In-Hospital Cardiac Arrest in the Cardiac Catheterization Laboratory: Effective Transition from an ICU- to CCU-Led Resuscitation Team.

OBJECTIVES: (1) To examine the incidence and outcomes of in-hospital cardiac arrests (IHCAs) in a large unselected patient population who underwent coronary angiography at a single tertiary academic center and (2) to evaluate a transitional change in which the cardiologist is positioned as the cardiopulmonary resuscitation (CPR) leader in the cardiac catheterization laboratory (CCL) at our local tertiary care institution. BACKGROUND: IHCA is a major public health concern with increased patient morbidity and mortality. A proportion of all IHCAs occurs in the CCL. Although in-hospital resuscitation teams are often led by an Intensive Care Unit- (ICU-) trained physician and house staff, little is known on the role of a cardiologist in this setting. METHODS: Between 2012 and 2016, a single-center retrospective cohort study was performed examining 63 adult patients (70 ± 10 years, 60% males) who suffered from a cardiac arrest in the CCL. The ICU-led IHCAs included 19 patients, and the Coronary Care Unit- (CCU-) led IHCAs included 44 patients. RESULTS: Acute coronary syndrome accounted for more than 50% of cardiac arrests in the CCL. Pulseless electrical activity was the most common rhythm requiring chest compression, and cardiogenic shock most frequently initiated a code blue response. No significant differences were observed between the ICU-led and CCU-led cardiac arrests in terms of hospital length of stay and 1-year survival rate. CONCLUSION: In the evolving field of Critical Care Cardiology, the transition from an ICU-led to a CCU-lead code blue team in the CCL setting may lead to similar short-term and long-term outcomes.

High output cardiac state: evaluating the incidence, plausible etiologies and outcomes.

INTRODUCTION: The high output cardiac state (HOCS) [cardiac index (CI) >4 L/min/m2 ], primarily driven by abnormally low systemic vascular resistance (SVR), is a relatively under-recognized condition. Although, majority of these patients meet criteria for heart failure (HF), their treatment should be aimed at the primary pathology, as the majority of guideline directed HF therapies can reduce SVR further. OBJECTIVES: To characterize patients with HOCS and provide valuable insight into the condition. METHODS: Patients investigated by right heart catheterization (RHC) at the St. Boniface Hospital, Winnipeg, Canada between January 2009 and November 2021 were reviewed. Two groups of patients were included: 1) HOCS [CI >4 L/min/m2], and 2) pre-HOCS [CI between 3.8-4.0 L/min/m2]. Their medical records were reviewed to identify plausible etiologies, relevant investigations, and outcomes. RESULTS: 177/2950 (6 %) patients met criteria for inclusion: 144/177 (81 %) with HOCS [mean age 51 years (range 19 - 82); 67/144 (47 %) female] and 33/177 (19 %) with pre-HOCS [mean age 55 years (range 30 - 83); 6/33 (18 %) female]. The most common plausible etiologies for the HOCS included anemia (36 %), obesity (34 %), cirrhosis (17 %), and lung disease (32 %). Trans-thoracic echocardiography and magnetic resonance imaging findings were non-specific and predominantly described preserved left ventricular ejection fraction, and pulmonary hypertension. The population experienced high rates of hospitalization, and significantly high mortality [36/144 (25 %) of HOCS at a median follow-up of 31.5 months, and 13/33 (39 %) of pre-HOCS at a median follow-up of 17 months]. CONCLUSIONS: HOCS is not an uncommon condition and is associated with high mortality. Current HF guideline should incorporate such evaluation into the diagnostic criteria.

Clinical outcomes and cost implications of routine early PCI after fibrinolysis: one-year follow-up of the Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) study.

BACKGROUND: In patients with ST-elevation myocardial infarction treated with fibrinolysis, routine early percutaneous coronary intervention (r-PCI) improves clinical outcomes at 30 days compared with a more standard approach of performing early PCI only for failed fibrinolysis (s-PCI). METHODS: We report prespecified secondary clinical outcomes and cost implications of r-PCI compared with s-PCI from the Canadian TRANSFER-AMI trial. Average cost per patient in each arm was calculated based on a microcosting approach. Bootstrap method (5,000 samples) was used to calculate standard errors and 95% CI. RESULTS: At 1 year, rates of death or reinfarction (10.3% vs 11.6%, P = .50), hospital readmission (15.4% vs 16.5%, P = .64) and subsequent revascularization after index hospitalization (6.9% vs 8.7%, P = .30) were similar between the r-PCI and s-PCI arms. The difference in cost per patient between r-PCI and s-PCI was CAD $1,003 (95% CI, -$247 to $2,211). Since a greater proportion of patients were transported by air (vs land) in the r-PCI arm (9.4% vs 3%), and the ratio of abciximab to eptifibatide use was higher in the r-PCI arm compared with s-PCI (2:1 vs 4:5), we undertook additional post hoc cost scenario analyses. In a scenario where patients are transported by land only and eptifibatide is used as the sole GPIIb/IIIa inhibitor, the difference in cost per patient between r-PCI and s-PCI was estimated to be CAD $108 (95% CI, -$1,114 to $1,344). CONCLUSIONS: At 1 year, there is no difference in the clinical composite outcome of death or reinfarction between r-PCI and s-PCI strategies. Greater cost with r-PCI, although statistically insignificant, is economically important.

Routine early angioplasty after fibrinolysis for acute myocardial infarction.

BACKGROUND: Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary PCI and therefore receive fibrinolysis. The role and optimal timing of routine PCI after fibrinolysis have not been established. METHODS: We randomly assigned 1059 high-risk patients who had a myocardial infarction with ST-segment elevation and who were receiving fibrinolytic therapy at centers that did not have the capability of performing PCI to either standard treatment (including rescue PCI, if required, or delayed angiography) or a strategy of immediate transfer to another hospital and PCI within 6 hours after fibrinolysis. All patients received aspirin, tenecteplase, and heparin or enoxaparin; concomitant clopidogrel was recommended. The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days. RESULTS: Cardiac catheterization was performed in 88.7% of the patients assigned to standard treatment a median of 32.5 hours after randomization and in 98.5% of the patients assigned to routine early PCI a median of 2.8 hours after randomization. At 30 days, the primary end point occurred in 11.0% of the patients who were assigned to routine early PCI and in 17.2% of the patients assigned to standard treatment (relative risk with early PCI, 0.64; 95% confidence interval, 0.47 to 0.87; P=0.004). There were no significant differences between the groups in the incidence of major bleeding. CONCLUSIONS: Among high-risk patients who had a myocardial infarction with ST-segment elevation and who were treated with fibrinolysis, transfer for PCI within 6 hours after fibrinolysis was associated with significantly fewer ischemic complications than was standard treatment. (ClinicalTrials.gov number, NCT00164190.)

Efficacy of early invasive management post-fibrinolysis in men versus women with ST-elevation myocardial infarction: a subgroup analysis from Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).

BACKGROUND: The TRANSFER-AMI study demonstrated that early routine percutaneous coronary intervention post-fibrinolysis (pharmacoinvasive strategy) is superior to conservative management for ST-elevation myocardial infarction. However, it is not clear whether treatment efficacy differs between men and women. METHODS: In this pre-specified subgroup analysis, we compared the efficacy of a pharmacoinvasive strategy in men versus women with acute ST-elevation myocardial infarction who were randomized to a pharmacoinvasive versus standard management following fibrinolysis. The primary end point was a composite of death, recurrent myocardial infarction, recurrent ischemia, heart failure and shock at 30 days. We tested for treatment heterogeneity between men and women using the Breslow-Day test. We also performed multivariable analysis adjusting for GRACE risk score and its interaction with treatment assignment, and evaluated for death/recurrent myocardial reinfarction as a secondary outcome. RESULTS: Of the 1059 patients, 843 were men and 216 were women. Compared to men, women were older, had worse Killip class, higher GRACE risk score, and higher rates of death and death/myocardial reinfarction at 30 days. The primary end point did not differ significantly between men and women (13.4% vs 16.7%, P = .22). Compared to standard treatment, a pharmacoinvasive strategy was associated with a lower rate of the primary end point in men (17.5% vs 9.4%, respectively, P < .001), but not in women (16.2% vs 17.1%, P = .86). There was a trend toward an interaction between treatment assignment and sex for the composite primary end point (P = .06). After adjustment for the significant interaction between GRACE risk score and treatment (P < .001), there was no significant interaction between sex and treatment for all the end points (all P > .40). CONCLUSION: The borderline heterogeneity in treatment efficacy of a pharmacoinvasive strategy in men versus women was no longer evident after adjustment for the difference in baseline risk. This suggests that sex per se was not an important determinant of the efficacy of a pharmacoinvasive strategy. Owing to the small number of women in this trial, further study in this area is needed.

Efficacy and safety of enoxaparin compared with unfractionated heparin in the pharmacoinvasive management of acute ST-segment elevation myocardial infarction: Insights from the TRANSFER-AMI trial.

AIMS: An early invasive strategy after fibrinolysis for ST-elevation myocardial infarction (STEMI) improves outcomes, but the relative efficacy and safety of enoxaparin compared with unfractionated heparin (UFH) as part of this approach are unknown. METHODS AND RESULTS: In the TRANSFER-AMI trial, patients with high-risk STEMI received fibrinolysis and were then randomized to either standard treatment or to immediate transfer for coronary angiography. In this substudy, the outcome of patients aged <75 years treated with enoxaparin is compared with that of patients who received UFH. Logistic regression and propensity score models were used to evaluate the efficacy and safety of these anticoagulants. Enoxaparin was administered to 498 patients, and UFH, to 448 patients, at the time of fibrinolysis. Approximately 50% in each group were randomized to the early invasive strategy. The primary composite end point of death, reinfarction, recurrent ischemia, new or worsening heart failure, or cardiogenic shock at 30 days occurred in 11.9% and 11.6% of the patients who received enoxaparin and UFH, respectively (adjusted odds ratio 0.95 [95% CI 0.60-1.51], P = .84). Enoxaparin use was associated with more access site bleeding (5.0% vs 2.9%, P = .04) and mild bleeding (12.1% vs 7.8%, P = .03). CONCLUSIONS: Among high-risk patients with STEMI undergoing early or late transfer for cardiac catheterization after fibrinolysis, enoxaparin was associated with similar efficacy compared with UFH, but there was more minor bleeding with enoxaparin (ClinicalTrials.gov no. NCT00164190).

The acutely occluded left main coronary artery culprit in cardiogenic shock and initial percutaneous coronary intervention: a substudy of the Manitoba "no option" left main PCI registry.

We aim to describe the in-hospital outcomes of the first reported Canadian cohort of patients with cardiogenic shock and acute myocardial infarction (MI) due to acute and total occlusion of the left main coronary artery, treated with initial percutaneous coronary intervention (PCI). Acute left main thromboses with cardiogenic shock were identified (N = 8) from a retrospective consecutive cohort of high risk left main PCI (N = 56) performed at our institution from 2004-2009. The mean age was 62.3 ± 13.2 years, with 6 (75%) male patients. Successful PCI was performed in all patients, with thrombectomy utilized in 4 patients (50%), stenting in 7 patients (88%), and intra-aortic balloon pump augmentation in 7 patients (88%). Two patients (25%) required extracorporeal membrane oxygenation (ECMO) and 2 other patients required ventricular assist devices. Post-PCI coronary artery bypass grafting (CABG) was performed for 2 patients (25%). The mean SYNTAX score was 26.6 ± 10.5. The mean logistic EuroSCORE was 30.4 ± 12.6%. In-hospital mortality occurred in 3 patients (38%). Acute left main occlusion is a rare but devastating presentation of myocardial infarction, invariably with cardiogenic shock. Emergent PCI may be an effective method to acutely revascularize this subset of patients; however, aggressive post-PCI care including ECMO, CABG, and ventricular support may be required to improve patient survival.

Relationship between risk stratification at admission and treatment effects of early invasive management following fibrinolysis: insights from the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).

AIMS: We sought to determine the effectiveness of early routine percutaneous coronary intervention (PCI) post-fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to baseline risk status. METHODS AND RESULTS: In this post hoc subgroup analysis of Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI), we stratified 1059 STEMI patients receiving tenecteplase into low-intermediate [Global Registry of Acute Coronary Events (GRACE) risk score<155; n=889] vs. high-risk (GRACE risk score ≥155; n=170) groups, based on the GRACE risk score for in-hospital mortality. There was a significant interaction between treatment assignment and risk status for the composite endpoint of death/re-MI at 30 days (P for interaction<0.001). Compared with the standard treatment, pharmacoinvasive therapy (early routine PCI) was associated with a lower rate of death/re-MI at 30 days in the low-intermediate risk stratum (8.1 vs. 2.9%, P<0.001), but a higher rate of death/re-MI in the high-risk group (13.8 vs. 27.8%, P=0.025). We found similar heterogeneity in the treatment effects on 30-day mortality and death/re-MI at 1 year (P for interaction=0.008 and 0.001, respectively), when the GRACE risk score was analysed as a continuous variable (P for interaction<0.001) and when patients were stratified by the Thrombolysis In Myocardial Infarction (TIMI) risk score (P for interaction=0.001). CONCLUSION: We observed a strong heterogeneity in the treatment effects of a pharmacoinvasive strategy after fibrinolysis for STEMI, which is associated with improved outcomes only among patients with a low-intermediate GRACE risk score. Conversely, the early invasive strategy is associated with worse outcomes in high-risk patients. These novel findings should be considered exploratory only and require confirmation in other trials and meta-analyses. CLINICAL TRIAL REGISTRATION INFORMATION: http://www.clinicaltrials.gov/ct2/show/NCT00164190 ClinicalTrials.gov number, NCT00164190.

Using the Zwolle Risk Score at Time of Coronary Angiography to Triage Patients With ST-Elevation Myocardial Infarction Following Primary Percutaneous Coronary Intervention or Thrombolysis.

Background The Zwolle Risk Score was designed to identify the risk of complications in patients with ST-segment‒elevation myocardial infarction (STEMI) following percutaneous coronary intervention (PCI). Its utility following PCI in STEMI treated with thrombolysis is unknown. The objective was to evaluate the safety of using the Zwolle Risk Score to triage patients with STEMI following PCI, including patients receiving thrombolysis. Methods and Results Patients aged ≥18 years with STEMI and primary PCI or PCI after thrombolysis were included. A triage protocol was developed, with high-risk patients those with Zwolle Risk Score ≥4 triaged to the cardiac intensive care unit. A prospective evaluation of the triaging protocol was performed on 452 patients, mean age 65±12 years, 73% men. Median Zwolle Risk Score was 3 (interquartile range, 2‒5), with 257 low-risk (57%), and 195 high-risk (43%) patients. Adherence to the protocol was 91%. In-hospital mortality was 0.4% in low-risk and 13% in high-risk patients (P<0.001). Seventy-two patients (16%) received thrombolysis. Median time post-thrombolysis to PCI was 281 minutes (interquartile range, 219‒376). In-hospital mortality was 0% versus 9% (P=0.083) for low- and high-risk patients, respectively. High-risk patients had higher rates of cardiogenic shock (34% versus 1%, P<0.001), pulmonary edema (60% versus 9%, P<0.001), arrhythmia (25% versus 2%, P<0.001), blood transfusion (10% versus 2%, P<0.001), and stroke (4% versus 0.4%, P=0.011). Median hospital costs decreased by $1419 per low-risk patient after protocol implementation. Conclusions For patients with STEMI following primary PCI or PCI following thrombolysis, a Zwolle-based triaging system is safe and may decrease cardiac intensive care unit usage costs.

Does a Heart Team Improve Clinical Outcomes?

Consultation by a Heart Team (HT) is a class I recommendation by the American College of Cardiology, American Heart Association, and the European Society of Cardiology for the management of patients with complex cardiac disease. Despite the class I recommendation, there is a paucity of data to support the role of an HT with only level C quality of evidence. This study was performed to follow patients who were referred for HT consultation and long-term outcomes in relation to whether the recommendation of the HT was followed or not. We performed a prospective analysis of our cohort of patients who underwent consultation by the HT. A total of 342 cases have been followed. Patient characteristics, referring physicians' favored treatment, and key outcomes were followed. A total of 336 patients were reviewed; 70.4% were male patients with a median age of 66.3 years and an average EuroSCORE II score of 7.2%. A total of 79.9% of the discussions resulted in a unanimous decision. The recommendations made by the HT differed from those documented by the referring physician in 54% of cases. In conclusion, recommendations made by the HT were followed in 269 cases (83.8%). There was a significant reduction in cardiac death (6.3% vs 15.3%, p = 0.042), composite cardiac outcome (23.4% vs 51.9%, p ≤0.001), and hospital admissions (10.4% vs 36.5%, p ≤0.001) when recommendations were followed. There was no statistical difference between the 2 groups when looking at noncardiac death, stroke, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, dialysis, or an emergency room visit.

The ability to achieve complete revascularization is associated with improved in-hospital survival in cardiogenic shock due to myocardial infarction: Manitoba cardiogenic SHOCK Registry investigators.

OBJECTIVES: To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort. BACKGROUND: Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization. METHODS: A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in-hospital survival were identified utilizing logistic regression. RESULTS: ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09-0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002-1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04-11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73-39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1-6.2)) and peak lactate (P = 0.02). CONCLUSIONS: The ability to achieve complete revascularization may be strongly associated with improved in-hospital survival in patients with cardiogenic shock.

Reducing Delay to Treatment of ST-Elevation Myocardial Infarction With Software Electrocardiographic Interpretation and Transmission (SCINET).

BACKGROUND: Prehospital diagnosis of ST-elevation myocardial infarction (STEMI) has resulted in improved outcomes. However, many patients still walk in to the emergency department (ED) with STEMI, experiencing delays and worse outcomes. Software electrocardiogram (ECG) diagnosis of STEMI and electronic transmission to a cardiologist may result in improved door-to-device (D2D) times. METHODS: We retrospectively identified all patients presenting with STEMI from January 2015 to September 2016. Components of delay in D2D, ED variables, and the patients' ECGs were extracted from our regional database. All ECGs performed for suspected myocardial infarction in the region were extracted over the study period. We assessed the accuracy of the software 12SL in diagnosing STEMI, ED contributors to delays in D2D, and the potential reduction in D2D if software diagnosis of STEMI resulted in activation of the cardiac catheterization laboratory. RESULTS: A total of 379 patients presented to an ED in our region and received primary percutaneous coronary intervention over the study period. In the 143,574 ECGs performed over the study period for suspected STEMI, the overall sensitivity and specificity of 12SL were 90.5% and 99.98%, respectively. We estimated a potential 17-minute reduction in D2D in the 90.5% of patients correctly identified as having STEMI, with a false activation rate of 4%. Female patients and older patients experienced an even larger potential benefit, with 24- and 25-minute reductions in D2D, respectively. CONCLUSIONS: Patients who walk in to an ED with STEMI experience significant system-related delays in recognition and treatment. Automated software diagnosis of STEMI is accurate and could result in significant improvements in D2D times.

CONTEXTE: Le diagnostic préhospitalier de l'infarctus du myocarde avec élévation du segment ST (STEMI) contribue à améliorer les résultats pour les patients. Toutefois, de nombreux patients subissant un STEMI se présentent encore d'eux-mêmes au service des urgences, ce qui retarde leur traitement et entraîne des conséquences plus graves. Le diagnostic de STEMI au moyen d'un logiciel de prise d'électrocardiogramme (ECG) qui est ensuite transmis à un cardiologue par voie électronique pourrait réduire le délai entre l'arrivée à l'hôpital et la pose d'un dispositif (délai avant l'intervention). MÉTHODOLOGIE: Nous avons rétrospectivement recensé tous les patients ayant subi un STEMI entre janvier 2015 et septembre 2016. Les facteurs entraînant l'augmentation du délai avant l'intervention, les variables relatives au service des urgences et les ECG des patients ont été extraits d'une base de données régionale. Tous les ECG réalisés dans les cas d'infarctus du myocarde suspectés dans la région pendant la période visée ont été extraits. Nous avons évalué l'exactitude des diagnostics de STEMI obtenus à l'aide du logiciel 12SL, les facteurs contribuant au délai avant l'intervention et la réduction potentielle de ce délai lorsque le diagnostic de STEMI obtenu par logiciel a permis au laboratoire de cathétérisme cardiaque de se préparer avant l'arrivée du patient. RÉSULTATS: Au total, 379 patients se sont présentés au service des urgences d'un hôpital de la région et ont subi une intervention coronarienne percutanée primaire durant la période visée par l'étude. Sur les 143 574 ECG réalisés dans les cas de STEMI suspectés durant la période étudiée, la sensibilité et la spécificité globales du logiciel 12SL s'établissaient respectivement à 90,5 % et à 99,98 %. Nous avons estimé que le délai avant l'intervention avait été potentiellement réduit de 17 minutes chez les patients ayant reçu un diagnostic de STEMI correct (90,5 %), le taux d'activation inutile du laboratoire de cathétérisme s'établissant à 4 %. Les femmes et les patients plus âgés sont ceux qui semblent avoir bénéficié le plus de cette stratégie, la réduction potentielle du délai avant l'intervention s'établissant dans leurs cas à 24 et à 25 minutes, respectivement. CONCLUSIONS: Les patients subissant un STEMI qui se présentent eux-mêmes au service des urgences doivent passer par toutes les étapes du processus d'admission avant que leur état soit reconnu et traité. Les outils de diagnostic automatisé du STEMI donnent des résultats justes, et leur utilisation pourrait réduire considérablement le délai entre l'arrivée à l'hôpital et l'intervention.

Spinal Epidural Hematoma Secondary to Tenecteplase for ST-Elevation Myocardial Infarction in the Setting of Trauma and Cervical Endplate Fracture.

A 78-year-old woman presented with an inferior ST-segment elevation myocardial infarction in the setting of a fall resulting in facial trauma causing an unrecognized C6 cervical endplate fracture. After administration of tenecteplase, she developed a spinal epidural hematoma requiring intubation for airway protection and cessation of antiplatelet therapies. The need to delay coronary intervention in this setting led to a recurrent inferolateral ST-segment elevation myocardial infarction that eventually required coronary bypass grafting. In the first report of a spinal epidural hematoma after tenecteplase for ST-segment elevation myocardial infarction, we emphasize the need for imaging after significant trauma before initiating thrombolysis.

Une femme de 78 ans a été vue en consultation pour un infarctus du myocarde inférieur avec élévation du segment ST, dans un contexte de trauma facial entraîné par une chute, causant une fracture du plateau vertébral de C6 non diagnostiquée. Après avoir reçu du ténectéplase, la patiente a présenté un hématome épidural rachidien ayant nécessité l'intubation pour protéger les voies respiratoires et l'arrêt des traitements antiplaquettaires. La nécessité de retarder l'intervention coronarienne dans ce contexte a entraîné un nouvel infarctus du myocarde inférolatéral avec élévation du segment ST, ayant par la suite nécessité un pontage aortocoronarien. Relativement au premier rapport d'hématome épidural rachidien survenu après l'administration de ténectéplase pour le traitement de l'infarctus du myocarde avec élévation du segment ST, nous insistons sur l'importance de procéder, avant d'instaurer la thrombolyse, à des examens d'imagerie chez les patients ayant subi un trauma important.

Nonculprit Lesion Severity and Outcome of Revascularization in Patients With STEMI and Multivessel Coronary Disease.

BACKGROUND: In the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial, angiography-guided percutaneous coronary intervention (PCI) of nonculprit lesions with the aim of complete revascularization reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (MI) and multivessel coronary artery disease. OBJECTIVES: The purpose of this study was to determine the effect of nonculprit-lesion stenosis severity measured by quantitative coronary angiography (QCA) on the benefit of complete revascularization. METHODS: Among 4,041 patients randomized in the COMPLETE trial, nonculprit lesion stenosis severity was measured using QCA in the angiographic core laboratory in 3,851 patients with 5,355 nonculprit lesions. In pre-specified analyses, the treatment effect in patients with QCA stenosis ≥60% versus <60% on the first coprimary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischemia-driven revascularization was determined. RESULTS: The first coprimary outcome was reduced with complete revascularization in the 2,479 patients with QCA stenosis ≥60% (2.5%/year vs. 4.2%/year; hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47 to 0.79), but not in the 1,372 patients with QCA stenosis <60% (3.0%/year vs. 2.9%/year; HR: 1.04; 95% CI: 0.72 to 1.50; interaction p = 0.02). The second coprimary outcome was reduced in patients with QCA stenosis ≥60% (2.9%/year vs. 6.9%/year; HR: 0.43; 95% CI: 0.34 to 0.54) to a greater extent than patients with QCA stenosis <60% (3.3%/year vs. 5.2%/year; HR: 0.65; 95% CI: 0.47 to 0.89; interaction p = 0.04). CONCLUSIONS: Among patients with ST-segment elevation MI and multivessel coronary artery disease, complete revascularization reduced major CV outcomes to a greater extent in patients with stenosis severity of ≥60% compared with <60%, as determined by quantitative coronary angiography.

Clinical Practice Variations in the Management of Stress-Induced Cardiomyopathy: A Canadian Perspective.

Despite increased recognition of stress-induced cardiomyopathy (SIC), there are no randomized controlled trials or established guidelines to direct therapeutic strategies and little is known about the local experience in Canada. The objective of this study was to better understand the clinical practice variations in the management of SIC across Canada. By using an online platform, a series of questions were distributed to practicing cardiologists between October and November 2018. In total, 172 cardiologists completed the survey. Although many cardiologists have managed patients with SIC, more than two-thirds do not adhere to any guidelines or references. Of those who do, the top referenced resources included expert consensus statements from the American College of Cardiology, the European Society of Cardiology, general heart failure guidelines, and UpToDate. Regarding investigations, most participants routinely order TTEs and coronary angiograms, and a minority would order pheochromocytoma workup. Common medications prescribed for hemodynamically stable patients include ß-blockers, angiotensin-converting enzyme inhibitors, antiplatelet agents, and anticoagulation. Some 3% of participants reported not prescribing any cardiac medications. Most respondents follow up with patients with SIC within a 3-month period. The risk factors most believed to be associated with SIC included female gender, anxiety, older age, ethnicity, and diabetes. No participants believed that male gender was a risk factor. Many participants believed there needs to be improvements made, such as a Canadian guideline, a Canadian registry, or dedicated workshops at the national cardiology conference. This study demonstrates ongoing variability in the clinical management of SIC across Canada and illustrates a potential area for further research.

Rationale and design of the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).

BACKGROUND: Most patients with ST-elevation myocardial infarction present to hospitals without percutaneous coronary intervention (PCI) facilities and receive fibrinolysis. The role of routine early PCI after fibrinolysis, using stents and contemporary pharmacotherapy, has not been studied in a large adequately powered randomized trial. OBJECTIVE: To compare a pharmacoinvasive strategy of transfer for routine PCI within 6 hours after fibrinolysis with standard treatment after fibrinolysis (including predefined criteria for rescue PCI and delayed cardiac catheterization for patients who do not require rescue PCI). METHODS: A total of 1200 patients with high-risk ST-elevation myocardial infarction presenting to non-PCI centers will be randomized to a pharmacoinvasive strategy (transfer for routine PCI within 6 hours of fibrinolysis) or to standard treatment after fibrinolysis. The primary end point is the 30-day composite of death, reinfarction, recurrent ischemia, heart failure, or shock. RESULTS: More than 900 patients have been enrolled as of April 2007. An interim safety analysis of the first 536 patients demonstrated no safety concerns. Enrolment is expected to be completed in late 2007. CONCLUSIONS: This study will provide important data on whether routine early PCI within 6 hours after fibrinolysis is safe and superior to the standard treatment of fibrinolysis with rescue PCI or delayed cardiac catheterization.

Long-term Follow-up of the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).

BACKGROUND: The Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) demonstrated superiority of routine early coronary angiography (and percutaneous coronary intervention [PCI]) compared with standard therapy in fibrinolytic-treated patients with ST-segment elevation myocardial infarction (STEMI) at 30 days. The aim of the current study was to evaluate the long-term (>7 year) effects of an early invasive strategy. METHODS: We linked the study cohort and administrative datasets to assess long-term follow-up status including repeat procedures, hospitalizations, and major adverse cardiovascular events (MACE). Kaplan-Meier and Cox regression analysis were used to evaluate the relationship between randomized treatment and long-term adverse outcomes. RESULTS: A total of 881 patients had long-term follow-up and were included in our study. After a mean follow-up of 7.8 years, there were no significant differences in death, myocardial infarction (MI), unstable angina, stroke, transient ischemic attack (TIA), or heart failure admissions (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.73-1.13]; P = 0.41) between those randomized to an early invasive vs standard treatment strategy. Following the index hospitalization, there were no significant difference in the rates of coronary revascularization between the early invasive and the standard therapy groups (81 [19.3%] vs 76 [17.9%]; P = 0.61). CONCLUSIONS: Despite the short-term benefit and safety of an early invasive strategy in patients with STEMI receiving fibrinolysis, no statistically significant differences in MACE were observed over 7.8 years.

Iatrogenic Great Cardiac Vein Anastomosis during Coronary Artery Bypass Surgery.

Inadvertent anastomosis of the left internal mammary artery (LIMA) or a saphenous vein graft (SVG) to the great cardiac vein (GCV) is a rare complication of coronary artery bypass grafting (CABG). We present two cases with a LIMA to GCV and a SVG to GCV anastomosis, respectively, resulting in angina and dyspnea in the postoperative state. As an alternative to repeat CABG, both patients underwent percutaneous coronary intervention with percutaneous coil embolization or implantation of an Amplatzer vascular plug within the bypass graft to GCV conduit. This report highlights that percutaneous options exist for the relief of ischemic symptoms in this rare clinical setting.

Autologous Bone Marrow Stem Cell Therapy in Patients With ST-Elevation Myocardial Infarction: A Systematic Review and Meta-analysis.

BACKGROUND: Randomized controlled trials (RCTs) on bone marrow stem cell (BMSC) therapy in ST-elevation myocardial infarction (STEMI) patients have reported conflicting results. Our main objective was to critically appraise and meta-analyze best-available evidence on efficacy and safety of intracoronary administration of autologous BMSC therapy in STEMI patients after primary percutaneous coronary intervention. METHODS: We conducted a search of MEDLINE, PubMed, EMBASE, CENTRAL, Global Health, CINAHL, and conference proceedings in February 2017. Our primary outcome was all-cause mortality. Secondary and safety outcomes included cardiac death, heart failure, arrhythmias, repeat myocardial infarction, or target vessel revascularizations; or improved health-related quality of life, left ventricular ejection fraction, or infarct size. Summary relative and absolute risks were obtained using random effects models. We also evaluated the strength of evidence. RESULTS: A comprehensive database search identified 42 RCTs (3365 STEMI patients). BMSC therapy did not significantly decrease mortality (risk ratio, 0.71; 95% confidence interval, 0.45-1.11; I2, 0%; absolute risk reduction, 0.1%; 95% confidence interval, -0.71 to 0.91; 40 trials; 3289 participants; I2, 0%; low strength of evidence). BMSC therapy had no effect on secondary or adverse outcomes. Trial sequential analysis for all-cause mortality showed no evidence of a clinically important difference, with a very low probability that future studies can change the current conclusion. CONCLUSIONS: On the basis of evidence from 42 RCTs published in the past 15 years, we provide conclusive evidence for a lack of beneficial effect for autologous BMSC therapy in patients with STEMI.