Code Stroke Alert: Focus on Emergency Department Time Targets and Impact on Door-to-Needle Time across Day and Night Shifts.

BACKGROUND AND OBJECTIVES: To minimize stroke-related deaths and maximize the likelihood of cerebral reperfusion, medical professionals developed the "code stroke" emergency protocol, which allows for the prompt evaluation of patients with acute ischemic stroke symptoms in pre-hospital care and the emergency department (ED). This research will outline our experience in implementing the stroke code protocol for acute ischemic stroke patients and its impact on door-to-needle time (DTN) in the ED. METHODS: Our study included patients with a "code stroke alert" upon arrival at the emergency department. The final sample of this study consisted of 258 patients eligible for intravenous (IV) thrombolysis with an onset-to-door time < 4.5 h. ED admissions were categorized into two distinct groups: "day shift" (from 8 a.m. to 8 p.m.) (n = 178) and "night shift" (from 8 p.m. to 8 a.m.) (n = 80) groups. RESULTS: An analysis of ED time targets showed an increased median during the day shift for onset-to-ED door time of 310 min (IQR, 190-340 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), for door-to-physician (emergency medicine doctor) time of 5 min (IQR, 3-9 min), and for door-to-physician (neurologist) time of 7 min (IQR, 5-10 min), also during the day shift. During the night shift, an increased median was found for door-to-CT time of 21 min (IQR, 16.75-23 min), for door-to-CT results of 40 min (IQR, 38-43 min), and for door-to-needle time of 57.5 min (IQR, 46.25-60 min). Astonishingly, only 17.83% (n = 46) of these patients received intravenous thrombolysis, and the proportion of patients with thrombolysis was significantly higher during the night shift (p = 0.044). A logistic regression analysis considering the door-to-needle time (minutes) as the dependent variable demonstrated that onset-to-ED time (p < 0.001) and door-to-physician (emergency medicine physicians) time (p = 0.021) are predictors for performing thrombolysis in our study. CONCLUSIONS: This study identified higher door-to-CT and door-to-emergency medicine physician times associated with an increased DTN, highlighting further opportunities to improve acute stroke care in the emergency department. Further, door-to-CT and door-to-CT results showed statistically significant increases during the night shift.

The Benefits of a Comprehensive Cardiac Rehabilitation Program for Patients with Acute Coronary Syndrome: A Follow-Up Study.

BACKGROUND AND OBJECTIVES: Secondary prevention after acute coronary syndrome (ACS) is essential to reduce cardiovascular mortality and hospital readmission, ensuring patients return to normal with an improved quality of life. Thus, we investigate the benefits of a comprehensive cardiac rehabilitation (CR) program on lifestyle, risk factors and adherence to guideline-directed medical therapy (GDMT) in patients after ACS and myocardial revascularization through coronary artery by-pass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS: This is a prospective, longitudinal study in consecutive post-CABG or PCI patients after ACS that participated or not in a comprehensive CR. Cardiovascular risk factors, quality of life and adherence to GDMT were analyzed in terms of assessing the benefit of 12 months of comprehensive CR on reaching guidelines secondary prevention targets. RESULTS: At the inclusion in comprehensive CR of all patients (n = 480), 85% had hypertension; 86% had elevated total cholesterol values; 69% were characterized by metabolic syndrome; 43% were obese; 31% were active smokers and 29% had type 2 diabetes mellitus. Only 26.66% (n = 128) followed the entire program for 12 months. No statistically significant differences in the prescription of GDMT at hospital discharge after myocardial revascularization between the CR (+) group (n = 128) versus CR (-) group (n = 352) (p > 0.05) were observed. After 12 moths, a significant adherence to GDMT in the CR (+) group vs. CR (-) group was recorded, as follows: antiplatelet agents (100% versus 96%, p = 0.001), beta-blockers (99% versus 92%, p = 0.02), ACE inhibitors/ARAB (89% versus 79%, p = 0.04), lipid-lowering drugs (100% versus 89%, p = 0.001). In total, 82% of the CR (+) patients had a significantly higher adherence at GDMT (82% versus 64%, p = 0.001). At 12 moths, the CR (+) group was characterized by significantly lower values than at the inclusion but some values still increased: systolic blood pressure (139.25 + 19.20 mmHg (p < 0.03)), total cholesterol (171.07 + 48.59 mg/dL (p = 0.0001)) and LDL-cholesterol (102.83 + 41.30 mg/dL (p = 0.009)). At the same time, the analysis of psychosocial factors using the HAD questionnaire revealed a statistically significant improvement in anxiety and depression scores: HAD-A score (9.1 ± 3.7 at T0 vs. 7.1 ± 4.2 at T1, p = 0.001) and HAD-D score (7.7 ± 3.19 at T0 vs. 6.4 ± 4.3 at T1, p = 0.003). A multivariable analysis, following GDMT, showed the actual value or information and training of patients regarding optimal cardiovascular risk factor control was independently associated with lower values of systolic blood pressure (R2 = 0.48), diastolic (R2 = 0.38), serum glucose (R2 = 0.48), glycated hemoglobin (R2 = 0.50), total cholesterol (R2 = 0.31), LDL-cholesterol (R2 = 0.30), HDL-cholesterol (R2 = 0.19) and serum triglycerides (R2 = 0.20). CONCLUSION: The twelve-month participation of post-ACS patients in comprehensive CR resulted in excellent post-revascularization management, as well as good adherence to guideline-directed medical therapy, provided further confirmation of the benefit of secondary prevention. Despite high adherence to drug treatments, targets for blood pressure, total cholesterol and LDL-cholesterol are inadequately achieved. Therefore, in the era of personalized medicine, patients with ACS should benefit from specific, comprehensive cardiovascular recovery programs that contain physiotherapists, psychologists, nutritionists and an experienced cardiologist in cardiovascular rehabilitation.

MTHFR Gene Polymorphisms Prevalence and Cardiovascular Risk Factors Involved in Cardioembolic Stroke Type and Severity.

BACKGROUND: Cardioembolic stroke (CES), generally known as the most severe subtype of ischemic stroke, is related to many factors, including diabetes mellitus (DM), hypertension (HTN), smoking, hyperlipidemia and atrial fibrillation (AF). Genetic mutations of the methylenetetrahydrofolate reductase (MTHFR) gene C677T and A1298C have been recently associated with ischemic stroke. The purpose of this study was to analyze the prevalence of MTHFR gene polymorphisms correlated with cardiovascular risk factors in a selected population of patients with CES due to non-valvular AF (NVAF). METHODS: This cross-sectional study was performed on 67 consecutive patients with acute cardioembolic stroke admitted to our hospital. The protocol included general physical examination, neurological clinical status and stroke severity evaluation, imagistic evaluation and genetic testing of MTHFRC677T and A1298C polymorphisms. RESULTS: The prevalence of MTHFR polymorphisms in the study population was 38.2% for C677T and 40.3% for A1298C. The C677T mutation was significantly correlated with increased diastolic blood pressure (DBP) values (p = 0.007), higher total cholesterol (TC) (p = 0.003), low-density lipoprotein cholesterol (LDLc) (p = 0.003) and triglycerides (TGL) (p = 0.001), increased high-sensitive C-reactive protein (hsCRP) values (p = 0.015), HbA1c (p = 0.004) and left ventricle ejection fraction (LVEF) (p = 0.047) and lower high-density lipoprotein cholesterol (HDLc) (p < 0.001) compared to patients without this genetic variant. This genetic profile also included significantly higher CHA2DS2VASC (p = 0.029) and HASBLED (Hypertension, Abnormal liver/renal function, Stroke, Bleeding, Labile INR, Elderly age(>65 years), Drug/Alcohol usage history/Medication usage with bleeding predisposition) (p = 0.025) scores. Stroke severity in patients with MTHFRA1298C mutation was significantly increased when applying National Institutes of Health Stroke Scale (NIHSS) (p = 0.006) and modified Rankin scale (mRS) (p = 0.020) scores. The presence of A1298C mutation as a dependent variable was associated with significantly higher TGL values (odds ratio (OR) = 2.983, 95%CI = (1.972, 7.994)). CONCLUSIONS: The results obtained in this study demonstrate that MTHFR gene polymorphisms have a high prevalence in an NVAF cardioembolic stroke population. Moreover, an association between C677T mutation and stroke severity was highlighted. The C677T mutation in patients with NVAF was correlated with a higher incidence of cardiovascular comorbidities (hypertension HTN, heart failure (HF), dyslipidemia, type II diabetes mellitus (T2DM) with high HbA1c and increased inflammatory state). The A1298CMTHFR gene mutation was associated with a higher incidence of previous lacunar stroke and stroke recurrence rate, while dyslipidemia was the main cardiovascular comorbidity in this category.

Evaluation of Psychological Stress Parameters in Coronary Patients by Three Different Questionnaires as Pre-Requisite for Comprehensive Rehabilitation.

BACKGROUND: Negative psychological conditions are common in patients with cardiovascular diseases. Although depression has been scrutinized over the years in these patients, only recently has anxiety emerged as another important risk factor. The purpose of this study was to compare the parameters of psychological stress in a population of coronary patients with and without myocardial revascularization procedures and to analyze lifestyle and socio-economic contributors to the state of health of these patients before inclusion in a comprehensive individualized rehabilitation program. METHODS: This study included 500 patients with coronary artery disease (CAD) in stable condition divided in 2 groups: 200 patients who underwent coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) (Group 1) and 300 patients without myocardial revascularization (Group 2) with stable angina or thrombolyzed myocardial infarction. The protocol included screening for anxiety/depression after procedure using three different scales: Duke Anxiety-Depression Scale, Hospital Anxiety and Depression Scale (HADS) and the Type D Personality Scale (DS-14) scale that evaluates negative affectivity (NA) and social inhibition (SI). RESULTS: Significant differences between groups were observed for HAD-A (9.1 ± 4.18 for Group 1 vs. 7.8 ± 4.03 for Group 2, p = 0.002) and DUKE scores (30.2 ± 12.25 for Group 1 vs. 22.7 ± 12.13 for Group 2, p < 0.001). HAD-A scores (p = 0.01) and DUKE scores (p = 0.04) were significantly higher in patients who underwent PTCA vs. CABG. CAD patients without myocardial revascularization (Group 2, n = 300) presented anxiety in proportion of 72.3% (n = 217) out of which 10.7% (n = 32) had severe anxiety, and 180 patients had depression (a proportion of 60%) out of which 1.3% (n = 4) presented severe depression. The correlation between the presence of type 2 diabetes mellitus (T2DM) and type D personality in revascularized patients (n = 200) was significant (Chi2 test, p = 0.010). By applying multinomial regression according to the Cox and Snell R-square model and multivariate linear regression by the Enter method, we demonstrated that male gender, age and marital status proved significant predictors for psychological stress in our study population. CONCLUSIONS: The results obtained in this study provide a framework for monitoring anxiety, depression and type D personality in coronary patients before inclusion in comprehensive rehabilitation programs. Behavioral and psychological stress responses in patients with CAD significantly correlate with risk factors, and could influence the evolution of the disease. Moreover, other factors like gender, income and marital status also seem to play a decisive role. Evaluation of psychological stress parameters contributes to a better individualization at the start of these programs, because it allows adjusting of all potential factors that may influence positive outcomes.

The Importance of DS-14 and HADS Questionnaires in Quantifying Psychological Stress in Type 2 Diabetes Mellitus.

Background and Objectives: The comorbid association between type 2 diabetes mellitus (T2DM) and a psychological profile characterized by depression and/or anxiety has been reported to increase the risk of coronary heart disease (CAD), the most striking macrovascular complication of diabetes. The purpose of the present study was to quantify anxiety, depression and the presence of type D personality, and to correlate the scores obtained with cardiovascular risk factors and disease severity in diabetic patients. Materials and methods: The retrospective study included 169 clinically stable diabetic patients divided into two groups: group 1 without macrovascular complications (n = 107) and group 2 with CAD, stroke and/or peripheral vascular disease (n = 62). A biochemical analysis and an assessment of psychic stress by applying the Hospital Anxiety and Depression Scale (HADS)and the Type D scale (DS-14) to determine anxiety, depression and D personality scores were done in all patients. Statistical analysis was made using SPSSv17 and Microsoft Excel, non-parametric Kruskal-Wallis and Mann-Whitney tests. Results: Following application of the HAD questionnaire for the entire group (n = 169), anxiety was present in 105 patients (62.2%), and depression in 96 patients (56.8%). Group 2 showed significantly higher anxiety scores compared to group 1 (p = 0.014), while depression scores were not significantly different. Per entire group, analysis of DS-14 scores revealed social inhibition (SI) present in 56 patients (33%) and negative affectivity (NA) in 105 patients (62%). TheDS-14 SI score was significantly higher in group 2 compared to group 1 (p = 0.036). Type D personality, resulting from scores above 10 in both DS-14 parameter categories, was present in 51 patients of the study group (30%). There was a direct and significant correlation (r = 0.133, p = 0.025) between the Hospital Anxiety and Depression Scale-Anxiety (HAD-A) score and the LDL-c values. Conclusions: The results of this study demonstrated that more than a half of patients with diabetes had anxiety and/or depression and one third had Type D personality, sustaining that monitoring of emotional state and depression should be included in the therapeutic plan of these patients. New treatment strategies are needed to improve the well-being of diabetic patients with psychological comorbidities.

Correlations between Vascular Stiffness Indicators, OPG, and 25-OH Vitamin D3 Status in Heart Failure Patients.

Background and objectives: The purpose of the study is to correlate vascular calcification biomarkers osteoprotegerin (OPG) and 25-hydroxyvitamin D3 (25-OH-D3), indicators of arterial stiffness carotid-femoral pulse wave velocity (c-f PWV) and renal resistive index (RRI), with parameters of left ventricular function in heart failure patients versus control. Materials and methods: Our case-control study compared 60 patients with ischemic heart failure and reduced left ventricular ejection fraction (LVEF) (<40%) with a control group of 60 healthy age-matched subjects (CON). Serum levels of OPG and 25-OH-D3 were determined by ELISA. Left ventricular volumes (LVESV, LVEDV) and LVEF were measured by echocardiography. C-f PWV was determined using the arteriograph device. RRI was measured by duplex Doppler. Peak systolic velocity (PSV) and minimum end-diastolic velocity (EDV) were determined using angle correction. The estimated glomerular filtration rate (eGFR) was calculated using the MDRD equation. The Pearson's correlation coefficient was used for interpretation of results. Results: OPG values were significantly higher in heart failure (HF) patients vs. CON (4.7 ± 0.25 vs. 1.3 ± 0.67 ng/mL, p < 0.001). 25-OH vitamin D3 levels were significantly lower in HF patients vs. CON (20.49 ± 7.31 vs. 37.09 ± 4.59 ng/mL, p < 0.001). Multiple regression analysis considering 25-OH D3 as a dependent variable demonstrated indicators of vascular stiffness RRI, c-f PWV and vascular calcification biomarker OPG as predictors. OPG values were significantly correlated with cardiac parameters LVEDV (r = 0.862, p < 0.001), LVEF (r = -0.832, p < 0.001), and c-f PWV(r = 0.833, p < 0.001), and also with 25-OH-D3 (r = -0.636, p < 0.001). RRI values were significantly correlated with cardiac parameters LVEDV (r = 0.586, p < 0.001) and LVEF (r = -0.587, p < 0.001), and with eGFR (r = -0.488, p < 0.001), c-f PWV(r = 0.640, p < 0.001), and 25-OH-D3 (r = -0.732, p < 0.001). Conclusions: This study showed significant correlations between vitamin D deficit and vascular stiffness indicators in heart failure patients with reduced ejection fraction, demonstrating the importance of these examinations for a better evaluation of these patients. Together with the evaluation of renal function, the measurement of vascular stiffness indicators and biomarkers might play a key role in identifying patients at greater risk for worsening disease prognosis and for shorter life expectancy, who could benefit from vitamin D supplementation. The abstract was accepted for presentation at the Congress of the European Society of Cardiology, Munich, 2018.