Real-World Experience with Cangrelor as Adjuvant to Percutaneous Coronary Intervention: A Single-Centre Observational Study.

Background: Reversible P2Y12 inhibition can be obtained with cangrelor administered intravenously. More experience with cangrelor use in acute PCI with unknown bleeding risk is needed. Objectives: To describe real-world use of cangrelor including patient and procedure characteristics and patient outcomes. Methods: We performed a single-centre, retrospective, and observational study including all patients treated with cangrelor in relation to percutaneous coronary intervention at Aarhus University Hospital during the years 2016, 2017, and 2018. We recorded procedure indication and priority, the indications for cangrelor use, and patient outcomes within the first 48 hours after initiation of cangrelor treatment. Results: We treated 991 patients with cangrelor in the study period. Of these, 869 (87.7%) had an acute procedure priority. Among acute procedures, patients were mainly treated for STEMI (n = 723) and the remaining were treated for cardiac arrest and acute heart failure. Use of oral P2Y12 inhibitors prior to percutaneous coronary intervention was rare. Fatal bleeding events (n = 6) were only observed among patients undergoing acute procedures. Stent thrombosis was observed in two patients receiving acute treatment for STEMI. Thus, cangrelor can be used in relation to PCI under acute circumstances with advantages in terms of clinical management. The benefits and risks, in terms of patient outcomes, should ideally be assessed in randomized trials.

Haemolysis in prehospital blood samples.

The increasing use of Point Of Care Testing (POCT) in the prehospital setting demands a high and consistent quality of blood samples. We have investigated the degree of haemolysis in 779 prehospital blood samples and found a significant increase in haemolysis compared to intrahospital samples. The degree of haemolysis was within acceptable limits for current analyses. However, haemolysis should be taken into account when implementing future analyses in the prehospital field.

Cardiac Myosin-Binding Protein C to Diagnose Acute Myocardial Infarction in the Pre-Hospital Setting.

Background Early triage is essential to improve outcomes in patients with suspected acute myocardial infarction (AMI). This study investigated whether cMyC (cardiac myosin-binding protein), a novel biomarker of myocardial necrosis, can aid early diagnosis of AMI and risk stratification. Methods and Results cMyC and high-sensitivity cardiac troponin T were retrospectively quantified in blood samples obtained by ambulance-based paramedics in a prospective, diagnostic cohort study. Patients with ongoing or prolonged periods of chest discomfort, acute dyspnoea in the absence of known pulmonary disease, or clinical suspicion of AMI were recruited. Discrimination power was evaluated by calculating the area under the receiver operating characteristics curve; diagnostic performance was assessed at predefined thresholds. Diagnostic nomograms were derived and validated using bootstrap resampling in logistic regression models. Seven hundred seventy-six patients with median age 68 [58;78] were recruited. AMI was the final adjudicated diagnosis in 22%. Median symptom to sampling time was 70 minutes. cMyC concentration in patients with AMI was significantly higher than with other diagnoses: 98 [43;855] versus 17 [9;42] ng/L. Discrimination power for AMI was better with cMyC than with high-sensitivity cardiac troponin T (area under the curve, 0.839 versus 0.813; P=0.005). At a previously published rule-out threshold (10 ng/L), cMyC reaches 100% sensitivity and negative predictive value in patients after 2 hours of symptoms. In logistic regression analysis, cMyC is superior to high-sensitivity cardiac troponin T and was used to derive diagnostic and prognostic nomograms to evaluate risk of AMI and death. Conclusions In patients undergoing blood draws very early after symptom onset, cMyC demonstrates improved diagnostic discrimination of AMI and could significantly improve the early triage of patients with suspected AMI.

Computed tomography derived fractional flow reserve testing in stable patients with typical angina pectoris: influence on downstream rate of invasive coronary angiography.

Aims: To assess the use of downstream coronary angiography (ICA) and short-term safety of frontline coronary CT angiography (CTA) with selective CT-derived fractional flow reserve (FFRCT) testing in stable patients with typical angina pectoris. Methods and results: Between 1 January 2016 and 30 June 2016 all patients (N = 774) referred to non-emergent ICA or coronary CTA at Aarhus University Hospital on a suspicion of CAD had frontline CTA performed. Downstream testing and treatment within 3 months and adverse events ≥90 days were registered. Patients were divided into two groups according to the presence of typical angina pectoris, which according to local practice would have resulted in referral to ICA, (low-intermediate-risk, n = 593 [76%]; high-risk, n = 181 [24%]) with mean pre-test probability of CAD of 31 ± 16% and 67 ± 16%, respectively. Coronary CTA was performed in 745 (96%) patients in whom FFRCT was prescribed in 212 (28%) patients. In the high- vs. low-intermediate-risk group, ICA was cancelled in 75% vs. 91%. Coronary revascularization was performed more frequently in high-risk than in low-intermediate-risk patients, 76% vs. 52% (P = 0.03). Mean follow-up time was 157 ± 50 days. Serious clinical events occurred in four patients, but not in any patients with cancelled ICA by coronary CTA with selective FFRCT testing. Conclusion: Frontline coronary CTA with selective FFRCT testing in stable patients with typical angina pectoris in real-world practice is associated with a high rate of safe cancellation of planned ICAs.

Prehospital diagnosis of patients with acute myocardial infarction.

Primary percutaneous intervention (PPCI) is the preferred treatment in patients with ST elevation myocardial infarction (STEMI) if this can be performed in a timely manner. The 2012 ESC Guidelines on management of AMI in patients presenting with ST-segment elevation advice that PPCI should be performed within 120 min of first medical contact. Prehospital diagnosis of patients with STEMI is performed to save time and make PPCI available to the majority of patients. Although diagnosing patients with STEMI is usually easy, there are important pitfalls and patients with STEMI are missed on occasion. In addition, it is well know that patients without ST elevation may also have a high-risk cardiac condition. The 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation stress the importance of urgent CAG in patients with high-risk non ST-segment elevation myocardial infarction (NSTEMI). Unfortunately, these patients are difficult to diagnose in the acute phase and important time may be spend establishing the correct diagnosis. Prehospital biomarker measurement has emerged as a method to gain important additional information. We review the evidence on prehospital diagnosis of patients with STEMI and, In addition, we present the current knowledge on the new diagnostic methods that could have a future role in prehospital rule-in and rule-out of cardiac disease.

Regional systems-of-care for primary percutaneous coronary intervention in ST-elevation myocardial infarction.

ST-elevation myocardial infarction (STEMI) is a critical, time-dependent condition requiring immediate reperfusion of the coronary arteries to minimize mortality and morbidity. The preferred method of revascularization is a primary percutaneous coronary intervention (PCI) if this can be performed in a timely manner. This requires an effective and well-organized setup from symptom onset to revascularization. Such regional networks for the diagnosis and treatment of STEMI patients have been proven to be very effective in achieving the treatment goals stipulated by the international guidelines. Several trials have provided evidence that prehospital ECG recording and early diagnosis combined with direct referral to a primary PCI center reduces treatment delay considerably. In-hospital awareness with early notification of the PCI operator and technicians and admission directly to the catheterization laboratory also reduces time to treatment. There is solid evidence that the reduction in treatment delay achieved by dedicated STEMI networks is associated with a lower mortality and morbidity. Regional STEMI networks are now implemented in many countries with highly varying geographical challenges and healthcare systems, allowing patients everywhere to receive optimal treatment with primary PCI.

Diagnosis and outcome in a prehospital cohort of patients with bundle branch block and suspected acute myocardial infarction.

BACKGROUND: Immediate revascularization is beneficial in patients with presumed new-onset bundle branch block myocardial infarction (BBBMI). In the prehospital setting, it is a challenge to diagnose new-onset BBBMI and triage accordingly. METHODS: ECG, final diagnosis, and mortality were assessed in a prehospital cohort of 4905 consecutive patients with suspected acute myocardial infarction (AMI). Bundle branch block (BBB) was defined as QRS duration ≥120 ms caused by delayed intraventricular conduction. Mortality and angiography data were obtained from the Central Office of Civil Registration and the Western Denmark Heart Registry. Definite diagnosis of AMI and the onset of BBB were determined by expert consensus. Patients were divided into four groups: with or without AMI and with or without BBB. Mortality was evaluated by Kaplan-Meier plots and compared using log-rank statistics. RESULTS: AMI was diagnosed in 954 patients, of whom 118 had BBB. In 3951 patients without AMI, 436 had BBB. Patients with BBBMI were less often revascularized than patients with AMI without BBB (24 vs. 54%, p<0.001). BBBMI was categorized as new onset in 43 patients of whom two were triaged for acute angioplasty. One-year mortality was 47.2, 17.5, 20.8, and 8.6% (log-rank <0.001) in patients with BBBMI, patients with AMI without BBB, patients with BBB without AMI, and patients without AMI or BBB, respectively. CONCLUSIONS: Patients with BBBMI have a high mortality. Less than 25% undergo revascularization and only very few patients with new-onset BBBMI are transferred for urgent revascularization. Focus on improving triage and prehospital identification of high-risk patients with BBB and chest pain could improve outcome.

Quantitative point-of-care troponin T measurement for diagnosis and prognosis in patients with a suspected acute myocardial infarction.

Improvement of prehospital triage is essential to ensure rapid management of patients with acute myocardial infarction (AMI). This study evaluates the feasibility of prehospital quantitative point-of-care cardiac troponin T (POC-cTnT) analysis, its ability to identify patients with AMI, and its capacity to predict mortality. The study was performed in the Central Denmark Region from May 2010 to May 2011. As a supplement to electrocardiography, a prehospital POC-cTnT measurement was performed by a paramedic in patients with suspected AMI. AMI was diagnosed according to the universal definition of myocardial infarction using the ninety-ninth percentile upper reference level as diagnostic cut point. The paramedics performed POC-cTnT measurements in 985 subjects with a symptom duration of 70 minutes (95% CI, 35 to 180); of whom, 200 (20%) had an AMI. The prehospital sample was obtained 88 minutes (range, 58 to 131) before the sample made on admission to the hospital. The sensitivity for detection of patients with an AMI was 39% (95% CI, 32% to 46%) and the diagnostic accuracy of the POC-cTnT values was 0.67 (95% CI, 0.64 to 0.71). Adjusted survival analysis showed a strong significant association between elevated prehospital POC-cTnT level above the detection level of 50 ng/L and mortality in patients with a suspected AMI irrespective of whether an AMI was diagnosed. In conclusion, large-scale quantitative prehospital POC-cTnT testing by paramedics is feasible. An elevated prehospital POC-cTnT value contains diagnostic information and is highly predictive of mortality in patients with a suspected AMI.

Update: Innovation in cardiology (II). Telecardiology: past, present and future.

Technological advances over the past decades have allowed improved diagnosis and monitoring of patients with acute coronary syndromes as well as patients with advanced heart failure. High-quality digital recordings transmitted wirelessly by cellular telephone networks have augmented the prehospital use of transportable electrocardiogram machines as well as implantable devices for arrhythmia monitoring and therapy. The impact of prehospital electrocardiogram recording and interpretation in patients suspected of acute myocardial infarction should not be underestimated. It enables a more widespread access to rapid reperfusion therapy, thereby reducing treatment delay, morbidity and mortality. Further, continuous electrocardiogram monitoring has improved arrhythmia diagnosis and dynamic ST-segment changes have been shown to provide important prognostic information in patients with acute ST-elevation myocardial infarction. Likewise, remote recording or monitoring of arrhythmias and vital signs seem to improve outcome and reduce the necessity of re-admissions or outpatient contacts in patients with heart failure or arrhythmias. In the future telemonitoring and diagnosis is expected to further impact the way we practice cardiology and provide better care for the patient with cardiovascular disease.

Prehospital troponin T testing in the diagnosis and triage of patients with suspected acute myocardial infarction.

Prehospital electrocardiographic (ECG) diagnosis has improved triage and outcome in patients with acute ST-elevation myocardial infarction. However, many patients with acute myocardial infarction (AMI) present with equivocal ECG patterns making prehospital ECG diagnosis difficult. We aimed to investigate the feasibility and ability of prehospital troponin T (TnT) testing to improve diagnosis in patients with chest pain transported by ambulance. From June 2008 through September 2009, patients from the central Denmark region with suspected AMI and transported by ambulance were eligible for prehospital TnT testing with a qualitative point-of-care test (cutpoint 0.10 ng/ml). Quantitative TnT was measured at hospital arrival and after 8 and 24 hours (cutpoint 0.03 ng/ml). A prehospital electrocardiogram was recorded in all patients. Prehospital TnT testing was attempted in 958 patients with a 97% success rate. In 258 patients, in-hospital TnT values were increased (≥0.03 ng/ml) during admission. The prehospital test identified 26% and the first in-hospital test detected 81% of patients with increased TnT measurements during admission. A diagnosis of AMI was established in 208 of 258 patients with increased TnT. The prehospital test identified 30% of these patients, whereas the first in-hospital test detected 79%. Median times from symptom onset to blood sampling were 83 minutes (46 to 167) for the prehospital sample and 165 minutes (110 to 276) for the admission sample. In conclusion, prehospital TnT testing is feasible with a high success rate. This study indicates that prehospital implementation of quantitative tests, with lower detection limits, could identify most patients with AMI irrespective of ECG changes.

Urban and rural implementation of pre-hospital diagnosis and direct referral for primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction.

AIMS: Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-elevation myocardial infarction (STEMI). The distance to primary PCI centres and the inherent time delay in delivering primary PCI, however, limit widespread use of this treatment. This study aimed to evaluate the impact of pre-hospital diagnosis on time from emergency medical services contact to balloon inflation (system delay) in an unselected cohort of patients with STEMI recruited from a large geographical area comprising both urban and rural districts. METHODS AND RESULTS: From February 2004 until January 2007, data on pre-hospital timing and transport distance were prospectively recorded. Patients were divided into groups depending on achievement of pre-hospital diagnosis and/or direct referral to a primary PCI centre. Seven hundred and fifty-nine consecutive STEMI patients were included. In patients with a pre-hospital diagnosis and direct referral, the system delay was 92 vs. 153 min in patients without pre-hospital diagnosis (P < 0.001). Patients from rural areas were transported a median of 30 km longer than patients from urban areas; however, this prolonged the system delay by only 9 min. CONCLUSION: Pre-hospital electrocardiographic (ECG) diagnosis and direct referral for primary PCI enables STEMI patients living far from a PCI centre to achieve a system delay comparable with patients living in close vicinity of a PCI centre.

System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.

CONTEXT: Timely reperfusion therapy is recommended for patients with ST-segment elevation myocardial infarction (STEMI), and door-to-balloon delay has been proposed as a performance measure in triaging patients for primary percutaneous coronary intervention (PCI). However, focusing on the time from first contact with the health care system to the initiation of reperfusion therapy (system delay) may be more relevant, because it constitutes the total time to reperfusion modifiable by the health care system. No previous studies have focused on the association between system delay and outcome in patients with STEMI treated with primary PCI. OBJECTIVE: To evaluate the associations between system, treatment, patient, and door-to-balloon delays and mortality in patients with STEMI. DESIGN, SETTING, AND PATIENTS: Historical follow-up study based on population-based Danish medical registries of patients with STEMI transported by the emergency medical service and treated with primary PCI from January 1, 2002, to December 31, 2008, at 3 high-volume PCI centers in Western Denmark. Patients (N = 6209) underwent primary PCI within 12 hours of symptom onset. The median follow-up time was 3.4 (interquartile range, 1.8-5.2) years. MAIN OUTCOME MEASURES: Crude and adjusted hazard ratios of mortality obtained by Cox proportional regression analysis. RESULTS: A system delay of 0 through 60 minutes (n = 347) corresponded to a long-term mortality rate of 15.4% (n = 43); a delay of 61 through 120 minutes (n = 2643) to a rate of 23.3% (n = 380); a delay of 121 through 180 minutes (n = 2092) to a rate of 28.1% (n = 378); and a delay of 181 through 360 minutes (n = 1127) to a rate of 30.8% (n = 275) (P < .001). In multivariable analysis adjusted for other predictors of mortality, system delay was independently associated with mortality (adjusted hazard ratio, 1.10 [95% confidence interval, 1.04-1.16] per 1-hour delay), as was its components, prehospital system delay and door-to-balloon delay. CONCLUSION: System delay was associated with mortality in patients with STEMI treated with primary PCI.

Prevalence and significance of accelerated idioventricular rhythm in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

Accelerated idioventricular rhythm (AIVR) has been considered a marker of successful reperfusion in fibrinolytic-treated patients. Evidence is limited regarding its significance in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PPCI). The purpose of the present study was to determine the prevalence and associated outcomes of arrhythmias and conduction disturbances occurring during PPCI. In 503 patients with ST-elevation myocardial infarction, the arrhythmias and conduction disturbances occurring from arrival at the catheterization laboratory to 90 minutes after PPCI were registered. Continuous ST-monitoring was performed to determine the interval from the first wire to complete ST resolution. The area at risk was evaluated in the acute phase and the final infarct size (FIS) after 1 month using myocardial perfusion imaging. Mortality was registered at a median follow-up of 2.9 years. The most common arrhythmias observed during PPCI were AIVR (42%), sinus bradycardia (28%), and nonsustained ventricular tachycardia (26%). The arrhythmias associated with the FIS included AIVR (unstandardized regression coefficient [B] = 5.27, p <0.001), sustained ventricular tachycardia (B = 15.7, p <0.001), and sinus bradycardia (B = -4.12, p = 0.001). Right bundle branch block was the only conduction disturbance associated with FIS (B = 7.17, p = 0.001). Patients with AIVR less often achieved spontaneous ST resolution before PPCI (13% vs 36%, p <0.001), less often had Thrombolysis In Myocardial Infarction flow 3 on admission (3% vs 33%, p <0.001), had a larger area at risk (35% vs 23% of the left ventricle, p <0.001), had a longer time to complete ST resolution (39 vs 21 minutes, p <0.001), had a larger FIS (13% vs 5% of the left ventricle, p <0.001) but had similar mortality (8.6% and 6.5%, p = 0.39) compared to patients without AIVR. In conclusion, AIVR is the most frequent arrhythmia occurring during PPCI in patients with ST-elevation myocardial infarction. However, it is not a marker of successful reperfusion but is associated with extensive myocardial damage and delayed microvascular reperfusion.

Significance of T-wave amplitude and dynamics at the time of reperfusion in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

BACKGROUND: Peri-interventional T-wave changes may reflect the microvascular reperfusion status and potentially carry early independent, prognostic information in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHODS: The first available electrocardiogram (ECG) (index ECG) and the ECG recorded immediately post-PCI were analyzed for T-wave morphology in 207 patients with STEMI. Absolute T-wave amplitude was recorded and any change in T-wave amplitude from index ECG to post-PCI ECG was calculated. Continuous ST monitoring was performed from hospital arrival until 90 minutes after PCI. Maximum troponin level and left ventricular ejection fraction were evaluated before discharge. Final infarct size was assessed by myocardial perfusion imaging after 1 month. RESULTS: Large, positive T-wave amplitude in the index ECG and the post-PCI ECG was associated with delayed ST resolution after PCI. In the post-PCI ECG, T-wave amplitude was positively associated with troponin-T value (P < .001) and final infarct size (P = .036), and inversely associated with left ventricular ejection fraction (P < .001). However, T-wave amplitude in the post-PCI ECG was also associated with procedural increase in ST elevation (P < .001) and inversely associated with spontaneous ST resolution (P < .017). A net decrease in T-wave amplitude during reperfusion therapy was associated with faster microvascular reperfusion as evaluated by time to ST resolution. CONCLUSION: Large T-wave amplitudes in static pre- and post-PCI ECGs are associated with delayed microvascular reperfusion, whereas the dynamic development of more negative T waves during PCI is associated with earlier microvascular reperfusion. However, in the acute setting, T waves provide little incremental information when compared to ST parameters available in the per-interventional phase.

[Differences in the prescription of analgesics in the treatment of cancer pain in six Danish pain treatment units]. / Forskelle på ordinationsmønstret af analgetika ved behandling af cancersmerter på seks danske smertebehandlingsenheder.

30-40% of cancer patients suffer from pain at diagnosis while 70-80% of patients at progressed stages of the disease suffer from pain. Background pain is treated with long-acting opioids. Breakthrough pain can be treated with shorter acting non-opioid analgesics or opioids. The aim of this study was to describe the medical treatment of pain in cancer patients in connection with six Danish hospital units with special expertise in pain treatment. Differences in the prescription of analgesics were studied. The study was performed as a cross section study of prescribed analgesics. Data was collected by reviewing medical records. The study included 347 patients. A total of 278 patients out of 347 were treated with opioids for background pains. A significant difference was found (P < 0.001) in the frequency of prescribing morphine, oxycodone and fentanyl. For the treatment of background pain secondary analgesics were prescribed for 40% of the patients while 50% of the patients were treated with paracetamol and/or NSAID. According to the medical records 79% of the patients were prescribed analgesics for breakthrough pain. 73% of the 347 patients had strong opioids prescribed for breakthrough pain. For the treatment of background pain opioids were prescribed for the majority of the cancer patients. Morphine and oxycodone were prescribed most frequently. Secondary analgesics and paracetamol and/or NSAID were also prescribed for background pain. The strong opioids were prescribed for the treatment of breakthrough pain. Differences in the prescription of analgesics between the six hospital units were observed in this study.