Principales recomendaciones de reanimación cardiopulmonar y atención cardiovascular de emergencia para el año 2020 / Best practice recommendations for cardiopulmonary resuscitation and emergency cardiovascular care for 2020

Las altas tasas de letalidad y mortalidad a causa del paro cardiorespiratorio por fibrilación ventricular son considerados un problema de salud pública, cobrando gran relevancia la posibilidad de que sean revertidos rápidamente con la presencia de profesionales capacitados o por personal "lego" actualizados en reanimación cardiopulmonar. El objetivo del presente artículo de revisión fue analizar las nuevas recomendaciones de la American Heart Association para reanimación cardiopulmonar y atención cardiovascular de emergencia para el año 2020.

High rates of lethality and mortality due to ventricular fibrillation cardiorespiratory arrest are considered a public health problem, Thus, the possibility of reversed quickly by trained professionals or updated "lego" staff in cardiopulmonary resuscitation is taking great relevance. The objective of this review article was to discuss the New Recommendations of the American Heart Association for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care for 2020.

The Effect of a Quality Improvement Intervention on Sleep and Delirium in Critically Ill Patients in a Surgical ICU.

BACKGROUND: Delirium is a deleterious condition affecting up to 60% of patients in the surgical ICU (SICU). Few SICU-focused delirium interventions have been implemented, including those addressing sleep-wake disruption, a modifiable delirium risk factor common in critically ill patients. RESEARCH QUESTION: What is the effect on delirium and sleep quality of a multicomponent nonpharmacologic intervention aimed at improving sleep-wake disruption in patients in the SICU setting? STUDY DESIGN AND METHODS: Using a staggered pre-post design, we implemented a quality improvement intervention in two SICUs (general surgery or trauma and cardiovascular) in an academic medical center. After a preintervention (baseline) period, a multicomponent unit-wide nighttime (ie, efforts to minimize unnecessary sound and light, provision of earplugs and eye masks) and daytime (ie, raising blinds, promotion of physical activity) intervention bundle was implemented. A daily checklist was used to prompt staff to complete intervention bundle elements. Delirium was evaluated twice daily using the Confusion Assessment Method for the Intensive Care Unit. Patient sleep quality ratings were evaluated daily using the Richards-Campbell Sleep Questionnaire (RCSQ). RESULTS: Six hundred forty-six SICU admissions (332 baseline, 314 intervention) were analyzed. Median age was 61 years (interquartile range, 49-70 years); 35% of the cohort were women and 83% were White. During the intervention period, patients experienced fewer days of delirium (proportion ± SD of ICU days, 15 ± 27%) as compared with the preintervention period (20 ± 31%; P = .022), with an adjusted pre-post decrease of 4.9% (95% CI, 0.5%-9.2%; P = .03). Overall RCSQ-perceived sleep quality ratings did not change, but the RCSQ noise subscore increased (9.5% [95% CI, 1.1%-17.5%; P = .02). INTERPRETATION: Our multicomponent intervention was associated with a significant reduction in the proportion of days patients experienced delirium, reinforcing the feasibility and effectiveness of a nonpharmacologic sleep-wake bundle to reduce delirium in critically ill patients in the SICU. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03313115; URL: www.clinicaltrials.gov.

French annual national observational study of 2015 outpatient and inpatient healthcare utilization by approximately half a million patients with previous heart failure diagnosis.

BACKGROUND: Heart failure management guidelines have been published, but the degree of adherence to these guidelines remains unknown. AIMS: To study in 2015 healthcare utilization and causes of death for people previously identified with heart failure. METHODS: The national health data system was used to identify adult general scheme (86% of the French population) hospitalized for heart failure between 2011 and 2014 or with only a long-term chronic disease allowance for heart failure. The frequency and median (interquartile range) of at least one healthcare use among those still alive in 2015 was calculated. RESULTS: A total of 499,296 adults (1.4% of the population) were included, and 429,853 were alive in 2015; median age 79 (68-86) years. At least one utilization was observed for a general practitioner in 95% of patients (median 8 [interquartile range 5-13] consultations), a cardiologist in 42% (2 [1-3]), a nurse in 78% (16 [4-100]), a loop diuretic in 64% (11 [8-12] dispensations), an aldosterone antagonist in 21% (8 [5-11]), a thiazide in 15% (7 [4-11]), a renin-angiotensin system inhibitor in 68% (11 [8-13]), a beta-blocker in 65% (11 [7-13]), a beta-blocker plus a renin-angiotensin system inhibitor in 57%, and a beta-blocker plus a renin-angiotensin system inhibitor plus an aldosterone antagonist in 37%. Hospitalization for heart failure was present for 8% (1 [1,2]). Higher levels of healthcare utilization were observed in the presence of hospitalization for heart failure before 2015. Among the 13.9% of people who died in 2015, heart failure accounted for 8% of causes, cardiovascular disease accounted for 39%. CONCLUSIONS: General practitioners and nurses are the main actors in the regular follow-up of patients with heart failure, whereas cardiologist consultations and dispensing of first-line treatments are insufficient with respect to guidelines.

Direct Admission of Patients With ST-Segment-Elevation Myocardial Infarction to the Catheterization Laboratory Shortens Pain-to-Balloon and Door-to-Balloon Time Intervals but Only the Pain-to-Balloon Interval Impacts Short- and Long-Term Mortality.

Background Shortening the pain-to-balloon (P2B) and door-to-balloon (D2B) intervals in patients with ST-segment-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI) is essential in order to limit myocardial damage. We investigated whether direct admission of PPCI-treated patients with STEMI to the catheterization laboratory, bypassing the emergency department, expedites reperfusion and improves prognosis. Methods and Results Consecutive PPCI-treated patients with STEMI included in the ACSIS (Acute Coronary Syndrome in Israel Survey), a prospective nationwide multicenter registry, were divided into patients admitted directly or via the emergency department. The impact of the P2B and D2B intervals on mortality was compared between groups by logistic regression and propensity score matching. Of the 4839 PPCI-treated patients with STEMI, 1174 were admitted directly and 3665 via the emergency department. Respective median P2B and D2B were shorter among the directly admitted patients with STEMI (160 and 35 minutes) compared with those admitted via the emergency department (210 and 75 minutes, P<0.001). Decreased mortality was observed with direct admission at 1 and 2 years and at the end of follow-up (median 6.4 years, P<0.001). Survival advantage persisted after adjustment by logistic regression and propensity matching. P2B, but not D2B, impacted survival (P<0.001). Conclusions Direct admission of PPCI-treated patients with STEMI decreased mortality by shortening P2B and D2B intervals considerably. However, P2B, but not D2B, impacted mortality. It seems that the D2B interval has reached its limit of effect. Thus, all efforts should be extended to shorten P2B by educating the public to activate early the emergency medical services to bypass the emergency department and allow timely PPCI for the best outcome.

Part 7: Systems of Care: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Survival after cardiac arrest requires an integrated system of people, training, equipment, and organizations working together to achieve a common goal. Part 7 of the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care focuses on systems of care, with an emphasis on elements that are relevant to a broad range of resuscitation situations. Previous systems of care guidelines have identified a Chain of Survival, beginning with prevention and early identification of cardiac arrest and proceeding through resuscitation to post-cardiac arrest care. This concept is reinforced by the addition of recovery as an important stage in cardiac arrest survival. Debriefing and other quality improvement strategies were previously mentioned and are now emphasized. Specific to out-of-hospital cardiac arrest, this Part contains recommendations about community initiatives to promote cardiac arrest recognition, cardiopulmonary resuscitation, public access defibrillation, mobile phone technologies to summon first responders, and an enhanced role for emergency telecommunicators. Germane to in-hospital cardiac arrest are recommendations about the recognition and stabilization of hospital patients at risk for developing cardiac arrest. This Part also includes recommendations about clinical debriefing, transport to specialized cardiac arrest centers, organ donation, and performance measurement across the continuum of resuscitation situations.

Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

The 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.

Nuclear Cardiology practice in COVID-19 era.

The Coronavirus Disease 2019 (COVID-19) pandemic is the biggest shock in decades to the well developed healthcare system and resources worldwide. Although there was a wide variation in the level of preparedness, the transition was tough even for the most renowned healthcare systems. Increasing the capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure. However, while the system is preoccupied with a pandemic infection, patients suffering from other illnesses are in high risk to get infected, also being compromised by the imperative shift in medical resources and significant restrictions on routine medical care. For example patients with cardiovascular disease and others referred for nuclear cardiology procedures are frequently greater than 60 years of age and have other comorbidities (e.g. hypertension, diabetes, chronic lung disease, and chronic renal disease) that place them at a high-risk for adverse outcomes with COVID-19, providing unique challenges for their management in healthcare facilities, as well as for the care of health care personnel. Numerous medical specialty societies and governmental agencies issued guidelines aiming at the specification of preventive measures and amendments in everyday clinical practice during the escalation and peak of the pandemic. In accordance, the American Society of Nuclear Cardiology (ASNC) and the Society of Nuclear Medicine and Molecular Imaging (SNMMI), issued a common statement in late March 2020, which was provided as an initial response to this pandemic, offering specific recommendations for adapting nuclear cardiology practices at each step in a patient's journey through the lab-for inpatients, outpatients and emergency department patients. One of the main recommendations was cancelling or delaying of all non-urgent nuclear cardiology studies. As COVID-19 follows a different time course in different geographic regions and lockdowns begin to lift in many countries, the issue of re-establishment of non-emergent care, in nuclear cardiology laboratories amongst others, has to be addressed in a watchful and balanced way, keeping in mind that the COVID-19 crisis is far from over. Furthermore measuring what is happening in the current crisis is essential to ensuring preparedness for a possible next wave of the pandemic. Recently the ASNC, SNMMI, the International Atomic Energy Agency (IAEA) and the Infectious Disease Society of America (IDSA), issued an information statement which describes a careful approach to reestablishment of non-emergent care in nuclear cardiology laboratories reflecting diverse settings from the United States and worldwide. In the same spirit it is also the reintroduction guidance issued by North American Cardiovascular Societies. In this paper we provide a synopsis of the basic steps of adapting nuclear cardiology practice in the era of COVID-19 in order to balance between the risk of viral transmission while also providing crucial cardiovascular assessments for our patients.

Cardiac Pacing Training in Africa: Endorsed by the Africa Heart Rhythm Association (AFHRA): JACC International.

The field of pacing in Africa has evolved in an uncoordinated way across the continent with significant variation in local expertise, cost, and utilization. There are many countries where pacemaker services do not meet one-hundredth of the national demand. Regional, national, and institutional standards for pacemaker qualification and credentials are lacking. This paper reviews the current needs for bradycardia pacing and evaluates what standards should be set to develop pacemaker services in a resource-constrained continent, including the challenges and opportunities of capacity building and training as well as standards for training programs (training prerequisites, case volumes, program content, and evaluation).

Position paper concerning the competence, performance and environment required for the practice of ablation in children and in congenital heart disease.

The population of patients with congenital heart disease (CHD) is continuously increasing, and a significant proportion of these patients will experience arrhythmias because of the underlying congenital heart defect itself or as a consequence of interventional or surgical treatment. Arrhythmias are a leading cause of mortality, morbidity and impaired quality of life in adults with CHD. Arrhythmias may also occur in children with or without CHD. In light of the unique issues, challenges and considerations involved in managing arrhythmias in this growing, ageing and heterogeneous patient population and in children, it appears both timely and essential to critically appraise and synthesize optimal treatment strategies. The introduction of catheter ablation techniques has greatly improved the treatment of cardiac arrhythmias. However, catheter ablation in adults or children with CHD and in children without CHD is more technically demanding, potentially causing various complications, and thus requires a high level of expertise to maximize success rates and minimize complication rates. As French recommendations regarding required technical competence and equipment are lacking in this situation, the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the Affiliate Group of Paediatric and Adult Congenital Cardiology have decided to produce a common position paper compiled from expert opinions from cardiac electrophysiology and paediatric cardiology. The paper details the features of an interventional cardiac electrophysiology centre that are required for ablation procedures in adults with CHD and in children, the importance of being able to diagnose, monitor and manage complications associated with ablations in these patients and the supplemental hospital-based resources required, such as anaesthesia, surgical back-up, intensive care, haemodynamic assistance and imaging. Lastly, the need for quality evaluations and French registries of ablations in these populations is discussed. The purpose of this consensus statement is therefore to define optimal conditions for the delivery of invasive care regarding ablation of arrhythmias in adults with CHD and in children, and to provide expert and - when possible - evidence-based recommendations on best practice for catheter-based ablation procedures in these specific populations.

Using parent-reported experience measures as quality improvement tools in paediatric cardiothoracic services: making it happen.

OBJECTIVE: Patient experience is a core component of quality and service improvement. In the case of child health, it is parents who often report on their experiences of the child's healthcare. However, these parent experiences are rarely used to drive change. Our aim was to develop and implement the systematic collection of parent experience data across a range of cardiothoracic services, using quality improvement methodology to implement change. DESIGN: Plan-Do-Study-Act methodology was used to develop parent-reported experience measures. Setting: Specialist children's hospital. PARTICIPANTS: Parents of children under the care of one of a number of cardiothoracic services at the hospital. INTERVENTION(S): Completion of questionnaires about hospital experience comprising quantitative and qualitative questions. MAIN OUTCOME MEASURE(S): Response rates and completion of a specific-measurable-achievable-realistic-timely (SMART) action plan by the individual clinical teams. RESULTS: During the first cycle 17 surveys were developed for different clinical services and questionnaires sent/given to 1876 parents. The overall response rate was 30% (15-100%). Clinical teams developed SMART plans following eight (47%) surveys; three teams have reviewed and reported back on their progress against their plan and started on the second cycle of questionnaires. Challenges included lack of resources (time, finances and electronic data collection tools) and problems with actioning SMART plans. However, teams engaged positively, recognizing the importance of parent experience and actively seeking solutions to problems. CONCLUSIONS: Parent-reported experience measures are practical and acceptable quality improvement tools in healthcare but challenges need to be addressed, primarily related to resources, training and sustainability.

Management of patients with acute ST-segment elevation myocardial infarction in Russian hospitals adheres to international guidelines.

Objective: Russia has one of the highest cardiovascular mortality rates. Modernisation of the Russian health system has been accompanied by a substantial increase in uptake of percutaneous coronary intervention (PCI), which substantially reduces the risk of mortality in patients with acute ST-elevation myocardial infarction (STEMI). This paper aims to describe contemporary Hospital treatment of acute STEMI among patients in a range of hospitals in the Russian Federation. Methods: This study used data from a prospective observational cohort of 1128 suspected patients with myocardial infarction recruited in both PCI and non-PCI hospitals across 13 regions and multiple levels of the health system in Russia. The primary objective was to examine the use of reperfusion strategies in patients with STEMI. Results: Among patients reaching PCI centres within 12 hours of symptom onset, the vast majority received angiography and PCI, regardless of age, sex and comorbidity, in line with current European Society of Cardiology guidelines. Conclusion: Patients reaching Russian hospitals are very likely to receive appropriate treatment, although performance varies. The best hospitals can serve as beacons of good practice as PCI facilities continue to expand across Russia where geography allows.

The Asia-Pacific Society of Cardiology (APSC) Expert Committee Consensus Recommendations for Assessment of Suspected Acute Coronary Syndrome Using High-Sensitivity Cardiac Troponin T in the Emergency Department.

The Asia-Pacific Society of Cardiology (APSC) high-sensitivity troponin T (hs-TnT) consensus recommendations and rapid algorithm were developed to provide guidance for healthcare professionals in the Asia-Pacific region on assessing patients with suspected acute coronary syndrome (ACS) using a hs-TnT assay. Experts from Asia-Pacific convened in 2 meetings to develop evidence-based consensus recommendations and an algorithm for appropriate use of the hs-TnT assay. The Expert Committee defined a cardiac troponin assay as a high-sensitivity assay if the total imprecision is ≤10% at the 99th percentile of the upper reference limit and measurable concentrations below the 99th percentile are attainable with an assay at a concentration value above the assay's limit of detection for at least 50% of healthy individuals. Recommendations for single-measurement rule-out/rule-in cutoff values, as well as for serial measurements, were also developed. The Expert Committee also adopted similar hs-TnT cutoff values for men and women, recommended serial hs-TnT measurements for special populations, and provided guidance on the use of point-of-care troponin T devices in individuals suspected of ACS. These recommendations should be used in conjunction with all available clinical evidence when making the diagnosis of ACS.