Does the Position of Foot-Mounted IMU Sensors Influence the Accuracy of Spatio-Temporal Parameters in Endurance Running?

Wearable sensor technology already has a great impact on the endurance running community. Smartwatches and heart rate monitors are heavily used to evaluate runners' performance and monitor their training progress. Additionally, foot-mounted inertial measurement units (IMUs) have drawn the attention of sport scientists due to the possibility to monitor biomechanically relevant spatio-temporal parameters outside the lab in real-world environments. Researchers developed and investigated algorithms to extract various features using IMU data of different sensor positions on the foot. In this work, we evaluate whether the sensor position of IMUs mounted to running shoes has an impact on the accuracy of different spatio-temporal parameters. We compare both the raw data of the IMUs at different sensor positions as well as the accuracy of six endurance running-related parameters. We contribute a study with 29 subjects wearing running shoes equipped with four IMUs on both the left and the right shoes and a motion capture system as ground truth. The results show that the IMUs measure different raw data depending on their position on the foot and that the accuracy of the spatio-temporal parameters depends on the sensor position. We recommend to integrate IMU sensors in a cavity in the sole of a running shoe under the foot's arch, because the raw data of this sensor position is best suitable for the reconstruction of the foot trajectory during a stride.

Coronary angiography in out-of-hospital cardiac arrest without ST elevation on ECG-Short- and long-term survival.

BACKGROUND: The potential benefit of early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients without ST elevation on ECG is unclear. The aim of this study was to evaluate the association between early coronary angiography and survival in these patients. METHODS: Nationwide observational study between 2008 and 2013. Included were patients admitted to hospital after witnessed OHCA, with shockable rhythm, age 18 to 80 years and unconscious. Patients with ST-elevation on ECG were excluded. Patients that underwent early CAG (within 24 hours) were compared with no early CAG (later during the hospital stay or not at all). Outcomes were survival at 30 days, 1 year, and 3 years. Multivariate analysis included pre-hospital factors, comorbidity and ECG-findings. RESULTS: In total, 799 OHCA patients fulfilled the inclusion criteria, of which 275 (34%) received early CAG versus 524 (66%) with no early CAG. In the early CAG group, the proportion of patients with an occluded coronary artery was 27% and 70% had at least one significant coronary stenosis (defined as narrowing of coronary lumen diameter of ≥50%). The 30-day survival rate was 65% in early CAG group versus 52% with no early CAG (P < .001). The adjusted OR was 1.42 (95% CI 1.00-2.02). The one-year survival rate was 62% in the early CAG group versus 48% in the no early CAG group with the adjusted hazard ratio of 1.35 (95% CI 1.04-1.77). CONCLUSION: In this population of bystander-witnessed cases of out-of-hospital cardiac arrest with shockable rhythm and ECG without ST elevation, early coronary angiography may be associated with improved short and long term survival.

Comparison of Different Algorithms for Calculating Velocity and Stride Length in Running Using Inertial Measurement Units.

Running has a positive impact on human health and is an accessible sport for most people. There is high demand for tracking running performance and progress for amateurs and professionals alike. The parameters velocity and distance are thereby of main interest. In this work, we evaluate the accuracy of four algorithms, which calculate the stride velocity and stride length during running using data of an inertial measurement unit (IMU) placed in the midsole of a running shoe. The four algorithms are based on stride time, foot acceleration, foot trajectory estimation, and deep learning, respectively. They are compared using two studies: a laboratory-based study comprising 2377 strides from 27 subjects with 3D motion tracking as a reference and a field study comprising 12 subjects performing a 3.2-km run in a real-world setup. The results show that the foot trajectory estimation algorithm performs best, achieving a mean error of 0.032 ± 0.274 m/s for the velocity estimation and 0.022 ± 0.157 m for the stride length. An interesting alternative for systems with a low energy budget is the acceleration-based approach. Our results support the implementation decision for running velocity and distance tracking using IMUs embedded in the sole of a running shoe.

Thrombus aspiration during ST-segment elevation myocardial infarction.

BACKGROUND: The clinical effect of routine intracoronary thrombus aspiration before primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is uncertain. We aimed to evaluate whether thrombus aspiration reduces mortality. METHODS: We conducted a multicenter, prospective, randomized, controlled, open-label clinical trial, with enrollment of patients from the national comprehensive Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and end points evaluated through national registries. A total of 7244 patients with STEMI undergoing PCI were randomly assigned to manual thrombus aspiration followed by PCI or to PCI only. The primary end point was all-cause mortality at 30 days. RESULTS: No patients were lost to follow-up. Death from any cause occurred in 2.8% of the patients in the thrombus-aspiration group (103 of 3621), as compared with 3.0% in the PCI-only group (110 of 3623) (hazard ratio, 0.94; 95% confidence interval [CI], 0.72 to 1.22; P=0.63). The rates of hospitalization for recurrent myocardial infarction at 30 days were 0.5% and 0.9% in the two groups, respectively (hazard ratio, 0.61; 95% CI, 0.34 to 1.07; P=0.09), and the rates of stent thrombosis were 0.2% and 0.5%, respectively (hazard ratio, 0.47; 95% CI, 0.20 to 1.02; P=0.06). There were no significant differences between the groups with respect to the rate of stroke or neurologic complications at the time of discharge (P=0.87). The results were consistent across all major prespecified subgroups, including subgroups defined according to thrombus burden and coronary flow before PCI. CONCLUSIONS: Routine thrombus aspiration before PCI as compared with PCI alone did not reduce 30-day mortality among patients with STEMI. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT01093404.).

The role of a simulator-based course in coronary angiography on performance in real life cath lab.

BACKGROUND: The aim of this study was to explore if a course consisting of lectures combined with simulator training in coronary angiography (CA) could accelerate the early learning curve when performing CA on patients.Knowledge in performing CA is included in the curriculum for the general cardiologist. The method, according to American College of Cardiology and European Society of Cardiology guidelines, for this training is not well defined but simulator training is proposed to be an option. However, the transfer effect from a CA simulator to performance in real world cath lab is not validated. METHODS: Fifty-four residents without practical skills in CA completed the course and 12 continued to training in invasive cardiology. These residents were tracked in the Swedish Coronary Angiography and Angioplasty Registry and compared to a control group of 46 novel operators for evaluation of performance metrics. A total of 4472 CAs were analyzed. RESULTS: Course participants demonstrated no consistent acceleration in the early learning curve in real world cath lab. They had longer fluoroscopy time compared to controls (median 360 seconds (IQR 245-557) vs. 289 seconds (IQR 179-468), p < 0.001). Safety measures also indicated more complications appearing at the ward, in particular when using the femoral approach (6.25% vs. 2.53%, p < 0.001). CONCLUSIONS: Since the results of this retrospective non-randomized study were negative, the role of a structured course including simulator training for skills acquisition in CA is still uncertain. Randomized transfer studies are warranted to justify further use of simulators for training in CA.

The use of fluoroscopy to construct learning curves for coronary angiography.

OBJECTIVES: The aim of this study was to assess learning curves for coronary angiography using registry data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). BACKGROUND: ACC and ESC guidelines for cardiologists in training recommend 200-300 coronary angiographies as primary operator. Whether this is safe or sufficient to reach an adequate proficiency level is not known. The development of learning curves and factors that can determine progress is not yet clearly stated. METHODS: We extracted data from SCAAR 2005-2009 and identified 20 novel and 21 expert operators in coronary angiography during this observation period. Metrics possibly influenced by proficiency level were compared between the two groups. Learning curves were then identified with the expert's performance as reference defined as interquartile range (IQR). RESULTS: Data from a total of 24,000 coronary angiographies were examined. Beginners used similar volumes of contrast but had longer fluoroscopy time compared with experts. Fluoroscopy time appeared to be a metric that demonstrated a clear learning curve and beginners reached experts IQR in 50 % (median) of the procedures after ∼140 coronary angiographies. The risk of complications was independently associated with fluoroscopy time. CONCLUSIONS: Fluoroscopy time seems to be the best metric to determine coronary angiography performance level and might therefore be a good proficiency measure during training. On the basis of our results we recommend the trainee to perform at least 150 coronary angiographies during supervision before proceeding with unsupervised procedures. It is not clear if the suggested number of procedures will result in decreased number of complications but the data suggests that fluoroscopy time might be a surrogate marker for complications.

Effective cholesterol lowering after myocardial infarction in patients with nephrotic syndrome may require a multi-pharmacological approach: a case report.

BACKGROUND: Nephrotic syndrome causes severe hypercholesterolaemia due to increased production and altered clearance of lipoproteins from the liver. It is challenging for patients with nephrotic syndrome and coronary heart disease to meet LDL-cholesterol (LDL-C) goals for secondary prevention with conventional lipid-lowering therapy. CASE SUMMARY: We present a man with nephrotic syndrome caused by focal segmental glomerular sclerosis (FSGS) and hypercholesterolaemia. He presented at the emergency room (ER) with an ST-elevation myocardial infarction at the age of 26. On follow-up, the patient had persistent hypercholesterolaemia [LDL-C 3.9 mmol/L and lipoprotein(a) 308 nmol/L] despite a combination of lipid-lowering therapy with atorvastatin 80 mg/day and ezetimibe 10 mg/day. Addition of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitory antibody evolocumab 140 mg bi-monthly did not improve cholesterol levels. However, after addition of the sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin 10 mg/day on top of other anti-proteinuric treatments, the patient's proteinuria was reduced and a dramatic drop in LDL-C level by 3.2-0.6 mmol/L (-81%) was observed when evolocumab was re-introduced. DISCUSSION: We show that target LDL-C levels were obtained in this patient with therapy-resistant FSGS and hypercholesterolaemia following multi-pharmacological treatment with SGLT2 and PCSK9 inhibitors on top of conventional lipid-lowering therapy. The SGLT2-inhibitor reduced proteinuria and, speculatively, also reduced urinary loss of PCSK9-antibody. Therefore, in patients with nephrotic syndrome and cardiovascular disease novel therapeutic options to manage proteinuria could be considered to improve the efficacy of the lipid-lowering therapy, especially when the protein-based PCSK9 inhibitors are used.

Assessment of thrombus in acute middle cerebral artery occlusion using thin-slice nonenhanced Computed Tomography reconstructions.

BACKGROUND AND PURPOSE: We sought to evaluate how accurately length and volume of thrombotic clots occluding cerebral arteries of patients with acute ischemic stroke can be assessed from nonenhanced CT (NECT) scans reconstructed with different slice widths. METHODS: NECT image data of 58 patients with acute ischemic stroke with vascular occlusion proven by CT angiography were reconstructed with slice widths of 1.25 mm, 2.5 mm, 3.75 mm, and 5 mm. Thrombus lengths and volumes were quantified based on these NECT images by detecting and segmenting intra-arterial hyperdensities. The results were compared with reference values of thrombus length and volume obtained from CT angiography images using Bland-Altman analysis and predefined levels or tolerance to find NECT slice thicknesses that allow for sufficiently accurate thrombus quantification. RESULTS: Thrombus length can be measured with high accuracy using the hyperdense middle cerebral artery sign detected in NECT images with slice thicknesses of 1.25 mm and 2.5 mm. We found mean deviations from the reference values and limits of agreement of -0.1 mm+/-0.6 mm with slice widths of 1.25 mm and 0.1 mm+/-0.7 mm for slice widths of 2.5 mm. Thrombus length measurements in NECT images with higher slice width and all evaluated thrombus volume measurements exhibited severe dependence on the level and did not match the accuracy criteria. CONCLUSIONS: The length of the hyperdense middle cerebral artery sign as detected on thin-slice NECT reconstructions in patients with acute ischemic stroke can be used to quantify thrombotic burden accurately. Thus, it might qualify as a new diagnostic parameter in acute stroke management that indicates and quantifies the extent of vascular obliteration.

The hyperdense anterior cerebral artery sign (HACAS) as a computed tomography marker for acute ischemia in the anterior cerebral artery territory.

BACKGROUND: Hyperdense arteries in cranial CT of acute stroke patients have been described as a sign for acute ischemia in various brain-feeding arteries. However, only 1 case of a hyperdense anterior cerebral artery sign (HACAS) has been published to date. In this study, the frequency and association of HACAS with clinical symptoms and outcome are described. METHODS: Our radiological databases were searched for patients with infarcts in the territory of the anterior cerebral artery (ACA). Only patients who received an initial CT and a follow-up CT or MRI were included. The presence of a HACAS was rated by 2 independent observers using the Cohen kappa-statistics. Further data recorded were early ischemic signs, final size of infarct, symptoms, initial NIHSS (National Institute of Health Stroke Scale) score, latency between symptom onset and initial CT, etiology, modified Rankin Scale (mRS) score at discharge and secondary hemorrhage. RESULTS: A HACAS could be visualized in 11/24 patients (46%). Interobserver agreement was substantial with Cohen's kappa = 0.66. Patients with a HACAS had a significantly higher NIHSS score (9.45 +/- 8.41; median: 8) than those without (3.69 +/- 2.09; median: 4). A HACAS was visible more frequently when the CT was performed early (<2.5 h after symptom onset). There was no correlation with single symptoms, size of infarct, etiology, mRS or the tendency to hemorrhage. CONCLUSIONS: HACAS is associated with a higher NIHSS score. It is an early sign of ischemia which can be reversible over time. It can be helpful in the detection of ischemia in the territory of the ACA.

Complication rate in unprotected carotid artery stenting with closed-cell stents.

INTRODUCTION: The discussion on the use of protection devices (PDs) in carotid artery stenting (CAS) is gaining an increasing role in lowering the periprocedural complication rates. While many reviews and reports with retrospective data analysis do promote the use of PDs the most recent multi-centre trials are showing advantages for unprotected CAS combined with closed-cell stent designs. METHODS: We retrospectively analysed 358 unprotected CAS procedures performed from January 2003 to June 2009 in our clinic. Male/female ratio was 2.68/1. The average age was 69.3 years. Seventy-three percent (261/358) showed initial neurological symptoms. All patients were treated on a standardised interventional protocol. A closed and small-sized cell designed stent was implanted in most cases (85.2%). One hundred seventy-one (47.8%) were controlled by Doppler ultrasonography usually at first in a 3-month and later in 6-month intervals. RESULTS: The peri-interventional and 30-day mortality/stroke rate was 4.19% (15/358). These events included three deaths, five hyperperfusion syndromes (comprising one death by a secondary fatal intracranial haemorrhage), one subarachnoid haemorrhage and seven ischaemic strokes. Only 20% (3/15) of all complications occurred directly peri-interventional. The overall peri-interventional complication rate was 0.8% (3/358). Most complications occurred in initial symptomatic patients (5.36%). The in-stent restenosis rate for more than 70% was 7% (12/171) detected at an average of 9.8 month. CONCLUSION: Our clinical outcome demonstrates that unprotected CAS with small cell designed stents results in a very low procedural complication rate, which makes the use of a protection device dispensable.

Post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest patients randomized to immediate coronary angiography versus standard of care.

BACKGROUND: Immediate coronary angiography with subsequent percutaneous coronary intervention (PCI) has the potential to reduce post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest (OHCA) patients. The aim of this study was to see if immediate coronary angiography, with potential PCI, in patients without ST-elevation on the ECG, influenced post-resuscitation myocardial function and cardiac biomarkers. METHODS: A secondary analysis of the Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest (DISCO) trial (ClinicalTrials.gov ID: NCT02309151). Patients with bystander-witnessed OHCA, without ST-elevations on the ECG were randomly assigned to immediate coronary angiography within two hours of cardiac arrest (n = 38) versus standard-of-care with deferred angiography (n = 40). Outcome measures included left ventricle ejection fraction (LVEF) at 24 h, peak Troponin T levels, lactate clearance and NT-proBNP at 72 h. RESULTS: In the immediate-angiography group, median LVEF at 24 h was 47% (Q1-Q3; 30-55) vs. 46% (Q1-Q3; 35-55) in the standard-of-care group. Peak Troponin-T levels during the first 24 h were 362 ng/L (Q1-Q3; 174-2020) in the immediate angiography group and 377 ng/L (Q1-Q3; 205-1078) in the standard-of-care group. NT-proBNP levels at 72 h were 931 ng/L (Q1-Q3; 396-2845) in the immediate-angiography group and 1913 ng/L (Q1-Q3; 489-3140) in the standard-of-care group. CONCLUSION: In this analysis of OHCA patients without ST-elevation on the ECG randomized to immediate coronary angiography or standard-of-care, no differences in post-resuscitation myocardial dysfunction parameters between the two groups were found. This finding was consistent also in patients randomized to immediate coronary angiography where PCI was performed compared to those where PCI was not performed.

Percutaneous Coronary Intervention for Vulnerable Coronary Atherosclerotic Plaque.

BACKGROUND: Acute coronary syndromes most commonly arise from thrombosis of lipid-rich coronary atheromas that have large plaque burden despite angiographically appearing mild. OBJECTIVES: This study sought to examine the outcomes of percutaneous coronary intervention (PCI) of non-flow-limiting vulnerable plaques. METHODS: Three-vessel imaging was performed with a combination intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) catheter after successful PCI of all flow-limiting coronary lesions in 898 patients presenting with myocardial infarction (MI). Patients with an angiographically nonobstructive stenosis not intended for PCI but with IVUS plaque burden of ≥65% were randomized to treatment of the lesion with a bioresorbable vascular scaffold (BVS) plus guideline-directed medical therapy (GDMT) versus GDMT alone. The primary powered effectiveness endpoint was the IVUS-derived minimum lumen area (MLA) at protocol-driven 25-month follow-up. The primary (nonpowered) safety endpoint was randomized target lesion failure (cardiac death, target vessel-related MI, or clinically driven target lesion revascularization) at 24 months. The secondary (nonpowered) clinical effectiveness endpoint was randomized lesion-related major adverse cardiac events (cardiac death, MI, unstable angina, or progressive angina) at latest follow-up. RESULTS: A total of 182 patients were randomized (93 BVS, 89 GDMT alone) at 15 centers. The median angiographic diameter stenosis of the randomized lesions was 41.6%; by near-infrared spectroscopy-IVUS, the median plaque burden was 73.7%, the median MLA was 2.9 mm2, and the median maximum lipid plaque content was 33.4%. Angiographic follow-up at 25 months was completed in 167 patients (91.8%), and the median clinical follow-up was 4.1 years. The follow-up MLA in BVS-treated lesions was 6.9 ± 2.6 mm2 compared with 3.0 ± 1.0 mm2 in GDMT alone-treated lesions (least square means difference: 3.9 mm2; 95% confidence interval: 3.3 to 4.5; p < 0.0001). Target lesion failure at 24 months occurred in similar rates of BVS-treated and GDMT alone-treated patients (4.3% vs. 4.5%; p = 0.96). Randomized lesion-related major adverse cardiac events occurred in 4.3% of BVS-treated patients versus 10.7% of GDMT alone-treated patients (odds ratio: 0.38; 95% confidence interval: 0.11 to 1.28; p = 0.12). CONCLUSIONS: PCI of angiographically mild lesions with large plaque burden was safe, substantially enlarged the follow-up MLA, and was associated with favorable long-term clinical outcomes, warranting the performance of an adequately powered randomized trial. (PROSPECT ABSORB [Providing Regional Observations to Study Predictors of Events in the Coronary Tree II Combined with a Randomized, Controlled, Intervention Trial]; NCT02171065).

The correlation between quantitative T2' and regional cerebral blood flow after acute brain ischemia in early reperfusion as demonstrated in a middle cerebral artery occlusion/reperfusion model of the rat.

INTRODUCTION: qT2'-maps are calculated by subtracting T2- from T2*-relaxation rates. They are oxygen-sensitive and depict oxygen extraction. In several studies they have been used to describe the penumbra in patients with acute ischemic stroke. No correlation between rCBF and qT2' has been performed to date. In this study a correlation between rCBF and qT2' was performed in a temporary middle cerebral occlusion-reperfusion model of the rat. MATERIALS AND METHODS: Temporary middle cerebral artery occlusion was performed on seven Sprague-Dawley rats. After 60 min of occlusion and 90 min of reperfusion MRI was performed including DWI, dynamic susceptibility contrast-weighted MR imaging (DSC-MRI) and qT2'. ROIs were placed inside the DWI lesion and transferred to rCBF- and qT2'-maps. rCBF and qT2' were compared to corresponding tissue in the contralateral hemisphere. RESULTS: qT2' was lower in the infarcted areas when compared to the contralateral hemisphere. Correlation between rCBF and qT2' was r = 0.41, p = 0.14 (Pearson's correlation coefficient), when corrected for outliers it was r = 0.58, p = 0.04. CONCLUSION: Our results show that there is a moderate correlation between rCBF and qT2'. qT2'-maps could be used to explore cerebral perfusion without the application of contrast agent or radiation.

The MOVEMENT Trial.

Background Morphine administration is a strong predictor of delayed onset of action of orally administered ticagrelor in patients with ST-segment-elevation myocardial infarction, likely because of impaired gastrointestinal motility. The aim of this study was to evaluate whether the peripheral opioid antagonist methylnaltrexone could improve pharmacodynamics and pharmacokinetics of orally administered ticagrelor in patients with ST-segment-elevation myocardial infarction receiving morphine. Methods and Results The MOVEMENT (Methylnaltrexone to Improve Platelet Inhibition of Ticagrelor in Morphine-Treated Patients With ST-Segment Elevation Myocardial Infarction) trial was a multicenter, prospective, randomized, controlled trial in patients with ST-segment-elevation myocardial infarction treated with morphine and ticagrelor. Upon arrival to the catheterization laboratory, patients were randomized to a blinded intravenous injection of either methylnaltrexone (8 or 12 mg according to weight) or 0.9% sodium chloride. The proportion of patients with high on-treatment platelet reactivity and plasma concentrations of ticagrelor and AR -C124910XX were assessed at baseline (arrival in the catheterization laboratory) and 1 and 2 hours later. A total of 82 patients received either methylnaltrexone (n=43) or placebo (n=39). Median (interquartile range) time from ticagrelor administration to randomization was 41 (31-50) versus 45.5 (37-60) minutes ( P=0.16). Intravenous methylnaltrexone administration did not significantly affect prevalence of high on-treatment platelet reactivity at 2 hours after inclusion, the primary end point, when compared with placebo (54% versus 51%, P=0.84). Plasma concentrations of ticagrelor and its active metabolite, the prespecified secondary end points, did not differ significantly between the groups over time. There was no significant difference in patient self-estimated pain between the groups. Conclusions Methylnaltrexone did not significantly improve platelet reactivity or plasma concentrations of orally administered ticagrelor in patients with ST-segment-elevation myocardial infarction receiving morphine. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02942550.

Direct or subacute coronary angiography in out-of-hospital cardiac arrest (DISCO)-An initial pilot-study of a randomized clinical trial.

BACKGROUND: The clinical importance of immediate coronary angiography, with potentially subsequent percutaneous coronary intervention (PCI), in out-of-hospital cardiac arrest (OHCA) patients without ST-elevation on the ECG is unclear. In this study, we assessed feasibility and safety aspects of performing immediate coronary angiography in a pre-specified pilot phase of the 'DIrect or Subacute Coronary angiography in Out-of-hospital cardiac arrest' (DISCO) randomized controlled trial (ClinicalTrials.gov ID: NCT02309151). METHODS: Resuscitated bystander witnessed OHCA patients >18 years without ST-elevation on the ECG were randomized to immediate coronary angiography versus standard of care. Event times, procedure related adverse events and safety variables within 7 days were recorded. RESULTS: In total, 79 patients were randomized to immediate angiography (n = 39) or standard of care (n = 40). No major differences in baseline characteristics between the groups were found. There were no differences in the proportion of bleedings and renal failure. Three patients randomized to immediate angiography and six patients randomized to standard care died within 24 h. The median time from EMS arrival to coronary angiography was 135 min in the immediate angiography group. In patients randomized to immediate angiography a culprit lesion was found in 14/38 (36.8%) and PCI was performed in all these patients. In 6/40 (15%) patients randomized to standard of care, coronary angiography was performed before the stipulated 3 days. CONCLUSION: In this out-of-hospital cardiac arrest population without ST-elevation, randomization to a strategy to perform immediate coronary angiography was feasible although the time window of 120 min from EMS arrival at the scene of the arrest to start of coronary angiography was not achieved. No significant safety issues were reported.

Hemodynamic assessment of carotid stenosis by functional magnetic resonance imaging.

BACKGROUND: Functional magnetic resonance imaging (fMRI) is a method usually used to identify cortical representations of cerebral functions. Some studies and case reports suggest that stenoses of the brain-supplying arteries influence the BOLD (blood-oxygenation-level-dependent) signal. The objective of this study was to find out whether the BOLD signal differs in the ipsilateral hemisphere of patients with hemodynamically relevant and those with irrelevant stenosis of the internal carotid artery (ICA) and if a successful treatment might have an influence on the BOLD signal. METHODS: We included 10 patients with hemodynamically relevant stenosis in group 1; another 10 patients with hemodynamically irrelevant stenosis of the ICA were included in group 2. Patients underwent recanalization by either stenting or operation of the ICA. fMRI with a hand-tapping task was performed before and after treatment. Data were analyzed with 'Statistical Parametric Mapping' 2 for both hemispheres. An asymmetry index (AI, range 0-2) was calculated for the hand motor areas. RESULTS: All data are given as means +/- SD. The mean preinterventional AI in group 1 was 1.08 +/- 0.87 and 0.30 +/- 0.54 in group 2 (p = 0.029). The mean postinterventional AI was 0.32 +/- 0.29 in group 1 and 0.25 +/- 0.21 in group 2 (p = 0.599). CONCLUSION: fMRI is not only capable of delivering spatial information, but also of distinguishing a hemodynamically relevant from an irrelevant stenosis of the ICA.

Stent thrombosis rates the first year and beyond with new- and old-generation drug-eluting stents compared to bare metal stents.

OBJECTIVES: Old-generation drug-eluting coronary stents (o-DES) have despite being safe and effective been associated with an increased propensity of late stent thrombosis (ST). We evaluated ST rates in o-DES, new-generation DES (n-DES) and bare metal stents (BMS) the first year (< 1 year) and beyond 1 year (> 1 year). METHODS: We evaluated all implantations with BMS, o-DES (Cordis Cypher, Boston Scientific Taxus Liberté and Medtronic Endeavor) and n-DES in the Swedish coronary angiography and angioplasty registry (SCAAR) between 1 January 2007 and 8 January 2014 (n = 207 291). All cases of ST (n = 2 268) until 31 December 2014 were analyzed. RESULTS: The overall risk of ST was lower in both n-DES and o-DES compared with BMS up to 1 year (n-DES versus BMS: adjusted risk ratio (RR) 0.48 (0.41-0.58) and o-DES versus BMS: 0.56 (0.46-0.67), both p < 0.001). From 1 year after stent implantation and onward, the risk for ST was higher in o-DES compared with BMS [adjusted RR, 1.82 (1.47-2.25], p < 0.001). N-DES were associated with similar low ST rates as BMS from 1 year and onward [adjusted RR 1.21 (0.94-1.56), p = 0.135]. CONCLUSION: New-generation DES were associated with lower ST rates in comparison to BMS during the first-year post-stenting. After 1 year, n-DES and BMS were associated with similar ST rates. TRIAL REGISTRATION: This study was a retrospective observational study and as such did not require clinical trial database registration.

Predictive Value of High-Sensitivity Troponin T for Systolic Dysfunction and Infarct Size (Six Months) After ST-Elevation Myocardial Infarction.

The association of markers of myocardial injury and dysfunction with infarct size (IS) and ejection fraction (EF) are well documented. However, limited data are available on the newer high-sensitivity troponin assays and comparison with morphologic and functional assessment with cardiac magnetic resonance imaging. We aimed to examine the associations of high-sensitivity cardiac Troponin-T (hs-cTnT), creatine kinase MB iso-enzyme (CKMB), and N-terminal pro B-type Natriuretic Peptide (NT-proBNP) to IS and EF at 6 months. Blood samples from 119 ST-segment elevation myocardial infarction patients from the Rapid Endovascular Catheter Core Cooling Combined With Cold Saline solution as an Adjunct to Percutaneous Coronary Intervention for the Treatment of Acute Myocardial Infarction trial were collected at baseline, 6, 24, and 48 hours after admission. Cardiac magnetic resonance was performed at 4 ± 2 days and 6 months. The association of biomarker levels to IS and EF was tested with Pearson's correlation coefficients and linear regression models with bootstrap resampling. The correlation coefficient of biomarker to IS was (CKMB: r = 0.71); (NT-proBNP: r = 0.55); (hs-cTnT: r = 0.80); and for EF (CKMB: r = 0.57); (NT-proBNP: r = 0.48); and (peak hs-cTnT: r = 0.68). IS and EF at 4 ± 2 days had the strongest correlations with IS and EF at 6 months respectively (IS: r = 0.84) and (EF: r = 0.74). Receiver operating characteristic of peak hs-cTnT for predicting EF ≤40% at 6 months was 0.87 compared with 0.75 for early IS. Early EF was a negative predictor of late EF <40%, 1-area under curve = 0.93. In conclusion, high-sensitivity Troponin T is a rapid, cheap, generally available tool for accurate prediction of systolic dysfunction in patients 6 months after first-time ST-segment elevation myocardial infarction.

Proteomics in Hypothermia as Adjunctive Therapy in Patients with ST-Segment Elevation Myocardial Infarction: A CHILL-MI Substudy.

Cardiovascular and inflammatory biomarkers in therapeutic hypothermia have been studied in cardiac arrest, but data on patients with ST-segment elevation myocardial infarction (STEMI) treated with therapeutic hypothermia are currently unavailable. A multiplex proximity extension assay allowed us to measure 157 cardiovascular disease (CVD) and inflammatory disease-related biomarkers in patients from the international, multicenter, and randomized trial; CHILL-myocardial infarction (MI) and to explore the associations of cardiovascular and inflammatory biomarkers. Blood samples were obtained from 119 patients with STEMI, randomized to hypothermia as adjunctive therapy to percutaneous coronary intervention (PCI) or standard care with PCI only. Blood samples were obtained at baseline (0 hour), 6, 24, and 96 hours post PCI, and stored at -80°C until they were analyzed by PROSEEK Multiplex CVD and PROSEEK Multiplex INF (Olink Bioscience, Uppsala, Sweden). Peak values from 6, 24, and 96 hours postrandomization were compared between treatment groups. One hundred fifty-seven cardiovascular and inflammatory biomarkers were evaluated. Peak values of four biomarkers (BDNF, DNER, CCL20, MMP3) were reduced in the hypothermia group as compared with the control group. In addition, seven markers were slightly elevated in the hypothermia group (OPG, FGF21, FS, IL12B, PRL, TIM, IL6). In a prespecified subgroup analysis of anterior infarctions, two additional markers were reduced (PTX3 and SELE). In this explorative proteomic study from the randomized trial CHILL-MI, four biomarkers were identified as having reduced peak plasma values in patients with STEMI treated with therapeutic hypothermia as adjunctive therapy to PCI as compared with patients treated with standard care of PCI. In addition, seven biomarkers were elevated in the group treated with hypothermia therapy. The effect of hypothermia on biomarker peak values was modest, possibly due to a low reduction in mean body temperature. Whether a faster and deeper cooling results in more pronounced effects is yet to be established.

Virtual reality training in coronary angiography and its transfer effect to real-life catheterisation lab.

AIMS: The aim of this study was to explore if proficiency-based training in a coronary angiography (CA) simulator can transfer acquired skills from virtual reality (VR) to the real world in order to improve early performance. METHODS AND RESULTS: Sixteen senior cardiology residents were randomised to proficiency-based VR training or control. Two consecutive CAs were performed on patients. Skills metrics and errors were compared between the groups. Thirty-two CAs were performed under the supervision of an experienced interventionalist. VR-trained residents practised for a mean of 10 hours in a CA simulator. In real life, the VR-trained group had shorter fluoroscopy and total procedure times than the controls (median 558 vs. 842 seconds, p=0.003 and 1,356 vs. 1,623 seconds, p=0.032, respectively). The controls had a higher error score (median 27 vs. 15, p=0.002) and a lower performance score (median 47 vs. 68, p=0.006) than the VR-trained residents. CONCLUSIONS: Simulator-based training in CA improved skills and decreased errors compared to mentor-based training only. CA training in VR resulted in a superior performance, measured by fluoroscopy and total procedure times, and superior error and performance scores, thereby confirming transfer validity. Our recommendation is to incorporate VR training in the curriculum for the general cardiologist to improve safe learning in CA.