Archive

Archive for April, 2015

Diagnostic performance z-score of cardiac Troponin in patients with suspected acute coronary syndrome

This paper is instructive of an emerging approach to interpretation of low level troponin in patients presenting with acute coronary syndrome.

The following comments of Dr William Parsonage provide guiding insights:

A. Patients with a z-score of >2 that WERE NOT diagnosed with Type 1 AMI – as you can see the majority of these (and essentially all of those with z>3) had significant other cardiac diagnosis and probably would fit the diagnosis of type 2 AMI, and

B. Those with z-score of <2 that WERE diagnosed with Type 1 AMI – again, there were not many of these and in most cases the absolute troponin levels were significantly elevated and one would doubt whther the z-score would really come into play.

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Journal Club 22 April 2015

Paper

The influence of system delay on 30-day and on long-term mortality in patients with anterior versus non-anterior ST-segment elevation myocardial infarction: a cohort study

Presenter

AB

Summary

Aim:

To evaluate the relationship between system delay and 30-day and long-term mortality in patients
with anterior versus non-anterior ST-elevation
myocardial infarction (STEMI).

Methods:

We conducted a prospective observational
cohort study. Patients with STEMI who were
transported to the Isala Hospital, Zwolle, and
underwent primary percutaneous coronary intervention
(pPCI) from 2005 until 2010 were included. These
patients were divided into quartiles of system delay
(time from first medical contact until reperfusion
therapy): Q1–Q4.

Results:

In total, 3041 patients were included in our
study. 41% (n=1253) of the patients had an anterior
myocardial infarction (MI) and 59% of the patients
(n=1788) had a non-anterior MI. Only in patients with
an anterior MI, prolonged system delay was associated
with a higher mortality (30-day Q1: 2.6%, Q2: 3.1%,
Q3: 6.8%, Q4: 7.4%, p=0.001; long-term Q1: 12.8%,
Q2: 13.7%, Q3: 24.1%, Q4: 22.6%, p<0.001). After
multivariable adjustment, prolonged system delay was
associated with a higher 30-day and long-term mortality
in patients with an anterior MI (30 day Q2: HR 1.18,
95% CI (0.46 to 3.00), Q3: HR 2.45, 95% CI (1.07 to
5.63), Q4: HR 2.25, 95% CI (0.97 to 5.25)); long-term
Q2: HR 1.09, 95% CI (0.71 to 1.68), Q3: HR 1.68, 95%
CI (1.13 to 2.49), Q4: HR 1.55, 95% CI (1.03 to 2.33)),
but not in patients with a non-anterior MI.

Conclusions:

Prolonged system delay significantly
increased short-term as well as long-term mortality in
patients with an anterior MI. This effect was not
demonstrated in patients with a non-anterior MI.
Therefore, it is of the greatest importance to minimise
system delay in patients who present with an anterior MI.

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Optical Coherence Tomography: Useful Resources

The following useful references in relation to optical coherence tomography (provided by Angie Gannon, St Jude Medical):

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Professor Poole Presentation

The presentation of Professor Poole on subcutaneous implantable cardioverter defibrillators (set in the context of the development and pivotal trial information of ICDs) of 18 March 2015 is available here. I strongly encourage readers to look at this excellent and insightful presentation by Professor Poole.

Categories: Uncategorized

Journal Club 1 April 2015

Paper

Randomized Trial of Primary PCI with or
without Routine Manual Thrombectomy

Presenter

CB

Summary

Background

During primary percutaneous coronary intervention (PCI), manual thrombectomy
may reduce distal embolization and thus improve microvascular perfusion. Small
trials have suggested that thrombectomy improves surrogate and clinical outcomes,
but a larger trial has reported conflicting results.

Methods

We randomly assigned 10,732 patients with ST-segment elevation myocardial infarction
(STEMI) undergoing primary PCI to a strategy of routine upfront manual
thrombectomy versus PCI alone. The primary outcome was a composite of death
from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or
New York Heart Association (NYHA) class IV heart failure within 180 days. The key
safety outcome was stroke within 30 days.

Results

The primary outcome occurred in 347 of 5033 patients (6.9%) in the thrombectomy
group versus 351 of 5030 patients (7.0%) in the PCI-alone group (hazard ratio in the
thrombectomy group, 0.99; 95% confidence interval [CI], 0.85 to 1.15; P = 0.86). The
rates of cardiovascular death (3.1% with thrombectomy vs. 3.5% with PCI alone;
hazard ratio, 0.90; 95% CI, 0.73 to 1.12; P = 0.34) and the primary outcome plus
stent thrombosis or target-vessel revascularization (9.9% vs. 9.8%; hazard ratio,
1.00; 95% CI, 0.89 to 1.14; P = 0.95) were also similar. Stroke within 30 days occurred
in 33 patients (0.7%) in the thrombectomy group versus 16 patients (0.3%)
in the PCI-alone group (hazard ratio, 2.06; 95% CI, 1.13 to 3.75; P = 0.02).

Conclusions

In patients with STEMI who were undergoing primary PCI, routine manual thrombectomy,
as compared with PCI alone, did not reduce the risk of cardiovascular
death, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart
failure within 180 days but was associated with an increased rate of stroke within
30 days.