[Evaluation of a public health programme: direct Clopidogrel administration by cardiology units in acute myocardial infarction]. / Valutazione di un intervento di sanità pubblica: somministrazione diretta del trattamento con Clopidogrel nell'infarto miocardico acuto.

OBJECTIVES: to compare the benefit of a personalised outpatient therapy prescribed upon discharge by the cardiology unit to the patients undergoing a percutaneous coronary intervention with drug-eluting stent or bare-metal stent vs. the usual practice. DESIGN: controlled, multicentre, non-randomized study that enrolled patients who underwent coronary stent implantation and treated in the year after stent implantation with two protocols: the treatment group received Clopidogrel directly from the cardiology unit at each monitoring visit; the control group received a prescription for outpatient treatment through the standard retail pharmacy channel. SETTING AND PARTICIPANTS: the recruited centres adopting the new treatment protocol are Magenta, Legnano, and Rho (ASL Milano1, Magenta - Lombardy Region, Northern Italy), with 477 patients included; the recruited centres following for the standard protocol are Niguarda and San Carlo (ASL Milano), with 307 patients included. We identified all patients aged ≥40 years, discharged after coronary stent implantation between January 1st, 2010 and March 31st, 2011, and followed for 1 year. MAIN OUTCOME MEASURES: all coronary events, second coronary interventions or deaths in the year after hospital discharge. RESULTS: we found differences between the two treatments in relation with coronary events: hazard ratio (HR) for the control group in patients with ST-elevation myocardial infarction (STEMI) is 3.32 (95%CI 1.67- 6.62), HR in patients with non-ST elevation myocardial infarction (NSTEMI) is 2.44 (95%CI 1.07-5.57). The compliance at 1 year is 80% in the treated group vs. 70% in the control group, respectively (p-value <0.01). CONCLUSIONS: the application of the therapeutic plan, governed by the interventional cardiology, increases treatment adherence and reduces the risk of cardiovascular events subsequent to the insertion of a stent. It is crucial, therefore, to improve the adherence to dual antiplatelet therapy by using high levels of integration between inpatient and outpatient care to reduce adverse health outcomes during post-surgery phase and to ensure the taking in charge of the patient.

[Remote monitoring of implantable cardiac devices: health technology assessment ]. / Monitoraggio remoto dei dispositivi cardiaci impiantabili: health technology assessment.

Clinical follow-up of patients with cardiac implantable electronic devices is challenging because of the increasing technical complexity of devices and clinical complexity of patients. Remote monitoring (RM) offers the opportunity to optimize clinic workflow and to improve device monitoring and patient management by reducing in-hospital visits, physician and nurse time required for patient follow-up, and hospital and social costs. Continuous RM may lead to early detection of device malfunctions and clinical events, such as arrhythmias and heart failure. Early reaction may improve patient outcome. RM is easy to use and patients show a high level of acceptance and satisfaction. Implementing RM in daily practice may require changes in clinical workflow. Primary nursing-based models have demonstrated the best results. In spite of a favorable cost-benefit ratio, RM reimbursement still represents an issue in several European countries, including Italy, which limits widespread RM utilization. The fee-for-service payment approach, the global budget for device patient follow-up and/or integrated care packages for heart failure management represent the keys to introduce reimbursement and to improve patient care, while reducing healthcare costs.

[Upstream administration of oral antiplatelet agents in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention]. / Utilizzo upstream degli antiaggreganti piastrinici orali nei pazienti con infarto miocardico acuto con sopraslivellamento del tratto ST trattati con angioplastica primaria.

Current guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) recommend the administration of dual antiplatelet therapy with aspirin and an ADP receptor blocker "as early as possible" before angiography (upstream), though this suggestion is not based on the results of randomized clinical trials designed to investigate pre-hospital rather than in-hospital drug administration. The present review analyzed randomized clinical trials, registries and observational studies that assessed clopidogrel, prasugrel and ticagrelor administration in STEMI patients undergoing primary PCI to evaluate if their upstream use may be justified in clinical practice. A significant difference favoring early clopidogrel administration has been demonstrated in observational studies. No evidence is available for prasugrel and ticagrelor; however, the initial delay of their antiplatelet effect in STEMI patients could support an upstream strategy to obtain complete platelet inhibition in the first hours after PCI and prevent major adverse events (e.g., stent thrombosis) despite an increased risk of major bleeding, particularly in case of urgent bypass surgery. Data from specifically designed randomized clinical trials are warranted to establish whether early administration of prasugrel and ticagrelor may favor reperfusion and improve clinical outcome with an acceptable risk-benefit ratio.

Cost-utility analysis of the EVOLVO study on remote monitoring for heart failure patients with implantable defibrillators: randomized controlled trial.

BACKGROUND: Heart failure patients with implantable defibrillators place a significant burden on health care systems. Remote monitoring allows assessment of device function and heart failure parameters, and may represent a safe, effective, and cost-saving method compared to conventional in-office follow-up. OBJECTIVE: We hypothesized that remote device monitoring represents a cost-effective approach. This paper summarizes the economic evaluation of the Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators (EVOLVO) study, a multicenter clinical trial aimed at measuring the benefits of remote monitoring for heart failure patients with implantable defibrillators. METHODS: Two hundred patients implanted with a wireless transmission-enabled implantable defibrillator were randomized to receive either remote monitoring or the conventional method of in-person evaluations. Patients were followed for 16 months with a protocol of scheduled in-office and remote follow-ups. The economic evaluation of the intervention was conducted from the perspectives of the health care system and the patient. A cost-utility analysis was performed to measure whether the intervention was cost-effective in terms of cost per quality-adjusted life year (QALY) gained. RESULTS: Overall, remote monitoring did not show significant annual cost savings for the health care system (€1962.78 versus €2130.01; P=.80). There was a significant reduction of the annual cost for the patients in the remote arm in comparison to the standard arm (€291.36 versus €381.34; P=.01). Cost-utility analysis was performed for 180 patients for whom QALYs were available. The patients in the remote arm gained 0.065 QALYs more than those in the standard arm over 16 months, with a cost savings of €888.10 per patient. Results from the cost-utility analysis of the EVOLVO study show that remote monitoring is a cost-effective and dominant solution. CONCLUSIONS: Remote management of heart failure patients with implantable defibrillators appears to be cost-effective compared to the conventional method of in-person evaluations. TRIAL REGISTRATION: ClinicalTrials.gov NCT00873899; http://clinicaltrials.gov/show/NCT00873899 (Archived by WebCite at http://www.webcitation.org/6H0BOA29f).

Home-based telesurveillance program in chronic heart failure: effects on clinical status and implications for 1-year prognosis.

BACKGROUND: Studies focusing on the effects of telemanagement programs for chronic heart failure (CHF) on functional status are lacking, and the prognostic value of the clinical response to the programs is unknown. In the Lombardy region of Italy, a home-based telesurveillance program (HTP) including multidisciplinary management and remote telemonitoring for patients with CHF was introduced in 2000 and was formally adopted, as part of the services delivered by the regional healthcare system, in 2006. This article reports the effect of the HTP on the functional status and quality of life and describes the main outcomes observed within 1 year from the end of the program. MATERIALS AND METHODS: Six-month variations of New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), 6-min walking distance (6MWD), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score were evaluated in 602 CHF patients. Patients showing at least two of the following conditions-NYHA class reduction, increase in LVEF ≥5%, 6MWD >30 m, and a reduction of >24 points of MLHFQ-were defined as "responders." One-year events included unplanned cardiovascular readmissions and mortality. RESULTS: A significant improvement in NYHA class, LVEF, 6MWD, and MLHFQ was observed. Clinical events occurred in 24.1% of non-responders and in 15.9% of responders (p=0.03). An unfavorable response to the program, the presence of an implantable cardioverter defibrillator, and multiple comorbidities were predictors of poor outcome. CONCLUSIONS: The HTP was effective in improving CHF patient functional status, and an unsuccessful response to the intervention seems to be an independent marker of poor prognosis.

Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study.

BACKGROUND: Heart failure patients with implantable cardioverter-defibrillators (ICDs) or an ICD for resynchronization therapy often visit the hospital for unscheduled examinations, placing a great burden on healthcare providers. We hypothesized that Internet-based remote interrogation systems could reduce emergency healthcare visits. METHODS AND RESULTS: This multicenter randomized trial involving 200 patients compared remote monitoring with standard patient management consisting of scheduled visits and patient response to audible ICD alerts. The primary end point was the rate of emergency department or urgent in-office visits for heart failure, arrhythmias, or ICD-related events. Over 16 months, such visits were 35% less frequent in the remote arm (75 versus 117; incidence density, 0.59 versus 0.93 events per year; P=0.005). A 21% difference was observed in the rates of total healthcare visits for heart failure, arrhythmias, or ICD-related events (4.40 versus 5.74 events per year; P<0.001). The time from an ICD alert condition to review of the data was reduced from 24.8 days in the standard arm to 1.4 days in the remote arm (P<0.001). The patients' clinical status, as measured by the Clinical Composite Score, was similar in the 2 groups, whereas a more favorable change in quality of life (Minnesota Living With Heart Failure Questionnaire) was observed from the baseline to the 16th month in the remote arm (P=0.026). CONCLUSIONS: Remote monitoring reduces emergency department/urgent in-office visits and, in general, total healthcare use in patients with ICD or defibrillators for resynchronization therapy. Compared with standard follow-up through in-office visits and audible ICD alerts, remote monitoring results in increased efficiency for healthcare providers and improved quality of care for patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00873899.

Healthcare continuity from hospital to territory in Lombardy: TELEMACO project.

OBJECTIVES: To verify implementation and use of TELEMACO (TELEMedicina Ai piccoli COmunilombardi; http://www.telemaco.regione.lombardia.it/), which provides specialized continuity of care with innovative healthcare services in remote areas of the Lombardy region of Italy; to design a network in the territory for sharing of continuityof- care programs; and to allow the relevant health authorities to collect cost data to establish a model for sustainable pricing for implementing these services. METHODS: TELEMACO provides home-based telemanagement services for patients with chronic heart failure and chronic obstructive pulmonary disease (COPD), as well as second-opinion teleconsultations in cardiology, dermatology, diabetology, and pulmonology for general practitioners and second-opinion teleconsultations on digital images in cases of traumatic brain injury and stroke. A total of 2 service centers, 10 cardiology and pneumology departments, 30 specialists, 176 general practitioners, 40 nurses, 2 emergency departments, and 2 consultant hospitals were involved. RESULTS: A total of 166 patients with chronic heart failure and 474 patients with COPD were enrolled. There were 4830, 51, and 44 second-opinion teleconsultations for cardiologic, dermatologic, and diabetic conditions, respectively. There were 147 second-opinion teleconsultations on digital images, 68 for stroke, and 79 for traumatic brain injury. Implementation of TELEMACO introduced innovations in working methods and provided evidence to the health authorities for allocating funds for such services. CONCLUSIONS: TELEMACO provided evidence that there is a growing need for home management of patients using telemedicine, a common and efficacious approach that can ensure care continuity, especially in chronic diseases.

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.

Design of the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study to assess the ability of remote monitoring to treat and triage patients more effectively.

BACKGROUND: Heart failure patients with implantable defibrillators (ICD) frequently visit the clinic for routine device monitoring. Moreover, in the case of clinical events, such as ICD shocks or alert notifications for changes in cardiac status or safety issues, they often visit the emergency department or the clinic for an unscheduled visit. These planned and unplanned visits place a great burden on healthcare providers. Internet-based remote device interrogation systems, which give physicians remote access to patients' data, are being proposed in order to reduce routine and interim visits and to detect and notify alert conditions earlier. METHODS: The EVOLVO study is a prospective, randomized, parallel, unblinded, multicenter clinical trial designed to compare remote ICD management with the current standard of care, in order to assess its ability to treat and triage patients more effectively. Two-hundred patients implanted with wireless-transmission-enabled ICD will be enrolled and randomized to receive either the Medtronic CareLink monitor for remote transmission or the conventional method of in-person evaluations. The purpose of this manuscript is to describe the design of the trial. The results, which are to be presented separately, will characterize healthcare utilizations as a result of ICD follow-up by means of remote monitoring instead of conventional in-person evaluations. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00873899.

Remote monitoring of patients with biventricular defibrillators through the CareLink system improves clinical management of arrhythmias and heart failure episodes.

PURPOSE: The aim of the present study is to evaluate if remote monitoring with the CareLink Network may improve clinical management of tachyarrhythmias and heart failure episodes in patients treated with biventricular defibrillators (CRT-D). METHODS: Patients implanted with CRT-D for more than 6 months received the CareLink monitor and were trained to perform device interrogation. At-home transmissions were scheduled at 2 weeks, 1 and 2 months after training, with a final in-office visit after 3 months. RESULTS: Sixty-seven patients performed 264 data transmissions. Twenty-three unscheduled data transmissions were requested by the centers after patient contact. Ventricular tachyarrhythmias were reported in nine patients during 16 data reviews. Thirteen data reviews (81%) were performed remotely via CareLink transmissions (nine scheduled and four unscheduled), in seven patients. Of these events, in two cases (15%) in-hospital visits were requested, while in 11 (85%) no action was needed and no additional in-clinic visits were scheduled. During the study period, in 20/28 (71%) intra-thoracic impedance alerts, the patients remotely transmitted their device data. After remote data review, in ten cases drug therapy was adjusted by phone and in four cases no action was needed and the patient reassured. In six episodes an in-hospital extra visit was scheduled. On the whole, in 14 cases (70%), the patient could be managed remotely avoiding a visit to the hospital. CONCLUSIONS: Our study showed that remote follow-up is an efficient method to manage tachyarrhythmias and heart failure episodes in CRT-D patients. Early reaction to clinical events may improve overall patient care.

Remote monitoring of CRT-ICD: the multicenter Italian CareLink evaluation--ease of use, acceptance, and organizational implications.

PURPOSE: The Medtronic CareLink allows remote implantable device follow-up. In this first European experience with CareLink, we assessed the ease of use of the system, the acceptance, and satisfaction of patients and clinicians. METHODS: Patients implanted with biventricular defibrillators for more than 6 months received the CareLink monitor and were trained to perform home device interrogation and transmission. Patient and clinician experience and preference were evaluated through specific questionnaires. RESULTS: Sixty-seven patients were enrolled and were able to perform data transmissions during the 3-month study duration. The overall duration of interrogation procedure was 7 +/- 5 minutes, and frequently the procedure did not require the assistance of a caregiver. Patients reported a general preference for remote versus in-clinic follow-up and described a sense of reassurance created by the remote monitoring capability.In the centers, the review procedure was successful; its mean duration was 5 +/- 2 minutes per transmission and the users indicated that the access and navigation of the review website were easy. At the end of the evaluation, the data available for remote review were judged complete and adequate to provide almost the same standard of care as that offered in traditional in-clinic visit. In general, the remote monitoring was seen as a potential tool to improve the clinical management of patients with device. CONCLUSIONS: The ease of use, satisfaction, and acceptance of the CareLink Network in European clinical practice appears elevated both for patients and for clinicians.

Follow-up of CRT-ICD: implications for the use of remote follow-up systems. Data from the InSync ICD Italian Registry.

BACKGROUND: Launch of remote follow-up systems in Europe is currently underway. However, there is insufficient understanding of postimplant practices with respect to device follow-up, reprogramming of device features, and postshock clinic visits. METHODS: We analyzed device-stored data from patients implanted with biventricular defibrillators (CRT-ICD) to characterize the management of patients in current clinical practice and the potential impact of remote follow-up systems. RESULTS: Two hundred and seventeen patients were identified, all with complete device-data for at least one year. Over a follow-up period of 570 +/- 158 days, 1,959 device interrogations were performed. Of these, the majority (1,280, 65%) involved the reprogramming of device parameters. The mean time interval between interrogations was 70 +/- 25 days. Overall, a marked reduction of interrogations requiring reprogramming was observed between the first six months of follow-up and subsequent periods (from 3.6 +/- 1.8 to 1.1 +/- 1.0 interrogations/six months). A mean of 6.0 +/- 5.9 device parameters was reprogrammed during the first six months of follow-up, versus 4.4 +/- 5.6 (P = 0.000) during the subsequent period. From multivariate analysis, a higher-than-median number of interrogations was found to be significantly associated with defibrillator shocks (OR:2.51; 95%CI:1.42-4.42). Following a shock, a total of 133 interrogations in 60 patients were performed with 80% of these occurring within five days of the shock, and 49% did not require device reprogramming. CONCLUSION: Six months after implant, reprogramming of device parameters is significantly less frequent, making the use of remote follow-up systems a practical alternative for patients and physicians. Moreover, a considerable portion of post-shock interrogations does not involve reprogramming and may therefore be performed remotely.

[Cardiological emergency network in Lombardy]. / Le reti dell'emergenza in Cardiologia: i'esperienza lombarda.

AIMS: To achieve a reduction of time to reperfusion through the organization of an interhospital network and the involvement of the Regional Health Authority. METHODS: Four major endpoints were identified: institutional governance action, clinical management of acute ST-elevation myocardial infarction (STEMI), priority actions for cardiac arrest and early defibrillation, actions to avoid the delay related to decision-making, and logistic factors. Since 2001 in the urban area of Milan a network has been operating among 23 coronary care units, the 118 Dispatch Center (national free number for medical emergencies) and the Health Country Government Agency named Group for Prehospital Cardiac Emergency. In order to monitor the network activity and time to treatment and clinical outcomes a periodic monthly survey, called MOMI (One Month Monitoring Myocardial Infarction), was undertaken and repeated twice yearly. Data were evaluated according to hospital admission modality. RESULTS: Global times are: symptom onset to first medical contact 116 min (interquartile range [IQR] 189), time to first ECG 7 min (IQR 12), door-to-balloon time 77 min (IQR 81.7). Non-parametric test showed that the modality of hospital admittance was the most critical determinant of door-to-balloon time. The shortest one (49.5 min) was that of patients transported by means of advanced rescue units with 12-lead ECG teletransmission and activation of a fast track directly to the cath lab. CONCLUSIONS: Our data show how in a complex urban area the organization of an interhospital network and the availability of ECG teletransmission are effective in reducing time to reperfusion, in the treatment of major arrhythmias and in pre-alert of coronary care units and cath labs in case of confirmed STEMI. This experience also stimulated an improvement in technological equipment of rescue units with extension of 12-lead teletransmission to basic life support units. Through the Health Country Government Agency and the Scientific Societies we carry on with our job to create a regional network for cardiac emergency involving all the hospitals.

[The early management of ST-elevation acute myocardial infarction in the Lombardy Region (GestIMA)]. / La gestione della fase iperacuta dell'infarto miocardico con sopraslivellamento del tratto ST nella Regione Lombardia (GestIMA).

BACKGROUND: Recent international and national surveys on the management of ST-elevation myocardial infarction have described a number of crucial issues regarding the prehospital phase, the criteria to address patients to primary angioplasty, the organization of interhospital transfers. GestIMA is a perspective survey organized by the Lombardy Sections of the Italian Cardiology Societies (ANMCO and SIC) aimed to investigate the management of the acute phase of myocardial infarction in the Lombardy Region. METHODS: Between October 15 and November 14, 2003, consecutive patients hospitalized for ST-elevation myocardial infarction in the coronary care units of 60 hospitals in Lombardy were enrolled into the study. RESULTS: Among 612 patients (median age 67 years, interquartile range 56-76 years, 68% males, 43% with acute anterior myocardial infarction), 43% reached the hospital using the 118 emergency medical service, in 20% an ECG was recorded before arrival (reported in 47%), 1.5% were treated with thrombolysis and 1.0% with glycoprotein IIb/IIIa inhibitors before hospital admission. Sixty-eight percent of patients underwent a reperfusion treatment: 43% with primary angioplasty (6% facilitated), 25% with thrombolysis (18% of them had rescue angioplasty). Primary angioplasty was mainly performed in younger patients and in those directly admitted to centers equipped with interventional facilities. During the acute phase of myocardial infarction, 10% of patients arrived to the coronary care units from 39 peripheral hospitals without coronary care unit; 21% of patients had a secondary transport between hospitals with coronary care unit (47% for primary angioplasty). CONCLUSIONS: In the Lombardy Region, where a high rate of patients with ST-elevation myocardial infarction was treated with primary angioplasty in 2003, the 118 emergency medical service and the transmission of ECG by telephone are still underutilized. Moreover, the prehospital pharmacological treatment, the prehospital triage of patients to address to primary angioplasty and the organization of secondary transfer need to be improved.

[The network for the management of acute coronary syndromes in Milan: results of a four-year experience and perspectives of the prehospital and interhospital cardiological network]. / La rete per la gestione delle sindromi coronariche acute della Città di Milano: risultati di quattro anni di esperienza e prospettive del network cardiologico preospedaliero e interospedaliero.

In patients with acute ST-elevation myocardial infarction (STEMI), in order to shorten the time to definitive treatment, it is essential to coordinate the intervention between the local healthcare system and the hospitals. In 1999, a Working Group for Prehospital Emergency in Cardiology was established in Milan, and a network for 12-lead ECG transmission between advances life support (ALS) ambulances, the headquarter of 118 Rescue Service and the Coronary Care Units (CCU) or Divisions of Cardiology was developed: between February 1, 2001 and May 1, 2005, 6821 patients with suspected heart attack were rescued and their ECG recorded and transmitted (177 patients/month, 20% of them with an ST-segment shift, 11% ST-segment elevation, 9% non-ST-segment elevation, 24% with normal ECG). The rate of false positive automatic diagnosis of acute myocardial infarction was 0.3%, the rate of false negative was 0.8%. Forty-six patients with ventricular fibrillation underwent DC-shock. After May 1, 2004, clinical data of patients with STEMI transferred to the hospitals by ALS ambulances were reported in a database: 82% of the 89 patients were treated with primary angioplasty. The time (median, interquartile ranges) between ECG arrival to the CCU and the ECG report was 2 min (1-5), between ECG arrival to the CCU and patient arrival to the hospital was 34 min (24-42), between ECG arrival to the CCU and primary angioplasty was 69 min (50-93); the door-to-balloon time was 33 min (22-60). The telephone ECG transmission has been demonstrated to be a useful and rapid tool, easy to use; the automatic ECG diagnosis was accurate. In patients with STEMI the telephone ECG transmission shortened the time of delivery of therapy, helped to recover arrhythmic complications, allowed both the coordination between the 118 System and the Divisions of Cardiology and the implementation of the triage for primary angioplasty. Increasing the technological level of the service will be the next step of the program: the protocol will be upgraded in order to increase the number of patients rescued, to shorten the time of operation and to administer prehospital fibrinolytic therapy in selected patients.

Service level web monitoring in the field management of emergencies.

Cardiologic Emergency Project is based on a hospital network in Milan, Italy, in order to provide patients with more efficient first aid immediately after the occurrence of an Acute Coronary Syndrome. The Project includes ECG transmission from running ambulances to the 118 telephone central help desk, and from there to the suitable hospital. Since the maximum total transfer time should stay within a few tens of minutes, and given that a number of different factors may cause very dangerous delays, the effective coordination of several healthcare systems, devices and organizations is critical. Monitoring of the activities on each component is a must. Cardiologic Emergency Project uses a Web application devoted to the monitoring and evaluation of the service levels. Web applications allow the quantitative monitoring of the durations of extra-hospital operations. Several types of tables and graphics are automatically filled for the best care of the patient. For example, given a lengthy total time request by a satisfactory full ECG transmission, the system allows analysis of the ECG machine, of the cellular phone partial-only coverage along the ambulance pathway, of the transfer time in rush hours, etc., to determine which elements in the process can be improved to avoid future delays.

Informatica en cardiología: propuesta para una terminologia estandarizada para el expediente clínico y la electroestimulación cardiaca permanente / Informatics in cardiology a proposal for a standard language for clinical practice and for permanent cardiac stimulation

Con el objeto de hacer operativos dos programas computarizados, uno dedicado al expediente clínico cardiológico (PAC) y el otro a la electroestimulación cardíaca permanente (PGP), hemos codificado cerca de 4000 voces concernientes al campo médico general y cardiológico en particular. Se enfatiza la importancia de la estandarización del lenguaje médico cardiológico, especialmente en relación con la sistematización de la información, necesaria para el empleo de sistemas computarizados

Empleo de la vena subclavia para la estimulación cardíaca permanente / Use of subclavian vein for permanent cardiac stimulation

Los autores refieren su experiencia sobre 101 implantes de marcapaso definitivo, en los que siempre se utilizó la vena subclavia para la introducción del electrodocateter. Tal vía de acceso en todos los casos se alcanzó directamente en todos los casos desde el plano muscular, después de haberse asegurado de la ausencia del calibre inadecuado de la vena cefálica. La punción de la arteria subclavia, las "microlesiones"-fugaces del plexo branquial, y el neumotorax, fueron vistos respectivamente en el 4.3 y 3% de los casos. La luxación precoz del electrodo (incluyendo dos casos de microluxación) se presentó en el 5% de los pacientes. Como complicaciones tardías tuvimos dos casos de destrucción de la vaina protectora del electrododo y un caso de ruptura del electrododo. A pesar de los riesgos de complicaciones directamente relacionados a la punción de la vena, y a la relativamente menor garantía de estabilidad del electrodocateter - por el particular sistema de fijarlo-, pensamos que el acceso por la subclavia constituye una alternativa a la disección de la vena cefálica para la colocación de catéteres para estimulación permanente