Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction.

BACKGROUND: It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI). METHODS: Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days. RESULTS: The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups. CONCLUSIONS: Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).

Official lay basic life support courses in Germany: is delivered content up to date with the guidelines? An observational study.

BACKGROUND AND OBJECTIVES: Educating the lay public in basic life support (BLS) is a cornerstone to improving bystander cardiopulmonary resuscitation (CPR) rates. In Germany, the official rescue organisations deliver accredited courses based on International Liaison Committee on Resuscitation (ILCOR) guidelines to up to 1 million participants every year. However, it is unknown how these courses are delivered in reality. We hypothesised that delivered content might not follow the proposed curriculum, and miss recent guideline updates. METHODS: We analysed 20 official lay BLS courses of 240 min (which in Germany are always embedded into either a 1-day or a 2-day first aid course). One expert rated all courses as a participating observer, remaining incognito throughout the course. Teaching times for specific BLS elements were recorded on a standardised checklist. Quality of content was rated by 5-point Likert scales, ranging from -2 (not mentioned) to +2 (well explained). RESULTS: Median total course time was 101 min (range 48-138) for BLS courses if part of a 1-day first aid course, and 123 min (53-244) if part of a 2-day course. Median teaching time for CPR was 51 min (range 20-70) and 60 min (16-138), respectively. Teaching times for recovery position were 44 min (range 24-66) and 55 min (24-114). Quality of content was rated worst for 'agonal gasping' (-1.35) and 'minimising chest compression interruptions' (-1.70). CONCLUSIONS: Observed lay BLS courses lasted only half of the assigned curricular time. Substantial teaching time was spent on non-evidence-based interventions (eg, recovery position), and several important elements of BLS were not included. The findings call for curriculum revision, improved instructor training and systematic quality management.

Impact of advanced age on myocardial perfusion, distal embolization, and mortality patients with ST-segment elevation myocardial infarction treated by primary angioplasty and glycoprotein IIb-IIIa inhibitors.

Despite mechanical reperfusion, the outcome is still unsatisfactory in elderly patients with ST-segment elevation myocardial infarction (STEMI). The vast majority of studies have been conducted without extensive use of glycoprotein (Gp) IIb-IIIa inhibitors, which have been associated with improved perfusion and survival. Thus the aim of the current study was to evaluate the impact of age on the angiographic and clinical outcome patients with STEMI undergoing primary angioplasty with Gp IIb-IIIa inhibitors. Our population is represented by a total of 1,662 patients undergoing primary angioplasty for STEMI included in 11 randomized trials comparing early versus late administration of Gp IIb-IIIa inhibitors. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. A total of 231 (13.9 %) patients were older than 75 years. Elderly patients showed a larger prevalence of female gender, hypertension, and diabetes, more advanced Killip class at presentation and longer time to treatment, but a smaller prevalence of smoking. All patients were treated with GP IIb-IIIa inhibitors. Elderly patients showed a significantly impaired postprocedural thrombolysis in myocardial infarction (TIMI) flow (TIMI 0-2: 17.7 vs 10.3 %, P = 0.002) and myocardial perfusion (myocardial blush grade 0-1: 38.3 vs 26.5 %, P = 0.001), and higher prevalence of distal embolization (19.2 vs 9.8 %, P < 0.001), whereas no difference was observed in terms of ST-segment resolution. At follow-up, elderly patients showed a significantly higher mortality (3.2 vs 11.0 %, hazard ratio (HR) (95 % confidence interval (CI)) = 3.78 (2.31-6.16), P < 0.001), which was confirmed after adjustment for baseline confounding factors (HR (95 % CI) = 5.01 (2.63-9.55), P < 0.0001). This study showed that among patients with STEMI undergoing primary angioplasty, advanced age is an independent predictor of mortality after primary angioplasty. Higher rates of distal embolization and poor myocardial perfusion, in addition to the worse risk profile, contribute toward explaining the impact of aging on mortality.

Thrombolysis during resuscitation for out-of-hospital cardiac arrest.

BACKGROUND: Approximately 70% of persons who have an out-of-hospital cardiac arrest have underlying acute myocardial infarction or pulmonary embolism. Therefore, thrombolysis during cardiopulmonary resuscitation may improve survival. METHODS: In a double-blind, multicenter trial, we randomly assigned adult patients with witnessed out-of-hospital cardiac arrest to receive tenecteplase or placebo during cardiopulmonary resuscitation. Adjunctive heparin or aspirin was not used. The primary end point was 30-day survival; the secondary end points were hospital admission, return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and neurologic outcome. RESULTS: After blinded review of data from the first 443 patients, the data and safety monitoring board recommended discontinuation of enrollment of asystolic patients because of low survival, and the protocol was amended. Subsequently, the trial was terminated prematurely for futility after enrolling a total of 1050 patients. Tenecteplase was administered to 525 patients and placebo to 525 patients; the two treatment groups had similar clinical profiles. We did not detect any significant differences between tenecteplase and placebo in the primary end point of 30-day survival (14.7% vs. 17.0%; P=0.36; relative risk, 0.87; 95% confidence interval, 0.65 to 1.15) or in the secondary end points of hospital admission (53.5% vs. 55.0%, P=0.67), return of spontaneous circulation (55.0% vs. 54.6%, P=0.96), 24-hour survival (30.6% vs. 33.3%, P=0.39), survival to hospital discharge (15.1% vs. 17.5%, P=0.33), or neurologic outcome (P=0.69). There were more intracranial hemorrhages in the tenecteplase group. CONCLUSIONS: When tenecteplase was used without adjunctive antithrombotic therapy during advanced life support for out-of-hospital cardiac arrest, we did not detect an improvement in outcome, in comparison with placebo. (ClinicalTrials.gov number, NCT00157261.)

Gender-related differences in outcome after ST-segment elevation myocardial infarction treated by primary angioplasty and glycoprotein IIb-IIIa inhibitors: insights from the EGYPT cooperation.

Several studies have found that among patients with ST-elevation myocardial infarction (STEMI) treated by thrombolysis, female sex is associated with a worse outcome. The aim of this study was to investigate sex-related differences in clinical and angiographic findings in patients with STEMI treated with primary angioplasty and Gp IIb-IIIa inhibitors. Our population is represented by 1662 patients undergoing primary angioplasty included in the EGYPT database. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. Among 1662 patients, 379 were women (22.8%). Female sex was associated with more advanced age, higher prevalence of diabetes, hypertension, more advanced Killip class, longer ischemia time, less often smokers, with higher prevalence of preprocedural recenalization. No difference was observed in terms of postprocedural TIMI flow, myocardial perfusion and distal embolization. Similar findings were observed in terms of enzymatic infarct size and preprocedural ejection fraction. Female gender was associated with higher mortality (6.4% vs. 3.6%, HR = 1.83 [1.12-3.0], P = 0.015). However, the difference disappeared after correction for baseline confounding factors (HR = 1.01 [0.56-1.83], P = 0.98). This study shows that in patients with STEMI treated by primary angioplasty, female gender is associated with higher mortality rate in comparison with men, and this is mainly due to their higher clinical and angiographic risk profiles. In fact, female sex did not emerge as an independent predictor of mortality.

Impact of distal embolization on myocardial perfusion and survival among patients undergoing primary angioplasty with glycoprotein IIb-IIIa inhibitors: insights from the EGYPT cooperation.

Even though primary angioplasty is able to obtain TIMI 3 flow in the vast majority of STEMI patients, epicardial recanalization does not guarantee optimal myocardial perfusion, that remain suboptimal in a relatively large proportion of patients. Large interest has been focused in recent years on the role of distal embolization as major determinant of impaired reperfusion. The aim of the current study was to investigate in a large cohort of STEMI undergoing primary angioplasty with Gp IIb-IIIa inhibitors the impact of distal embolization on myocardial perfusion and survival. Our population is represented by patients undergoing primary angioplasty for STEMI included in the EGYPT database. Distal embolization was defined as an abrupt ''cutoff'' in the main vessel or one of the coronary branches of the infarct-related artery, distal to the angioplasty site. Myocardial perfusion was evaluated by angiography or ST-segment resolution, whereas infarct size was estimated by using peak CK and CK-MB. Follow-up data were collected between 30 days and 1 year after primary angioplasty. Data on distal embolization were available in a total of 1182 patients (71% of total population). Distal embolization was observed in 132 patients (11.1%). Patients with distal embolization were older (P < 0.001), with larger prevalence of diabetes (P = 0.01), previous MI (P = 0.048) and advanced Killip class at presentation (P = 0.018), abciximab administration (P < 0.001), with a lower prevalence of smoking (P = 0.04). Patients with distal embolization had more often poor preprocedural recanalization (P = 0.061), less often postprocedural TIMI 3 flow (P < 0.001), postprocedural MBG 2-3 (P < 0.001), complete ST-segment resolution (P = 0.021) and larger infarct size (CK-MB: 328 +/- 356 U/l vs. 259 +/- 226 U/l, P = 0.012). The impact of distal embolization on myocardial perfusion was confirmed after correction for baseline confounding factors as evaluated by MBG 2-3 (adjusted OR [95% CI] = 3.14 [2.06-4.77], P < 0.0001) but not complete ST-segment resolution (adjusted OR [95% CI] = 1.23 [0.84-1.92], P = 0.26). At 208 +/- 160 days follow-up, distal embolization was associated with a significantly higher mortality (9.2% vs. 2.7%, HR [95% CI] = 3.41 [1.73-6.71], P < 0.0001), that was confirmed after correction for baseline confounding factors (adjusted HR [95% CI] = 2.23 [1.1-4.7], P = 0.026). This study showed among STEMI patients treated with Gp IIb-IIIa inhibitors, that distal embolization is independently associated with impaired myocardial perfusion and survival.

In out-of-hospital cardiac arrest, is the positioning of victims by bystanders adequate for CPR? A cohort study.

OBJECTIVES: Outcome from out-of-hospital cardiac arrest (OHCA) highly depends on bystander cardiopulmonary resuscitation (CPR) with high-quality chest compressions (CCs). Precondition is a supine position of the victim on a firm surface. Until now, no study has systematically analysed whether bystanders of OHCA apply appropriate positions to victims and whether the position is associated with a particular outcome. DESIGN: Prospective observational cohort study. SETTING: Metropolitan emergency medical services (EMS) serving a population of 400 000; dispatcher-assisted CPR was implemented. We obtained information from the first EMS vehicle arriving on scene and matched this with data from semi-structured interviews with witnesses of the arrest. PARTICIPANTS: Bystanders of all OHCAs occurring during a 12-month period (July 2006-July 2007). From 201 eligible missions, 200 missions were fully reported by EMS. Data from 138 bystander interviews were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of positions suitable for effective CCs; related survival with favourable neurological outcome at 3 months. RESULTS: Positioning of victims at EMS arrival was 'supine on firm surface' in 64 cases (32.0%), 'recovery position (RP)' in 37 cases (18.5%) and other positions unsuitable for CCs in 99 cases (49.5%). Survival with favourable outcome at 3 months was 17.2% when 'supine position' had been applied, 13.5% with 'RP' and 6.1% with 'other positions unsuitable for CCs'; a statistically significant association could not be shown (p=0.740, Fisher's exact test). However, after 'effective CCs' favourable outcome at 3 months was 32.0% compared with 5.3% if no actions were taken. The OR was 5.87 (p=0.02). CONCLUSION: In OHCA, two-thirds of all victims were found in positions not suitable for effective CCs. This was associated with inferior outcomes. A substantial proportion of the victims was placed in RP. More attention should be paid to the correct positioning of victims in OHCA. This applies to CPR training for laypersons and dispatcher-assisted CPR.

Reperfusion rate and inhospital mortality of patients with ST segment elevation myocardial infarction diagnosed already in the prehospital phase: results of the German Prehospital Myocardial Infarction Registry (PREMIR).

AIMS: We sought to evaluate the in-hospital fate of patients with ST segment elevation myocardial infarction (STEMI) diagnosed already in the prehospital phase by physican equipped ambulances. METHODS: A total of 2326 consecutive STEMI patients were included in PREMIR. For this analysis 218 patients with prehospital cardiopulmonary resuscitation were excluded. RESULTS: The median time between symptom onset and 12-lead ECG was 85 min. The median time intervals between the diagnostic 12-lead ECG and prehospital fibrinolysis were 10 min, until inhospital fibrinolysis 52 min and until primar PCI 86min, respectively. Reperfusion therapy with prehospital fibrinolysis (24%), inhospital fibrinolysis (13%) or primary PCI (45%) was performed in 82% of the patients. Inhospital mortality was 6.0% in patients with prehospital fibrinolysis (n = 504), 5.8% in patients with inhospital fibrinolysis (n = 278), 4.5% in patients with primary percutaneous coronary intervention (n = 962) and 16.2% in patients without early reperfusion therapy (n = 377), respectively. In the multivariate propensity score analysis comparing prehospital fibrinolysis and primary PCI we observed no significant difference in the odds for in-hospital mortality (odds ratio: 1.57, 95% CI: 0.94-2.63). The final discharge diagnosis was STEMI in 90% of the patients, in patients with prehospital fibrinolysis 95%. CONCLUSIONS: In patients with STEMI already diagnosed in the prehospital phase the ischemic time is short, accuracy of the diagnosis is high and reperfusion therapy is performed in over 82%. Inhospital mortality was not different between prehospital fibrinolysis and primary PCI.

Benefits of pharmacological facilitation with glycoprotein IIb-IIIa inhibitors in diabetic patients undergoing primary angioplasty for STEMI. A subanalysis of the EGYPT cooperation.

The Early Glycoprotein IIb-IIIa inhibitors in Primary angioplasty (EGYPT) cooperation aimed at evaluating, by pooling individual patient's data of randomized trials, the benefits of pharmacological facilitation with Gp IIb-IIIa inhibitors among STEMI patients undergoing primary angioplasty. In the current study we analyze the benefits of early Gp IIb-IIIa inhibitors in diabetic patients. The literature was scanned by formal searches of electronic databases (MEDLINE, EMBASE) from January 1990 to October 2007. We examined all randomized trials on facilitation by early administration of Gp IIb-IIIa inhibitors in STEMI. No language restrictions were enforced. Individual patients' data were obtained from 11 out of 13 trials, including 1,662 patients. Diabetes was present in 281 (16.9%). Early Gp IIb-IIIa inhibitors were associated with improved preprocedural TIMI 3 flow (26.0% vs. 13.1%, P = 0.006), postprocedural TIMI 3 flow (90.1% vs. 75.0%, P = 0.18), MBG 3 (40.8% vs. 30.4%, P = 0.004), and less distal embolization (11.6% vs. 20.8%, P = 0.05). However, early Gp IIb-IIIa inhibitors did not significantly reduce mortality (8.3% vs. 9.5%, P = 0.64). This meta-analysis shows that pharmacological facilitation with early administration of Gp IIb-IIIa inhibitors in STEMI patients with diabetes undergoing primary angioplasty, is associated with significant benefits in terms of preprocedural and postprocedural TIMI flow, improved myocardial perfusion, without significant benefits in mortality.

Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction.

Up to 90% of cardiac arrests are due to acute myocardial infarction or severe myocardial ischaemia. Thrombolysis is an effective treatment for ST-elevation myocardial infarction (STEMI), but there is no evidence or guideline to put forward a thrombolysis strategy during cardiopulmonary resuscitation (CPR). In two physician-manned emergency medical service (EMS) units in Berlin, Germany, using thrombolysis is based on an individual judgment of the EMS physician managing the CPR attempt. In this retrospective analysis over 3 years (total 22.164 scene calls), thrombolysis was started at the scene in 50 patients during brief intermittent phases of spontaneous circulation, and in 3 patients during ongoing CPR. On-scene diagnosis of myocardial infarction was established in 45 patients (85%) by a 12-lead ECG, 5 (9%) patients had a left bundle branch block. Sixteen patients (30%) died at the scene, 37 patients (70%) were admitted to a hospital. In-hospital mortality was 35% (13 of 37 patients), with cause of death being cardiogenic shock in nine patients, hypoxic cerebral coma in two and acute haemorrhage in two other patients. All 24 of 53 (45%) survivors were discharged with an excellent neurological recovery. CPR was started by an EMS physician in 18 of the 24 survivals (75%) and emergency medical technicians who arrived first in six (25%). Duration of CPR until return of spontaneous circulation was <10 min in 13 of 24 (54%) of the survivors. Thrombolysis was initiated during intermittent phases of spontaneous circulation in 50 (94%) of all patients and in 23 (96%) of the 24 survivors. In conclusion, this retrospective analysis shows excellent survival rates and neurological outcome in selected patients with a high likelihood of myocardial infarction, who develop cardiac arrest and are treated with thrombolysis.

Public access resuscitation program including defibrillator training for laypersons: a randomized trial to evaluate the impact of training course duration.

BACKGROUND: Time to cardiopulmonary resuscitation (CPR) is a main determinant of survival after out-of-hospital cardiac arrest. Only widespread implementation of training courses for laypersons can decrease response time. METHODS AND RESULTS: In this prospective randomized trial, we evaluated how laypersons retained CPR skills and skills in using the automated external defibrillator (AED). A total of 1095 volunteers were randomly assigned to receive CPR/AED-training courses of 2h (375 persons), 4h (378 persons) or 7h (342 persons) duration. Courses were held in accordance with the guidelines for CPR. All trainees were tested immediately after the initial class in a standardized test scenario using an AED and a manikin. Either at 6 or at 12 months, retests were given to 164 and 206 volunteers, respectively. In 479 volunteers, retesting was completed at both 6- and 12-month intervals. At the immediate tests, the 7-h training group showed a slightly higher rate of correct responses (7h: 96%, 4h: 94%, 2h: 92%) (p<0.001). Skill retention decreased significantly in the three groups and was lowest after 12 months if no 6-month retests were done. In trainees who did undergo retesting at 6 months, skills did not deteriorate at 12 months. There were no significant differences between the three groups (overall correct responses: 2h: 72%, 4h: 73%, 7h: 74%) (ns). CONCLUSIONS: A 2-h class is sufficient to acquire and retain CPR and AED skills for an extended time period provided that a brief re-evaluation is performed after 6 months.

The accuracy of an out-of-hospital 12-lead ECG for the detection of ST-elevation myocardial infarction immediately after resuscitation.

STUDY OBJECTIVE: Severe myocardial ischemia is the leading cause of arrhythmic sudden cardiac death. It is unclear, however, in which percentage of patients sudden cardiac death is triggered by ST-elevation myocardial infarction (STEMI) and whether the diagnosis of STEMI can be reliably established immediately after resuscitation from out-of-hospital sudden cardiac death. METHODS: A 12-lead ECG was registered after return of spontaneous circulation after cardiac arrest. After hospital admission, further ECG, creatine kinase MB, and troponin measures; results of coronary angiograms; and autopsies were evaluated to confirm the definitive diagnosis of STEMI. RESULTS: Seventy-seven patients were included in our study (67% men, age 64 [14 to 93] years). STEMI was diagnosed in 44 patients. The diagnosis of myocardial infarction was confirmed in 84% of the 77 patients who survived to hospital admission. The sensitivity of the out-of-hospital ECG was 88% (95% confidence interval [CI] 74% to 96%), the specificity 69% (95% CI 51% to 83%), the positive predictive value 77% (95% CI 62% to 87%), and the negative predictive value 83% (95% CI 64% to 87%). The accuracy of the out-of-hospital ECG and that registered on admission was the same. CONCLUSION: The diagnosis of STEMI can be established in the field immediately after return of spontaneous circulation in most patients. This may enable an early decision about reperfusion therapy, ie, immediate out-of-hospital thrombolysis or targeted transfer for percutaneous coronary intervention.

How sudden is sudden cardiac death?

BACKGROUND: Out-of-hospital sudden cardiac death (SCD) is a frequent cause of death. Survival rates remain low despite increasing efforts in medical care. Better understanding of the circumstances of SCD could be helpful in developing preventive measures and facilitating proper reactions to such a pending event. METHODS AND RESULTS: Information on cases of out-of-hospital SCD was collected in the Berlin, Germany, emergency medical system via a questionnaire. Bystander interviews were performed by the emergency physician on scene immediately after declaration of death or return of circulation. Of 5831 rescue missions, 406 involved patients with presumed cardiac arrest. Sixty-six percent had a known cardiac disease. In 72%, the arrest occurred at home, and in 67%, it occurred in the presence of an eyewitness. Information on symptoms immediately preceding the arrest was available in 80% (n = 323) of all 406 patients and in 274 of those with witnessed arrest. Symptoms were identical in the 2 groups. Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour. CONCLUSIONS: SCD occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms. Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority.

Medical students teaching basic life support to school children as a required element of medical education: a randomised controlled study comparing three different approaches to fifth year medical training in emergency medicine.

OBJECTIVES: Basic life support (BLS) by doctors has been shown to be of poor quality. To improve medical education training should be simplified, and simultaneously the learner should be involved more actively. To combine both ideas we trained medical students to give BLS courses and sent them to teach school children. This was a requirement for their emergency medicine course. Our model was compared to conventional teaching. DESIGN: Medical students were assigned at random to one of three groups. Group 1 ("university") attended a conventional university BLS/ALS course. Group 2 ("EMS") accompanied a BLS vehicle of the emergency medical service (EMS) after suitable preparation. Group 3 ("school") was instructed to teach BLS and then sent to teach at schools. MAIN OUTCOME MEASURES: Clinically significant BLS skills, and overall BLS skills, each assessed by structured clinical examination (SCE). Theoretical knowledge assessed by written (open question) test. RESULTS: Clinically relevant mistakes were seen in 37.5% in group 1 ("university"), compared to 28.8% in group 2 ("EMS"), and 11.3% in group 3 ("school"). Highly significant differences were shown between "school" and "EMS" (p=0.011), and between "school" and "university" (p<0.001). In practical testing for overall performance the "university" group reached a median of 78.8% (25th-75th percentile 69.2-84.6%), group "EMS" reached 76.9% (69.2-88.5%), and group "school" 84.6% (76.9-90.0). Group "school" showed significant advantages over "university" (p=0.015) and "EMS" (p=0.010). Written test results did not differ statistically. CONCLUSION: Medical students teaching BLS to school children as a compulsory element of their own medical training showed superior practical skills as compared to conventional teaching. Theoretical knowledge was equivalent to the control groups, although their course contained less theoretical information.

Efficacy and safety of clopidogrel 600 mg administered pre-hospitally to improve primary percutaneous coronary intervention in patients with acute myocardial infarction (CIPAMI): study rationale and design.

Clopidogrel, in combination with acetylsalicylic acid, has become a mainstay of the pharmacological therapy for patients with acute coronary syndromes, especially in those undergoing percutaneous coronary interventions (PCI). While a series of studies has shown that pre-treatment with a loading dose of clopidogrel 300 or 600 mg prior to PCI is effective in reducing cardiovascular complications, the optimal dose and timing in various patient groups is still unclear. The primary objective of the present randomized, open-label Clopidogrel to Improve Primary percutaneous coronary Intervention in Acute Myocardial Infarction (CIPAMI) study is to evaluate the efficacy and the safety of a 600 mg loading dose of clopidogrel in addition to standard acetylsalicylic acid/heparin treatment in the pre-hospital setting in 654 patients with acute ST elevation myocardial infarction scheduled for primary PCI. The primary efficacy endpoint is the TIMI 2/3 patency of the infarct-related artery immediately prior to PCI. The rationale, design and methods of this study are described.

Effects of early treatment with statins on short-term clinical outcomes in acute coronary syndromes: a meta-analysis of randomized controlled trials.

CONTEXT: The short-term effects of early treatment with statins in patients after the onset of acute coronary syndromes (ACS) for the outcomes of death, myocardial infarction (MI), and stroke are unclear. OBJECTIVE: To evaluate relevant outcomes of patients from randomized controlled trials comparing early statin therapy with placebo or usual care at 1 and 4 months following ACS. DATA SOURCES AND STUDY SELECTION: Systematic search of electronic databases (MEDLINE, EMBASE, PASCAL, Cochrane Central Register) from their inception to August 2005, which was supplemented by contact with experts in the field. Two reviewers independently determined the eligibility of randomized controlled trials that compared treatment with statins with a control, were initiated within 14 days after onset of ACS, and had a minimal follow-up of 30 days. Trials with cerivastatin were only included in a sensitivity analysis. DATA EXTRACTION: Information on baseline characteristics of included trials and patients, reported methodological quality, lipid levels, and clinical outcome was independently extracted by 2 investigators. Investigators from each included trial contributed additional data if necessary. DATA SYNTHESIS: Twelve trials involving 13 024 patients with ACS were included in the meta-analysis. The risk ratios for the combined end point of death, MI, and stroke for patients treated with early statin therapy compared with control therapy were 0.93 (95% confidence interval [CI], 0.80-1.09; P = .39) at 1 month and 0.93 (95% CI, 0.81-1.07; P = .30) at 4 months following ACS. There were no statistically significant risk reductions from statins for total death, total MI, total stroke, cardiovascular death, fatal or nonfatal MI, or revascularization procedures (percutaneous coronary intervention or coronary artery bypass graft surgery). Sensitivity analyses with restriction to trials of high quality or with additional data from a large trial using cerivastatin indicated summary risk ratios even closer to 1. CONCLUSION: Based on available evidence, initiation of statin therapy within 14 days following onset of ACS does not reduce death, MI, or stroke up to 4 months.

[When to terminate resuscitation in adults?]. / Reanimation bei Erwachsenen: Wann kann eine Wiederbelebung beendet werden?

Resuscitation in cardiac arrest rarely results in survival with a good neurologic outcome. It is therefore a common problem to decide when resuscitation should not be initiated or an ongoing attempt has to be terminated. Resuscitation attempts should be withheld or terminated if there is a do not resuscitate order (DNR), if resuscitation is not in accordance with the presumptive will of the patient or does not have a chance to allow the patient to continue an independent living. As long as ventricular fibrillation or pulseless ventricular tachycardia are present, however, resuscitation should be continued. Also in pulmonary embolism prolonged resuscitation measures may be necessary. In out-of-hospital cardiac arrest resuscitation may be stopped when the three criteria are met: not witnessed arrest, no ventricular fibrillation or pulseless tachycardia, and no return of spontaneous circulation before arrival at the hospital. According to current guidelines in-hospital resuscitation can be terminated if the patient is in asystole for at least 20 minutes. In any case termination of a resuscitation attempt is an individual decision where all possible information on circumstances and on the patient should be taken into account.

[Role of coronary intervention after successful cardiopulmonary resuscitation]. / Die Rolle der Koronarintervention nach erfolgreicher kardiopulmonaler Reanimation.

Immediate coronary angiography and intervention in suitable stenoses in patients resuscitated from cardiac arrest of presumed coronary origin and return of spontaneous circulation is widely established in interventional centers. The procedure is based on the analogy of positive results achieved with coronary intervention in many forms of acute coronary syndromes on the one hand and otherwise from registries showing promising data from coronary intervention of resuscitated patients. Results from randomized controlled studies, however, are not yet available. With respect to ST-elevation myocardial infarction, the diagnostic reliability of an ECG registered shortly after cardiopulmonary resuscitation is sufficient. The results of the registries are specifically promising for patients with ST-elevation myocardial infarction but less favorable for other forms of acute coronary syndromes. Moreover, insight into the results of the registries reveals that patients with the best prognostic conditions were preferentially selected for coronary intervention (e.g., younger patients, those with an initially shockable arrhythmia, bystander resuscitation), whereas those, for example, with cardiac or renal failure were excluded. For better definition of the actual benefit of coronary intervention after resuscitation from cardiac arrest and the optimal target groups, randomized controlled studies on patients with ST-elevation myocardial infarction are desirable, while for other forms of acute coronary syndromes these studies are essential.