The Automated External Defibrillator: Heterogeneity of Legislation, Mapping and Use across Europe. New Insights from the ENSURE Study.

INTRODUCTION: The rapid use of an automated external defibrillator (AED) is crucial for increased survival after an out-of-hospital cardiac arrest (OHCA). Many factors could play a role in limiting the chance of an AED use. We aimed to verify the situation regarding AED legislation, the AED mapping system and first responders (FRs) equipped with an AED across European countries. METHODS: We performed a survey across Europe entitled "European Study about AED Use by Lay Rescuers" (ENSURE), asking the national coordinators of the European Registry of Cardiac Arrest (EuReCa) program to complete it. RESULTS: Nineteen European countries replied to the survey request for a population covering 128,297,955 inhabitants. The results revealed that every citizen can use an AED in 15 countries whereas a training certificate was required in three countries. In one country, only EMS personnel were allowed to use an AED. An AED mapping system and FRs equipped with an AED were available in only 11 countries. The AED use rate was 12-59% where AED mapping and FR systems were implemented, which was considerably higher than in other countries (0-7.9%), reflecting the difference in OHCA survival. CONCLUSIONS: Our survey highlighted a heterogeneity in AED legislation, AED mapping systems and AED use in Europe, which was reflected in different AED use and survival.

Follow-up strategies and individual risk profile after percutaneous coronary intervention: The prospective post percutaneous coronary intervention registry.

BACKGROUND: A multidisciplinary consensus document (MCD) provided a follow-up strategy after percutaneous coronary intervention (PCI) based on individual risk profiles: A, high; B, intermediate; and C, low. AIM: To assess patterns of follow-up after PCI and to evaluate the potential reduction of cardiologic examinations with the application of the MCD. METHODS: The post-PCI registry was carried out at 31 Italian Hospitals and included consecutive patients undergoing PCI. We collected cardiologic consults (CC), noninvasive stress tests (ST), and echocardiograms (EC) actually performed at 12 months and we compared them with the expected by the MCD. RESULTS: We included 1,113 patients (58% with acute coronary syndrome) that underwent 1,567 CC, 398 ST, and 612 EC. The performed CC and ST were significantly lower compared to the expected, respectively [1.6 (95% CI, 1.5-1.7) vs. 1.9 (95% CI, 1.8-2.0), and 0.40 (95% CI, 0.4-0.5) vs. 0.61 (95% CI, 0.6-0.7), p < .001]; the performed EC were significantly higher [0.6 (95% CI, 0.6-0.7) vs. 0.3 (95% CI, 0.3-0.37), p < .001]. Patients at moderate low risk had an excess of noninvasive tests whereas patients at higher risk received less examinations than the expected. The individual risk profile was an independent predictor of increased number of cardiac examination in patients at intermediate and low risk [profile B, OR 2.56 (95%CI 1.38-4.75); profile C, OR 27.00 (95%CI 8.13-89.62), p < .001]. CONCLUSION: In real world patients undergoing PCI, the intensity of follow-up at 12 months appeared not based on individual risk profile, with a higher numbers of examinations, particularly EC, performed in low risk subjects.

The automated external defibrillator, an underused simple life-saving device: a review of the literature. A joint document from the Italian Resuscitation Council (IRC) and Associazione Italiana di Aritmologia e Cardiostimolazione (AIAC).

: The role of early defibrillation has been well established as a pivotal ring of the chain of survival since the nineties. In the following years, the scientific evidences about the beneficial role of early defibrillation have grown, and most of all, it has been demonstrated that the main determinant of survival is the time of defibrillation more than the type of rescuer. Early lay defibrillation was shown to be more effective than delayed defibrillation by healthcare providers. Moreover, because of the ease of use of automated external defibrillators (AEDs), it has been shown that also untrained lay rescuers can safely use an AED leading the guidelines to encourage early defibrillation by untrained lay bystanders. Although strong evidence has demonstrated that an increase in AED use leads to an increase in out-of-hospital cardiac arrest (OHCA) survival, the rate of defibrillation by laypeople is quite variable worldwide and very low in some realities. Our review of the literature about lay defibrillation highlights that the AED is a life-saving device as simple and well tolerated as underused.

Dual antiplatelet therapy prolongation in high-risk patients with prior myocardial infarction: insights from the post-PCI registry.

BACKGROUND: Patients surviving a myocardial infarction (MI) are at a heightened risk for recurrent ischemic events that can be reduced with the long-term addition of a second antithrombotic drug to aspirin. However, data about real prescription of this therapy are lacking and sometimes controversial. METHODS: We aimed to describe the incidence and the determinants of a dual antiplatelet therapy (DAPT) prolongation beyond 12 months in a cohort of consecutive patients undergoing percutaneous coronary intervention (PCI) with prior MI undergoing PCI and features of high ischemic risk intended as age more than 65 years, second MI, type 2 diabetes mellitus, multivessel coronary artery disease (MVCAD) and chronic kidney disease (CKD). We analysed patients enrolled in the prospective 'Post-PCI' registry that included patients treated with PCI for stable coronary artery disease (CAD) or acute coronary syndromes. At 12 months' follow-up, we collected data about DAPT prolongation in patients with prior MI and at least one of the previous features of high risk who did not experience ischemic and bleeding events during the follow-up. RESULTS: Among 1113 patients included in the registry, 778 (72%) presented the inclusion criteria for the present study: 434 (66%) were more than 65 years old, 245 (37%) had a second MI, 189 (29%) diabetes mellitus, 480 (73%) MVCAD and 216 (33%) CKD. Despite a DAPT being prescribed for 1 year in 86% of the patients, it was prolonged for over 12 months in 105 (16%) of them. At multivariable analysis, only second MI and MVCAD were independent predictors of DAPT prolongation in a model including age more than 65 years, diabetes mellitus, CKD and PCI on left main/left anterior descending coronary artery. We found no significant difference in DAPT prolongation according to a DAPT-score value at least 2 or based on the physician who actually performed the follow-up (clinical cardiologist, interventional cardiologist or other). CONCLUSION: In patients with prior MI and features of high ischemic risk undergoing PCI, the rate of DAPT prolongation beyond 12 months was low; recurrent MI and MVCAD appeared as its main determinants.

The paradox of clopidogrel use in patients with acute coronary syndromes and diabetes: insight from the Diabetes and Acute Coronary Syndrome Registry.

BACKGROUND: Patients with diabetes mellitus (DM) and acute coronary syndromes have a greater level of platelet aggregation and a poor response to oral antiplatelet drugs. Clopidogrel is still widely used in clinical practice, despite the current evidence favoring ticagrelor and prasugrel. AIM: The aim of this study was to investigate the determinants of clopidogrel use in the population of the multicenter prospective 'Acute Coronary Syndrome and Diabetes Registry' carried out during a 9-week period between March and May 2015 at 29 Hospitals. PATIENTS AND METHODS: A total of 559 consecutive acute coronary syndrome patients [mean age: 68.7±11.3 years, 50% ST-elevation myocardial infarction (STEMI)], with 'known DM' (56%) or 'hyperglycemia' at admission, were included in the registry; 460 (85%) patients received a myocardial revascularization. RESULTS: At hospital discharge, dual antiplatelet therapy was prescribed to 88% of the patients (clopidogrel ticagrelor and prasugrel to 39, 38, and 23%, respectively). Differences in P2Y12 inhibitor administration were recorded on the basis of history of diabetes, age, and clinical presentation (unstable angina/non-STEMI vs. non-STEMI). On univariate analysis, age older than 75 years or more, known DM, peripheral artery disease, previous myocardial infarction, previous revascularization, complete revascularization, previous cerebrovascular event, creatinine clearance, unstable angina/non-STEMI at presentation, Global Registry of Acute Coronary Events Score, EuroSCORE, CRUSADE Bleeding Score, and oral anticoagulant therapy were significantly associated with clopidogrel choice at discharge. On multivariate analysis, only oral anticoagulant therapy and the CRUSADE Bleeding Score remained independent predictors of clopidogrel prescription. CONCLUSION: In the present registry of a high-risk population, clopidogrel was the most used P2Y12 inhibitor at hospital discharge, confirming the 'paradox' to treat sicker patients with the less effective drug. Diabetic status, a marker of higher thrombotic risk, did not influence this choice; however, bleeding risk was taken into account.

ANMCO/SIT Consensus Document: telemedicine for cardiovascular emergency networks.

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyse the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education, and legal aspects.

Management of diabetic patients hospitalized for acute coronary syndromes: a prospective multicenter registry.

BACKGROUND: Patients with diabetes mellitus and acute coronary syndrome (ACS) present an increased risk of adverse cardiovascular events. An Italian Consensus Document indicated 'three specific must' to obtain in this subgroup of patients: optimal oral antiplatelet therapy, early invasive approach and a tailored strategy of revascularization for unstable angina/non-ST-elevation-myocardial infarction (UA/NSTEMI); furthermore, glycemia at admission should be managed with dedicated protocols. AIM: To investigate if previous recommendations are followed, the present multicenter prospective observational registry was carried out in Lombardia during a 9-week period between March and May 2015. METHODS AND RESULTS: A total of 559 consecutive ACS patients (mean age 68.7 ±â€Š11.3 years, 35% ≥75 years, 50% STEMI), with 'known DM' (56%) or 'hyperglycemia', this last defined as blood glucose value ≥ 126 mg/dl at admission, were included in the registry at 29 hospitals with an on-site 24/7 catheterization laboratory. Patients with known diabetes mellitus received clopidogrel in 51% of the cases, whereas most patients with hyperglycemia (72%) received a new P2Y12 inhibitor: according to clinical presentation in case STEMI prasugrel/ticagrelor were more prescribed than clopidogrel (70 vs. 30%, P < 0.001); on the contrary, no significant difference was found in case of UA/NSTEMI (48 vs. 52%, P = 0.57).Overall, 96% of the patients underwent coronary angiography and 85% received a myocardial revascularization (with percutaneous coronary intervention in 92% of cases) that was however performed in fewer patients with known diabetes mellitus compared with hyperglycemia (79 vs. 90%, P = 0.001).Among UA/NSTEMI, 85% of patients received an initial invasive approach, less than 72 h in 80% of the cases (51% <24 h); no difference was reported comparing known diabetes mellitus to hyperglycemia. Despite similar SYNTAX score, patients with known diabetes mellitus had a higher rate of Heart Team discussion (29 vs. 12%, P = 0.03) and received a surgical revascularization in numerically more cases.Most investigators (85%) followed a local protocol for glycemia management at admission, but insulin was used in fewer than half of the cases; diabetes consulting was performed in 25% of the patients and mainly in case of known diabetes mellitus. CONCLUSION: Based on data of the present real world prospective registry, patients with ACS and known diabetes mellitus are treated with an early invasive approach in case of UA/NSTEMI and with a tailored revascularization strategy, but with clopidogrel in more cases; glycemia management is taken into account at admission.

[ANMCO/SIT Consensus document: Telemedicine and the emergency/urgency care network]. / Documento di consenso ANMCO/SIT: La telemedicina e la rete dell'emergenza-urgenza.

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. This consensus document aims to analyze the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education and legal aspects.

Mortality in primary angioplasty patients starting antiplatelet therapy with prehospital prasugrel or clopidogrel: a 1-year follow-up from the European MULTIPRAC Registry.

AIM: MULTIPRAC was designed to provide insights into the use and outcomes associated with prehospital initiation of antiplatelet therapy with either prasugrel or clopidogrel in the context of primary percutaneous coronary intervention. After a previous report on efficacy and safety outcomes during hospitalization, we report here the 1-year follow-up data, including cardiovascular (CV) mortality. METHODS AND RESULTS: MULTIPRAC is a multinational, prospective registry of patients with ST-elevation myocardial infarction (STEMI) from 25 hospitals in nine countries, all of which had an established practice of prehospital start of dual antiplatelet therapy in place. The key outcome was CV death at 1 year. Among 2,036 patients followed-up through 1 year, 49 died (2.4%), 10 during the initial hospitalization and 39 within 1 year after hospital discharge. The primary analysis was based on the P2Y12-inhibitor, used from prehospital loading dose through hospital discharge. Prasugrel (n=824) was more commonly used than clopidogrel (n=425). The observed 1-year rates for CV death were 0.5% with prasugrel and 2.6% with clopidogrel. After adjustment for differences in baseline characteristics, treatment with prasugrel was associated with a significantly lower risk of CV death than treatment with clopidogrel (odds ratio 0.248; 95% confidence interval 0.06-0.89). CONCLUSION: In STEMI patients from routine practice undergoing primary angioplasty, who were able to start oral antiplatelet therapy prehospital, treatment with prasugrel as compared to clopidogrel was associated with a lower risk of CV death at 1-year follow-up.

[Implementation of post-resuscitation care in adult cardiac arrest patients - Experts' opinion]. / Implementazione del trattamento post-rianimazione da arresto cardiaco nell'adulto - Opinione di un panel di esperti.

Current evidence on post-resuscitation care suffers from important knowledge gaps on new treatments and prognostication, mainly because of the lack of large multicenter randomized trials. However, optimization of post-resuscitation care is crucial, and the establishment of a treatment easy to be accepted and implemented locally, based on currently available evidence, is advisable. The present article is a multisociety experts' opinion on post-cardiac arrest that aims (i) to provide schematic and clear suggestions on therapeutic interventions to be delivered following resuscitation from cardiac arrest, so as to implement local protocols with a standardized post-resuscitation care; (ii) to suggest post-resuscitation therapeutic interventions that may result in improved survival with good neurological recovery, intended as a Cerebral Performance Category (CPC) score of 1-2; and finally (iii) to propose a pragmatic and schematic approach to post-resuscitation care for rapid initiation of intensive treatments (i.e. temperature management). The suggestions reported in this document are intended for adult patients resuscitated from both out-of-hospital and in-hospital cardiac arrest. They should be considered solely as an experts' opinion aimed to improve post-cardiac arrest care and they do not represent an official national guideline.

MULTInational non-interventional study of patients with ST-segment elevation myocardial infarction treated with PRimary Angioplasty and Concomitant use of upstream antiplatelet therapy with prasugrel or clopidogrel--the European MULTIPRAC Registry.

AIMS: Early initiation of dual antiplatelet therapy (DAPT) is guideline-recommended. MULTIPRAC was conducted to gain insights into the use patterns and outcomes of pre-hospital DAPT initiation with prasugrel or clopidogrel. METHODS AND RESULTS: MULTIPRAC is a multinational, multicentre, prospective registry enrolling 2053 ST-segment elevation myocardial infarction (STEMI) patients. Patients were grouped according to adherence to the initially prescribed thienopyridine. Pre-hospital use of prasugrel increased from 12.5% to 67.1% at study end. Prasugrel compared to clopidogrel-initiated patients more often adhered to the medication through discharge (87% vs. 38%) whereas 49% of the clopidogrel-initiated patients were switched to prasugrel. Patients who continued on clopidogrel were substantially older. In-hospital mortality was 0.5%, early stent thrombosis 0.1%. The major adverse cardiac events (MACE) rate was 1.6% in prasugrel-treated vs. 2.3% in clopidogrel-treated patients (adjusted OR 0.749, 95% CI [0.285-1.968]). Non-coronary artery bypass graft (non-CABG) bleeding occurred in 4.1% of prasugrel-treated vs. 6.1% of clopidogrel-treated patients (adjusted OR 0.686 [0.349-1.349]). Pre-percutaneous coronary intervention (PCI) TIMI flow 2-3 was seen in 38.7% treated with prasugrel vs. 35.6% with clopidogrel (adjusted OR 1.170 [0.863-1.585]). Post PCI ST-segment resolution ⩾50%, was 71.6% with prasugrel vs. 65.0% with clopidogrel (adjusted OR 1.543 [1.138-2.093], p=0.0052). CONCLUSIONS: MULTIPRAC demonstrated a steady increase in prasugrel use over time without an increase in bleeding rates compared to clopidogrel. ST resolution was more pronounced with prasugrel. Switching between antiplatelet drugs occurs frequently. The low rates of MACE, in-hospital mortality and bleeding, suggests that pre-hospital loading with thienopyridines is confined to low-risk patients. These results emphasize the need for more randomized pre-hospital studies and should be seen in the context of upcoming randomized trials involving pre-hospital antiplatelet therapies.

Amplitude spectrum area to guide defibrillation: a validation on 1617 patients with ventricular fibrillation.

BACKGROUND: This study sought to validate the ability of amplitude spectrum area (AMSA) to predict defibrillation success and long-term survival in a large population of out-of-hospital cardiac arrests. METHODS AND RESULTS: ECGs recorded by automated external defibrillators from different manufacturers were obtained from patients with cardiac arrests occurring in 8 city areas. A database, including 2447 defibrillations from 1050 patients, was used as the derivation group, and an additional database, including 1381 defibrillations from 567 patients, served as validation. A 2-second ECG window before defibrillation was analyzed, and AMSA was calculated. Univariable and multivariable regression analyses and area under the receiver operating characteristic curve were used for associations between AMSA and study end points: defibrillation success, sustained return of spontaneous circulation, and long-term survival. Among the 2447 defibrillations of the derivation database, 26.2% were successful. AMSA was significantly higher before a successful defibrillation than a failing one (13 ± 5 versus 6.8 ± 3.5 mV-Hz) and was an independent predictor of defibrillation success (odds ratio, 1.33; 95% confidence interval, 1.20-1.37) and sustained return of spontaneous circulation (odds ratio, 1.22; 95% confidence interval, 1.17-1.26). Area under the receiver operating characteristic curve for defibrillation success prediction was 0.86 (95% confidence interval, 0.85-0.88). AMSA was also significantly associated with long-term survival. The following AMSA thresholds were identified: 15.5 mV-Hz for defibrillation success and 6.5 mV-Hz for defibrillation failure. In the validation database, AMSA ≥ 15.5 mV-Hz had a positive predictive value of 84%, whereas AMSA ≤ 6.5 mV-Hz had a negative predictive value of 98%. CONCLUSIONS: In this large derivation-validation study, AMSA was validated as an accurate predictor of defibrillation success. AMSA also appeared as a predictor of long-term survival.

[Multidisciplinary management of patients with acute coronary syndrome and diabetes mellitus: from antithrombotic therapy to treatment of hyperglycemia]. / Gestione multidisciplinare del paziente con sindrome coronarica acuta e diabete mellito: dalla terapia antitrombotica al trattamento dell'iperglicemia.

Patients with diabetes mellitus (DM) and acute coronary syndromes (ACS) present a significantly higher risk of developing ischemic complications as compared to nondiabetic patients. Multiple mechanisms contribute to DM patients' enhanced prothrombotic status, including impaired fibrinolysis and coagulation, as well as endothelial and platelet dysfunction. Therefore, antithrombotic agents generally, and antiplatelet agents in particular, represent a logical secondary preventive strategy to reduce the risk of recurrent ischemic events in DM patients with ACS. However, DM patients often show attenuated responses to antiplatelet therapies for ACS patients. DM patients benefit from early coronary angiography and revascularization. Although randomized clinical trials have demonstrated that surgical revascularization is associated with an improved prognosis compared to percutaneous coronary intervention, a tailored revascularization strategy should be provided for each patient. The type of revascularization should be decided on the basis of SYNTAX score, surgical risk profile, and feasibility of total arterial revascularization in case of surgery. An accurate diagnosis and prompt treatment of hyperglycemia should also be provided for all patients. The present multidisciplinary document provides practical recommendations regarding diagnosis of DM and the management of hyperglycemia, from the acute phase to discharge. It is aimed at favoring early detection of hyperglycemia and identification of diabetic patients so as to provide adequate glucose control.

[Cardiac arrest management: any news? When the literature does not meet clinical practice]. / Quali novità nella gestione dell'arresto cardiaco. Quando la letteratura non incontra la pratica clinica.

The percentage of patients transported alive to hospital after an out-of-hospital cardiac arrest has increased in recent years thanks to growing population education. In 2010 the International Liaison Committee on Resuscitation (ILCOR) has published new guidelines for the management of cardiac arrest. These guidelines present several new features, but cardiac compression remains the mainstay of optimal cardiopulmonary resuscitation. Use of atropine and endotracheal drugs are no longer recommended, and early ultrasound evaluation and intraosseous vascular access are new methods now standardized. The best chances of improving patient prognosis are in the period immediately after return of spontaneous circulation (ROSC). It is well known that most patients who experience cardiac arrest without an obvious extra-cardiac cause, show significant underlying coronary artery disease. Hence, the importance of widespread and early use of primary percutaneous coronary intervention. An early percutaneous coronary intervention was found to be crucial not only in increasing survival, but also in improving neurological outcome at discharge. The ILCOR consensus statement suggests that therapeutic hypothermia should be considered as the standard treatment for comatose patients resuscitated from cardiac arrest. This was supported by the evidence that moderate hypothermia is the only treatment for post-ROSC as it is associated with a significant increase in survival. For this reason, it should be started as early as possible, preferably in the pre-hospital setting. Despite the bulk of available literature on the early treatment of cardiac arrest, the studies carried out in Italy indicate that most post-ROSC patients are undertreated or untreated. This results in poor resource utilization with a high social and personal impact that involves both the patients and their families. Teamwork activities addressing the chain of survival become a fundamental tool for the treatment of resuscitated patients. Given the crucial importance of the time elapsing from collapse to cardiopulmonary resuscitation in terms of final prognosis, efforts should be made to promote the "culture of cardiopulmonary resuscitation" not only among health professionals, but also among the general population.

Mortality and ST resolution in patients admitted with STEMI: the MOMI survey of emergency service experience in a complex urban area.

BACKGROUND: Since 2001, the urban area of Milan has been operating a network among 23 cardiac care units, the 118 dispatch centre (national free number for medical emergencies), and the county government health agency called Group for Prehospital Cardiac Emergency. METHODS AND RESULTS: In order to monitor the network activity, time to treatment, and clinical outcome, a periodic survey, called MOMI(2), was repeated two or three times a year. Each survey lasted 30 days and was repeated in comparable periods. Data were stratified for hospital admission mode. We collected data concerning 708 consecutive ST-elevation myocardial infarction (STEMI) patients (male 72.6%; mean age 64.4 years). In these six surveys, we observed a high rate of primary percutaneous coronary intervention (73.2%) and a mortality rate of 6.3%. Using advanced statistical models, we identified age, Killip class, and the symptom onset-to-balloon time as most relevant prognostic factors. Nonparametric test showed that the modality of hospital admittance was the most critical determinant of door-to-balloon time. 12-lead ECG tele-transmission and activation of a fast track directly to the catheterization laboratory are easy action to reduce time to treatment. CONCLUSIONS: The experience of the Milan network for cardiac emergency shows how a network coordinating the community, rescue units, and hospitals in a complex urban area and making use of medical technology contributes to the health care of patients with STEMI.