Consensus guidelines for interventional cardiology services delivery during covid-19 pandemic in Australia and new Zealand.

The global coronavirus disease (COVID-19) pandemic poses an unprecedented stress on healthcare systems internationally. These Health system-wide demands call for efficient utilisation of resources at this time in a fair, consistent, ethical and efficient manner would improve our ability to treat patients. Excellent co-operation between hospital units (especially intensive care unit [ICU], emergency department [ED] and cardiology) is critical in ensuring optimal patient outcomes. The purpose of this document is to provide practical guidelines for the effective use of interventional cardiology services in Australia and New Zealand. The document will be updated regularly as new evidence and knowledge is gained with time. Goals Considerations.

Long-term outcomes in patients with restrictive filling following ST-segment elevation myocardial infarction.

This study evaluated the effect of restrictive filling pattern (RFP) on 5-year outcomes in patients following ST-segment elevation myocardial infarction (STEMI). A hundred STEMI patients treated either by rescue or primary percutaneous coronary intervention with an echocardiogram performed within 6 weeks of STEMI comprised the study group. Creatinine kinase (CK) and left ventricular ejection fraction were independent determinants of RFP, and RFP was an independent predictor of cardiac and all-cause mortality at median follow up of 5 years.

The pharmaco-invasive approach to STEMI: when should fibrinolytic-treated patients go to the "cath lab"?

Although primary percutaneous coronary intervention (PCI) in clinical trials has lower rates of reinfarction, stroke and mortality than fibrinolytic therapy, because of system delays in routine practice, field triage and prehospital administration of fibrinolytic therapy may lead to similar clinical outcomes, especially in those patients who present in the first 2 h after symptom onset. Necessary for these outcomes is the liberal use of both rescue PCI and in-hospital revascularisation. Non-invasive prediction of failed reperfusion may be enhanced by the use of ST recovery, patient characteristics and troponin T levels, measured by point-of-care assays. This review focuses on the timing of, and indications for, an invasive strategy after fibrinolytic therapy, including that for failed pharmacological reperfusion.

Nephrotoxic effects of iodixanol and iopromide in patients with abnormal renal function receiving N-acetylcysteine and hydration before coronary angiography and intervention: a randomized trial.

BACKGROUND: The use of contrast agents during coronary intervention can result in nephropathy, particularly in patients with renal dysfunction. We aimed to determine whether the use of iso-osmolar iodixanol is less nephrotoxic than that of low-osmolar iopromide when patients are adequately prehydrated and have received N-acetylcysteine. METHODS: We conducted a randomized, double-blind, multicentre study of patients with impaired renal function undergoing a coronary interventional procedure. Primary end-point was the incidence of contrast-induced nephropathy (CIN) on day 2, defined as an increase in serum creatinine concentration of > or =44 micromol/L (0.5 mg/dL) or by a relative increase of > or =25% from baseline. Secondary end-points included peak increase in serum creatinine between baseline and day 7. RESULTS: Of 191 patients recruited, 15% (95% CI: 8-22) of the patients receiving iopromide and 12% (95% CI: 5-19) of the patients receiving iodixanol developed CIN (95% CI of the difference: 13 to -7, P = 0.56). When including peak serum creatinine on day 7, CIN developed in 23% of patients receiving iopromide and in 27% of patients receiving iodixanol (95% CI of the difference: 8 to -16, P = 0.48). The peak increase in serum creatinine concentration at day 7 was similar in both groups (patients receiving iopromide, 18.4 +/- 24.4 micromol/L, vs patients receiving iodixanol, 21.9 +/- 24.2 micromol/L; P = 0.33). CONCLUSION: There remains a high incidence of CIN despite prehydration and routine use of N-acetylcysteine in patients with pre-existing renal dysfunction undergoing coronary interventional procedures. Although our study is underpowered, iodixanol was not associated with a statistically significant lower incidence of CIN when compared with iopromide.

The pharmaco-invasive approach to STEMI: when should fibrinolytic-treated patients go to the "cath lab"?

Although primary percutaneous coronary intervention (PCI) in clinical trials has lower rates of reinfarction, stroke and mortality than fibrinolytic therapy, because of system delays in routine practice, field triage and prehospital administration of fibrinolytic therapy may lead to similar clinical outcomes, especially in those patients who present in the first 2 h after symptom onset. Necessary for these outcomes is the liberal use of both rescue PCI and in-hospital revascularisation. Non-invasive prediction of failed reperfusion may be enhanced by the use of ST recovery, patient characteristics and troponin T levels, measured by point-of-care assays. This review focuses on the timing of, and indications for, an invasive strategy after fibrinolytic therapy, including that for failed pharmacological reperfusion.

How compliant are we with guidelines for coronary angiography in clinical practice?

BACKGROUND: The American College of Cardiology and American Heart Association have published guidelines for coronary angiography. We evaluated the compliance rate with these guidelines in clinical practice, its correlation to results of angiography and aimed to identify problem areas of non-compliance. METHODS: We prospectively evaluated 802 consecutive referrals for coronary angiography over 5 months in 2002 in a tertiary referral hospital. These referrals were assessed by two independent reviewers blinded to the results of angiography. RESULTS: Patient age was 62 +/- 11 years (522 men, 433 inpatients, 369 day-only patients). Referrals were outside published guidelines in 34.3 and 36.2% as evaluated by the two reviewers (concordance rate 88.2%, kappa = 0.74, p < 0.001). Intraobserver agreement was 97.5%. The rate of angiography showing either normal arteries or only minor diseases (<50%) was higher for referrals outside guidelines (68.4 vs 22.6%, P < 0.001). Compliance rate was high with indications of non-ST-elevation myocardial infarction (99.2%) and ST-elevation myocardial infarction (95.8%), valvular disease (80%) and arrhythmia (80%). Compliance rate was lower with assessment of dyspnoea or heart failure (74.3%) and before non-cardiac surgery (72.7%) and was particularly low with assessment of chest pain (53.2%). Younger age (odds ratio (OR) 1.04, P < 0.001), female sex (OR 2.67, P < 0.001), day-only procedure (OR 2.27, P < 0.001) and non-invasive cardiologist referrer (OR 1.41, P = 0.046) were independent predictors of non-compliance. CONCLUSION: Referrals for coronary angiography were outside guidelines in a significant proportion of patients. Rate of negative angiography was higher when the referrals were outside guidelines. Problematic areas of non-compliance could be identified. Measures specifically targeting these areas may be more effective in improving the overall guideline compliance in clinical practice.

Use of a quantitative point-of-care test for the detection of serum cardiac troponin T in patients with suspected acute coronary syndromes.

We compared a third generation quantitative cardiac troponin T (cTnT) point-of-care testing (POCT) from Roche Diagnostics with the laboratory assay (Roche Elecsys 2010 immunoassay analyser). Heparin-treated blood and serum were collected simultaneously in 133 unselected patients (mean age 62 +/- 14 years, 38% females) presenting to our hospital with possible cardiac chest pain. Results of the POCT were measured against the laboratory-based assay considered as the gold standard. There were 18 POCT positive versus 24 laboratory assay positive (> or = 0.03 ng/mL) patients. POCT was falsely negative in six patients, with values between 0.03 and 0.1 ng/mL. The POCT had a sensitivity of 75%, specificity of 100%, positive predictive value of 100%, negative predictive value of 95% and a total accuracy of 95%; kappa = 0.831 (P < 0.001). There was good correlation between the values of POCT and the laboratory assay: Y = 1.195X + 0.002, r2 = 0.94 (P < 0.0001). Whereas cTnT levels > 0.1 mg/mL were reliably detected with this current generation of POCT, cTnT levels between 0.03 and 0.10 ng/mL were not. Future generations of devices will need to improve sensitivity to reliably risk stratify patients with suspected acute coronary syndromes.

[Sixty-four cases of percutaneous coronary angioplasty on saphenous vein bypass grafts].

OBJECTIVE: To evaluate the early clinical result of percutaneous transluminal coronary intervention (PCI) and stenting on saphenous vein grafts. METHODS: Percutaneous intervention was performed in 91 saphenous vein grafts in 64 patients. The data of clinical results during operation and hospitalization and that of other interventional assisting device were recorded in database and were analyzed. RESULTS: The success rate of operation was 95.3%, non-Q wave myocardial infarction occurred in 1 patient (1.6%) and temporary no-reflow phenomenon occurred in 4 patients (6.3%) during operation. Reduced antegrade flow and ventricular fibrillation happened in 1 patient after stenting and normal antegrade flow obtained after cardiac compression and tracheal intubation and insertion of IABP. The distal protection devices were used in 7 patients (10.9%), X-sizer extraction system in 4 patients. Platelet glycoprotein IIb/IIIa receptor blockers were administered in 25 patients (35.9%). Non-Q wave myocardial infarction occurred in two cases, the incidence of major adverse clinical event was 3.1% during the period of hospitalization. CONCLUSIONS: The instant success rate of PTCA and stenting of saphenous vein bypass grafts is high and recent clinical result is promising, but the middle and long term results remain to be further followed. The use of distal embolic protection device and GPIIb/IIIa receptor blockers may improve its prognosis.

A novel approach for crossing a virtually occluded vessel using ultra-low-profile balloon backup.

We discuss a case in which a novel ultra-low-profile angioplasty balloon was used to provide wire backup by advancing the uninflated balloon nose into the entry point of a virtually occluded lesion. This enabled crossing of the lesion, and demonstrates how an improved balloon design can directly lead to improved clinical outcomes.

Use of the multifunction probing catheter as an adjunctive device for occluded vein graft intervention.

We describe the use of the multifunction probing catheter (Schneider, Bulach, Switzerland) as an adjunct to conventional techniques in the treatment of a recent vein graft occlusion by thrombus, in order to highlight a possible further use for this device.

Second generation bifurcation stent: the rapid development of device technology.

A 57-year-old male with unstable angina and an eccentric 88% diameter stenosis of the left anterior descending artery prior to, and involving the first diagonal branch was treated with the 2nd generation Jomed Sidebranch stent (Jomed, Randingengen, Germany). This case outlines the improvements in this novel stent design and demonstrates the rapid advance of device design.

Hemorrhagic complications of intravenous heparin use.

To document the incidence of bleeding complications occurring in patients admitted to a cardiology service treated with intravenous heparin and to identify the major risk factors for these adverse events. Intravenous heparin is effective treatment for a variety of cardiologic conditions but is associated with a number of adverse effects, including hemorrhage. During the study, 1,253 consecutive patients were admitted for acute cardiac care and of these, 416 were treated with intravenous heparin. A total of 39 complications occurred in 37 heparin-treated patients (8.9%), of which 23 were hemorrhagic complications occurring in 21 heparin-treated patients (5.5%). Of these hemorrhagic complications, 12 were directly related to a vascular access site and 11 were apparently "spontaneous" hemorrhages. There was no apparent relation between the dose (mean 1,021 U/hour [range 531 to 1,882]) or duration (6.7 +/- 5.7 days) of heparin therapy and hemorrhagic complications. In a multivariate analysis, female gender (odds ratio [OR] 4.76 [14.39 to 1.56]; p = 0.006), recent thrombolytic therapy (OR 12.9 [4.1 to 40.6]; p <0.0001), and a reduced admission hemoglobin (OR 1.41 [0.52 to 0.97]; p = 0.031) were significantly predictive of a hemorrhagic event. The incidence of cardiac catheterization procedures was not significantly higher in the complication group (OR 3.9 [0.84 to 18.4]; p = 0.082). Aspirin therapy, admission platelet count, and weight were noncontributory. Hemorrhagic complications occurred in 5.5% of patients receiving a continuous infusion of heparin. The use of thrombolytic therapy, female gender (independent of weight), and a reduced admission hemoglobin were significant independent predictors of hemorrhagic events.

Routine platelet transfusion in patients undergoing emergency coronary bypass surgery after receiving abciximab.

Abciximab has been shown to reduce the ischemic complications of high-risk angioplasty procedures. The appropriate management of patients who have received abciximab and require emergency coronary artery bypass surgery after failed coronary angioplasty is as yet undetermined. We present the outcomes of a small series of such patients who were given platelet transfusions before or during cardiopulmonary bypass.

Primary angioplasty for acute myocardial infarction.

The use of thrombolytic therapy has been widely accepted for the treatment of acute myocardial infarction. Despite improving mortality, thrombolytic therapy may be contraindicated in many patients presenting with myocardial infarction and is associated with a small, yet significant risk of hemorrhagic sequelae. This article outlines the rationale behind reperfusion therapy, the use of pharmacological thrombolysis and the role of adjunctive angioplasty. The potential advantages of a therapeutic strategy of primary angioplasty, instead of thrombolysis, are discussed. These include anatomical definition, risk stratification, reduced recurrent ischemia, enhanced coronary perfusion and improved coronary patency. The randomized trials in which primary angioplasty and thrombolytic therapy were compared are reviewed. We conclude that angioplasty results in a reduction of short-term mortality and nonfatal reinfarction and therefore advocate the routine use of coronary angioplasty as a primary reperfusion strategy for acute myocardial infarction. The potential limitations of primary angioplasty in the community hospital setting are discussed. Finally, we examine the roles of adjunctive mechanical (e.g. stents) and pharmacological (e.g. Abciximab) means of further enhancing outcomes after primary angioplasty.

Electrocardiographic measurement of infarct size after thrombolytic therapy.

OBJECTIVES: We examined the utility of the 32-point QRS score from the 12-lead electrocardiogram (ECG) for measurement of the ischemic risk region and infarct size in patients receiving thrombolytic therapy. BACKGROUND: The QRS score offers a means of evaluating the therapeutic benefit of thrombolytic therapy by comparing final infarct size with the initial extent of ischemic myocardium. METHODS: The study included 38 patients (34 men, 4 women; mean [+/-SD] age 54 +/- 10 years) with a first infarction (18 anterior, 20 inferior). The maximal potential QRS score (QRS0) was assigned to all leads with >/= 100-microV ST elevation on the initial ECG. The QRS scores were calculated at 7 and 30 days after infarction. Left ventricular ejection fraction was measured by radionuclide ventriculography at 1 month. Twenty-eight patients had thallium (Tl)-201 and technetium (Tc)-99m pyrophosphate tomographic measurement of the ischemic region and infarct size. RESULTS: The QRS0 was 10.3 +/- 3.1 (mean +/- SD) for anterior and 10.4 +/- 3.5 for inferior infarcts. The QRS scores were similar at 7 and 30 days for both anterior (5.6 +/- 3.4 vs. 5.5 +/- 3.4) and inferior infarcts (3.7 +/- 2.6 vs. 2.9 +/- 2.2). The day 7 QRS score and ejection fraction at 1 month were inversely correlated (r = -0.74, p < 0.01). The Tl-201 perfusion defect was 34 +/- 11% of the left ventricle for anterior and 32 +/- 7% for inferior infarcts. Subsequent Tc-99m pyrophosphate infarct size was 15 +/- 9% of the left ventricle for anterior and 17 +/- 9% for inferior infarcts. The QRS0 was correlated with the extent of the Tl-201 perfusion defect (r = 0.79, p < 0.001), and the day 7 QRS score was correlated with Tc-99m pyrophosphate infarct size (r = 0.79, p < 0.005). CONCLUSIONS: The 32-point QRS score can provide useful immediate measurements of the ischemic risk region and subsequent infarct size.