Impact of mild therapeutic hypothermia on bioavailability of ticagrelor in patients with acute myocardial infarction after out-of-hospital cardiac arrest

Background: Out-of-hospital cardiac arrest (OHCA) frequently occurs in the early phase of acute myocardial infarction (MI). Survivors require percutaneous coronary intervention (PCI) with concomitantdual antiplatelet therapy. Target temperature management, including mild therapeutic hypothermia (MTH), should be applied in comatose patients after resuscitation. However, an increased risk of stent thrombosis in patients undergoing hypothermia is observed. The aim of this study was to assess the impact of MTH on pharmacokinetics of ticagrelor in cardiac arrest survivors with MI treated with MTH and PCI.Methods: In a prospective, observational, single-center study pharmacokinetics of ticagrelor were evaluated in 41 MI patients, including 11 patients after OHCA undergoing MTH (MTH group) and 30 MI patients without OHCA and MTH (no-MTH group). Blood samples were drawn before administration of a 180 mg ticagrelor loading dose, and 30 min, 1, 2, 4, 6, 12, and 24 h after the loading dose.Results: In patients treated with MTH total exposure to ticagrelor during the first 12 h after the loading dose and maximal plasma concentration of ticagrelor were significantly lower than in the no-MTH group (AUC(0–12): 3403 ± 2879 vs. 8746 ± 5596 ng·h/mL, difference: 61%, p = 0.01; Cmax: 475 ± 353 vs. 1568 ± 784 ng/mL, p = 0.0002). Time to achieve maximal ticagrelor plasma concentration was also delayed in the MTH group (tmax for ticagrelor: 12 [6–24] vs. 4 [2–12] h, p = 0.01).Conclusions: Bioavailability of ticagrelor was substantially decreased and delayed in MI patients treated with MTH after OHCA. Trial registration: ClinicalTrials.gov Identifier: NCT0261193

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries

Aims Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries. Methods and results A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries. Conclusion Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encourage

Coronary features across the spectrum of out-of-hospital cardiac arrest with ST-elevation myocardial infarction (CAD-OHCA study)

Aim: We hypothesized that adult patients with out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) requiring prolonged resuscitation have more severe coronary artery disease (CAD) than those responding rapidly, and more severe CAD than patients with STEMI without OHCA. Methods: Consecutive conscious and comatose OHCA patients with STEMI after reestablishment of spontaneous circulation (ROSC), and patients with refractory OHCA undergoing veno-arterial extracorporeal membrane oxygenation (E-CPR OHCA) were compared to STEMI without OHCA (STEMI no OHCA). CAD severity was assessed by a single physician blinded to the resuscitation method, time to ROSC and level of consciousness. Results: Between 2016 and 2022, 71 conscious OHCA, 157 comatose OHCA, 50 E-CPR OHCA and 101 STEMI no OHCA underwent immediate coronary angiography. Acute culprit lesion was documented less often in OHCA (88.1% vs 97%p = 0.009) but complete occlusion was more frequent (68.8% vs 58.4%p = 0.038) than in STEMI no OHCA. SYNTAX score was 5.6 in STEMI no OHCA, 10.2 in conscious OHCA, 13.4 in comatose OHCA and 26.8 in E-CPR OHCA (p < 0.001). There was a linear correlation between SYNTAX score and delay to ROSC/ECMO initiation (r$^2$ = 0.61p < 0.001). Post PCI culprit TIMI 3 flow was comparable between the groups (≥86%). SYNTAX score was among independent predictors of 5-year survival which was significantly decreased in comatose OHCA (56.1%) and E-CPR OHCA (36.0%) compared to conscious OHCA (83.1%) and STEMI no OHCA (88.1%). Conclusion: Compared to STEMI no OHCA, OHCA was associated with increased incidence of acute coronary occlusion and more complex non culprit CAD which progressively increased from conscious OHCA to E-CPR OHCA. Severity of CAD was associated with increased delays to ROSC/ECMO initiation and decreased long term survival

Dual-Modular Versus Single-Modular Stems for Primary Total Hip Arthroplasty: A Long-Term Survival Analysis

Background and Objectives: Increased revision rate of dual-modular (DM) femoral stems in primary total hip arthroplasty (THA) because of modular-neck breakage and adverse local tissue reactions (ALTRs) to additional junction damage products is well established and some designs have been recalled from the market. However, some long-term studies of specific DM stems did not confirm the inferiority of these stems compared to standard single-modular (SM) stems, and a head-to-head comparison THA is missing. The objectives of this multicentre study were to determine the survivorship and complication rates of a common DM stem design compared to a similar SM stem. Materials and Methods: In a time frame from January 2012 to November 2015, a cohort of 807 patients (882 hips) consecutively underwent primary cementless THAs at two orthopaedic centres. 377 hips were treated with a Zweimüller-type DM stem THA system and 505 hips with a similar SM stem THA system, both including a modern press-fit acetabulum. Kaplan-Meier survivorship and complication rates were compared between both groups in a median follow-up of 9.0 years (maximum, 9.9 years). Results: The 9-year survivorship of the DM stem THA system (92.6%, 95% CI 89.9–95.3) was significantly lower than that of the SM stem THA system (97.0%, 95% CI 95.2–98.8). There were no differences in revision rates for septic loosening, dislocation, and periprosthetic fractures between the two groups. One ceramic inlay and one Ti-alloy modular neck breakage occurred in the DM stem THA system group, but the main reason for revision in this group was aseptic loosening of components. Conclusions: The survivorship of the DM stem THA system was lower than the similar SM stem THA system in a comparable clinical environment with long-term follow-up. Our results confirmed that no rationale for stem modularity exists in primary THAs

The impact of mild therapeutic hypothermia on platelet reactivity in comatose survivors of cardiac arrest with acute myocardial infarction treated with ticagrelor

Background: The aim of the study was to assess the antiplatelet effect of ticagrelor in patients with myocardial infarction (MI) after out-of-hospital cardiac arrest (OHCA) treated with percutaneous coronary intervention (PCI) and mild therapeutic hypothermia (MTH) vs. MI patients without OHCA treated with PCI. Methods: The study was designed and performed as a phase IV, single-center, investigator-initiated, prospective, observational study assessing the early pharmacodynamic effect (within first 24 h) of a ticagrelor loading dose (180 mg) in both groups of patients (MTH group vs. MI group). For assessment of ticagrelor pharmacodynamics Multiple Electrode Aggregometry (MEA) was applied. Results: Compared with the MTH group, platelet inhibition was persistently stronger in the MI group over the entire observation period (up to 24 h), with the highest difference at 4 hours after loading with ticagrelor (25.8 ± 26.4 vs. 75.8 ± 40.9 U, p = 0.002). As a consequence, there was a higher prevalence of high platelet reactivity in the MTH group, with the most explicit difference at 6 hours after the loading dose of ticagrelor (78% vs. 7%, p &lt; 0.001). Conclusions: In comparison with patients treated with primary PCI for uncomplicated MI, the antiplatelet effect of ticagrelor in patients with MI complicated with OHCA, undergoing MTH and primary PCI, is attenuated and delayed

Relational Family Therapy in the Treatment of Sudden Cardiac Arrest Survivors and their Relatives

Sudden cardiac arrest is the most common single cause of death in the contemporary world, but the proportion of survivors is increasing thanks to modern intensive methods of hospital treatment. However, data show that survivors experience high rates of neurological and cognitive deficits and poorer emotional well-being, which is a major challenge in treating these individuals and encouraging their integration in everyday life. These issues range from a number of emotional problems, such as anxiety and depression, to lower levels of participation in social life and a low rate of return to their workplace. The need for security and support increases because of the feelings of insecurity, vulnerability and fear of the recurrence of symptoms. Relatives/caregivers who report emotional problems and a higher level of post-traumatic stress are physically and mentally burdened, too. Hence, sudden cardiac arrest is a life-threatening event which is traumatic for survivors and their close relatives. It triggers strong emotional responses that are characteristic of all types of trauma (reliving the trauma, avoidance, negative thoughts and mood, increased agitation). People who have survived trauma thus suffer long-term effects, which are reflected in various dysfunctional behaviours and activities due to inadequate regulation of affective states. Because of these issues, there is a need for effective interventions that can psychologically help patients and relatives after surviving sudden cardiac arrest. In this paper, we will present the model of Relational Family Therapy, which can enable survivors and their relatives to appropriately emotionally-affectively process this experience and thus more appropriately integrate into a new way of life. With the qualitative research method of task analysis, we will show the process of change, which is based on the establishment of a new regulation of affect and allows in-depth processing of difficult emotional states after this event

Impact of Cusp-Overlap View for TAVR with Self-Expandable Valves on 30-Day Conduction Disturbances

Background and Aim. Conduction disturbances leading to permanent pacemaker implantation (PPMI) remains a common complication for TAVR procedures, particularly when self-expanding valves are used. We compared the 30-day incidence of new-onset left bundle branch block (LBBB) and permanent pacemaker implantation (PPMI) rate between two consecutive groups using either conventional 3-cusp coplanar view (CON) and right/left cusp-overlap view (COVL) for implantation. Methods and Results. We retrospectively compared 257 consecutive patients undergoing TAVR with self-expandable valves using either CON (n = 101) or COVL (n = 156) in four intermediate/low volume centers. There were no significant differences in baseline characteristics between the groups. The 30-day incidence of new-onset LBBB (12.9% vs. 5.8%; p=0.05) and PPMI rate (17.8% vs. 6.4%; p=0.004) was significantly lower when using the COVL implantation view. There was no difference between the CON and COVL groups in 30-day incidence of death (4.9% vs. 2.6%), any stroke (0% vs. 0.6%), and the need for surgical aortic valve replacement (0% for both groups). Conclusion. Using the COVL view for implantation, we achieved a significant reduction of the LBBB and PPMI rate after TAVR in comparison with the traditional CON view, without compromising the TAVR outcomes when using self-expandable prostheses

Relational Family Therapy in the Treatment of Sudden Cardiac Arrest Survivors and their Relatives

Sudden cardiac arrest is the most common single cause of death in the contemporary world, but the proportion of survivors is increasing thanks to modern intensive methods of hospital treatment. However, data show that survivors experience high rates of neurological and cognitive deficits and poorer emotional well-being, which is a major challenge in treating these individuals and encouraging their integration in everyday life. These issues range from a number of emotional problems, such as anxiety and depression, to lower levels of participation in social life and a low rate of return to their workplace. The need for security and support increases because of the feelings of insecurity, vulnerability and fear of the recurrence of symptoms. Relatives/caregivers who report emotional problems and a higher level of post-traumatic stress are physically and mentally burdened, too. Hence, sudden cardiac arrest is a life-threatening event which is traumatic for survivors and their close relatives. It triggers strong emotional responses that are characteristic of all types of trauma (reliving the trauma, avoidance, negative thoughts and mood, increased agitation). People who have survived trauma thus suffer long-term effects, which are reflected in various dysfunctional behaviours and activities due to inadequate regulation of affective states. Because of these issues, there is a need for effective interventions that can psychologically help patients and relatives after surviving sudden cardiac arrest. In this paper, we will present the model of Relational Family Therapy, which can enable survivors and their relatives to appropriately emotionally-affectively process this experience and thus more appropriately integrate into a new way of life. With the qualitative research method of task analysis, we will show the process of change, which is based on the establishment of a new regulation of affect and allows in-depth processing of difficult emotional states after this event.Sudden cardiac arrest is the most common single cause of death in the contemporary world, but the proportion of survivors is increasing thanks to modern intensive methods of hospital treatment. However, data show that survivors experience high rates of neurological and cognitive deficits and poorer emotional well-being, which is a major challenge in treating these individuals and encouraging their integration in everyday life. These issues range from a number of emotional problems, such as anxiety and depression, to lower levels of participation in social life and a low rate of return to their workplace. The need for security and support increases because of the feelings of insecurity, vulnerability and fear of the recurrence of symptoms. Relatives/caregivers who report emotional problems and a higher level of post-traumatic stress are physically and mentally burdened, too. Hence, sudden cardiac arrest is a life-threatening event which is traumatic for survivors and their close relatives. It triggers strong emotional responses that are characteristic of all types of trauma (reliving the trauma, avoidance, negative thoughts and mood, increased agitation). People who have survived trauma thus suffer long-term effects, which are reflected in various dysfunctional behaviours and activities due to inadequate regulation of affective states. Because of these issues, there is a need for effective interventions that can psychologically help patients and relatives after surviving sudden cardiac arrest. In this paper, we will present the model of Relational Family Therapy, which can enable survivors and their relatives to appropriately emotionally-affectively process this experience and thus more appropriately integrate into a new way of life. With the qualitative research method of task analysis, we will show the process of change, which is based on the establishment of a new regulation of affect and allows in-depth processing of difficult emotional states after this event