Standardised pre-hospital care of acute myocardial infarction patients: MISSION! guidelines applied in practice.

Background. To improve acute myocardial infarction (AMI) care in the region 'Hollands-Midden' (the Netherlands), a standardised guideline-based care program was developed (MISSION!). This study aimed to evaluate the outcome of the pre-hospital part of the MISSION! program and to study potential differences in pre-hospital care between four areas of residency.Methods. Time-to-treatment delays, AMI risk profile, cardiac enzymes, hospital stay, in-hospital mortality, and pre-AMI medication was evaluated in consecutive AMI patients (n=863, 61±13years, 75% male) transferred to the Leiden University Medical Center for primary percutaneous coronary intervention (PCI).Results. Median time interval between onset of symptoms and arrival at the catheterisation laboratory was 150 (interquartile range [IQR] 101-280) minutes. The alert of emergency services to arrival at the hospital time was 48 (IQR 40-60) minutes and the door-to-catheterisation laboratory time was 23 (IQR 13-42) minutes. Despite significant regional differences in ambulance transportation times no difference in total time from onset of symptoms to arrival at the catheterisation room was found. Peak troponin T was 3.33 (IQR 1.23-7.04) µg/l, hospital stay was 2 (IQR 2-3) days and in-hospital mortality was 2.3%. Twelve percent had 0 known risk factors, 30% had one risk factor, 45% two to three risk factors and 13% had four or more risk factors. No significant differences were observed for AMI risk profiles and medication pre-AMI. Conclusions. This study shows that a standardised regional AMI treatment protocol achieved optimal and uniformly distributed pre-hospital performance in the region 'Hollands-Midden', resulting in minimal time delays regardless of area of residence. Hospital stay was short and in-hospital mortality low. Of the patients, 88% had ≥1 modifiable risk factor. (Neth Heart J 2010;18:408-15.).

[Unexplained non-cardiac chest pain; its prevalence and natural course]. / Onverklaarde niet-cardiale pijn op de borst: prevalentie en natuurlijk beloop.

OBJECTIVE: (a) To assess whether data on prevalence and natural course of unexplained chest pain are similar to previous results reported for patients with unexplained chest pain in foreign literature; (b) to find biographical or medical record variables predictive of continuing pain. DESIGN: Retrospective research of medical records. SETTING: University Medical Centre and Diaconessenhuis (peripheral hospital), Leiden, the Netherlands. METHOD: Medical records of patients who had been newly referred between 1992 and 1995 to the cardiac outpatient clinic were screened on the discharge diagnosis: unexplained chest pain. Patients were approached by mail with a questionnaire, inquiring about duration, frequency, intensity, functional limitations and medical consumption with regard to their unexplained chest pain. RESULTS: In 39.8% (1053/2648) of the patients, no explanation was found for their complaints. After 12 and 24 months, 72% and 56% respectively reported still having complaints. 37% experienced limitations in daily activities at the time of the investigation. Sex and duration of pain before visiting the cardiologist were predictors of the persistence of chest pain. 31% of the patients did consult their general practitioner at least once more after the discharge by the cardiologist. CONCLUSION: Unexplained chest pain is a common complaint of patients visiting an outpatient clinic for cardiology and often persists. The present results are largely similar to those reported in foreign literature.

Coronary heart disease risk factors in women.

Coronary heart disease is the leading cause of death among women. Reported risk factors for women are smoking, use of oral contraceptives, diabetes, elevated blood pressure, elevated blood lipids, low socio-economic status, low educational attainment, Type A behaviour and chronic troubling emotions. Via an on-line literature search (Medline and Psychlit) all case-control and prospective studies of coronary heart disease risk factors in women have been collected from 1978 to 1993. Smoking remains the most prominent risk factor for myocardial infarction in young women, the risk increasing significantly with the amount of cigarettes smoked. Use of modern low-dose oral contraceptives in healthy, non-smoking women does not increase the risk. Oestrogen replacement therapy seems to protect against coronary heart disease, although the reduction in risk may have been over-estimated. Elevated cholesterol and elevated blood pressure are major risk factors, and diabetes seems to have a stronger impact on risk in women than in men. Low socio-economic class is a stronger risk factor for women than for men and the double loads of career and family seem to increase risk for women.

Arteriographic evaluation of small coronary arteries.

The purpose of this study was to determine the accuracy of imaging small coronary arteries with current radiographic equipment. Phantom assessments were performed using a phantom that comprises a large array of circular objects of varying diameter and contrast density. More objects could be identified in the moving cinearteriogram than in single cine frames. Using the largest object as the calibration standard, diameters less than 1 mm were markedly overestimated. A simple morphometric method showed that arteriographic visualization of small vessels was better by digital processing than by cine recording. However, there was no statistically significant difference in the average size of the smallest identifiable vessel by either method (0.5 versus 0.51 mm). After correcting for overestimation and the inaccurate imaging of the smallest detectable vessels, the practical arteriographic threshold is approximately 0.5 mm. Parametric imaging holds promise, but its significance for evaluating small vessel disease has yet to be determined.

Coronary arterial aneurysm: possible relation with malaria?

We report a case of an aneurysm of a coronary artery in a 29-year-old male with an acute myocardial infarction. The patient had no risk factors for atherosclerosis and his medical history revealed only repeated episodes of quartian malaria three years before. Coronary arteriography showed aneurysmal dilatation of the proximal part of the left anterior descending coronary artery with thrombus formation at the site of the dilatation. The right coronary artery and the left circumflex artery were free from disease. To the best of our knowledge, this is the first presentation of coronary arterial aneurysm probably related to quartian malaria.