Cardiovascular MRI in clinical trials: expanded applications through novel surrogate endpoints

Recent advances in cardiovascular magnetic resonance (CMR) now allow the accurate and reproducible measurement of many aspects of cardiac and vascular structure and function, with prognostic data emerging for several key imaging biomarkers. These biomarkers are increasingly used in the evaluation of new drugs, devices and lifestyle modifications for the prevention and treatment of cardiovascular disease. This review outlines a conceptual framework for the application of imaging biomarkers to clinical trials, highlights several important CMR techniques which are in use in randomised studies, and reviews certain aspects of trial design, conduct and interpretation in relation to the use of CMR

Occupational Therapy After Myocardial or Cerebrovascular Infarction: Which Factors Influence Referrals?

Background: Cardiovascular diseases remain the number one cause of death worldwide, and many survivors suffer lasting disabilities. Occupational therapy can help such patients regain as much function as possible. However, little is known about the factors influencing referrals to occupational therapy after stroke or myocardial infarction (MI). Method: Data from the IMS Disease Analyzer® database were observed for a three-year period. The study population included 7,440 patients who were examined by a cardiologist due to stroke or MI. In addition to baseline characteristics, the presence of certain cardiovascular risk factors or comorbidities was recorded. Cox regression analyses were performed and the Charlson Comorbidity Index (CCI) was utilized. Results: Occupational therapy was received by 1,779 patients; 88.5% had suffered an MI and 11.5% a stroke. In the group without referral (n = 5,661), 60.7% had experienced an MI and 39.3% a stroke. No significant gender-related differences were observed. Younger age, an MI diagnosis, and the presence of hypertension positively influenced referral rate and time, while risk factors, such as adiposity, delayed therapy. The CCI was higher in the group with occupational therapy. Conclusion: The chance of being offered occupational therapy increased with younger age, history of MI, and the presence of hypertension. Future studies should also consider severity of ischemic lesion to account for the degree of remaining impairment

Preclinical models of myocardial infarction: from mechanism to translation

Approximately 7 million people are affected by acute myocardial infarction (MI) each year, and despite significant therapeutic and diagnostic advancements, MI remains a leading cause of mortality worldwide. Pre-clinical animal models have significantly advanced our understanding of MI and enable the development of therapeutic strategies to combat this debilitating disease. Notably, some drugs currently used to treat MI and heart failure (HF) in patients had initially been studied in pre-clinical animal models. Despite this, pre-clinical models are limited in their ability to fully recapitulate the complexity of MI in humans. The pre-clinical model must be carefully selected to maximise the translational potential of experimental findings. This review describes current experimental models of MI and considers how they have been used to understand drug mechanisms of action (MOA) and support translational medicine development

The SOS Pilot Study: a RCT of routine oxygen supplementation early after acute stroke—effect on recovery of neurological function at one week

Mild hypoxia is common after stroke and associated with poor long-term outcome. Oxygen supplementation could prevent hypoxia and improve recovery. A previous study of routine oxygen supplementation showed no significant benefit at 7 and 12 months. This pilot study reports the effects of routine oxygen supplementation for 72 hours on oxygen saturation and neurological outcomes at 1 week after a stroke

The Effects of Oxygen Therapy on Myocardial Salvage in ST Elevation Myocardial Infarction Treated with Acute Percutaneous Coronary Intervention: The Supplemental Oxygen in Catheterized Coronary Emergency Reperfusion (SOCCER) Study.

Despite a lack of scientific evidence, oxygen has long been a part of standard treatment for patients with acute myocardial infarction (AMI). However, several studies suggest that oxygen therapy may have negative cardiovascular effects. We here describe a randomized controlled trial, i.e. Supplemental Oxygen in Catheterized Coronary Emergency Reperfusion (SOCCER), aiming to evaluate the effect of oxygen therapy on myocardial salvage and infarct size in patients with ST elevation myocardial infarction (STEMI) treated with a primary percutaneous coronary intervention (PCI)

Assessing Myocardial Perfusion after Myocardial Infarction

Ashrafian and colleagues describe the use of myocardial contrast echocardiography to assess a 63-year-old man with ischemic heart disease

A descriptive study of the use of troponin I testing at a Cape Town district hospital

Introduction: Troponin I tests have been shown to be accurate and are relied upon to assist in making critical decisions regarding patient care in patients presenting with chest pain. The tests are expensive, however, and so their rational use becomes extremely important in a budget-constrained public health sector. The aim of this study was to describe how Troponin I tests are used throughout Victoria Hospital, by a range of requesting clinicians, working in different specialties. Methods A cross-sectional, prospective design was employed, using multiple data sources. We collected a consecutive sample over a three-month period from Victoria hospital’s Emergency Centre using a dedicated data collection tool connected to use of the point-of-care troponin I test. We supplemented this prospective sample with outcome data, using the hospital’s electronic admission record. Results Three hundred and sixteen patient entries were included in the final results. The majority of Troponin tests were negative (70%). Discharge directly from Emergency Centre was 10% in Troponin I positive patients, 37,5% in Equivocal Troponin patients, and 65% in Troponin negative patients. Furthermore, patients were twice as likely to be transferred to a tertiary facility if their Troponin was positive (24%), compared to equivocal (10.4%) or negative (12%). Discussion Chest pain was the most common presenting complaint, with Acute Coronary Syndrome being the most common working diagnosis. The clinical management of patients varied considerably when comparing their Troponin I result. Troponin I appears to be used as an effective rule-out tool in the decision-making pathway

Optimising coronary reperfusion in acute myocardial infarction: the role of primary angioplasty

PhDThrombolysis remains the predominant reperfusion strategy for ST segment elevation myocardial infarction (STEMI) in the United Kingdom. Although primary angioplasty may offer superior outcomes, the logistics of delivering this therapy in the UK have not been investigated. This thesis describes the development of a pilot primary angioplasty service in North East London. Outcomes are compared with the thrombolytic strategy, and platelet activation is explored as a possible biological mechanism determining reperfusion. The impact of the thrombolytic strategy on revascularisation following STEMI in North East London was first investigated. Thrombolytic delivery was effective, but necessitated frequent early revascularisation, leading to prolonged hospital stay. A primary angioplasty service was developed at the cardiac centre, and expanded to serve six network hospitals. Within the limitations of a daytime pilot, the service improved clinical outcomes, and was associated with a substantial reduction in hospital stay. Two admission strategies were compared - direct access to the cardiac centre following pre-hospital diagnosis by ambulance crews, and transfer of patients presenting to network emergency (A&E) departments after upstream administration of abciximab and clopidogrel. Direct access significantly reduced reperfusion times. Upstream anti-platelet therapy improved angiographic reperfusion prior to primary angioplasty, possibly compensating for inter hospital transfer delays. A subgroup of STEMI patients underwent platelet activation studies. Lower baseline platelet monocyte aggregate (PMA) levels predicted improved angiographic reperfusion following primary angioplasty, supporting the concept that PMAs may reflect plaque rupture severity, and may promote microvascular 2 dysfunction. Early anti-platelet therapy reduced PMAs following intervention, which may explain the benefit of early abciximab observed in clinical trials. In summary this thesis has demonstrated that primary angioplasty can be del ivered safely and eff ectively in North East London. The eff icacy of reperf usion may be determined by mechanisms involving platelet activation. Delivery of a 24 hour seven day service should now be addressed

Contemporary NSTEMI management: the role of the hospitalist.

Non-ST-segment elevation myocardial infarction (NSTEMI) is defined as elevated cardiac biomarkers of necrosis in the absence of persistent ST-segment elevation in the setting of anginal symptoms or other acute event. It carries a poorer prognosis than most ST-segment elevation events, owing to the typical comorbidity burden of the older NSTEMI patients as well as diverse etiologies that add complexity to therapeutic decision-making. It may result from an acute atherothrombotic event (\u27Type 1\u27) or as the result of other causes of mismatch of myocardial oxygen supply and demand (\u27Type 2\u27). Regardless of type and other clinical factors, the hospital medicine specialist is increasingly responsible for managing or coordinating the care of these patients. Following published guidelines for risk stratification and basing anti-anginal, anticoagulant, antiplatelet, other pharmacologic therapies, and overall management approach on that individualized patient risk assessment can be expected to result in better short- and long-term clinical outcomes, including near-term readmission and recurrent events. We present here a review of the evidence basis and expert commentary to assist the hospitalist in achieving those improved outcomes in NSTEMI. Given that the Society for Hospital Medicine cites care of patients with acute coronary syndrome as a core competency for hospitalists, it is essential that those specialists stay current on optimal NSTEMI care