Care of patients with ST-elevation myocardial infarction: an international analysis of quality indicators in the acute coronary syndrome STEMI Registry of the EURObservational Research Programme and ACVC and EAPCI Associations of the European Society of Cardiology in 11 462 patients.

AIMS: To use quality indicators to study the management of ST-segment elevation myocardial infarction (STEMI) in different regions. METHODS AND RESULTS: Prospective cohort study of STEMI within 24 h of symptom onset (11 462 patients, 196 centres, 26 European Society of Cardiology members, and 3 affiliated countries). The median delay between arrival at a percutaneous cardiovascular intervention (PCI) centre and primary PCI was 40 min (interquartile range 20-74) with 65.8% receiving PCI within guideline recommendation of 60 min. A third of patients (33.2%) required transfer from their initial hospital to one that could perform emergency PCI for whom only 27.2% were treated within the quality indicator recommendation of 120 min. Radial access was used in 56.6% of all primary PCI, but with large geographic variation, from 76.4 to 9.1%. Statins were prescribed at discharge to 98.7% of patients, with little geographic variation. Of patients with a history of heart failure or a documented left ventricular ejection fraction ≤40%, 84.0% were discharged on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and 88.7% were discharged on beta-blockers. CONCLUSION: Care for STEMI shows wide geographic variation in the receipt of timely primary PCI, and is in contrast with the more uniform delivery of guideline-recommended pharmacotherapies at time of hospital discharge.

"You can also save a life!": children's drawings as a non-verbal assessment of the impact of cardiopulmonary resuscitation training.

Drawings made by training children into cardiopulmonary resuscitation (CPR) during the special education week called "School otherwise" can be used as non-verbal means of expression and communication to assess the impact of such training. We analyzed the questionnaires and drawings completed by 327 schoolchildren in different stages of education. After a brief overview of the basic life support (BLS) steps and after watching a video presenting the dynamic performance of the BLS sequence, subjects were asked to complete a questionnaire and make a drawing to express main CPR messages. Questionnaires were filled completely in 97.6 % and drawings were done in 90.2 % cases. Half of the subjects had already witnessed a kind of medical emergency and 96.94 % knew the correct "112" emergency phone number. The drawings were single images (83.81 %) and less cartoon strips (16.18 %). Main themes of the slogans were "Save a life!", "Help!", "Call 112!", "Do not be indifferent/insensible/apathic!" through the use of drawings interpretation, CPR trainers can use art as a way to build a better relation with schoolchildren, to connect to their thoughts and feelings and obtain the highest quality education.

Predictors of in-Hospital Mortality of ST-Segment Elevation Myocardial Infarction Patients Undergoing Interventional Treatment. An Analysis of Data from the RO-STEMI Registry.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality worldwide. Primary percutaneous coronary intervention (pPCI) is the preferred therapy for STEMI if it is done within 120 min from the first medical contact, by an experienced team in a high-volume center. The aim of this study was to assess the clinical characteristics and predictors of in-hospital mortality of patients with STEMI treated by percutaneous coronary interventions (PCIs). METHODS: We analyzed data from 15,076 STEMI patients enrolled in the RO-STEMI registry (ROmanian ST-Elevation Myocardial Infarction registry). Patients were divided into 2 groups: PCI (11.669; 77%) and conservative treated (3.407; 23%). PCI group includes both pPCI treated patients (84.3%), and patients undergoing rescue PCI (6.4%) and late PCI (9.3%). RESULTS: The mean age of STEMI patients was 62.7+/-12.7 years. 70% were males. Patients treated by PCI were younger (61.4+/-12.2 versus 67.2+/-13.3, p< 0.0001) and more often men (80% versus 71%, p< 0.0001). They were less likely to have acute heart failure (Killip class II-IV) at admission (p< 0.0001). During admission, patients treated by PCI received more often dual antiplatelet therapy (97.6% versus 90.8%, p< 0.0001), statins (96.3% versus 87.5%, p< 0.0001), beta-blockers (83.8% versus 73.2%, p< 0.0001), and RAAS blockers (82.6% versus 66.4%, p< 0.0001). Overall in-hospital mortality was 7.1%: 4.1% in the PCI group and 15.7% in the conservative treated group. Multivariate analysis showed that, after adjusting for all clinical variables, Killip class II-IV at admission (OR: 9.2; 95%CI: 6.2-13.6; p< 0.0001), LVEF< 35% (OR: 3.8; 95%CI: 2.6-5.4; p< 0.0001), age older than 65 years (OR: 2.2; 95%CI: 1.5-3.2; p< 0.0001), and anterior location of myocardial infarction (OR: 2.1; 95% CI: 1.5-3; p< 0.0001) remained independent predictors for in-hospital mortality for STEMI patients treated interventionally. CONCLUSION: Advanced Killip class, depressed LVEF, advanced age, and anterior location were the most powerful independent predictors of in-hospital mortality in STEMI patients who underwent interventional treatment.

Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries.

AIMS: Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary 'real-world' setting, using a methodology designed to improve the representativeness of the survey. METHODS: Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House. RESULTS: Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in >90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in >80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes. CONCLUSIONS: In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.

Impact of the Romanian national programme for interventional therapy in ST-elevation myocardial infarction.

A national programme for PPCI in STEMI patients was started in Romania in August 2010, based on an integrated and well-trained pre-hospital emergency medical system. Ten national centres experienced in PPCI were organised in a 24/7 system in five regional networks, in order to assist STEMI patients from areas offering PPCI within the first two hours after the first medical contact. For centres located further away, a strategy of local thrombolysis followed by transfer to the closest PCI centre was recommended. The total number of PPCI procedures increased from 1,289 in 2010 to 4,209 in 2011. The percentage of PPCI increased from 25.0% in 2010 to 49.32% in 2011. From 40 PPCI/million inhabitants in 2009, we reached 64/million in 2010 and 210/ million in 2011. In the Bucharest area there were 640 PPCI/ million in 2011. The global in-hospital mortality decreased from 13.5% in 2009 to 9.93% in 2011. In 2011 in-hospital mortality was 4.39%, 8.32% and 17.11% for PPCI, thrombolysis and no-reperfusion, respectively. In-hospital mortality was 7.28% in the PCI centres but 14.20% in centres without PCI facilities. The national programme for PPCI had a major impact on STEMI in-hospital mortality in Romania.

In-hospital case fatality rates for acute myocardial infarction in Romania.

BACKGROUND: We describe the clinical characteristics, treatments and in-hospital case-fatality rates in an unselected population of patients admitted for acute myocardial infarction. METHODS: From January 2000 to June 2007, we tracked consecutive patients who were admitted to 7 tertiary referral and 21 county hospitals in Romania for medical treatment of ST-segment elevation acute myocardial infarction. These patients were enrolled in the Romanian Registry for ST-segment Elevation Myocardial Infarction. For this prospective study, we collected data on demographic characteristics, cardiovascular risk factors, various aspects of treatment for myocardial infarction, and in-hospital death. RESULTS: The 9186 patients in the study group had a mean age of 63.8 years. The median time from onset of symptoms to thrombolysis was 230 (interquartile range 120-510) minutes. Of the 9186 patients, 4986 (54.3%) had hypertension, 1974 (21.5%) had diabetes mellitus, 3545 (38.6%) had lipid disorders and 4653 (50.7%) were smokers. The in-hospital mortality rate was 12.7% (1170 deaths). The study group consisted of 2893 women and 6293 men. The women were older than the men and had higher rates of hypertension and diabetes mellitus but were less likely to be smokers. A smaller proportion of women than men presented within 2 hours after onset of symptoms (23.1% v. 34.4%, p < 0.001). Smaller proportions of women received thrombolytics (40.8% v. 53.5%, p < 0.001), anticoagulants (93.4% v. 95.2%; p = 0.001), antiplatelet agents (88.3% v. 91.2%, p < 0.001) and primary percutaneous coronary interventions (1.5% v. 2.2%, p = 0.030). The risk of in-hospital death was greater for women, even after adjustment for confounders (odds ratio 1.33, 95% confidence interval 1.13-1.56; p < 0.001). INTERPRETATION: The rates of reperfusion therapy for patients with acute myocardial infarction were low, and in-hospital case-fatality rates were high in this study. Excess in-hospital mortality was more pronounced among women.

Accelerated streptokinase in ST-elevation myocardial infarction--a Romanian (ASK-ROMANIA) multicenter registry.

BACKGROUND: The classical streptokinase regimen (1.5 M.U. over 60 min) may be too slow in patients with ST-elevation myocardial infarction (STEMI). OBJECTIVE: To compare the efficacy and safety of four streptokinase regimens in STEMI patients. METHODS: 1880 consecutive patients admitted within 6 h of STEMI onset were allocated one of the following four streptokinase regimens: 1.5 M.U. over 60 min (n=517); 1.5 M.U./30 min (n=355); 1.5 M.U./20 min (n=507); 0.75 M.U./10 min, repeated or not after 50 min if no electrocardiographic criteria of reperfusion (n=501). RESULTS: Rates of coronary reperfusion (non-invasively detected) for SK1.5/30 (72.39%), SK1.5/20 (75.34%) and SK0.75/10 (72.85%) were similar and higher than for SK1.5/60 (64.03%, p=0.019, p<0.0001, and p=0.006, respectively). In-hospital mortality was significantly lower for SK1.5/20 (7.10%) and SK0.75/10 (7.38%) and at the limit of significance for SK1.5/30 (7.60%) compared with SK1.5/60 (11.60%, p<0.0001, 0.006, and 0.053, respectively). Intracerebral haemorrhage and other major bleeding had similar incidence in the four groups. CONCLUSIONS: Compared to the classical 1.5 M.U. over 60 min streptokinase regimen, significantly higher rates of coronary reperfusion and lower in-hospital mortality can be obtained by infusing the same dose over only 20 min, or either one or two half doses over only 10 min, without risk increase.

Primary left heart malignant fibrous histiocytoma.

We present the case of a 53 years-old woman presenting with congestive heart failure and pleural and pericardial effusions, in whom transthoracic and transesophageal echocardiography revealed multilocular cardiac tumor involving the left atrium wall, extending into the pericardium. Tumor was excised surgically and proved to be a malignant fibrous histiocytoma, primarily confined to the heart. Despite surgery followed by chemotherapy, the patient died a few months later. This is the 47th case of primary cardiac fibrous malignant histiocytoma reported in the literature. The pericardial involvement has been only rarely reported. Echocardiography was the method of diagnosis before rapid referral to surgery.

Accelerated streptokinase and enoxaparin in ST-segment elevation acute myocardial infarction (the ASENOX study).

BACKGROUND: The streptokinase (SK) regimen (1.5 MU/60 min) has remained unchanged in the ST-segment elevation acute myocardial infarction (STEMI) for the last 20 years. AIM: To compare the efficacy of an accelerated SK (ASK) regimen combined with enoxaparin (Enox) or heparin (UFH) with the standard SK and UFH combination in STEMI. METHODS: 633 consecutive patients, aged 21-74 years, admitted within 6 hours after the onset of STEMI, were divided in three groups: (1) ASKEnox (n=165): Enox 40 mg. i.v. followed by SK 1.5 MU over 20 min, either as a full dose or a double infusion of 0.75 MU over 10 min. separated by 50 min. After SK infusion, Enox was administered 1 mg/kg s.c. every 12 hours for 5-7 days; (2) ASKUFH (n=264): the same ASK regimen plus UFH 1,000 IU/h for 48-72 hours, (3) SSKUFH (n=204): SK 1.5 MU/60 min. plus UFH 1,000 IU/h for 48-72 hours. All patients received aspirin. Three coronary reperfusion (CR) criteria were used: 1. rapid cessation of chest pain; 2. rapid reduction of ST-segment elevation by more than 50% of the initial value; 3. rapid increase in plasma CK and CK-MB with a peak in the first 12 hours. RESULTS: The rates of CR in the ASKEnox (77.6%) and the ASKUFH (73.5%) groups were similar but both were significantly higher than that observed in the SSKUFH group (62.2%) (p=0.002 and 0.013, respectively). The 30-day mortality rates were similar in the ASKEnox (6.06%) and the ASKUFH (6.81%) groups but both were significantly lower than in the SSKUFH group (12.74%) (p=0.048 and 0.044, respectively). SK-induced hypotension was more frequent in the ASKEnox (39.4%) and ASKUFH (38.3%) groups compared with the SSKUFH group (20.6%) (p<0.0001), but it was transient and well tolerated. Haemorrhagic stroke occurred in two patients from the SSKUFH and one patient from the ASKUFH groups. CONCLUSIONS: ASKEnox and ASKUFH regimens are safe and result in a significantly higher rate of CR and a lower in-hospital mortality compared with the traditional SSKUFH regimen.

Efficacy and safety of a new streptokinase regimen with enoxaparin in acute myocardial infarction.

OBJECTIVE: To compare a new streptokinase regimen combined with either enoxaparin or unfractionated heparin (UFH) and the traditional streptokinase regimen combined with UFH in patients with acute myocardial infarction (AMI). METHODS: 412 patients (<75 years), hospitalized within 6 hours of the onset of chest pain, were allocated thrombolytic therapy by the treating physician: streptokinase 0.75 MU/10 minutes, repeated if no coronary reperfusion after one dose, plus enoxaparin 40 mg intravenously followed by 1 mg/kg bodyweight subcutaneously at 12-hour intervals for 5-7 days (n = 102); the same streptokinase regimen plus UFH 1000 IU/60 minutes intravenously for 48-72 hours ( n = 106); or streptokinase 1.5 MU/60 minutes plus the same UFH regimen (n = 204). All patients received 250-325 mg aspirin/day. Coronary reperfusion rates, 30-day mortality and hemorrhagic complications were recorded. RESULTS: Coronary reperfusion rates with 0.75 streptokinase + enoxaparin (78.4%) and 0.75 streptokinase + UFH (74.5%) were significantly higher than those with 1.5 streptokinase + UFH (62.2%), but there was no significant difference between the groups receiving the new regimen. Overall 30-day mortality (6.3%) was significantly lower than with 1.5 streptokinase + UFH (12.7%) ( p = 0.037). The incidence of major and minor hemorrhagic events was similar in all groups. CONCLUSIONS: The accelerated streptokinase regimen was well tolerated and resulted in a significantly higher coronary reperfusion rate and significantly lower mortality compared with the traditional regimen. The 0.75 streptokinase + enoxaparin combination was at least as efficacious as the 0.75 streptokinase + UFH combination and is preferred because of its ease of administration and predictable anticoagulant effect.