Access to Catheterization Facilities in Patients Admitted With ST-elevation Myocardial Infarction

The primary goal of therapy for acute ST-elevation myocardial infarction (STEMI) is rapid, complete and sustained restoration of the infarct related coronary artery blood flow and myocardial perfusion, with a consequent positive impact on the patient???s outcome. Timely reperfusion of the infarct-related artery is the cornerstone of therapy for this goal.Thrombolytic therapy and percutaneous coronary intervention (PCI) are effective means to achieve reperfusion, but current trends reflect an increasing preference for PCI. Even though the development of reperfusion strategies and ancillary therapies over the last decades resulted in significant improvement in the prognosis of STEMI, the implementation of such therapies in the ???real world??? is often inefficient. Despite the increasing use of primary PCI, the proportion of eligible patients undergoing early reperfusion remained constant at about 70%, from 1994 through 1999, with roughly 30% of patients receiving neither reperfusion therapy. Findings from the GRACE study showed that nearly one ???third of patients who presented with STEMI within 12 hours and who were eligible for reperfusion therapy did not receive it. Thus, a considerable proportion of patients with STEMI do not receive reperfusion therapy for a variety of reasons. These include age, gender, concomitant comorbid conditions, delays in seeking medical attention, disparities in health system organization, ???triaging??? problems, disparities in patients??? transfer, awareness of the public, and other reasons

Access to Catheterization Facilities in Patients Admitted With ST -Elevation Myocardial Infarction: A Pilot Study

BACKGROUND: Thrombolytic therapy and percutaneous coronary intervention (PCI) are effective means to achieve reperfusion in ST-elevation myocardial infarction (STEMI), but current trends favour primary PCI. However, there seems to be considerable international and national differences in the management of patients with STEMI. Pertinent epidemiological data for Greece are lacking. Thus, the aim of this pilot study was to investigate the current implementation of reperfusion strategies in North-Western (NW) Greece.   PATIENTS AND METHODS: The region of NW Greece is populated by 600,000 inhabitants, and is served by 6 district hospitals, and 1 tertiary university hospital, the only one offering PCI, but not on a 24-hour basis. Thus, the most prevalent reperfusion strategy in our region is thrombolytic therapy. The present study was a prospective population-based survey conducted over a 5-month period. Sources of data included cardiology departments, coronary care units, and intensive care departments located in the area.   RESULTS: The total study population consisted of 170 consecutive patients (135 men) with a mean age of 67 years, divided into three groups according to time between symptom onset and presentation: 99 patients (58.2%) presented within 3 hours (group I), 23 (13.5%) between 3-12 hours (Group II), and 48 (28.2%) after 12 hours (Group III). In group I, thrombolysis was performed in 78 (78.7%), primary PCI in 8 (8%) and rescue PCI in 6 (6%); 93 patients (94%) were subjected to elective coronary angiography and subsequently 38 (40.8%) had elective PCI, 4 (4.3%) coronary artery bypass grafting (CABG), and 51 (54.8%) were managed medically. In group II, thrombolysis was given in 17 (73.9%), and rescue PCI in 2 (8.6%) patients; all patients (100%) were subjected to elective coronary angiography and subsequently 10 (43.4%) to elective PCI, and 1 (4.3%) to CABG. In group III, thrombolysis was performed in 4 (8.3%), and rescue PCI in 1 (2.1%) patient; 42 (87.5%) patients were subjected to elective coronary angiography and subsequently 11 (22.9%) had elective PCI, and 8 (16.6%) CABG.   CONCLUSION: A large proportion of patients with STEMI arrive late, but reperfusion therapy is sufficiently implemented in NW Greece. The goal of 75% is certainly attainable. Organizing networks of reperfusion at regional level can help to improve the rate of reperfusion therapy. Finally, the option of next-day PCI after successful thrombolysis is gaining wider acceptance

Modelling the Role of Dietary Habits and Eating Behaviours on the Development of Acute Coronary Syndrome or Stroke: Aims, Design, and Validation Properties of a Case-Control Study

In this paper the methodology and procedures of a case-control study that will be developed for assessing the role of dietary habits and eating behaviours on the development of acute coronary syndrome and stroke is presented. Based on statistical power calculations, 1000 participants will be enrolled; of them, 250 will be consecutive patients with a first acute coronary event, 250 consecutive patients with a first ischaemic stroke, and 500 population-based healthy subjects (controls), age and sex matched to the cases. Socio-demographic, clinical, dietary, psychological, and other lifestyle characteristics will be measured. Dietary habits and eating behaviours will be evaluated with a special questionnaire that has been developed for the study

Drug-Eluting Stent Thrombosis The Kounis Hypersensitivity-Associated Acute Coronary Syndrome Revisited

The advent of drug-eluting stents (DES) has revolutionized the field of interventional cardiology. Their dramatic and persistent restenotic and target lesion revascularization advantages are unquestioned. However, concerns over the rare but potentially catastrophic risk of stent thrombosis (ST) have tempered universal acceptance of these devices. Although the precise mechanism of DES ST is undoubtedly multifactorial and as yet not fully elucidated, delayed or incomplete endothelial healing clearly plays a pivotal role. Detailed histopathological data have implicated a contributory allergic or hypersensitivity component, as verified by the Food and Drug Administration's Manufacturer and User Device Experience Center and the Research on Adverse Drug/device events And Reports (RADAR) project. These findings thus suggest a potential connection with the Kounis syndrome, the concurrence of acute coronary events with allergic, hypersensitivity, anaphylactic, or anaphylactoid reactions. Potential culprits responsible for this phenomenon include: arachidonic acid metabolites such as leukotrienes and thromboxane, proteolytic enzymes such as chymase and tryptase, histamine, cytokines, and chemokines. Additionally, inflammatory cells such as macrophages, T-lymphocytes, and mast cells are probably also contributory. Autopsy-confirmed infiltrates of various inflammatory cells including lymphocytes, plasma cells, macrophages, and eosinophils have been reported in all 3 vascular wall layers and are reminiscent of those associated with the Kounis syndrome. Although the concurrence of acute coronary syndromes with hypersensitivity reactions has been long established, the specific association with DES ST remains unproven. Potential incorporation of hypersensitivity suppressive agents might represent a promising paradigm shift from efficacy to safety in future DES designs

Programmed inappropriate ICD ventricular defibrillation for cardioversion of persistent atrial fibrillation

In this report we briefly describe a patient with a dual chamber implantable cardioverter defibrillator in the context of severe ischemic cardiomyopathy who developed persistent atrial fibrillation. After appropriate anticoagulation and under mild sedation the patient was successfully cardioverted to sinus rhythm after a programmed ventricular synchronized defibrillation using his defibrillator. Programmed internal cardioversion of persistent atrial fibrillation in patients who have an implantable cardioverter defibillator without atrial defibrillation capabilities could be an effective and safe therapeutic option. Unlike external electrical cardioversion, this strategy does not interfere with the implantable cardioverter defibrillator, is more effective, and obviates the need of general anesthesia. This strategy should be further evaluated in clinical trials

Patients with Atrial Fibrillation and Chronic Kidney Disease More Often Undergo Angioplasty of Left Main Coronary Artery – a 867 Patient Study

Background/Aims: Several studies have implicated atrial fibrillation (AF) as a contributing factor in chronic kidney disease (CKD) and cardiovascular events. The prevalence of coronary artery disease (CAD) in patients with AF varies substantially from 17% to 46.5%. There are only few studies concerning renal function in population with AF undergoing coronary angiography. The aim of the present study was to assess which type of AF is dominant in CKD population scheduled for coronary angiography and if it can influence patients’ outcome, the association between renal impairment and the type of coronary procedures in AF patients and the influence of renal function on in-hospital mortality. Methods: We retrospectively studied 867 patients with AF hospitalized due to coronary angiography in two year time. The cut off value of CKD was eGFR ≤ 60 ml/min./1.73m2 evaluated by CKD-EPI formula. Results: A total of 867 patients with AF (44% women; mean age 72±10 years) were included in the analysis. The mean eGFR was 44±11ml/min./1.73m2 in patients with CKD and 89±18 ml/min./1.73m2 in patients with preserved renal function. Patients with CKD and AF were older (p< 0.001), had more often diabetes (p=0.009), heart failure (p< 0.001) and anaemia (p< 0.001). Patients with CKD and AF had more often permanent type of AF (p< 0.001). In CKD patients CHA2DS2VASc score was 4.3±1.5 and HAS-BLED score was 2.0±1.2 and it was significantly higher as compared to population with preserved renal function (p< 0.001, p=0.02, respectively). The use of oral anticoagulation was less frequent in CKD group (p< 0.001) although these patients had higher CHA2DS2VASc score. Patients with AF and CKD were more often admitted due to myocardial infarction (STEMI or NSTEMI) (p=0.02, p< 0.001, respectively) and more often underwent percutaneous coronary intervention (PCI) (p=0.01). Among coronary arteries the percutaneous coronary intervention (PCI) of left main artery was done more frequently in CKD patients (p=0.01). Among CKD population in-hospital mortality was significantly higher in patients with eGFR < 30 ml/min (p< 0.001). Conclusion: Patients with CKD had more often permanent type of AF. Percutaneous interventions of the left main coronary artery, the only elective procedures influencing patients’ prognosis, were done more frequently in CKD patients with AF. In-hospital mortality was significantly higher in patients with severe renal impairment. Despite the higher risk of ischaemic stroke in CKD group the use of oral anticoagulation therapy was significantly less frequent and the patients were deprived of the confirmed benefits of such treatment

Predictors and prognosis of paroxysmal atrial fibrillation in general practice in the UK

BACKGROUND: Natural history of paroxysmal atrial fibrillation (AF) is not very well documented. Clinical experience suggests that paroxysmal AF could progress to chronic AF with estimates ranging between 15 and 30% over a period of 1–3 years. We performed an epidemiologic study to elucidate the natural history of paroxysmal AF, this study estimated its incidence in a general practice setting, identified associated factors and analyzed the progression into chronic AF as well as the mortality rate. METHODS: Using the UK General Practice Research Database (GPRD), we identified patients aged 40–89 years with a first-recorded episode of paroxysmal AF during 1996. Risk factors were assessed using 525 incident paroxysmal AF cases confirmed by the general practitioner (GP) and a random sample of controls. We follow-up paroxysmal AF patients and estimated their mortality rate and progression to chronic AF. RESULTS: The incidence of paroxysmal AF was 1.0 per 1,000 person-years. Major risk factors for paroxysmal AF were age and prior valvular heart disease, ischaemic heart disease, heart failure and hyperthyroidism. During a mean follow-up of 2.7 years, 70 of 418 paroxysmal AF patients with complete information progressed to chronic AF. Risk factors associated with progression were valvular heart disease (OR 2.7, 95% CI 1.2–6.0) and moderate to high alcohol consumption (OR 3.0, 95% CI 1.1–8.0). Paroxysmal AF patients did not carry an increased risk of mortality, compared to an age and sex matched sample of the general population. There was a suggestion of a small increased risk among patients progressing to chronic AF (RR 1.5, 96% CI 0.8–2.9). CONCLUSION: Paroxysmal AF is a common arrhythmia in the general practice setting, increasing with age and commonly associated with other heart diseases. It sometimes is the initial presentation and then progress to chronic AF. A history of valvular heart disease and alcohol consumption are associated with this progression

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology

Background: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines. Methods: A total of 6187 patients (18–80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012–2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys. Results: A total of 2846 (46%) patients had no diabetes, 1158 (19%) newly diagnosed diabetes and 2183 (35 %) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60%, respectively. A blood pressure target of 9.0% (>75 mmol/mol). Of the patients with diabetes 69% reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40%) and only 27% of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets. Conclusions: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease

A Multicenter, Long-Term Study on Arrhythmias in Children with Ebstein Anomaly

To assess the prevalence, history, and treatment of arrhythmias, in particular preexcitation and Wolff–Parkinson–White (WPW) syndrome, in patients with Ebstein anomaly (EA) during childhood and adolescence, we performed a multicenter retrospective study of all consecutive live-born patients with EA, diagnosed, and followed by pediatric cardiologists between 1980 and 2005 in The Netherlands. During a follow-up after EA diagnosis of 13 years 3 months (range: 6 days to 28 years 2 months), 16 (17%) of the 93 pediatric EA patients exhibited rhythm disturbances. Nine patients showed arrhythmic events starting as of the neonatal period. Supraventricular tachycardia was noted in 11 patients. One patient died in the neonatal period due to intractable supraventricular tachycardia resulting in heart failure and one patient died at 5 weeks of age most probably due to an arrhythmic event. The 14 surviving patients all show preexcitation, albeit 4 of them intermittently, and all have a right-sided accessory pathway location. Nine patients underwent catheter ablation of an accessory pathway. Only four patients are currently on antiarrhythmic drugs. The 17% prevalence of rhythm disturbances in pediatric EA patients, most commonly supraventricular arrhythmias, is significantly lower than in adult EA patients. Life-threatening rhythm disturbances are not frequent early in life. Symptomatic patients are well treated with radiofrequency catheter ablation