Οι Νέες Κατευθυντήριες Οδηγίες για το Οξύ Έμφραγμα (STEMI) / STEMI Guidelines Update 2007

Η σημαντική και ταχεία πρόοδος που σημειώνεται στη θεραπευτική αντιμετώπιση του με ανάσπαση του ST εμφράγματος του μυοκαρδίου, επιβάλλει όλο και συχνότερα προσθήκες και ανασκοπήσεις στις Κατευθυντήριες Οδηγίες που κατά καιρούς εκδίδονται από τις μεγάλες διεθνείς Καρδιολογικές Εταιρείες. Στη παρούσα εργασία θα σχολιασθούν οι αλλαγές που επιφέρει η αναθεώρηση του 20071 στις Κατευθυντήριες Οδηγίες που εκδόθηκαν το 2004 για την αντιμετώπιση του με ανάσπαση του ST εμφράγματος του μυοκαρδίου από American College of  Cardiology και American Heart Association. Ο σχολιασμός θα αφορά κυρίως τα κεφάλαια της επαναιμάτωσης και  της αντιθρομβωτικής αγωγής, που παρουσιάζουν ιδιαίτερο ενδιαφέρον για τη κοινότητα των επεμβατικών καρδιολόγων... (excerpt

Routine Early Coronary Angioplasty After Thrombolysis

 Over the recent years it has become abundantly clear that reperfusion by primary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals that lack facilities for percutaneous coronary intervention (PCI), on site thrombolysis remains their first option, or alternatively patients can be transferred to other institutions for PCI, if this can be accomplished within a tight time frame. For the latter strategy, an organized network of centers is needed to rapidly and safely transfer STEMI patients for primary PCI. Thus, although transferring STEMI patients for primary PCI appears to be a superior reperfusion strategy compared with on-site fibrinolysis at a no-PCI capable hospital, time delays associated with transferring patients for PCI in routine clinical practice remains a major drawback of the whole concept. The tight time interval of 90-120 min needed to take full advantage of primary PCI, probably can be extended several hours, if an initial reperfusion treatment with thrombolysis is chosen, followed by routine angioplasty in the subsequent hours. At least these are the convincing results from recent trials published over the last three years, such as TRANSFER-AMI, FAST-MI, GRACIA-1 and GRACIA-2, WEST-MI, and CARESS-AMI. When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of primary PCI. Finally, when analyzed according to the timing of PCI after thrombolysis, mortality tended to be lower with increasing time from thrombolysis when PCI was performed on a systematic basis, whereas it tended to increase with increasing time from thrombolysis when PCI was performed as a rescue procedure. Sufficient time course (probably >2-3 hours to 6-12 hours), which neutralizes the pre-hemorrhagic effect of thrombolysis and allows the antiplatelet agents to act, is the key point for a better outcome when thrombolysis is combined with early angioplasty, and this appears to be a more effective and practical way to treat STEMI patients, at least for those hospitals, whereby immediate PCI is not available.   Key Words: myocardial infarction; thrombolysis; reperfusion; coronary angioplast

Post-Infarction Ventricular Rupture

We report the case of a 67-year-old lady who developed apical ventricular septalrupture after suffering acute anterior myocardial infarction. Having experienced symptoms of acute chest pain three days earlier, she visited the health unit of her residence area, an Ionian sea island. Her electrocardiogram and elevated myocardial necrosis enzymes in blood tests, confirmed a presumptive diagnosis of acute anterior myocardial infarction. The patient was urgently transferred by air-ambulance to our hospital due to hemodynamic deterioration... (excerpt

Door-to-Balloon Time for Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction

Ιt has become clear, recently, that reperfusion by primary coronary intervention in patients with ST elevation myocardial infarction (STEMI) is superior to thrombolytic therapy and is the treatment of choice. However, this reperfusion strategy has some drawbacks, as cardiac catheterization laborato-ries are not always widely available 24h/7d and long-time delays related to primary percutaneous coronary intervention (pPCI) may have negative impact on mortality. The shorter the delay from symptom onset to reperfusion, the greater the amount of the myocardium rescued as it is obvious that “time is muscle”. Among pPCI related times the crucial time delay is the one from door–to-balloon (time from arrival at the hospital until the mechanical restoration of the vessel patency).This time delay is usually accurately recorded and depends on the national (or even local) health care system. The European Society of Cardiology guidelines on myocardial revascularization suggest that total ischemic time should not exceed 120min and especially 90min for patients <65 years old, with anterior infarction and early presentation (<2h) from onset of symptoms, because these categories of patients have even worse outcomes and increased mortality with prolonged door-to-balloon times, compared to other categories. Better patient education about symptoms suggesting myocardial ischaemia, pre-hospital diagnosis of STEMI based on 12-lead electrocardiogram with immediate transportation to a PCI-capable centre in order to eliminate inter-hospital delays, an effective emergency medical system capable of quick transportation, immediate activation of the cardiac catheterization laboratory from emergency physicians or an attendant cardiologist, the presence of an experienced team of high volume operators and skilled supporting staff capable of performing pPCI 24h/7d, new and more effective antithrombotic drugs and angioplasty materials, are the key elements to achieve shorter door-to-balloon and PCI delay times and therefore rescue the greater amount of myocardium and reduce mortality

Early Coronary Angioplasty After Thrombolysis

Over the recent years it has been clearly demonstrated that reperfusion by primary angioplasty in patients with ST-elevation myocardial infarction (STEMI) is the treatment of choice. For hospitals without the capacity of performing primary angioplasty, reperfusion with on-site thrombolysis or transportation of the patient to another institution for primary percutaneous coronary intervention (PCI) within a tight frame rate are the alternative options. For the latter strategy, an organized network of centers is needed to rapidly transfer STEMI patients for primary PCI. Although transferring STEMI patients for primary PCI is superior reperfusion therapy in comparison to on-site thrombolysis, there are concerns, regarding time delays of transfer in daily practice, which is a major drawback of this therapeutic strategy as delays of >120min from first medical contact to primary PCI negate the advantage of primary PCI over thrombolysis. The narrow time interval (<90-120min) that is mandatory for the superiority of primary PCI, could be extended if a pharmacoinvasive strategy (fibrinolysis followed by routine “early” angioplasty of the culprit artery) was chosen. Convincing results from trials such as TRANSFER-AMI, FAST-MI, GRACIA-2, WEST-MI, CARESS-AMI, NORDISTEMI and STREAM indicated that combined use of thrombolysis and PCI in a sufficient time course (>3hours to 6-12hours), in order to neutralize the pre-hemorrhagic effects of thrombolysis and allow full action of antiplatelet and antithrombotic agents, had comparable efficacy in comparison to primary PCI regarding early and 1 year survival. This appears to be an effective alternative option for the treatment of STEMI patients, at least for those hospitals whereby immediate PCI is unavailable

Translation, Adaptation and Validation of the Coronary Revascularization Outcome Questionnaire (CROQ) into Greek

Date of Acceptance: 31/05/2015Evaluating the impact of coronary revascularization on patients’ health related quality of life with a patient-based and disease-specific tool is important for drawing conclusions about treatment and outcomes. This study reports on the translation, adaptation and psychometric evaluation of a Greek version of the Coronary Revascularization Outcome Questionnaire (CROQ-Gr)Peer reviewe

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Left ventricular ejection fraction and Global Longitudinal Strain variability between methodology and experience

Introduction Although ejection fraction (EF) is the cornerstone of the assessment of left ventricular (LV) systolic function, its measurement faces a number of challenges related to image quality, assumptions of LV geometry, and expertise. The aim of this study was to test the inter-observer variability of EF and GLS measurement in patients with a broad spectrum of LV function, between physicians and investigators (Inv) with different levels of expertise. Methods In 122 patients, EF and GLS were measured by 4 Inv blinded to each other with different level of experience in echocardiography; EF was measured using 3 methods: visual assessment, biplane Simpson's method, and auto-EF method. GLS was measured from the 3 apical views. A significant difference for LVEF and for LVGLS was considered to be >10 and >2 absolute values, respectively. Results Intra-observer agreement was excellent for visually assessed EF (ICC = 0.87, P < .001) and GLS (ICC = 0.82, P < .001) and good for EF measured by Simpson's method (ICC = 0.70, P < .001) and auto-EF (ICC = 0.72, P < .001). Intra-observer and inter-observer agreements were excellent for GLS with ICCs above 0.8. GLS discordance between the 4 Inv was not significant. Discordance in EF and GLS measurements among the Inv was not related to image quality or wall motion abnormalities. Conclusion Although EF has proved its prognostic value in various cardiovascular entities, GLS seems to be more reliable for serial assessment of LV function, demonstrating lower intra- and inter-observer variability, even by different physicians with variant level of expertise