[Management and revascularization of diabetics with coronary artery disease in Iceland].

BACKGROUND: The incidence of diabetes is growing, and diabetics have increased risk of atherosclerosis and diffuse coronary artery disease (CAD). Our aim was to assess the revascularization treatment of diabetics with CAD in Iceland from 2010-2020, changes in management and long-term survival of patients. METHODS: All patients in Iceland with diabetes and CAD on cardiac catheterization 2010-2020 were included in this retrospective, population-based study. We analyzed data from the SCAAR/SWEDEHEART database: patients' background information, findings of cardiac catheterization, planned treatment and results. The Kaplan-Meier method was used to estimate long-term survival and Cox-regression-analysis to adjust for predictor variables. RESULTS: Of 1905 cases (1485 patients), 1230 (65%) underwent PCI, 274 (14%) CABG and 401 (21%) had medical therapy only. The age distribution differed: The PCI group had the widest age bracket, the CABG group the narrowest, and the medical therapy group had the highest mean age. Most patients with STEMI or cardiogenic shock underwent PCI, while most patients with concomitant heart-valve disease underwent CABG. The proportion of patients undergoing CABG increased with more diffuse CAD. 41% of patients with left main- and three-vessel disease underwent CABG while only 2% of those with single-vessel disease. From 2010-2020 the proportion of patients that underwent PCI increased from 49% to 72%. There was no difference in survival between the PCI and CABG groups (p=1.00). CONCLUSION: Three quarters of patients with diabetes and obstructive CAD are now treated with PCI. The PCI and CABG groups had overall equal survival but the groups had different characteristics.

[Management of patients with left main stem stenosis in Iceland 2010-2020: PCI or CABG].

INTRODUCTION: Coronary artery bypass surgery (CABG) has been standard treatment for patients with left main coronary artery disease (LMCAD) but percutaneous coronary intervention (PCI) can be a good alternative. Our aim was to evaluate revascularization of LMCAD-patients in Iceland and treatment changes in recent years. We also assessed the impact of patient background factors on treatment choice and long-term survival. METHODS: This retrospective, population-based registry-study analyzed data from the SCAAR-SWEDEHEART database. Patients with significant LMCAD on coronary angiography in Iceland 2010-2020, without previous history of CABG or contraindication for surgery were enrolled. The Kaplan-Meier method was used to study long-term survival and COX-regression analysis to adjust for predictor variables. FINDINGS: Of 702 LMCAD patients, 195 were treated with PCI, 460 with CABG and 47 with medical therapy. The widest age-range was in the PCI group and the mean age was highest in the medical therapy group. Patients with LMCAD and concomitant three vessel disease or heart valve disese were mostly treated with CABG (76.1% and 84.4%). The majority of patients with LMCAD only were treated with PCI, as well as patients presenting with STEMI or in cardiogenic shock (67.1% and 70.0%). The proportion of patients treated with PCI increased from 19.8% in 2010-2015 to 42.7% in 2016-2020. There was no significant difference in survival between the PCI and CABG-groups (p=0.41). CONCLUSIONS: In patients with LMCAD the main factors determining treatment choice are age, anatomical complexity and acuteness. There has been a significant increase in LMCAD patients treated with PCI.

Effect of replacing ambulance physicians with paramedics on outcome of resuscitation for prehospital cardiac arrest.

INTRODUCTION: Limited evidence suggests that the presence of a prehospital physician improves survival from cardiac arrest. A retrospective study is undertaken to examine this question. In Reykjavik, Iceland, prehospital physicians on ambulances were replaced by emergency medical technicians (EMTs) in 2007. The aim of this study is to compare the outcome of prehospital resuscitation from cardiac arrest during periods of time with and without prehospital physician involvement. METHODS: All cardiac arrests that underwent prehospital resuscitation by emergency medical systems between 2004 and 2014 were included. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (ROSC). Subgroup analyses were performed according to the type of cardiac arrest. RESULTS: A total of 471 cardiac arrests were included for analysis, 200 treated by prehospital physicians from 2004 to 2007 and 271 treated by EMTs from 2008 to 2014. The overall rate of survival to hospital discharge and ROSC was 23 and 50% during the study period. No significant difference was observed in the rate of survival to hospital discharge [25 vs 22%, difference 3% (95% confidence interval (CI): 11-5%)] or ROSC [53 vs 47%, difference -6% (95% CI: 15-3%)] between these two time periods. In the subgroup of patients with pulseless electrical activity, survival to hospital discharge did not differ between the two periods, but the rate of ROSC was higher in the 'physician period' [50 vs 30%, difference -20% (95% CI: -40 to -1%)]. CONCLUSIONS: The presence of a prehospital physician on the ambulance was not found to result in a significant improvement in survival or ROSC after cardiac arrest compared to care by EMTs. Patients with pulseless electrical activity experienced an increase in ROSC when a physician was present but without improvement in survival to hospital discharge.

[Results of pre-hospital cardiac resuscitation in the Reykjavik area 2004-2007]. / Árangur endurlífgunartilrauna utan spítala a Reykjavíkursvæðinu árin 2004-2007.

INTRODUCTION: In the Reykjavik area, a physician staffed ambulance -responded to cardiac arrests from 1982-2007. The aim of this study was to assess the outcome of attempted pre-hospital cardiac resuscitations in the period from 2004-2007 and compare to previous studies. MATERIAL AND METHODS: All cases of attempted prehospital resuscitations in cardiac arrests of presumed cardiac etiology. Data was gathered according to the Utstein template. RESULTS: Of a total of 289 cases in cardiac arrest, resuscitation was attempted in 279 and 200 of those were presumed to have a cardiac etiology. Men were 76% of the patients and the average age was 67.7 years. Average response time was 6.3 min. One hundred and seven (54%) survived to hospital admission and 50 (25%) survived to discharge compared to 16-19% in previous studies (p=0.16). The presenting rhythm was ventricular fibrillation/ventricular tachycardia (VF/VT) in 50% of the cases, 30% was in asystole and 20% in pulseless electrical activity (PEA). Of those admitted to intensive care unit/ department and had ventricular fibrillation on the first rhythm strip 70% were discharged during 2004-2007 compared to 49% during 1999-2002 (p=0.01). Bystander CPR was provided in 62% of witnessed cases compared to 54% in a previous study (p=0.26). One hundred and twenty (60%) were witnessed cases of which 37 (31%) survived to hospital discharge compared to 5 (8%)of non witnessed cases (p<0.01). CONCLUSION: One in every four cardiac arrest patients in the Reykjavik area survives to discharge. This is similar to previous studies in the area (16-19%) and high compared to international studies 3-16%. Survival of those admitted to intensive care unit/ department and had ventricular fibrillation on the first rhythm strip was significantly higher compared to previous studies. Survival was found to be significantly higher if the cardiac arrest was witnessed.