Intervensi Koroner Perkutan Primer untuk Infark Miokard Elevasi ST di Pusat Jantung Pemula di Indonesia: 100 pasien pertama

Background: The benefits of Primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) have been demon-strated, but most studies were conducted in experienced centres in western world. Experience, logistics and patient characteristics may differ in other parts of the world, particularly in a starting center.Methods: Data on all consecutive STEMI patients treated with primary PCI in Cinere hospital, Jakarta, Indonesia were collected in a prospective database.Results:,Between July 2006 and December 2008, a total of 100 patients with STEMI were treated by primary PCI. Mean age was 56.9 ±10.4 years (range 37-82), 88% was male. Mean time between onset of chest pain and admission was 369 ± 388 minutes. The mean time between admission and balloon inflation was 258 minutes. Before PCI, 50% of patients had TIMI 0 flow. After primary PCI 94% of patients had TIMI 2/3 flow. There were no deaths in the catheterisation room, and no emergency coronary bypass surgery was needed as a result of PCI complications. Mean left ventricular ejection fraction as measured by echocardiography after 1 day was 48 ± 12 %.Conclusions: Outcome after primary PCI at a starting center is excellent in this series. Primary PCI was effective in restoration of TIMI flow, without complications. Time delay between symptom onset, admission and balloon inflation was long and all efforts should be encouraged to shorten this.Latar belakang: Manfaat Intervensi perkutan primer (IKP) untuk Infark Miokard Elevasi ST (IMEST) telah terbukti, namun-demikian kebanyakan penelitian mengenai ini di laksanakan dipusat layanan jantung yang berpengalaman di dunia barat, Pengalaman , logistik dan karakteristik pasien mungkin berbeda di belahan dunia ini, terutama di pusat yang baru mulai.Metode: Seluruh data pasien konsekutif dengan IMEST yang ditangani dengan IKP primer di pusat jantung Cinere , Jakarta, Indonesia dihimpun melalui seperangkat data yang dilaksanakan secara propekstif.Hasil: Antara Juli 2006 dan Desember 2008, dari seluruh jumlah 100 pasien dengan IMEST yang ditangani dengan IKP primer. Rerata usia adalah 56,9 tahun ± 10,4 tahun (berkisar 37-82 tahun), 88 % diantaranya adalah pria. Rerata waktu antara onset nyeri dada dan masuk rumah sakit adalah 369 ± 388 menit. Rerata waktu antara masuk rumah sakit dengan inflasi balon adalah 258 menit. Sebelum IKP, 50 % pasien dengan aliran TIMI 0. Setelah IKP primer 94 % pasien memperoleh aliran TIMI 2/3. Tidak ada kematian didalam ruang kateterisasi maupun diperlukan tindakan bedah graft pintas arteri koroner yang gawat akibat komplikasi dari IKP. Rerata fraksi ejeksi yang diukur dengan ekokardiografi setelah 1 hari adalah 48±12 %.Kesimpulan: Hasil akhir yang diperoleh setelah IKP primer pada pusat jantung yang baru dimulai adalah baik pada serial ini. IKP primer efektif dalam memeperbaiki aliran TIMI, tanpa komplikasi. Keterlambatan waktu antara permulaan gejala, saat masuk dan inflasi balon masih panjang dan segala usaha harus diupayakan untuk memendekan waktu ini

The new European guideline on cardiovascular disease prevention; how to make progress in general practice?: Commentary on: Main messages for primary care from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

The new guideline on cardiovascular disease (CVD) prevention, issued by the European Society of Cardiology was endorsed by 10 other societies, including Wonca Europe. It advices on how to reduce the cardiovascular (CV) risk in the population and attributes an important role to the general practitioner (GP). The GP is involved in treatment of the high-risk population as well as in public health measures to encourage a healthy lifestyle and CV risk factor reduction in the whole population. The new guideline gives room for a personalized approach and emphasizes that CV risk estimation and counselling need regular follow-up. We highlight the recommendations that most caught our eye and comment on the challenges for general practice

Optimal Medical Therapy Prescription in Patients with Acute Coronary Syndrome in the Netherlands: A Multicenter Pilot Registry

Background: Unlike neighboring countries, the Netherlands does not have a national acute coronary syndrome (ACS) registry to evaluate quality of care. Objective: We conducted a pilot registry in two hospitals to assess the prescription of guideline-recommended therapies in Dutch patients with ACS. Methods: We included all consecutive patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (n = 1309) admitted to two Dutch percutaneous coronary intervention centers between March 2015 and February 2016. We collected follow-up medication use and reasons for discontinuation at discharge and 1, 6, and 12 months post-discharge. We assessed the use of optimal medical therapy (OMT), defined as the combined prescription of aspirin, P2Y12 inhibitors, statins, β-blockers, and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Results: OMT prescription was 43.2% at discharge, 60.1% at 1 month, and 28.7% at 12 months. At 1 month, OMT prescription was significantly lower in patients with NSTEMI (51.8 vs. 65.7% for STEMI; p < 0.001). OMT prescription was lower in women (6 months: 55.4 vs. 62.0%, p = 0.036) and in elderly patients. Conclusion: In this pilot study that aimed to extend a national Dutch ACS registry to patients with STEMI and NSTEMI, OMT prescription was comparable to that in other local registries, was lower in women and patients with NSTEMI, and decreased with increasing age

Association between gender and short-term outcome in patients with ST elevation myocardial infraction participating in the international, prospective, randomised Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery (ATLANTIC) trial: a prespecified analysis

International audienceObjectives: To evaluate gender differences in outcomes in patents with ST-segment elevation myocardial infarction (STEMI) planned for primary percutaneous coronary intervention (PPCI).Settings: A prespecified gender analysis of the multicentre, randomised, double-blind Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery.Participants: Between September 2011 and October 2013, 1862 patients with STEMI and symptom duration <6 hours were included.Interventions: Patients were assigned to prehospital versus in-hospital administration of 180 mg ticagrelor.Outcomes The main objective was to study the association between gender and primary and secondary outcomes of the main study with a focus on the clinical efficacy and safety outcomes. Primary outcome: the proportion of patients who did not have 70% resolution of ST-segment elevation and did not meet the criteria for Thrombolysis In Myocardial Infarction (TIMI) flow 3 at initial angiography. Secondary outcome: the composite of death, MI, stent thrombosis, stroke or urgent revascularisation and major or minor bleeding at 30 days.Results: Women were older, had higher TIMI risk score, longer prehospital delays and better TIMI flow in the infarct-related artery. Women had a threefold higher risk for all-cause mortality compared with men (5.7% vs 1.9%, HR 3.13, 95% CI 1.78 to 5.51). After adjustment, the difference was attenuated but remained statistically significant (HR 2.08, 95% CI 1.03 to 4.20). The incidence of major bleeding events was twofold to threefold higher in women compared with men. In the multivariable model, female gender was not an independent predictor of bleeding (Platelet Inhibition and Patient Outcomes major HR 1.45, 95% CI 0.73 to 2.86, TIMI major HR 1.28, 95% CI 0.47 to 3.48, Bleeding Academic Research Consortium type 3–5 HR 1.45, 95% CI 0.72 to 2.91). There was no interaction between gender and efficacy or safety of randomised treatment.Conclusion: In patients with STEMI planned for PPCI and treated with modern antiplatelet therapy, female gender was an independent predictor of short-term mortality. In contrast, the higher incidence of bleeding complications in women could mainly be explained by older age and clustering of comorbidities.Clinical trial registration NCT01347580;Post-results

Changes and prognostic value of cardiopulmonary exercise testing parameters in elderly patients undergoing cardiac rehabilitation: The EU-CaRE observational study

Objective: We aimed 1) to test the applicability of the previously suggested prognostic value of CPET to elderly cardiac rehabilitation patients and 2) to explore the underlying mechanism of the greater improvement in exercise capacity (peak oxygen consumption, VO2) after CR in surgical compared to non-surgical cardiac patients. Methods: Elderly patients (≥65 years) commencing CR after coronary artery bypass grafting, surgical valve replacement (surgery-group), percutaneous coronary intervention, percutaneous valve replacement or without revascularisation (non-surgery group) were included in the prospective multi-center EU-CaRE study. CPETs were performed at start of CR, end of CR and 1-year-follow-up. Logistic models and receiver operating characteristics were used to determine prognostic values of CPET parameters for major adverse cardiac events (MACE). Linear models were performed for change in peak VO2 (start to follow-up) and parameters accounting for the difference between surgery and non-surgery patients were sought. Results: 1421 out of 1633 EU-CaRE patients performed a valid CPET at start of CR (age 73±5.4, 81% male). No CPET parameter further improved the receiver operation characteristics significantly beyond the model with only clinical parameters. The higher improvement in peak VO2 (25% vs. 7%) in the surgical group disappeared when adjusted for changes in peak tidal volume and haemoglobin. Conclusion: CPET did not improve the prediction of MACE in elderly CR patients. The higher improvement of exercise capacity in surgery patients was mainly driven by restoration of haemoglobin levels and improvement in respiratory function after sternotomy

Training intensity and improvements in exercise capacity in elderly patients undergoing European cardiac rehabilitation – the EU-CaRE multicenter cohort study

Objectives: Guidelines for exercise intensity prescription in Cardiac Rehabilitation (CR) are inconsistent and have recently been discussed controversially. We aimed (1) to compare training intensities between European CR centres and (2) to assess associations between training intensity and improvement in peak oxygen consumption ([Formula: see text]O2) in elderly CR patients. Methods: Peak [Formula: see text]O2, heart rate and work rate (WR) at the first and second ventilatory thresholds were measured at start of CR. Training heart rate was measured during three sessions spread over the CR. Multivariate models were used to compare training characteristics between centres and to assess the effect of training intensity on change in peak [Formula: see text]O2. Results: Training intensity was measured in 1011 out of 1633 EU-CaRE patients in 7 of 8 centers and the first and secondary ventilatory threshold were identified in 1166 and 817 patients, respectively. The first and second ventilatory threshold were found at 44% (SD 16%) and 78% (SD 9%) of peak WR and 78% (SD 9%) and 89% (SD 5%) of peak heart rate, respectively. Training intensity and session duration varied significantly between centres but change in peak [Formula: see text]O2 over CR did not. Training above the first individual threshold (β 0.62, 95% confidence interval [0.25-1.02]) and increase in training volume per hour (β 0.06, 95%CI [0.01-0.12]) were associated with a higher change in peak [Formula: see text]O2. Conclusion: While training intensity and volume varied greatly amongst current European CR programs, changes in peak [Formula: see text]O2 were similar and the effect of training characteristics on these changes were small