Planning and monitoring of patients for electrical cardioversion for atrial fibrillation.

OBJECTIVES: This study evaluated the waiting list for elective electrical cardioversion (ECV) for persistent atrial fibrillation (AF), focusing on when and why procedures were postponed. We compared the effects of management of the waiting list conducted by physicians versus management by nurse practitioners (NPs) and we evaluated the safety of our anticoagulating policy by means of bleeding or thromboembolic complications during and after ECV. BACKGROUND: Not all patients selected for ECV receive their treatment at the first planned instance due to a variety of reasons. These reasons are still undocumented. METHODS: We evaluated 250 consecutive patients with persistent AF admitted to our clinic for elective ECV. RESULTS: Within 5 to 6 weeks, 186 of 242 patients (77%) received ECV. The main reason for postponing an ECV was an inadequate international normalised ratio (INR); other reasons included spontaneous sinus rhythm and switch to rate control. A total of 23 of the 147 patients (16%) managed by the research physician were postponed due to an inadequate INR at admission versus 4 out of 98 patients (4%) managed by NPs (p = 0.005) CONCLUSION: An inadequate INR is the main reason for postponing an ECV. Management of ECV by NPs is safe and leads to less postponing on admission.

Prehospital diagnosis in STEMI patients treated by primary PCI: the key to rapid reperfusion.

BACKGROUND: Primary coronary intervention (PCI) for acute myocardial infarction should be performed as quickly as possible, with a door-toballoon time of less then 90 minutes. However, in daily practice this cannot always be achieved. Prehospital diagnosis of ST-elevation myocardial infarction (STEMI) is of major importance in reducing time to treatment, in particular when patients can be transported directly to a centre with interventional capacities. OBJECTIVES: The aim of the current study was to evaluate the time from prehospital diagnosis of STEMI to balloon inflation and identify factors related to treatment delay in patients directly referred to the catheterisation laboratory of the University Medical Centre of Groningen. METHODS: A cross-sectional descriptive design was used to collect data on patients treated with primary PCI after prehospital diagnosis of STEMI. RESULTS: Median prehospital diagnosis-to-balloon time was 64 minutes for patients directly admitted to the catheterisation laboratory and 75 minutes for patients initially admitted to the coronary care unit. A delay longer than 90 minutes was observed in 18 patients. Higher age was associated with longer delay times (p=0.041). Long delays were not associated with diabetes (p=0.293), time from symptom onset to prehospital diagnosis (p=0.87) or time of day (p=0.09). Initial unavailability of the catheterisation laboratory due to running procedures contributed to longer delay times in ten cases. CONCLUSION: Prehospital diagnosis of STEMI and direct referral to a catheterisation laboratory for primary PCI allows a prehospital diagnosis-toballoon time of less than 90 minutes in 82% of patients. Older patients are at risk of longer delays. (Neth Heart J 2008;16:5-9.).

Closure of the femoral artery after cardiac catheterization: a comparison of Angio-Seal, StarClose, and manual compression.

OBJECTIVES: To compare Angio-Seal (AS) and StarClose (SC) and manual compression (MC) on efficacy of hemostasis, complication rate, safety of early mobilization, and patient comfort. BACKGROUND: Closure of the femoral artery after cardiac catheterization can be obtained through different methods. Today, physicians can choose from a number of different devices to achieve arterial closure. METHODS: In a prospective trial 450 patients were randomized to AS, SC, or MC. Patients were mobilized 1 to 2 hr after device placement, and 6 hr after MC. Data were collected during hospital admission and by telephone at one month after hospital discharge. RESULTS: Devices were used in 138/150 allocated to AS and 124/150 allocated to SC patients (92% vs. 83%, P = 0.015) Patients with MC experienced more pain during sheath removal than patients receiving a device, and rated their period of bed rest as less comfortable. Oozing and need for pressure bandage at the puncture site were observed in 37 AS patients and 57 SC patients (25% vs. 38%, P = 0.002). Hematoma occurred in 15 AS patients, in 17 SC patients, and in 14 MC patients (11 vs. 14 vs. 9%, ns). CONCLUSION: There is no difference in safety between the three methods of arterial closure. SC was more often not used or successfully deployed. SC patients more often had continuing oozing. On patient comfort, closure devices performed better than MC. Early ambulation in patients with a closure device is safe. AS is the preferred method of arterial closure after cardiac catheterization.