Relationship between treatment delay and final infarct size in STEMI patients treated with abciximab and primary PCI

Background Studies on the impact of time to treatment on myocardial infarct size have yielded   conflicting results. In this study of ST-Elevation Myocardial Infarction (STEMI) treated   with primary percutaneous coronary intervention (PCI), we set out to investigate the   relationship between the time from First Medical Contact (FMC) to the demonstration   of an open infarct related artery (IRA) and final scar size. Between February 2006 and September 2007, 89 STEMI patients treated with primary PCI   were studied with contrast enhanced magnetic resonance imaging (ceMRI) 4 to 8 weeks   after the infarction. Spearman correlation was computed for health care delay time   (defined as time from FMC to PCI) and myocardial injury. Multiple linear regression   was used to determine covariates independently associated with infarct size. Results An occluded artery (Thrombolysis In Myocardial Infarction, TIMI flow 0-1 at initial   angiogram) was seen in 56 patients (63%). The median FMC-to-patent artery was 89 minutes.   There was a weak correlation between time from FMC-to-patent IRA and infarct size,   r = 0.27, p = 0.01. In multiple regression analyses, LAD as the IRA, smoking and an occluded vessel   at the first angiogram, but not delay time, correlated with infarct size. Conclusions In patients with STEMI treated with primary PCI we found a weak correlation between   health care delay time and infarct size. Other factors like anterior infarction, a   patent artery pre-PCI and effects of reperfusion injury may have had greater influence   on infarct size than time-to-treatment per se

Longitudinal peak strain detects a smaller risk area than visual assessment of wall motion in acute myocardial infarction

<p>Abstract</p> <p>Background</p> <p>Opening of an occluded infarct related artery reduces infarct size and improves survival in acute ST-elevation myocardial infarction (STEMI). In this study we performed tissue Doppler analysis (peak strain, displacement, mitral annular movement (MAM)) and compared with visual assessment for the study of the correlation of measurements of global, regional and segmental function with final infarct size and transmurality. In addition, myocardial risk area was determined and a prediction sought for the development of infarct transmurality ≥50%.</p> <p>Methods</p> <p>Twenty six patients with STEMI submitted for primary percutaneous coronary intervention (PCI) were examined with echocardiography on the catheterization table. Four to eight weeks later repeat echocardiography was performed for reassessment of function and magnetic resonance imaging for the determination of final infarct size and transmurality.</p> <p>Results</p> <p>On a global level, wall motion score index (WMSI), ejection fraction (EF), strain, and displacement all showed significant differences (p ≤ 0.001, p ≤ 0.001, p ≤ 0.001 and p = 0.03) between the two study visits, but MAM did not (p = 0.17). On all levels (global, regional and segmental) and both pre- and post PCI, WMSI showed a higher correlation with scar transmurality compared to strain. We found that both strain and WMSI predicted the development of scar transmurality ≥50%, but strain added no significant information to that obtained with WMSI in a logistic regression analysis.</p> <p>Conclusions</p> <p>In patients with acute STEMI, WMSI, EF, strain, and displacement showed significant changes between the pre- and post PCI exam. In a ROC-analysis, strain had 64% sensitivity at 80% specificity and WMSI around 90% sensitivity at 80% specificity for the detection of scar with transmurality ≥50% at follow-up.</p

Strategies to improve outcome in patients with ST elevation myocardial infarction treated with primary PCI

Background: ST elevation myocardial infarction (STEMI) caused by a ruptured atherosclerotic plaque with overlying thrombosis leads to ischemia and progressively to the death of the myocardial cells supplied by the affected coronary artery. Rapid reperfusion with primary Percutaneous Coronary Intervention (PCI) in an experienced centre is the preferred therapy for these patients. The aim of the research program on which this thesis is based was to study the effect of antiplatelet therapy with abciximab on coronary patency  when administered early to an unselected cohort of patients with STEMI intended for primary PCI, to study the impact of health care delay time on infarct size measured with contrast enhanced Magnetic Resonance Imaging (ceMRI), and to evaluate if time delays could be reduced through reorganisation of logistics and personal feedback to staff involved in the care of STEMI patients. Finally measures of wall motion on cine MRI were evaluated to elucidate if functional measurements of the left ventricular wall could detect scar tissue visualised on ceMRI in a post-acute phase of primary PCI. Material and results: In paper I we report on a study of all consecutive patients who sustained a STEMI in 2005 in the county of Östergötland and who were to be treated with primary PCI. Abciximab given as pretreatment before (n=133) or at the cath-lab after a diagnostic angiography (n=109) was associated with a patent Infarct Related Artery (IRA), i.e. Thrombolysis in Myocardial Infarction (TIMI) flow 2-3, in 45.9% of patients in the early group versus 20.2% in the cath-lab group, p=0.0001. There were no statistically significant differences in bleeding or mortality rate during the initial hospital stay, nor were there any significant differences between the groups during one-year follow up regarding a Major Adverse Cardiac Event (MACE). Paper II is based on an examination of 30 patients in a stable clinical condition with ceMRI 4-8 weeks after they had been treated with primary PCI because of STEMI. Patients were selected on the presence of extensive myocardial scar in the anteroseptal segments (n=17) or no scar visible at all in this area or in any other part of the myocardium (n=13). The purpose of the study was to evaluate the ability of a new feature tracking software to measure functional parameters of the heart. The left ventricular wall was divided into 18 segments and myocardial contraction was measured with velocity, displacement and strain in the longitudinal and radial direction. The software calculated a mean value for the 18 segments for each parameter. Receiver-operatorcharacteristics curves (ROC) were constructed. The best area-under-curve (AUC) was for radial strain where a cut-off value of 38.8% had 80% sensitivity and 86% specificity to detect segments with scar&gt;50%. The impact of health care delay was examined in paper III based on a study in which 89 STEMI patients treated with primary PCI had their infarct size measured with ceMRI in the post-acute phase. Time from First Medical Contact (FMC) to a patent artery correlated weakly with infarct size, r=0.27, p=0.01. However, multivariable analysis showed the LAD as the Infarct Related Artery (IRA), active smoking and occlusion of the IRA at the time of the diagnostic angiogram were correlated with infarct size and that time from FMC to patent artery was not so correlated. Finally, in the study leading to paper IV, extensive measurements on time delays were performed on 67 consecutive patients with STEMI treated with primary PCI. Through collaboration with different stakeholders in the treatment of STEMI in the catchment area the following types of targeted refining of logistics were done; 1. Ambulance staff prioritise ECG recording, 2. Central evaluation of ECG in all patients with suspected STEMI, and 3. PCI team is ready to accept the patient when two out of three members are on site. Moreover, personal feedback on time delays for each STEMI patient was given to all staff involved in the treatment of the patient. Thereafter, all the time delays for a similar group of consecutive STEMI patients (n=89) were analysed and compared with the delays for the former group. Improvements seen in the post-intervention group were a reduction in time from ECG to cath-lab arrival by 11 minutes, p=0.02 and a non-significant decrease of FMC to a patent artery by six minutes. The main part of this improvement could probably be ascribed to the decision to see to it that an attending cardiologist was present 24/7 and to central evaluation of ECG. Conclusion: Abciximab given as pre-treatment to patients with STEMI intended for primary PCI was associated with a patent artery in 46% of patients. Moreover, we demonstrated a relationship between health care delay time and infarct size. This delay time could be reduced by a reorganisation of logistics and personal feedback on time delays. Finally, feature tracking analysis of cine MR images could detect segments with extensive myocardial scar in anterior infarction with 80% sensitivity and 86% specificity

Strategies to improve outcome in patients with ST elevation myocardial infarction treated with primary PCI

Background: ST elevation myocardial infarction (STEMI) caused by a ruptured atherosclerotic plaque with overlying thrombosis leads to ischemia and progressively to the death of the myocardial cells supplied by the affected coronary artery. Rapid reperfusion with primary Percutaneous Coronary Intervention (PCI) in an experienced centre is the preferred therapy for these patients. The aim of the research program on which this thesis is based was to study the effect of antiplatelet therapy with abciximab on coronary patency  when administered early to an unselected cohort of patients with STEMI intended for primary PCI, to study the impact of health care delay time on infarct size measured with contrast enhanced Magnetic Resonance Imaging (ceMRI), and to evaluate if time delays could be reduced through reorganisation of logistics and personal feedback to staff involved in the care of STEMI patients. Finally measures of wall motion on cine MRI were evaluated to elucidate if functional measurements of the left ventricular wall could detect scar tissue visualised on ceMRI in a post-acute phase of primary PCI. Material and results: In paper I we report on a study of all consecutive patients who sustained a STEMI in 2005 in the county of Östergötland and who were to be treated with primary PCI. Abciximab given as pretreatment before (n=133) or at the cath-lab after a diagnostic angiography (n=109) was associated with a patent Infarct Related Artery (IRA), i.e. Thrombolysis in Myocardial Infarction (TIMI) flow 2-3, in 45.9% of patients in the early group versus 20.2% in the cath-lab group, p=0.0001. There were no statistically significant differences in bleeding or mortality rate during the initial hospital stay, nor were there any significant differences between the groups during one-year follow up regarding a Major Adverse Cardiac Event (MACE). Paper II is based on an examination of 30 patients in a stable clinical condition with ceMRI 4-8 weeks after they had been treated with primary PCI because of STEMI. Patients were selected on the presence of extensive myocardial scar in the anteroseptal segments (n=17) or no scar visible at all in this area or in any other part of the myocardium (n=13). The purpose of the study was to evaluate the ability of a new feature tracking software to measure functional parameters of the heart. The left ventricular wall was divided into 18 segments and myocardial contraction was measured with velocity, displacement and strain in the longitudinal and radial direction. The software calculated a mean value for the 18 segments for each parameter. Receiver-operatorcharacteristics curves (ROC) were constructed. The best area-under-curve (AUC) was for radial strain where a cut-off value of 38.8% had 80% sensitivity and 86% specificity to detect segments with scar&gt;50%. The impact of health care delay was examined in paper III based on a study in which 89 STEMI patients treated with primary PCI had their infarct size measured with ceMRI in the post-acute phase. Time from First Medical Contact (FMC) to a patent artery correlated weakly with infarct size, r=0.27, p=0.01. However, multivariable analysis showed the LAD as the Infarct Related Artery (IRA), active smoking and occlusion of the IRA at the time of the diagnostic angiogram were correlated with infarct size and that time from FMC to patent artery was not so correlated. Finally, in the study leading to paper IV, extensive measurements on time delays were performed on 67 consecutive patients with STEMI treated with primary PCI. Through collaboration with different stakeholders in the treatment of STEMI in the catchment area the following types of targeted refining of logistics were done; 1. Ambulance staff prioritise ECG recording, 2. Central evaluation of ECG in all patients with suspected STEMI, and 3. PCI team is ready to accept the patient when two out of three members are on site. Moreover, personal feedback on time delays for each STEMI patient was given to all staff involved in the treatment of the patient. Thereafter, all the time delays for a similar group of consecutive STEMI patients (n=89) were analysed and compared with the delays for the former group. Improvements seen in the post-intervention group were a reduction in time from ECG to cath-lab arrival by 11 minutes, p=0.02 and a non-significant decrease of FMC to a patent artery by six minutes. The main part of this improvement could probably be ascribed to the decision to see to it that an attending cardiologist was present 24/7 and to central evaluation of ECG. Conclusion: Abciximab given as pre-treatment to patients with STEMI intended for primary PCI was associated with a patent artery in 46% of patients. Moreover, we demonstrated a relationship between health care delay time and infarct size. This delay time could be reduced by a reorganisation of logistics and personal feedback on time delays. Finally, feature tracking analysis of cine MR images could detect segments with extensive myocardial scar in anterior infarction with 80% sensitivity and 86% specificity

Open Access

Strategies TO reduce time delays in patient

http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-65947 Gender Difference in Prevalence and Prognostic Impact of Renal Insufficiency in Patients with ST-elevation Myocardial Infarction treated with Primary PCI

Gender difference in prevalence and prognostic impact of renal insufficiency in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary interventio

Strategies TO reduce time delays in patients with AcuTe coronary heart diasease treated with primary PCI - the STOP WATCH study : a multistage action research project

Objective To identify, evaluate and reduce system delay times in an ST-elevation myocardial infarction (STEMI) network by targeted reorganisation of logistics and personal feedback to staff on time delays. Design Multistage action research project. Three study phases were used (exploration, tailored intervention and evaluation). Setting Single centre study, Sweden. Patients Consecutive patients (N=156) with prehospital STEMI onset treated with primary percutaneous coronary intervention (PCI). Interventions Areas of delays were identified through participant observations and collaborative discussions. To increase the awareness of delay factors, continuous feedback on time delays was given. Elements of the logistics’ reorganisation were (1) prioritised ECG recording by emergency medical services personnel, (2) central evaluation of ECG in all patients and (3) start of PCI procedure when two of three PCI team members were on site. Multiple key time measurements were made before (N=67) and after (N=89) the intervention. Main outcomes Time difference (minutes) in system delay between the preintervention and postintervention phases. Results Time from first medical contact (FMC) to a patent artery and time from FMC-to-catheter laboratory (cath-lab) arrival decreased by 6 and 12 min, respectively (ns). Time from FMC-to-ECG recording remained unchanged after the intervention. Time from ECG to decision for primary PCI was reduced by 6 min, p=0.004 and time from ECG-to-cath-lab arrival by 11 min, p=0.02. Total time from diagnosis to a patent artery decreased by 11 min (ns). Conclusions Identification of time delays in an STEMI network with awareness of delay factors, reorganisation of logistics and continuous feedback can reduce system delay times significantly

Subjective Well-Being and Physical Activity in Relationship with Job Satisfaction

Mаģistrа dаrbа mērķis bijа аpkopot šobrīd zināmo informāciju pаr subjеktīvo lаbklājību, fizisko аktivitāti, un to sаistību аr аpmiеrinātību аr dаrbu. Kā аrī mērķis bijа noskаidrot vаi pаstāv stаtistiski nozīmīgа sаistībа stаrp subjеktīvo lаbklājību, fiziskās аktivitātеs līmеni un аpmiеrinātību аr dаrbu. Pētījumā piеdаlījās 203 pilnās slodzеs dаrbiniеki vеcumā no 18 līdz 56 gаdiеm (M=32,90, SD=7,547). Visiеm rеspondеntiеm tikа vеikti subjеktīvās lаbklājībаs mērījumi izmаntojot Аpmiеrinātībаs аr dzīvi Rivеrsаidа skаlu (RLSS) (Mаrgolis, еt аl., 2018), kаs tikа adaptēta dаrbа iеtvаros. Kā аrī kаtrаm tikа vеiktа fiziskās аktivitātеs līmеņа mērījumi, izmаntojot Fiziskās аktivitātеs līmеņа аptаuju (Judzikа, 2019), un аpmiеrinātībа аr dаrbu tikа mērītа, izmаntojot Аpmiеrinātību аr dаrbu (JSS) (Spеktor, 1997). Pētījumа rеzultāti liеcinа, kа ir vērojаmа stаtistiski nozīmīgа, pozitīvа sаistībа stаrp subjеktīvo lаbklājību un fiziskās аktivitātеs līmеni (r = 0,23, p < 0,01). Rеspеktīvi, piеаugot subjеktīvās lаbklājībаs rādītājiеm, piеаug аrī fiziskās аktivitātеs līmеņа rādītāji, un otrādi. Kā аrī tikа аtrаstа stаtistiski nozīmīgа sаistībа stаrp subjеktīvo lаbklājību un kopējo аpmiеrinātību аr dаrbu (r = 0,59, p < 0,01). Аrī visаs аpmiеrinātībаs аr dаrbu аpаkšskаlаs uzrādījа stаtistiski nozīmīgu pozitīvu sаkаrību аr subjеktīvo lаbklājību. Sаvukārt stаrp fiziskās аktivitātеs līmеni un аpmiеrinātību аr dаrbu nozīmīgа sаistībа nеtikа аtklātа.Thе аim of thе mаstеr's thеsis wаs to summаrizе thе currеntly known informаtion аbout subjеctivе wеll-bеing, physicаl аctivity, аnd job sаtisfаction. Thе аim wаs аlso to find out whеthеr thеrе wаs а stаtisticаlly significаnt rеlаtionship bеtwееn subjеctivе wеll-bеing, lеvеl of physicаl аctivity аnd job sаtisfаction. Thе study involvеd 203 full-timе respondents аgеd 18 to 56 yеаrs old (M = 32.90, SD = 7.547). Аll rеspondеnts hаd thе mеаsurеmеnts of thе subjеctivе wеll-bеing using thе Rivеrsidе Lifе Sаtisfаction Scаlе (RLSS) (Mаrgolis, еt аl., 2018), which wаs stаndаrdizеd аs pаrt of thе work. Аlso, physicаl аctivity lеvеl mеаsurеmеnts lеvеls wеrе mеаsurеd using а Physicаl Аctivity Lеvеl Survеy (Judzikа, 2019), аnd job sаtisfаction wаs mеаsurеd using Job Sаtisfаction (JSS) (Spеktor, 1997). Thе rеsults of thе study show thаt thеrе is а stаtisticаlly significаnt, positivе rеlаtionship bеtwееn subjеctivе wеll-bеing аnd thе lеvеl of physicаl аctivity (r = 0.23, p <0.01). Rеspеctivеly, аs thе indicаtors of subjеctivе wеll-bеing incrеаsе, so do thе indicаtors of thе lеvеl of physicаl аctivity, аnd vicе vеrsа. Аlso, а stаtisticаlly significаnt rеlаtionship wаs found bеtwееn subjеctivе wеll-bеing аnd ovеrаll job sаtisfаction (r = 0.59, p <0.01). Аll job sаtisfаction subscаlеs аlso showеd а stаtisticаlly significаnt positivе corrеlаtion with subjеctivе wеll-bеing. Howеvеr, no significаnt rеlаtionship wаs found bеtwееn thе lеvеl of physicаl аctivity аnd job sаtisfаction