Archive for March, 2013

Journal Club 27 March 2013


Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction





It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous
coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI).


Among 1892 patients with STEMI who presented within 3 hours after symptom
onset and who were unable to undergo primary PCI within 1 hour, patients were
randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus
tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and
enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed
6 to 24 hours after randomization. The primary end point was a composite of
death, shock, congestive heart failure, or reinfarction up to 30 days.


The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis
group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the
fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency
angiography was required in 36.3% of patients in the fibrinolysis group, whereas the
remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the
primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%,
P=0.45). The rates of nonintracranial bleeding were similar in the two groups.


Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within
1 hour after the first medical contact. However, fibrinolysis was associated with a
slightly increased risk of intracranial bleeding.


Journal Club 20 March 2013


Nonemergency PCI at Hospitals with or without On-Site Cardiac Surgery





Emergency surgery has become a rare event after percutaneous coronary intervention
(PCI). Whether having cardiac-surgery services available on-site is essential for ensuring
the best possible outcomes during and after PCI remains uncertain.


We enrolled patients with indications for nonemergency PCI who presented at hospitals
in Massachusetts without on-site cardiac surgery and randomly assigned these
patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that
had cardiac surgery services available. A total of 10 hospitals without on-site cardiac
surgery and 7 with on-site cardiac surgery participated. The coprimary end points
were the rates of major adverse cardiac events — a composite of death, myocardial
infarction, repeat revascularization, or stroke — at 30 days (safety end point) and
at 12 months (effectiveness end point). The primary end points were analyzed according
to the intention-to-treat principle and were tested with the use of multiplicative
noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness).


A total of 3691 patients were randomly assigned to undergo PCI at a hospital without
on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery
(917 patients). The rates of major adverse cardiac events were 9.5% in hospitals
without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at
30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for
noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98;
95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of
death, myocardial infarction, repeat revascularization, and stroke (the components
of the primary end point) did not differ significantly between the groups at either
time point.


Nonemergency PCI procedures performed at hospitals in Massachusetts without
on-site surgical services were noninferior to procedures performed at hospitals
with on-site surgical services with respect to the 30-day and 1-year rates of clinical

Supplementary material

Important supplementary material is here.

Emergency Cardiology Group WordPress Blog

March 17, 2013 1 comment

The Emergency Cardiology Group is a new important blog has been added to right sidebar. It is a byproduct of collaboration of the two groups and promises to educate as well as continue its successful research collaboration.

Categories: Uncategorized

Pre-industrial remains provide insights into Atherosclerosis

This paper from the Lancet provides very interesting insights into the prevalence, vascular distribution, relationship to age of atherosclerosis (as assessed by CT scanning) of pre-industrial mummies.

Mortality Morbidity Meeting 6 March 2013

This is a placeholder documenting that this meeting occurred.

Categories: Mortality Morbidity