therefore assessed acid-base imbalance in 257 consecutive uncomplicated STEMI patients submitted to PCI to determine whether its evaluation could help in identifying patients at higher risk for in-hospital complications (acute pulmonary edema and dysrhythmias). A basic metabolic profile was performed at hospital admission, that is before PCI. After PCI, we measured: creatinine, uric acid and NT-pro BNP and serum electrolytes. Peak troponin I was also considered. Acidemia was present in 11 patients (4.2%), HCO(3) < 22 in 62 (24.1%). Base excess < -3 was detectable in 70 patients (27.2%), anion gap > 12 in 13 (5.1%), Cl/Na < 0.79 in 93 patients (38.5%). Patients with a Cl/Na < 0.79 had a lower LVEF (p = 0.042) and higher values of NT-pro-BNP (p = 0.019) and of latency (p = 0.029) together with a higher length of stay (p = 0.017) and a higher incidence of in-hospital complications (p = 0.017). At backward stepwise regression analysis, the following variables resulted independent predictors of in-hospital complications: base excess OR 1.47 (95% CI 1.04-2.10) p = 0.031; Cl/Na ratio O.R. 1.85 (95% CI 1.05-3.27) p = 0.035. In STEMI patients submitted to mechanical revascularization the evaluation of acid-base status and, in particular the detection of even mild degrees of acidosis may help in risk stratification for in-hospital complications. A Cl/Na < 0.79 ratio and a base excess are independent predictors for in-hospital complications.

Procalcitonin in patients with acute coronary syndromes and cardiogenic shock submitted to percutaneous coronary intervention

Procalcitonin (PCT) is known to be a biological diagnostic marker for severe sepsis, or septic shock in critically ill patients. There are still contrasting data about a role of procalcitonin in patients with acute myocardial infarction or cardiogenic shock, and in those with acute coronary syndromes, that is, non-ST-elevation myocardial infarction or unstable angina. We evaluated plasma levels of procalcitonin and C-reactive protein (CRP) in 52 patients admitted to our intensive cardiac care unit (ICCU): 14 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI), 15 patients with uncomplicated ST-elevation myocardial infarction (STEMI), and 24 with non-ST-elevation myocardial infarction or unstable angina (NSTEMI/UA). In all patients, infective processes were excluded. Procalcitonin values were significantly higher in CS patients with respect to the other two subgroups (P < 0.001, P < 0.001) while CRP levels were higher than NSTEMI/UA patients (P < 0.001) but not with respect to STEMI patients (P = 0.063). No correlations were found in cardiogenic shock patients between CRP and PCT values (R = 0.02; P = 0.762, ns). Procalcitonin levels measured on ICCU admission are significantly higher in patients with cardiogenic shock following the acute myocardial infarction, and they are not correlated with those of CRP. The degree of myocardial ischemia (clinically indicated by the whole spectrum of ACS, from unstable angina to cardiogenic shock ST-elevation following myocardial infarction) and the related inflammatory-induced response are better reflected by CRP (which was positive in most acute cardiac care patients of all our subgroups), than by PCT which seems more reflective of a higher degree of inflammatory activation, being positive only in all CS patients.

Next Day Discharge After Successful Primary Angioplasty for Acute ST Elevation Myocardial Infarction An Open Randomized Study "Prague-5"

This study tested the feasibility and safety of next day hospital discharge after successful primary PCI for uncomplicated STEMI. Twenty-three p-PCI patients (out of 271 consecutive patients) who fulfilled the study inclusion criteria were enrolled in the pilot nonrandomized phase (transfer of patients from the coronary unit to a standard ward within 24 hours after their admission) of the study. The randomized phase of the study screened a total of 1946 consecutive STEMI patients undergoing p-PCI in the two participating centers. Only 56 (ie, 2.9% from all p-PCI) very low risk patients residing less than 20 km from the PCI center were selected. They were randomized 1:2 to either a standard hospital stay (group A, n = 19, age, 58 +/- 8) or first day discharge (group B, n = 37, age, 56 +/- 10; NS). There were no serious complications among 79 study patients within 30 days. The duration of hospital stay was 105 +/- 45 hours (group A) and 29 +/- 3 hours (P < 0.0001) in group B. Ejection fraction after 30 days was 56.8 +/- 6.5% in group A versus 57.3 +/- 7% in group B (NS). A patient comfort questionnaire showed a clear preference of first day discharge in all patients randomized into group B. The results indicate that next day discharge after successful p-PCI is feasible and safe in selected uncomplicated STEMI patients.

Monitoring nach akutem Myokardinfarkt

The prognosis for patients with acute myocardial infarction has dramatically improved within the last decades. Also the length of stay shortened substantially. This review gives an ovreview about the current knowlegde of monitoring and length of hospital stay after acute myocardial infarction. After uncomplicated STEMI monitoring for 24 hours in the CCU without adverse event and discharge on the morning of day 4 is feasible. After uncomplicated NSTEMI patients can be transferred to a step down unit within 24 hours and discharged the day after or after normalisation of the cardiac markers. In patients with complications such as recurrent angina, congestive heart failure, complex ventricular arrhythmias longer monitoring over 48-72 and hospital stays over 7-14 days seem necessary.

Bed rest for acute uncomplicated myocardial infarction

Bed rest is prescribed to all patients with acute myocardial infarction (AMI), but to a variable extent. Current guidelines (American College of Cardiology/ American Heart Association) recommend at least 12 hours bed rest in patients with uncomplicated ST-elevation myocardial infarction, however the basis for this recommendation is unclear. To compare the effects of short versus longer bed rest in patients with uncomplicated AMI. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2005), MEDLINE (January 1966 - August 2005), EMBASE (January 1988 - August 2005), PASCAL BioMed (January 1996 - August 2005); PsycINFO (January 1966 - August 2005) and BIOSIS Previews (January 1990 - August 2005). Randomised and quasi-randomised controlled trials of short versus longer bed rest in patients with uncomplicated AMI were sought. Study selection was performed independently by at least two investigators according to the predefined inclusion criteria. Data were extracted by two investigators independently and in duplicate. Authors were contacted to obtain missing information. We found 15 trials with 1487 patients assigned to a short period of bed rest (median 6 days) and 1471 patients assigned to longer bed rest (median 13 days). Generally the studies were outdated and appeared to be of moderate to poor methodological reporting quality. There was no evidence that shorter bed rest was more harmful than longer bed rest in terms of all cause mortality (RR=0.85 (95%CI 0.68 to 1.07), cardiac mortality (RR=0.81 (95%CI 0.54 to 1.19), or reinfarction (RR=1.07 (95%CI 0.79 to 1.44)). Bed rest ranging from 2 to 12 days appears to be as safe as longer periods of bed rest. The quality of most trials is unsatisfactory. Current bed rest recommendations are not supported by the existing evidence as the optimal duration of bed rest is unknown. The lack of adequate trials is surprising, considering the large size of several studies to compare effectiveness of drugs on people with AMI.

Reevaluation of Routine Invasive Strategy versus Noninvasive Testing following Uncomplicated ST-Elevation Myocardial Infarction

Background and Aims: While current guidelines recommend a selective invasive approach after low-risk ST-elevation myocardial infarction (STEMI) treated by thrombolysis, based on noninvasive identification of patients with residual or inducible myocardial ischemia, in many instances physicians employ a strategy of routine angiography. The present study was undertaken to reexamine the correlation between noninvasive testing and coronary angiography in patients recovering from uncomplicated STEMI with regard to detection and management of residual infarct artery stenosis and to identify patients with multivessel (MVD) or high-risk coronary disease. Methods: We prospectively performed predischarge exercise testing (ETT) and myocardial perfusion scintigraphy (MPS) prior to routine predischarge coronary angiography in 83/276 consecutive STEMI patients, who after treatment with initial and early thrombolysis, were defined as low risk by ACC/AHA risk classification. Results: ETT was positive for myocardial ischemia in 11/43 (26%) patients with single-vessel disease (SVD) and 11/22 (50%) patients with MVD, but normal or nondiagnostic in the remainder. MPS revealed significant reversible perfusion defects in 13/40 (32%) patients with SVD and 13/22 (59%) patients with MVD. A selective strategy of ETT followed by MPS for nondiagnostic ETT missed residual infarct-related artery stenosis and/or MVD in 31/81 (38%) of the cohort. Among patients who may not otherwise have been referred for angiography, severe (≧70%) residual stenosis of the infarct-related artery was present in 56% and MVD in 16%. Conclusions: Early predischarge ETT and/or MPS had limited sensitivity for the detection of coronary disease in low-risk post-STEMI patients. The study supports a simpler strategy of routine coronary angiography in most patients after low-risk STEMI.