Archive

Archive for the ‘ST elevation myocardial infarction’ Category

Journal Club 3 September 2014

Paper

Nonsystem Reasons for Delay in Door-to-Balloon Time and Associated In-Hospital Mortality
A Report From the National Cardiovascular Data Registry

Presenter

SH (paper chosen by RS)

Summary

Objectives

The goal of this study was to characterize nonsystem reasons for delay in door-to-balloon time (D2BT) and the
impact on in-hospital mortality.

Background

Studies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographic
characteristics. Limited data exist, however, for nonsystem reasons for delay in D2BT.

Methods

We analyzed nonsystem reasons for delay in D2BT among 82,678 ST-segment elevation myocardial infarction
patients who underwent primary percutaneous coronary intervention within 24 h of symptom onset in the Cath-
PCI Registry from January 1, 2009, to June 30, 2011.

Results

Nonsystem delays occurred in 14.7% of patients (n 12,146). Patients with nonsystem delays were more likely to
be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without
delay was 2.5% versus 15.1% for those with delay (p 0.01). Nonsystem delay reasons included delays in providing
consent (4.4%), difficult vascular access (8.4%), difficulty crossing the lesion (18.8%), “other” (31%), and cardiac
arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the
shortest time delay (median D2BT: 84 min; 25th to 75th percentile: 64 to 108 min); delays in providing consent had
a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT: 100 min; 25th to
75th percentile: 80 to 131 min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and
other was also higher (8.0%, 5.6%, and 5.9%, respectively) compared with nondelayed patients (p 0.0001). After
adjustment for baseline characteristics, in-hospital mortality remained higher for patients with nonsystem delays.

Conclusions

Nonsystem reasons for delay in D2BT in ST-segment elevation myocardial infarction patients presenting for primary
percutaneous coronary intervention are common and associated with high in-hospital mortality.

Additional Material

This paper was assessed as poor in relation to the inferences related to non-system delays. The editorial by Grines and Schreiber was fully supported. It is available here.

Journal Club 2 October 2013

Paper

Thrombus Aspiration during ST-Segment Elevation Myocardial Infarction

Presenter

YS

Summary

Background

The clinical effect of routine intracoronary thrombus aspiration before primary percutaneous
coronary intervention (PCI) in patients with ST-segment elevation myocardial
infarction (STEMI) is uncertain. We aimed to evaluate whether thrombus
aspiration reduces mortality.

Methods

We conducted a multicenter, prospective, randomized, controlled, open-label clinical
trial, with enrollment of patients from the national comprehensive Swedish
Coronary Angiography and Angioplasty Registry (SCAAR) and end points evaluated
through national registries. A total of 7244 patients with STEMI undergoing PCI were
randomly assigned to manual thrombus aspiration followed by PCI or to PCI only.
The primary end point was all-cause mortality at 30 days.

Results

No patients were lost to follow-up. Death from any cause occurred in 2.8% of the
patients in the thrombus-aspiration group (103 of 3621), as compared with 3.0% in
the PCI-only group (110 of 3623) (hazard ratio, 0.94; 95% confidence interval [CI],
0.72 to 1.22; P = 0.63). The rates of hospitalization for recurrent myocardial infarction
at 30 days were 0.5% and 0.9% in the two groups, respectively (hazard ratio,
0.61; 95% CI, 0.34 to 1.07; P = 0.09), and the rates of stent thrombosis were 0.2%
and 0.5%, respectively (hazard ratio, 0.47; 95% CI, 0.20 to 1.02; P = 0.06). There were
no significant differences between the groups with respect to the rate of stroke or
neurologic complications at the time of discharge (P = 0.87). The results were consistent
across all major prespecified subgroups, including subgroups defined according
to thrombus burden and coronary flow before PCI.

Conclusions

Routine thrombus aspiration before PCI as compared with PCI alone did not reduce
30-day mortality among patients with STEMI.

Journal Club 27 March 2013

Paper

Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction

Presenter

LAM

Summary

Background

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).

Methods

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.

Results

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.

Conclusion

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.

US STEMI Guidelines 2013

The Executive Summary of the US STEMI guidelines is found here. The online data supplement is here.

For those people who have visited this blog this year, thank you. Best wishes to all for this festive season and for 2013.