An Intervention to Reduce the Time Interval Between Hospital Entry and Emergency Coronary Angiography in Patients with ST-Elevation Myocardial Infarction.

BACKGROUND: Outcomes of patients with acute ST-elevation myocardial infarction (STEMI) are strongly correlated to the time interval from hospital entry to primary percutaneous coronary intervention (PPCI). Current guidelines recommend a door to balloon time of < 90 minutes. OBJECTIVES: To reduce the time from hospital admission to PPCI and to increase the proportion of patients treated within 90 minutes. METHODS: In March 2013 the authors launched a seven-component intervention program:  Direct patient evacuation by out-of-hospital emergency medical services to the coronary intensive care unit or catheterization laboratory Education program for the emergency department staff Dissemination of information regarding the urgency of the PPCI decision Activation of the catheterization team by a single phone call Reimbursement for transportation costs to on-call staff who use their own cars Improvement in the quality of medical records Investigation of failed cases and feedback. RESULTS: During the 14 months prior to the intervention, initiation of catheterization occurred within 90 minutes of hospital arrival in 88/133 patients(65%); during the 18 months following the start of the intervention, the rate was 181/200 (90%) (P < 0.01). The respective mean/median times to treatment were 126/67 minutes and 52/47 minutes (P < 0.01). Intervention also resulted in shortening of the time interval from hospital entry to PPCI on nights and weekends. CONCLUSIONS: Following implementation of a comprehensive intervention, the time from hospital admission to PPCI of STEMI patients shortened significantly, as did the proportion of patients treated within 90 minutes of hospital arrival.

BIOFLOW-III satellite-One-year clinical outcomes of diabetic patients treated with a biodegradable polymer sirolimus-eluting stent and comprehensive medical surveillance.

BACKGROUND: Drug-eluting stents with biodegradable polymer might be particularly useful in diabetic patients who are at increased risk for target lesion/target vessel revascularization. We therefore aimed at assessing the safety and performance of a biodegradable polymer sirolimus-eluting stent (BP-SES) in combination with comprehensive optimal medical therapy following coronary interventions. METHODS: This prospective, multicenter registry was conducted at six centers in Israel. Aside of stent treatment, we aimed for an LDL-C level<70mg/dl; at one and six months post-intervention a diabetic consultancy was required, and follow-up data were collected at six and twelve months. The primary outcome measure was target vessel failure, a composite of cardiac death, target-vessel myocardial infarction and clinically driven target vessel revascularization. Secondary outcomes were target lesion failure, its individual components, and stent thrombosis. RESULTS: From August 2013 until May 2014, 120 diabetic patients with 158 lesions were treated with a BP-SES. Mean age was 63.9±9.2years, 27.5% were insulin dependent, 28.3% had a history of myocardial infarction, and 47.5% had prior coronary interventions. By visual estimation, lesions were 3.0±0.5mm in diameter and 15.2±7.4mm long; mean stent diameter and length were 3.0±0.5mm and 19.2±6.8mm. Target vessel failure and target lesion failure at 12months occurred in seven (6.4% [95% CI: 3.1-13.0]) and four patients (3.5% [95% CI: 1.3-9.2]), respectively, and definite stent thrombosis in one patient (1.0% [95% CI: 0.1-7.0]). CONCLUSION: Treatment with a BP-SES demonstrated excellent target-vessel and target-lesion revascularization rates in a high-risk diabetic patient population undergoing catheter-based revascularization followed by intensified medical care. ANNOTATED TABLE OF CONTENTS: In 120 high-risk diabetic patients with coronary artery stenosis, treatment with the Orsiro sirolimus-eluting stent with biodegradable polymer and comprehensive antidiabetic therapy resulted in excellent clinical outcomes. Target vessel revascularization occurred in 6.4% of patients and target lesion revascularization in 3.5%.

Echocardiographic Brockenbrough-Braunwald-Morrow sign.

The Brockenbrough-Braunwald-Morrow sign is the paradoxical decrease in pulse pressure during the post-extrasystole beat seen in patients with hypertrophic obstructive cardiomyopathy. We present a case of intermittent left ventricular outflow tract obstruction and secondary mitral regurgitation resulting from post-extrasystolic potentiation following a premature atrial beat, demonstrating using echocardiography the mechanism behind this sign.

Intraoperative transesophageal echocardiography using a quantitative dynamic loading test for the evaluation of ischemic mitral regurgitation.

BACKGROUND: Intraoperative transesophageal echocardiography may underestimate ischemic mitral regurgitation (MR) as a result of the unloading effect of general anesthesia on the left ventricle (LV). An intraoperative loading test could prove useful to avoid underestimation of ischemic MR. METHODS: We prospectively studied 30 patients with ischemic MR referred for coronary artery bypass, mitral valve surgery, or both. Transthoracic echocardiography was performed 1.6 +/- 1.6 days preoperatively, and intraoperative transesophageal echocardiography after induction of general anesthesia before and after LV loading. Preload was adjusted using fluids (if pulmonary occlusion pressure < 15 mm Hg), and the afterload increased using intravenous phenylephrine aiming at systolic blood pressure of 160 mm Hg. MR severity was estimated using color Doppler, pulmonary venous flow, and the proximal isovelocity surface area method. RESULTS: Preoperative median MR grade was 2 (interquartile range 1-3), effective regurgitant orifice area was 0.16 +/- 0.17 cm2, and regurgitant volume was 23 +/- 23 mL. Intraoperative MR grade decreased to 1.5 (1-2.25), effective regurgitant orifice area to 0.13 +/- 0.16 cm2, and regurgitant volume to 21 +/- 26 mL (P = .02, P = .06, and P = .18). After LV loading, MR grade increased to 3 (1-4), effective regurgitant orifice area to 0.21 +/- 0.24 cm2, and regurgitant volume to 39 +/- 38 mL (P < or = .005). All patients with preoperative +3 MR or greater had +3 MR or greater after loading whereas most patients with +1 MR had +1 MR. Of the 11 patients with preoperative +2 MR, 6 had +3 and 2 had +4 MR. CONCLUSIONS: A quantitative loading test with fluids and phenylephrine is useful to avoid underestimation of ischemic MR by intraoperative transesophageal echocardiography, and may detect significant MR in some patients who had unloaded LVs and nonsignificant MR during their preoperative assessment.

Initial experience with a cardiologist-based chest pain unit in an emergency department in Israel.

BACKGROUND: Emergency room triage of patients presenting with chest pain syndromes may be difficult. Under-diagnosis may be dangerous, while over-diagnosis may be costly. OBJECTIVES: To report our initial experience with an emergency room cardiologist-based chest pain unit in Israel. METHODS: During a 5 week pilot study, we examined resource utilization and ER diagnosis in 124 patients with chest pain of uncertain etiology or non-high risk acute coronary syndrome. First assessment was performed by the ER physicians and was followed by a second assessment by the CPU team. Assessment was based on the following parameters: medical history and examination, serial electrocardiography, hematology, biochemistry and biomarkers for ACS, exercise stress testing and/or 64-slice multi-detector cardiac computed tomography angiography. Changes in decision between initial assessment and final CPU assessment with regard to hospitalization and utilization of resources were recorded. RESULTS: All patients had at least two cardiac troponin T measurements, 19 underwent EST, 9 echocardiography and 29 cardiac MDCT. Fourteen patients were referred for early cardiac catheterization (same/next day). A specific working diagnosis was reached in 71/84 patients hospitalized, including unstable angina in 39 (31%) and non-ST elevation myocardial infarction in 12 (10%). Following CPU assessment, 40/124 patients (32%) were discharged, 49 (39%) were admitted to Internal Medicine and 35 (28%) to the Cardiology departments. CPU assessment and extended resources allowed discharge of 30/101 patients (30%) who were initially identified as candidates for hospitalization after ER assessment. Furthermore, 13/23 patients (56%) who were candidates for discharge after initial ER assessment were eventually hospitalized. Use of non-invasive tests was significantly greater in patients discharged from the ER (85% vs. 38% patients hospitalized) (P < 0.0001). The mean ER stay tended to be longer (14.9 +/- 8.6 hours vs. 12.9 +/- 11, P = NS) for patients discharged. At 30 days follow-up, there were no adverse events (myocardial infarction or death) in any of the 40 patients discharged from the ER after CPU assessment. One patient returned to the ER because of chest pain and was discharged after reassessment. CONCLUSIONS: Our initial experience showed that an ER cardiologist-based chest pain unit improved assessment of patients presenting to the ER with chest pain, and enhanced appropriate use of diagnostic tests prior to a decision regarding admission/discharge from the ER.

Myocardial stunning demonstrated with rest and post-stress measurements of left ventricular function using dual-isotope gated myocardial perfusion SPECT.

OBJECTIVES: We have evaluated left ventricular ejection fraction (LVEF) at rest (REF) and after stress (SEF) with dual-isotope gated myocardial perfusion SPECT (GMPS) with 201Tl injected at rest and 99mTc sestamibi (99mTc-MIBI) injected at peak stress, to assess the occurrence of post-stress stunning. METHODS: Two hundred and thirty-six consecutive patients had GMPS at rest and post-stress. The summed stress and rest scores and the summed difference score (SDS) were calculated using a 17-segment model analysis of GMPS. An SDS >3 indicated significant ischaemia. The REF and SEF were automatically generated and the DEF (SEF-REF) was calculated. RESULTS: Significant stress induced ischaemia was observed in 103 patients (44%). REF was 54.72%+/-15.75% and SEF was 55.69%+/-16.65% (P<0.0015). DEF was -2.25+/-5.36 and 3.42+/-5.25 in patients with and without ischaemia, respectively (P<0.001). Post-stress stunning (>5% decrease in LVEF) was present in 68 patients (29%) and in 58/103 (56%) patients with ischaemia, after treadmill exercise or dipyridamole infusion and was more common in patients with severe ischaemia. The single significant predictor of DEF in univariate analysis and of stunning using logistic binary regression was stress induced ischaemia (P<0.0001). CONCLUSION: LVEF increases post-stress in patients with no ischaemia and may decrease in 56% of patients with ischaemia, possibly due to stunning. The best predictor of post-stress stunning is stress induced ischaemia and its occurrence is related to the degree of ischaemia.

Myocardial perfusion abnormalities early (12-24 h) after coronary stenting or balloon angioplasty: implications regarding pathophysiology and late clinical outcome.

OBJECTIVE: We prospectively examined the prevalence of reversible perfusion defects on very early (12-24 h) thallium-201 single photon emission computed tomography (SPECT) scintigraphy after angiographically successful percutaneous coronary intervention (PCI) by stenting and/or stand-alone balloon angioplasty and the predictive value of these defects for late target lesion revascularization (TLR). PATIENTS AND METHODS: 83 consecutive patients undergoing PCI for 88 lesions (38 balloon angioplasties, 50 stents) underwent very early (12-24 h) SPECT thallium-201 scintigraphy at rest and following administration of 0.7 mg/kg intravenous dipyridamole after PCI. Univariate and multivariate clinical, procedural and scintigraphic correlates of target lesion revascularization during long-term follow-up were examined. RESULTS: Coronary stenting achieved a larger immediate post-PCI minimal luminal dimension (2.7 +/- 0.4 vs. 2.1 +/- 0.4 mm, p < 0.001) and less residual stenosis (4 +/- 12 vs. 19 +/- 11%, p < 0.001) than stand-alone balloon angioplasty. Nonetheless, early reversible perfusion defects were similarly present in the territory supplied by 36% of stented lesions and 32% of lesions treated by balloon angioplasty (NS). Of 81 lesions (76 patients) available for long-term clinical follow-up, TLR was performed in 11% of the stent group and 14% of the balloon angioplasty group (NS). By multivariate logistic regression analysis, diabetes mellitus was the only predictor of late TLR (p < 0.05). The type of intervention (balloon or stent) predicted neither early perfusion defects nor late TLR. CONCLUSIONS: Early 201-thallium SPECT scintigraphy was abnormal in a third of patients treated by stand-alone balloon angioplasty or by stent placement. The very early SPECT scintigraphic findings did not differentiate between balloon and stent and did not predict late TLR.