Community-Based Pre-HospitalElectrocardiogram TransmissionProgram for Reducing Systemic TimeDelay in Acute ST-Segment ElevationMyocardial Infarction

Background and Objectives@#In acute ST-segment elevation myocardial infarction (STEMI),on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic timedelay to reperfusion and improve outcomes. However, it has not been adopted in communitybasedemergency transport system in Korea. @*Methods@#Busan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fireand Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECGtransmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated.Systemic time delay to reperfusion of STEMI patients in the program was compared with thatof 95 patients transported by 119 emergency medical system (EMS) before the program wasimplemented. @*Results@#During the study period, 289 ECG transmissions were made by 119 EMS personnel,executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as STsegmentelevation. Final diagnosis of STEMI was made in 20 patients who underwent primarypercutaneous coronary intervention. With the program, systemic time delay to reperfusion wassignificantly reduced (median [interquartile range; IQR], 76.0 [62.2–98.7] vs. 90.0 [75.0–112.0],p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0[34.0–69.5] vs. 58.0 [51.0–68.0], p=0.03). The proportion of patients with systemic time delayshorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission. @*Conclusions@#We developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions ofsystemic time delay and door-to-balloon time were observed. The expanded use of prehospitalECG transmission should be encouraged to realize the full potential of this program.

Severity of Coronary Artery Disease and Visceral Fat Obesity

BACKGROUND: The visceral fat obesity is known to be associated with coronary artery disease. We investigated the relation between visceral fat obesity and the severity of coronary artery disease by angiography. METHODS: The coronary artery disease (CAD) group included 54 angina patients (43 men and 11 women) with angiographically demonstrated coronary artery disease. The control group included angiographically normal 28 controls (15 men and 13 women). The subjects with hypertension, non-insulin dependent diabetes mellitus (NIDDM) and taking any medication known to affect the insulin sensitivity were excluded. We measured the visceral fat area, abdominal subcutaneous fat area, thigh muscle area and the thigh fat area with computed tomography (CT) in both groups. We measured the plasma lipid profile, fasting plasma insulin and glucose level in both groups. RESULTS: There were no differences in the age, sex ratio and body mass index (BMI) between both groups. Total cholesterol and triglyceride increased in CAD group significantly (p<0.05, p<0.001). The HDL cholesterol decreased in CAD group. But there was no statistical significance (p=0.056). The fasting insulin increased in CAD group significantly (p<0.001). There were significant differences between CAD group and the control group in the visceral fat area (117.8+/-34.4 cm2vs. 85.5+/-17.6 cm2, p<0.001), thigh fat area (50.0+/-22.3 cm2vs. 65.8+/-12.9 cm2, p<0.001), visceral fat to abdominal subcutaneous fat area ratio (VS ratio:0.81+/-0.31 vs. 0.51+/-0.15, p<0.001) and the visceral fat to thigh fat area ratio (VSFTF ratio:2.72+/-1.24 vs. 1.34+/-0.35, p<0.001). In the male subgroup (CAD:43, control:15), triglyceride and fasting insulin increased in CAD group significantly (p<0.001). The visceral fat area, VS ratio, and VSFTF ratio increased in CAD group significantly (P<0.001) The thigh fat area decreased in CAD group significantly (P<0.001). In the female subgroup (CAD:11, control:13), fasting insulin and visceral fat area increased in CAD group significantly (p<0.001, p<0.05). Multiple logistic regression analysis revealed that VSFTF ratio, fasting insulin and the HDL cholesterol were independent associated factors of coronary artery disease. In comparison with normal control, one-vessel disease and multi-vessel disease (two vessel and three vessel), there were significant differences between groups in fasting insulin, triglyceride, visceral fat area, thigh fat area, VS ratio, VSFTF ratio. In Turkey's HSD Post Hoc test, however, there were no significant differences between one-vessel disease and multi-vessel disease. CONCLUSION: We observed significant increases in the visceral fat area, VS ratio and VSFTF ratio and decrease in thigh fat area in angiographically demonstrated CAD group compared with age, BMI matched angiographically normal control. But we did not observed any relation between the visceral fat area and the severity of coronary disease by angiography.

The Changes in Coagulation and Fibrinolytic Activities in Acute Myocardial Infarction Patients Treated with Recombinant Tissue Plasminogen Activator and Urokinase

BACKGROUND: The coagulation and fibrinolytic activities increase in the setting of acute myocardial infarction (AMI) and has been shown to increase further after the administration of thrombolytic agents. The reocclusion rate was slightly higher in patients with recombinant tissue type plasminogen activator (rt-PA) than urokinase (UK). However, there are few studies on serial changes in coagulation and fibrinolytic activities during the thrombolytic therapy. METHODS: Twenty five AMI patients who visited Yongdong Severance Hospital from August 1996 to August 1997 were recruited. They were randomized two groups either double bolus UK or accelerated rt-PA. Plasma levels of fibrinogen, thrombin-antithrombin III complex (TAT), plasmin-alpha2 plasmin inhibitor complex (PIC), activities of protein C and protein S were checked before and 3, 12, 24hrs and 7days after the thrombolytic therapy. RESULTS: Plasma level of fibrinogen was decreased 3 and 12hrs after the initiation of thrombolytic therapy in both groups (p<0.05) however, the fibrinogen level in UK treated group (59.9+/-33.5 mg/dl) was decreased than rt-PA treated group (198.2+/-64.3 mg/dl) at 3hrs after thrombolytic therapy (p<0.05). Activities of protein C and protein S were increased at 3hrs after thrombolytic therapy in both groups and no difference was noticed between UK and rt-PA group. Concentrations of TAT and PIC were increased in both groups even before the thrombolytic therapy was initiated. The increment of TAT level was larger in rt-PA group (21.7+/-16.1, 8.9+/-5.4 ng/mL) compared with UK group (15.0+/-17.9, 4.6+/-1.9 ng/mL) at 3 and 12 hrs after thrombolytic therapy (p<0.05). PIC level was significantly increased at 3 and 12 hrs after the treatment in both groups and no difference was noted between UK and rt-PA group. CONCLUSION: Both coagulation and fibrinolytic activities, activated already before thrombolytic therapy, were further aug-mented after thrombolytic therapy in AMI patients. The increment of fibrinolytic activity showed no significant difference between UK and rt-PA treated group. However the coagulation activity in rt-PA treated group was increased more than UK treated group.

The Changes in Coagulation and Fibrinolytic Activities in Acute Myocardial Infarction Patients Treated with Recombinant Tissue Plasminogen Activator and Urokinase

BACKGROUND: The coagulation and fibrinolytic activities increase in the setting of acute myocardial infarction (AMI) and has been shown to increase further after the administration of thrombolytic agents. The reocclusion rate was slightly higher in patients with recombinant tissue type plasminogen activator (rt-PA) than urokinase (UK). However, there are few studies on serial changes in coagulation and fibrinolytic activities during the thrombolytic therapy. METHODS: Twenty five AMI patients who visited Yongdong Severance Hospital from August 1996 to August 1997 were recruited. They were randomized two groups either double bolus UK or accelerated rt-PA. Plasma levels of fibrinogen, thrombin-antithrombin III complex (TAT), plasmin-alpha2 plasmin inhibitor complex (PIC), activities of protein C and protein S were checked before and 3, 12, 24hrs and 7days after the thrombolytic therapy. RESULTS: Plasma level of fibrinogen was decreased 3 and 12hrs after the initiation of thrombolytic therapy in both groups (p<0.05) however, the fibrinogen level in UK treated group (59.9+/-33.5 mg/dl) was decreased than rt-PA treated group (198.2+/-64.3 mg/dl) at 3hrs after thrombolytic therapy (p<0.05). Activities of protein C and protein S were increased at 3hrs after thrombolytic therapy in both groups and no difference was noticed between UK and rt-PA group. Concentrations of TAT and PIC were increased in both groups even before the thrombolytic therapy was initiated. The increment of TAT level was larger in rt-PA group (21.7+/-16.1, 8.9+/-5.4 ng/mL) compared with UK group (15.0+/-17.9, 4.6+/-1.9 ng/mL) at 3 and 12 hrs after thrombolytic therapy (p<0.05). PIC level was significantly increased at 3 and 12 hrs after the treatment in both groups and no difference was noted between UK and rt-PA group. CONCLUSION: Both coagulation and fibrinolytic activities, activated already before thrombolytic therapy, were further aug-mented after thrombolytic therapy in AMI patients. The increment of fibrinolytic activity showed no significant difference between UK and rt-PA treated group. However the coagulation activity in rt-PA treated group was increased more than UK treated group.