Outcomes of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients with previous coronary bypass surgery.

OBJECTIVES: This study sought to determine the contemporary clinical characteristics and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and previous coronary artery bypass graft (CABG), including those with a saphenous vein graft culprit lesion. BACKGROUND: The outcome of STEMI patients with previous CABG is reported to be inferior to those without previous CABG, but limited data is available from the primary percutaneous coronary intervention era. METHODS: Data was extracted from a large, regional STEMI system's prospective database, which contained 3,542 unique STEMI episodes from March 4, 2003 through April 22, 2012. RESULTS: Previous CABG was present in 249 patients (7%). Despite higher comorbidity, patients with versus those without previous CABG had similar in-hospital (4.8% vs. 5.2%; p = 0.82) and 1-year (10.8% vs. 9.1%; p = 0.36) mortality, but 5-year (24.9% vs. 14.2%; p < 0.001) mortality was higher. Patients with previous CABG have similar door-to-balloon times. The culprit vessel was the saphenous vein graft in 84 patients (34%), a native vessel in 104 (42%), with no clear culprit in 59 (24%). The left internal mammary artery graft was not a culprit in any patient. Mortality at 30 days (8.3% vs. 3.9% vs. 1.7%, p = 0.19) and 1 year (14.3% vs. 9.0% vs. 6.8%; p = 0.35) was higher (but not statistically) with a saphenous vein graft culprit and was equivalent at 5 years (25.0% vs. 26.0% vs. 20.3%; p = 0.71). CONCLUSIONS: Patients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.

ST-elevation myocardial infarction diagnosed after hospital admission.

BACKGROUND: Treatment times for ST-elevation myocardial infarction (STEMI) patients presenting to percutaneous coronary intervention hospitals have improved dramatically over the past 10 years, particularly for patients using emergency medical services. Limited data exist regarding treatment times and outcomes for patients who develop STEMI after hospital admission. METHODS AND RESULTS: With the use of a comprehensive prospective regional STEMI program database, we evaluated the characteristics and outcomes for patients who develop STEMI after hospital admission. Of the 3795 consecutive STEMI patients treated by the use of the Minneapolis Heart Institute regional STEMI program from March 2003 to January 2013, 990 (26.1%) presented initially to the percutaneous coronary intervention facility, including 640 arriving via emergency medical services, 267 self/family driven, and 83 already admitted to the hospital. Patients with in-hospital presentation were older with higher body mass indexes, were more likely to have hypertension, and to present with pre-percutaneous coronary intervention cardiac arrest and cardiogenic shock. Door-to-balloon times (diagnostic ECG-to-balloon for in-hospital patients) were longer than for patients using emergency medical services (76 versus 51 minutes; P<0.001), but similar to self/family-driven patients (76 versus 66 minutes; P=0.13). In-hospital patients had longer lengths of stay (5 versus 3 versus 3 days; P<0.001) and higher 1-year mortality (16.9% versus 10.3% versus 7.1%; P=0.032). These patients frequently had high-risk and complex reasons for admission, including 30.1% with acute coronary syndrome, 22.9% postsurgery, 13.3% respiratory failure, and 8.4% ventricular fibrillation. CONCLUSIONS: Patients who develop STEMI while in-hospital represent a unique, high-risk subset of patients. They have increased treatment time and lengths of stay and higher mortality rates than the patients presenting via emergency medical services or who are self/family driven.

Feasibility of bedside thoracic ultrasound in the helicopter emergency medical services setting.

INTRODUCTION: Bedside thoracic ultrasound has been shown to be a valuable diagnostic tool in the emergency department. The purpose of this study was to evaluate the feasibility of bedside thoracic ultrasound in the prehospital HEMS setting. SETTING: Air ambulance helicopters during patient transportation. METHODS: This was a prospective pilot study. 71 consecutive, nonpregnant patients over 18 years old were enrolled. While in flight, providers completed limited bedside thoracic ultrasounds with the patient supine and recorded their interpretation of the presence or absence of the ultrasonographic sliding lung sign on a closed data-set instrument. RESULTS: 41 (58%) of the eligible patients had a recorded thoracic ultrasound acquired in flight. The level of agreement in image interpretation between the flight crew and expert reviewer was substantial (Kappa 0.67, CI 0.44-0.90). The reviewer rated 54% of all images as "good" in quality. The most common reason cited for not completing the ultrasound was lack of enough provider time or space limitations within the aircraft cabin. CONCLUSION: The results of this study suggest that, with limited training, bedside thoracic ultrasound image acquisition and interpretation for the sliding lung sign in the HEMS setting is feasible.

The Critical Imperative: Prehospital Management of the Patient with ST-Elevation Myocardial Infarction.

Prehospital care is critical to achieve the goal of timely reperfusion in patients with ST-elevation myocardial infarction. Prehospital care is delivered by emergency medical services (EMS) personnel, which include emergency medical dispatchers, first responders, and ambulance response. There is considerable variation in the training and capabilities of the EMS providers in the United States depending on the location (ie, rural vs urban) and local jurisdictions. In this article, the key components of prehospital care of the patient with ST-elevation myocardial infarction and the various levels of training and capabilities of EMS providers are discussed.