RESUMEN
OBJECTIVES: To investigate the outcomes of a cohort of acute and elective percutaneous coronary intervention (PCI) patients who were discharged home 6 hours postprocedure. BACKGROUND: Contemporary PCI is safe with a low rate of acute complications. It is well established as a day procedure in elective cases; however, data are lacking in acute cases. METHODS: We describe a prospective observational audit of routine clinical practice in the 3 PCI centers in Northern Ireland. Patients were selected for same-day discharge after 6 hours of post-PCI observation. Both elective and acute coronary syndrome (ACS) cases were included. Criteria for same-day discharge were based on the technical result of the procedure rather than lesion complexity or clinical presentation. Radial access was preferred but not mandatory. Patients were contacted directly to assess for 30-day major adverse cardiovascular events (MACE). Reported events were corroborated with the general practitioner or hospital notes. RESULTS: A total of 1,059 patients were selected for same-day discharge with 30-day follow-up available for all cases. Of these, 766 (72.3%) were elective and 293 (27.7%) were ACS patients. Radial access was almost universal (98%). A total of 1,224 lesions were stented, of which 432 (40.8%) were high risk (highest risk lesion in each case by AHA/ACC classification). MACE rate at 30 days was 0.85% with a sub-acute stent thrombosis rate of 0.4%. There were no MACE events from discharge to 24 hours. CONCLUSIONS: Selected acute and elective patients with a range of lesion complexity and risk can be discharged safely home early after PCI.
Asunto(s)
Síndrome Coronario Agudo/cirugía , Tiempo de Internación , Auditoría Médica , Intervención Coronaria Percutánea , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Assess the interaction between fibrinolysis and in-hospital percutaneous coronary intervention (PCI) in patients with inferior myocardial infarction (MI), particularly those with electrocardiographic evidence of right ventricular infarction (RVI). DESIGN: Retrospective observational study. PATIENTS: Consecutive patients with inferior MI identified from an MI registry between January 1998 and January 2004. INTERVENTIONS: Propensity analyses and multiple regression analysis were used to determine the mortality benefit of PCI. MAIN OUTCOME MEASURES: In-hospital morbidity and mortality. RESULTS: In total, 465 patients with inferior MI received fibrinolytic therapy (median pain-to-needle time of 167 minutes; IQR 100-311 minutes). The main predictors of PCI were recurrent chest pain, peak creatine kinase, age, reinfarction, presence of heart failure and male gender. Significant independent predictors of in-hospital mortality were age > or = 75 years, RVI, initial systolic blood pressure < or = 80 mmHg, female gender and no in-hospital PCI. In-hospital PCI was performed in 184/465 (40%) patients; 55 (30%) had rescue PCI performed < or = 6 hours post fibrinolysis, 45 (24%) within 6-24 hours and 84 (46%) > or = 24 hours. In-hospital PCI was associated with reduced in-hospital mortality (PCI: 9 [5%] vs. no PCI: 40 [14%]; p < 0.001) mainly in those with RVI (PCI: 8 [8%] vs. no PCI 33 [23%]; p = 0.002) compared with no RVI (PCI: 1 [1%] vs. no PCI 7 [5%]; p = 0.1). CONCLUSION: A strategy of timely fibrinolysis combined with in-hospital PCI including rescue PCI may result in a significant reduction in in-hospital mortality and morbidity in patients with inferior MI, particularly those with RVI.
Asunto(s)
Angioplastia Coronaria con Balón/métodos , Mortalidad Hospitalaria/tendencias , Infarto del Miocardio/terapia , Anciano , Angiografía Coronaria , Electrocardiografía , Femenino , Estudios de Seguimiento , Ventrículos Cardíacos , Humanos , Masculino , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/mortalidad , Irlanda del Norte/epidemiología , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Noncontact endocardial mapping allows accurate beat-to-beat reconstruction of the reentrant pathway of ventricular tachycardia and improves outcomes after ablation. Several studies support electrocardiographic imaging (ECGI) as a means of noninvasively outlining epicardial activation despite constraints of internal geometry. However, few have explored its clinical application. This study aims to evaluate ECGI during selective left ventricular (LV) pacing, relative to an invasive approach. METHODS: Multisite pacing was performed within the left ventricles of 3 patients undergoing invasive procedures. Simultaneous recording of endocardial potentials using a noncontact multielectrode array and body surface potentials (BSP) using an 80-electrode torso vest was performed. A total of 16 recordings were made. The inverse solution was applied to BSP to reconstruct epicardial activation. Single-paced beats from real and virtual electrograms were used to construct 3-dimensional isochronal and isopotential maps. Endocardial and epicardial data were then superimposed onto a single geometry to allow quantitative comparison of activation foci. RESULTS: Good correlation was observed between endocardial activation patterns and those reconstructed from BSP using ECGI. This was repeatedly demonstrated in all LV regions except for the septum (3 recordings). Epicardial isochronal maps were able to locate early and late activation to mean distances of 13.8 +/- 4.7 and 12.5 +/- 3.7 mm from endocardial data. Isopotential maps localized pacing sites with comparable accuracy (14 +/- 5.3 mm). CONCLUSIONS: Body surface potentials and reconstructed epicardial activation patterns during LV pacing correlate well with endocardial data acquired invasively. The exception was during pacing of the septum. Although early results are encouraging, further quantitative data are required to fully validate and apply this noninvasive tool in the clinical arena.
Asunto(s)
Mapeo del Potencial de Superficie Corporal/métodos , Estimulación Cardíaca Artificial/métodos , Diagnóstico por Computador/métodos , Diagnóstico por Imagen/métodos , Electrocardiografía/métodos , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/prevención & control , Anciano , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Epicardial electrical events were reconstructed using an inverse model for left ventricular (LV) pacing and during ventricular tachycardia (VT) induced during implantation of a biventricular pacemaker and/or internal defibrillator. The electrocardiographic position of the pacing lead, determined from the region of most negative potential 30 ms after the pacing spike, was compared with the radiographic position. Activation characterized by isochronal maps was correlated with the echocardiographic/myocardial scintigraphic data. Reconstructed epicardial isopotential/isochronal maps during VT were used to determine the presence of reentry. In 7 patients during LV pacing, epicardial isopotential maps located the maximum negative potentials anterolaterally (n = 3), posterolaterally (n = 2), and posteriorly (n = 2). Isochronal maps demonstrated activation patterns including regions of delayed activation that, in 5 patients, correlated with areas of akinesia/hypokinesia or fixed defects on echocardiography/myocardial scintigraphy. The mean difference between the radiographically measured right ventricular to LV pacing lead distance and calculated electrocardiographic right ventricular to LV pacing site distance was 1.7 cm. During VT, induced in 5 patients, single-loop reentry was observed in 3 and figure-of-8 reentry in 2. Exit site and regions of fast/slow conduction and conduction block that correlated with anatomic areas of infarction defined by echocardiography/myocardial scintigraphy were demonstrated. In conclusion, epicardial maps reconstructed from the body surface map can identify LV pacing sites and demonstrate reentry during VT. The body surface map could thus identify optimal pacing sites for LV pacing and targets for VT ablation.
Asunto(s)
Mapeo del Potencial de Superficie Corporal , Estimulación Cardíaca Artificial/métodos , Enfermedad Coronaria/complicaciones , Taquicardia Ventricular/fisiopatología , Disfunción Ventricular Izquierda/complicaciones , Anciano , Enfermedad Coronaria/fisiopatología , Estudios de Seguimiento , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Taquicardia Ventricular/complicaciones , Taquicardia Ventricular/terapia , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
Clopidogrel is an effective antiplatelet agent that has undergone rigorous assessment in the setting of ischaemic heart disease over the last decade. There is extensive evidence for the use of this drug in patients undergoing percutaneous coronary intervention, in those with stable ischaemic heart disease and also in those with acute coronary syndromes. This article examines the use of clopidogrel in patients with ischaemic heart disease.
Asunto(s)
Angioplastia Coronaria con Balón , Isquemia Miocárdica/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Ticlopidina/análogos & derivados , Adolescente , Adulto , Anciano , Aspirina/efectos adversos , Aspirina/uso terapéutico , Clopidogrel , Femenino , Hemorragia/etiología , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/terapia , Inhibidores de Agregación Plaquetaria/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Ticlopidina/efectos adversos , Ticlopidina/uso terapéuticoRESUMEN
AIMS: To compare the success rate for transthoracic direct current cardioversion (DCC) of atrial fibrillation (AF) with antero-posterior (AP) and antero-apical (AA) electrode positions using an impedance compensated biphasic (ICB) waveform. METHODS AND RESULTS: Three-hundred and seven patients [mean age 66 (SD+/-13), 195 male] with AF were recruited in three centres. Patients were randomized to an AA (n=150) or AP (n=144) pad position. Thirteen patients with implanted pacemakers were defaulted to the AP pad position. Cardioversion was performed using an ICB waveform with a 70, 100, 150, and 200 J energy selection protocol. If the fourth shock was unsuccessful, the pads were crossed over to the alternative position for a final 200 J shock. Shock 1 was successful in 54/150 (36%) AA and 45/144 (31%) AP patients, whereas success was achieved by shock 2 in 99/150 (66%) AA and 74/144 (51%) AP, by shock 3 in 123/150 (82%) AA and 109/144 (76%) AP, and by shock 4 in 143/150 (95%) AA and 127/144 (88%) AP and after cross-over in 144/150 (96%) AA and 135/144 (94%) AP. Overall success rate was higher than expected at 95%. Pad position was not associated significantly with success. There was a trend towards an improved outcome with the AA configuration (P=0.05). CONCLUSION: The influence of pad position for DCC of AF may be less pertinent with ICB waveforms than with monophasic waveforms.
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Fibrilación Atrial/terapia , Cardioversión Eléctrica/instrumentación , Anciano , Fibrilación Atrial/fisiopatología , Cardiografía de Impedancia , Cardioversión Eléctrica/métodos , Electrodos , Femenino , Humanos , Masculino , Resultado del TratamientoRESUMEN
AIMS: To assess the predictors of 1 year mortality in patients treated with fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI) and to determine whether a strategy of early percutaneous coronary intervention (PCI) improves outcome. METHODS AND RESULTS: Consecutive patients (n = 474) admitted to our unit (1998-2001) with STEMI were treated with fibrinolytic therapy. For each patient, age, gender, admission via mobile coronary care unit (MCCU), infarct location, initial systolic blood pressure and Killip class, prior history of ischaemic heart disease, hypertension, diabetes mellitus, smoking status, family history, hyperlipidaemia, and in-hospital PCI (n = 154) were recorded. Mortality at 1 year was obtained from medical records (n = 473). Binary logistic regression analysis was performed to determine independent predictors of 1 year mortality. Mortality in the non-PCI group was 21 vs. 7% in the PCI group. Independent predictors of 1 year mortality were age (risk ratio 1.12, 95% CI 1.08-1.15, P < 0.0001), initial SBP < or = 80 mmHg (risk ratio 4.34, 95% CI 1.68-11.2, P = 0.002), initial Killip class > or = 3 (risk ratio 2.97, 95% CI 1.42-6.2, P = 0.004), and lack of in-hospital PCI (risk ratio 0.39, 95% CI 0.19-0.81, P = 0.012). Although the PCI group were younger (P = 0.007), more likely to be admitted via the MCCU (P = 0.008), with a shorter pain to needle time (P = 0.04), multivariable analysis adjusted for these differences. CONCLUSION: In-hospital PCI in patients treated with fibrinolytic therapy for STEMI is associated with a substantial reduction in 1 year mortality.
Asunto(s)
Angioplastia Coronaria con Balón , Fibrinolíticos/uso terapéutico , Infarto del Miocardio/terapia , Anciano , Terapia Combinada , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/tratamiento farmacológico , Infarto del Miocardio/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
UNLABELLED: Early detection of acute myocardial infarction (MI) is vital in the management of acute coronary syndromes (ACS). Hence we compared the diagnostic capability of the standard 12-lead electrocardiogram (ECG) with the 80-lead ECG body surface map (BSM) prehospital. METHODS: Consecutive patients (n = 294) presenting prehospital with ischemic type chest pain were included. All had an ECG and BSM pretreatment and a baseline and 12-hour cardiac troponin-T or I (cTnT or cTnI). Acute MI was defined as cTnT > 0.09 or cTnI > 0.1 ng/mL. Acute MI on the BSM was defined as ST elevation measured at the J-point, > or = 1 mm inferior/right ventricular/high right anterior/lateral regions, > or = 2 mm anterior region, > or = 0.5 mm posterior region. RESULTS: Acute MI occurred in 182/294 (62%) based on cTnT or I. ST elevation on the standard ECG predicted acute MI in 103 (sensitivity 57%, specificity 94%; c-statistic 0.73). The optimal model for the standard ECG included ST elevation, summed ST depression and past history of MI (c-statistic 0.82; Chi-square (Wald) 120.7, 3df). The BSM predicted acute MI in 146 (sensitivity 80%, specificity 92%; c-statistic 0.86). The optimal model for the BSM included BSM criteria for acute MI and past history of MI (c-statistic 0.91; Chi-square (Wald) 180.3, 2df). CONCLUSION: The 80-lead BSM is superior to the standard 12-lead ECG in predicting acute MI prehospital.
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Mapeo del Potencial de Superficie Corporal/métodos , Enfermedad Coronaria/diagnóstico , Electrocardiografía Ambulatoria/métodos , Servicios Médicos de Urgencia , Angina de Pecho/diagnóstico , Femenino , Predicción , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/fisiopatología , Pericardio/fisiopatología , Sensibilidad y Especificidad , Troponina I/análisis , Troponina T/análisisRESUMEN
Limited data have been published on the use of external defibrillators that deliver impedance compensated biphasic (ICB) waveforms in patients. We compared 2 ICB defibrillators, the Heartstream XL (150-150-150 J protocol) and Heartsine Samaritan (100-150-200 J protocol) in 78 consecutive patients in cardiac arrest. The performance of the 2 devices over the first 2 shocks was statistically equivalent. By the third shock, the Heartsine Samaritan had significantly better performance in removing ventricular fibrillation (p = 0.029). Energy selection for ICB waveforms requires further validation.
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Cardioversión Eléctrica/instrumentación , Paro Cardíaco/terapia , Fibrilación Ventricular/terapia , Anciano , Anciano de 80 o más Años , Reanimación Cardiopulmonar/métodos , Estudios de Cohortes , Impedancia Eléctrica , Diseño de Equipo , Seguridad de Equipos , Femenino , Paro Cardíaco/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Probabilidad , Análisis de Supervivencia , Resultado del Tratamiento , Fibrilación Ventricular/mortalidadAsunto(s)
Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/tratamiento farmacológico , Ticlopidina/análogos & derivados , Algoritmos , Angina Inestable/diagnóstico , Clopidogrel , Enfermedad Coronaria/fisiopatología , Humanos , Infarto del Miocardio/diagnóstico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Medición de Riesgo , Ticlopidina/uso terapéuticoRESUMEN
Diagnosis of non-ST-elevation acute myocardial infarction (AMI) by a 12-lead electrocardiogram has poor sensitivity and specificity and, therefore, relies on biochemical markers of myocardial necrosis, which can only be reliably detected within 14 to 16 hours from symptom onset. The body surface map (BSM) improves AMI detection but is limited by its interpretation by inexperienced medical staff. To facilitate interpretation, an automated BSM algorithm was developed and is evaluated in this study. One hundred three patients with ischemic-type chest pain were recruited for this study from December 2001 to April 2002. A 12-lead electrocardiogram (Marquette Mac 5K) and BSM (PRIME-ECG) were recorded at initial presentation, and cardiac troponin I and/or creatine kinase-MB levels measured at 12 hours after symptom onset. The admitting physician's 12-lead electrocardiographic (ECG) interpretation, 12-lead ECG algorithm (Marquette 12 SL V233) diagnosis, and BSM algorithm diagnosis were documented for each patient. AMI, defined by elevation of troponin I to >1 microg/L and/or creatine kinase-MB to >25U/L, occurred in 53 patients. The admitting physician diagnosed 24 patients with AMI (sensitivity 45%, specificity 94%), the 12-lead ECG algorithm diagnosed 17 patients with AMI (sensitivity 32%, specificity 98%), and the BSM algorithm diagnosed 34 patients with AMI (sensitivity 64%, specificity 94%). The BSM algorithm improved the diagnostic sensitivity by 2.0 (p <0.001) and 1.4 (p = 0.002) compared with the 12-lead ECG algorithm or the admitting physician, respectively. There was no significant difference in specificity. Thus, the BSM algorithm improves detection of AMI compared with the 12-lead ECG algorithm or physician's 12-lead ECG interpretation.