Optimal Teaching of Cardiopulmonary Resuscitation in Schools: Better Education, More Lives Saved.

Teaching cardiopulmonary resuscitation in Romanian schools is a joint initiative of the Acute Cardiac Care Working Group of the Romanian Society of Cardiology, the Romanian National Resuscitation Council and the Romanian Society of Emergency Medicine and Disaster. Teaching young generations to save people in cardiac arrest requires a structural approach, whose starting point is the launching of a large-scale campaign in favor of introducing the basics of cardiopulmonary resuscitation (CPR) in the school curriculum. The training stages can be set according to the principle of repetition (i.e. every two years). Teachers seem to be the best candidates for the instructor position, taking into account the knowledge and skills they acquired throughout the teacher training programs, as well as, their continuous contact with the students; consequently, training teachers to become CPR instructors represents a long term investment. All acquired knowledge will implicitly spread to a secondary level (trainee's parents, relatives, etc.) and the number of individuals gaining access to CPR specific information will rise as a consequence. Entering the CPR training program should be promoted as a criterion for the accreditation and/or evaluation of primary schools, middle schools, and high schools. To begin with, this program must be implemented in Romania at first as part of the non-formal context of the special education week called "Scoala altfel" ("School otherwise").

Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology.

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.

[Thrombolysis: Bucarest registry]. / La thrombolyse. Registre roumain de Bucarest.

The end-point of this retrospective study was to evaluate the standard of care in terms of in-hospital morbidity and mortality for patients with acute myocardial infarction (AMI) treated by thrombolysis within the first 12 hours from the start of the symptoms in five cardiology centers from Bucarest for a period of 5 years (2000-2004). This retrospective registry on a central database included 1814 patients (73.63% men, mean age 59.9 +/- 11.8 years), presented in an average time of 211.63 minutes from pain start. The most frequently used fibrinolitic was streptokinase (66.21%), administered most often in 30 minutes and for a subgroup in 20 minutes--accelerated regimen, with a good efficiency for the reperfusion of the culprit vessel evaluated non-invasively (clinical, electrical and biological methods). The global in-hospital mortality was 11.1%. The only predictors of in-hospital mortality were female gender and advanced age (>75 years) [p < 0.05]. The rate of haemorrhagic complications was not different from the one described by other clinical studies. The treatment by anticoagulants, antiaplatelets agents like aspirin, ACE inhibitors and statins were significant determinants of in-hospital survival. In the subgroup followed-up for 1 year (315 patients), the most frequent complication was the heart failure. In conclusion, in Bucarest, where availability of primary angioplasty in AMI was limited, thrombolysis with streptokinase was still very much used, with acceptable low in-hospital mortality and relatively high rate of artery reperfusion appreciated by non-invasive methods.

Streptokinase-induced hypotension has no detrimental effect on patients with thrombolytic treatment for acute myocardial infarction. A substudy of the Romanian Study for Accelerated Streptokinase in Acute Myocardial Infarction (ASK-ROMANIA).

UNLABELLED: The Streptokinase (SK) regimen (1.5 MU/60 minutes) has remained unchanged for the past 20 years in patients with ST-segment elevation acute myocardial infarction (STEMI) due to fear of hypotension (a specific effect of this thrombolytic agent) and of hemorrhagic complications. OBJECTIVE: To evaluate the influence of the Streptokinase-induced hypotension (SK-hTA) on the rate of coronary reperfusion (CR), incidence of cardiogenic shock (CS), 30-day mortality and incidence of stroke in patients (pts.) with STEMI. The SK-hTA was defined as decrease of the systolic blood pressure with at least 20% within the first 20 min. after the start of the SK infusion. METHODS: A group of 837 pts. (age 20-90) with thrombolytic treatment, with three "accelerated" SK regimens within the first 6 hours after the onset of STEMI and enrolled in the Romanian open, prospective, non-randomised study for accelerated SK in STEMI (ASK-ROMANIA) have been included. The SK regimens consisted in infusing of the standard dose of 1.5 M.U. either in 30 min. (regimen SK1.5/30, 173 pts).) or in 20 min. (regimen SK1.5/20, 377 pts.) or of the half dose (0.75 M.U.) in 10 min. followed by a new infusion of 0.75 M.U. after 50 min. only if no bed-side signs of CR have been recorded (regimen SK 0.75/10, 287 pts.). The speed of the SK infusion was maintained in all pts. experiencing SK-hTA. All pts. received aspirin and heparin or enoxaparin if not contraindicated. Three noninvasive CR criteria have been used: 1. Rapid cessation of the chest pain. 2. Rapid decrease of the ST segment elevation by more than 50% of the initial value. 3. Rapid increase of the CK and CK-MB with a peak within the first 12 hrs. RESULTS: SK-hTA appeared in 372 pts. (44.55%) at 9+/-5 min after the start of the SK infusion. In this subgroup the rate of CR was 74.46%, non-significantly higher than the one of 68.81% registered in pts. without SK-hTA (p=0.071). SK-hTA disappeared in all patients after 16+/-6 minutes without a specific therapy. Fourteen pts. with SK-hTA (3.76%) and 16 pts. without SK-hTA (3.44%) developed CS after thrombolysis ( non-significant difference). The global in-hospital mortality was 10.21% in pts. with SK-hTA and 9.89% in pts. without this side effect (non-significant difference). The incidences of hemorrhagic and ischemic strokes were 0.26% (1 patient) respectively 0.52% (2 pts.) in the SK-hTA subgroup and 0.43% (2 pts.) respectively 0.64% (3 pts.) in the subgroup without SK-hTA. CONCLUSIONS: 1. Despite a very high incidence (44.55%) the SK-hTA has not a detrimental effect in pts. treated with accelerated SK regimens for STEMI. 2. Streptokinase can be rapidly administered without an increased risk.

Double bolus of 0.75 MU streptokinase plus enoxaparin versus front-loaded alteplase plus unfractionated heparin in ST-segment elevation myocardial infarction.

OBJECTIVE: To compare the efficacy and safety of an accelerated streptokinase regimen (double bolus of 0.75 MU in 10 min) in combination with enoxaparin (SK0.75Enox regimen) with the one of the front loaded alteplase (t-PA 100 mg/90 min) plus heparin (the t-PAHep regimen) in patients (pts.) with ST-segment elevation acute myocardial infarction (STAMI). METHODS: One hundred seventy three pts. (age 18-74) treated within the first 6 hrs. after the onset of STAMI with the above two mentioned thrombolytic regimens were included. 1. The group SK0.75Enox (102 pts.) received an i.v. bolus of 40 mg Enox followed by 0.75 MU SK in 10 min. A second bolus of 0.75 MU SK would be administrated only if no bed-side signs of coronary reperfusion (CR) were detected within the next 50 min. After thrombolysis Enox was administered 1 mg/kg bodyweight every 12 hrs. for 5-7 days. 2. The group t-PAHep (71 pts.) received 15 mg oft-PA in bolus followed by 50 mg in 30 min and 35 mg within the next 60 min; t-PA was followed by heparin 1000 u/hour for the next 48-72 hours. All the patients received aspirin. Three noninvasive CR criteria were used: 1. Rapid cesation of the chest pain. 2. Rapid decrease of the ST segment elevation by more than 50% from the initial value. 3. Rapid increase of the CK and CK-MB with a peak within the first 12 hrs. RESULTS: Two patients (2.85%) from the t-PAHep group had non-fatal stroke (one haemorrhagic, one ischemic). No other major haemoragical events were registered in both groups. During the thrombolytic infusion hypotension appeared more frequently in the SK0.75Enox group (31.4%) than in the t-PAHep one (8.5%) (p>0.0001) but without any consequence regarding the patients' outcome. The ratio of CR was 78.4% in the SK0.75Enox group and 70.4% in the t-PAHep one (p = 0.308). In-hospital reocclusion appeared in 4 pts. from the t-PAHep group (5.7%) but in none in the SK0.75Enox one. Six pts. (5.9%) from the SK0.75Enox group and 5 pts. from the t-PA one (7.04%) died within the first 30 days after the onset of STAMI (p = 0.993). CONCLUSIONS: The combination SK0.75Enox is at least as safe and efficacious as the t-PAHep one.

Streptokinase and enoxaparin in the pre-hospital management of the ST-segment elevation acute myocardial infarction.

UNLABELLED: In a pilot study, safety and efficacy of an accelerated Streptokinase (SK) regimen (0.75 MU/10 min. repeated after 50 min. if no signs of coronary reperfusion were detected) in combination with enoxaparin was evaluated in the prehospital (preASENOX regimen) and in the in-hospital (in ASENOX regimen) phase of the ST segment elevation acute myocardial infarction (STAMI) and compared to the in-hospital standard SK plus Heparin (the StSK regimen). METHODS: A group of 262 consecutive patients (age 34-74 years) thrombolised within the first 6 hours after the onset of STAMI was divided in three subgroups according to the mentioned regimens: preASENOX (64 patients); in ASENOX (69 patients) and StSK (129 patients). Enoxaparin was administered i.v. 40 mg before the first dose of 0.75 MU of SK and 1 mg/kg every 12 hours for 5-7 days. Heparin was infused 1000 i.u./h 48-96 hrs. Three noninvasive reperfusion criteria were used: 1) Rapid cessation of the chest pain; 2) Rapid decreasing of the ST segment elevations by more than 50% from the initial value; 3) Rapid increasing of the CK and CK-MB with a peak within the first 12 hrs. RESULTS: The chest pain-thrombolysis time was 145 +/- 52 min in the preASENOX subgroup, significantly shorter as that in the ASENOX subgroup (172 +/- 73 min, p = 0.016) and the StSK one (168 +/- 80 min, p = 0.038). The ratios of the CR were 81.2%, 78.2% and 62.0%, respectively (preASENOX vs StSK p = 0.025; in ASENOX vs StSK p = 0.030). The inhospital mortalities were: 3.12% (preASENOX); 5.8% (inASENOX) and 10.8% (StSK)(non-significant differences). Only one case of ischemic stroke was registered (in the inASENOX subgroup). Symptomatic hypotension appeared more frequent in the preASENOX (39.06%), and inASENOX (43.47%) subgroups as compared to the SSK one (20.15%). CONCLUSIONS: 1) The preASENOX and inASENOX regimens are safe, and lead toward a significant higher ratios of coronary reperfusion as compared to StSK regimen; 2) Our data suggest a very low mortality in patients treated with the preASENOX regimen. Further investigations (randomized studies) are needed for a definite conclusion.

Accelerated streptokinase--a new thrombolytic regimen in acute myocardial infarction.

Efficiency and safety of an accelerated regimen of streptokinase (1.5 M.U. over 20 min., 109 patients) has been compared with the standard regimen (1.5 M.U. over 60 min, 119 patients) in 218 patients admitted within the first 6 hours after the onset of the symptoms of acute myocardial infarction. Using the noninvasive criteria we found a coronary reperfusion rate of 77.04% in patients belonging to the accelerated regimen group and this value was significantly higher than the one of 57.14% registered in the standard group. No major hemorrhagic events were registered in both groups. Although the hypotension appeared to be more frequent in patients in whom the accelerated regimen was used, however this side effect proved to be transient and well controlled using the rapid infusion of natrium chloride solution. In conclusion, the accelerated regimen of streptokinase is safe and followed by a higher rate of coronary reperfusion as compared to the standard one.

Rapid infusion of streptokinase standard dose in acute myocardial infarction is followed by a higher rate of coronary reperfusion than standard protocol.

There are several opinions asserting that the accelerated t-PA is more efficient than the standard protocol of streptokinase (SK) administration in acute myocardial infarction (AMI). One hundred patients admitted within the first 6 hrs after the onset of the symptoms revealing AMI were divided in two subgroups, as follows: subgroup A (50 patients) in whom a dose of 1.5 M.U. SK was infused in 20 min (accelerated protocol) and subgroup B (50 patients) in whom the same dose was infused in 60 min (standard protocol). In order to assess the efficiency of thrombolytic therapy (TT), we used three noninvasive criteria: the rapid resolution of the chest pain, the rapid decreasing of the ST segment elevation by more than 50% from the initial value, and the rapid increasing of enzymes revealing necrosis. Using the above-mentioned criteria, we considered that coronary reperfusion appeared in 40 patients from subgroup A (80%) and in 29 patients from subgroup B (58%). The speed of coronary reperfusion was 40 +/- 26 min in patients with accelerated SK and this time was significantly shorter than the time of 60 +/- 24 min registered in the control group. No major hemorrhagic events appeared in both subgroups. Although hypotension appeared more frequently in subgroup A, this minor complication was well supported by our patients. The rapid infusion of the standard dose of SK was followed by a higher rate and speed of coronary reperfusion as compared to the standard protocol.

Non-paroxysmal ventricular tachycardia with isorhythmic atrioventricular dissociation.

The occurrence of ventricular tachycardias in clinical practice raises important problems of differential diagnosis and therapy. Four ECG tracings recorded in a patient admitted to the Coronary Care Unit of the Emergency Hospital Bucharest illustrate some peculiar features which might appear in such situations.

Aberrant intraventricular conduction and reciprocal beats. Two case reports.

Supraventricular rhythm disturbances with aberrant intraventricular conduction are sometimes interpreted as ventricular dysrhythmias, an error with important therapeutic implications. In the two cases reported below, the ignorance of signs suggestive for a ventricular aberrance has led to confusions of diagnosis and therapy.