Retrospective Study of 573 Patients with Heart Failure Evaluated for Coronary Artery Disease at Toulouse University Center, France.

BACKGROUND Heart failure (HF) most commonly occurs due to ischemic heart disease from stenotic coronary artery disease (CAD). HF is classified into 3 groups based on the percentage of the ejection fraction (EF): reduced (HFrEF), mid-range (HFmrEF), and preserved (HFpEF). This retrospective study included 573 patients who presented with HF based on the evaluation of EF and were evaluated for CAD by coronary angiography before undergoing coronary angioplasty at a single center in Toulouse, France. MATERIAL AND METHODS This retrospective observational study included patients recently diagnosed with HF or acute decompensation of chronic HF and referred for coronary angiography at Toulouse University Hospital between January 2019 and May 2020. RESULTS Significant CAD was found in 55.8%, 55%, and 55% of the whole population, HFpEF, and HFrEF groups, respectively. Older age, male sex, and diabetes mellitus were the main risk factors for ischemic HF. Except for age and sex, patients with ischemic HFpEF were comparable to those with non-ischemic HFpEF, unlike the ischemic HFrEF group, which had more common cardiovascular risk factors than the non-ischemic HFrEF group. The ischemic HFpEF group had an older age and higher rate of dyslipidemia than the ischemic HFrEF group. CONCLUSIONS At our center, CAD was diagnosed in more than half of patients who presented with heart failure with preserved or reduced EF. Older age and male sex were the common risk factors in patients with HFpEF and HFrEF.

Statin use and incident cardiovascular events in renal transplant recipients.

BACKGROUND: Statins achieve potent LDL lowering in the general population leading to a significant cardiovascular (CV) risk reduction. In renal transplant recipients (RTR) statins are included in treatment guidelines, however, conclusive evidence of improved cardiovascular outcomes has not been uniformly provided and concerns have been raised about simultaneous use of statins and the immunosuppressant cyclosporine. This study aimed to elucidate the effect of statins on a compound CV endpoint, comprised of ischaemic CV events and CV mortality in RTR, with subgroup analysis focussing on cyclosporine users. METHOD: 622 included RTR (follow-up 5.4 years) were matched based on propensity scores and dichotomized by statin use. Survival analysis was conducted. RESULTS: Cox regression showed that statin use was not significantly associated with the compound CV endpoint in a fully adjusted model (HR = 0.81, 95% CI = 0.53-1.24, P = .33). Subgroup analyses in RTR using cyclosporine revealed a strong positive association of statin use with the CV compound outcome in a fully adjusted model (HR = 6.60, 95% CI 1.75-24.9, P = .005). Furthermore, statin use was positively correlated with cyclosporine trough levels (correlation coefficient 0.11, P = .04). CONCLUSION: In conclusion, statin use does not significantly decrease incident CV events in an overall RTR cohort, but is independently associated with CV-specific mortality and events in cyclosporine using RTR, possibly due to a bilateral pharmacological interaction.

Impact of COVID-19 pandemic on STEMI care: An expanded analysis from the United States.

OBJECTIVE: To evaluate the impact of COVID-19 pandemic migitation measures on of ST-elevation myocardial infarction (STEMI) care. BACKGROUND: We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID-19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. METHODS: Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. RESULTS: Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (-0.2 to 44, p = .05). CONCLUSIONS: The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI.

Impact of Coronary Stent Design in Proximal Balloon Edge Dilation Technique for Bifurcation Percutaneous Coronary Intervention.

The proximal optimizing technique (POT) -proximal balloon edge dilation (PBED) sequence for side branch (SB) dilatation with cross-over single-stent implantation decreases both strut obstruction at the SB ostium and stent deformation at the main branch (MB).The purpose of this experimental bench test was to assess the impact of stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and stent strut malapposition in the POT-PBED sequence.Fractal coronary bifurcation bench models (60- and 80-degree angles) were used, and crossover single-stent implantation (3-link stent: XIENCE Sierra, Abbott Vascular, Santa Clara, CA, n = 10; 2-link stent: Synergy, Boston Scientific, Marlborough, MA, n = 10) was performed from the MB using the POT-PBED sequence. Jailing rates at the SB ostium, stent deformation, and stent strut malapposition of the bifurcation segment were assessed using videoscopy and optical coherence tomography.After SB dilatation using the PBED technique, jailing rates at the SB ostium and stent deformation did not differ significantly between the two types of stents. Conversely, the rate of malapposed struts of the bifurcation segment after the PBED procedure was significantly lower with 3-link stents than with 2-link stents for both 60- and 80-degree angles (60-degree angle: 4.3% ± 4.4% versus 22.0% ± 11.1%, P = 0.044; 80-degree angle: 20.8% ± 15.1% versus 57.2% ± 17.0%, P < 0.001, respectively).In the POT-PBED sequence, 3-link stents might be a preferable coronary bifurcation stent, maintaining a jailed SB ostium while significantly reducing stent strut malapposition of the bifurcation segment when compared with 2-link stents.

Impact of Lesion Preparation Technique on Side Branch Compromise in Calcified Coronary Bifurcations: A Subgroup Analysis of the PREPARE-CALC Trial.

OBJECTIVES: To analyze the impact of different techniques of lesion preparation of severely calcified coronary bifurcation lesions. BACKGROUND: The impact of different techniques of lesion preparation of severely calcified coronary bifurcation lesions is poorly investigated. METHODS: We performed an as-treated analysis on 47 calcified bifurcation lesions treated with scoring/cutting balloons (SCB) and 68 lesions treated with rotational atherectomy (RA) in the PREPARE-CALC trial. Compromised side branch (SB) as assessed in the final angiogram was the primary outcome measure and was defined as any significant stenosis, dissection, or thrombolysis in myocardial infarction flow <3. RESULTS: True bifurcation lesions were present in 49% vs. 43% of cases in the SCB and RA groups, respectively. After stent implantation, SB balloon dilatation was necessary in around one-third of cases (36% vs. 38%; p = 0.82), and a two-stent technique was performed in 21.3% vs. 25% (p = 0.75). At the end of the procedure, the SB remained compromised in 15 lesions (32%) in the SCB group and 5 lesions (7%) in the RA group (p = 0.001). Large coronary dissections were more frequently observed in the SCB group (13% vs. 2%; p = 0.02). Postprocedural levels of cardiac biomarkers were significantly higher in patients with a compromised SB at the end of the procedure. CONCLUSIONS: In the PREPARE-CALC trial, side branch compromise was more frequently observed after lesion preparation with SCB as compared with RA. Consequently, in calcified bifurcation lesions, an upfront debulking with an RA-based strategy might optimize the result in the side branch.

Propensity Score-Based Methods in Comparative Effectiveness Research on Coronary Artery Disease.

This review examines the conduct and reporting of observational studies using propensity score-based methods to compare coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy for patients with coronary artery disease. A systematic selection process identified 48 studies: 20 addressing CABG versus PCI; 21 addressing bare-metal stents versus drug-eluting stents; 5 addressing CABG versus medical therapy; 1 addressing PCI versus medical therapy; and 1 addressing drug-eluting stents versus balloon angioplasty. Of 32 studies reporting information on variable selection, 7 relied exclusively on statistical criteria for the association of covariates with treatment, and 5 used such criteria to determine whether product or nonlinear terms should be included in the propensity score model. Twenty-five (52%) studies reported assessing covariate balance using the estimated propensity score, but only 1 described modifications to the propensity score model based on this assessment. The over 400 variables used in the 48 propensity score models were classified into 12 categories and 60 subcategories; only 17 subcategories were represented in at least half of the propensity score models. Overall, reporting of propensity score-based methods in observational studies comparing CABG, PCI, and medical therapy was incomplete; when adequately described, the methods used were often inconsistent with current methodological standards.

Striving to meet targets for ideal treatment of acute myocardial infarction in Brazil: Data from the Midwest region.

OBJECTIVES: To evaluate the systematic chain of care for patients with acute ST-elevation myocardial infarction (STEMI) referred for primary angioplasty in a capital city in Midwestern Brazil. BACKGROUND: Acute myocardial infarction is recognized as an important cause of morbidity and mortality and as a public health problem worldwide. Early specialized care is crucial for a good prognosis. METHODS: All STEMI patients receiving care through the public health system at two tertiary care centers from March 2012 to June 2014 were retrospectively analyzed. Symptom onset-to-balloon time and door-to-balloon time were analyzed and compared with current guideline recommendations. RESULTS: A total of 835 patients were included. Median symptom onset-to-balloon time was 32 h. A total of 783 (94%) patients had had symptoms for more than 12 h and 507 (61%) for more than 24 h. Only 51 (6%) patients arrived within 12 h of symptom onset and were treated with primary angioplasty. Among these patients, median door-to-balloon time was 37 min, in accordance with guideline recommendations. CONCLUSION: Treatment of STEMI through the public health system in a capital city in Midwestern Brazil falls short of the recommended guidelines due to failure in the initial links of the chain of care. This potentially reversible failure has an important impact on patient outcomes and on health care burden.

The Comparison of Clinical Outcomes After Drug-Eluting Balloon and Drug-Eluting Stent Use for Left Main Bifurcation In-Stent Restenosis.

Increasing evidence is available for the use of percutaneous coronary intervention (PCI) in selected patients with unprotected left main (LM) bifurcation coronary lesions. However, little data have been reported on recurrent in-stent restenosis (ISR) for LM bifurcation lesions. The aim of this study was to evaluate the efficacy of a drug-eluting balloon (DEB) for LM bifurcation ISR compared with that of a drug-eluting stent (DES).Between December 2011 and December 2015, 104 patients who underwent PCI for unprotected LM bifurcation ISR were enrolled. We separated the patients into 2 groups: (1) those underwent PCI with further DEB and (2) those underwent PCI with further DES. Clinical outcomes were analyzed.Patients' average age was 67.14 ± 7.65 years, and the percentage of male patients was 76.0%. A total of 75 patients were enrolled in the DEB group, and another 29 patients were enrolled in the DES group. Similar target lesion revascularization (TLR) rate and recurrent myocardial infarction (MI) rate were noted for both groups. A significantly higher cardiovascular mortality rate was found in the DES group (10.7% versus 0%, P = 0.020), and a higher all-cause mortality rate was noted in the DES group (21.4% versus 6.8%, P = 0.067).It is feasible to use DEB for LM bifurcation ISR. When comparing DEB with DES, similar TLR rates were found, but lower recurrent MI and lower cardiovascular death were noted for DEB treatment.

[Prognostic significance of the total ischemic time in patients with ST-elevation myocardial infarction]. / A teljes ischaemiás ido prognosztikus jelentosége az ST-elevációval járó szívinfarktus miatt kezelt betegekben.

INTRODUCTION: The significance of the total ischemic time (from the beginning of the complaint to the opening of the vessel) is an important factor for myocardial salvage. AIM: The aim of the study was to determine the prognostic significance of the TIT in patients with ST elevation myocardial infarction in Hungary. METHOD: From 1 January 2014 all patients with myocardial infarction were recorded by law in an on-line database of the Hungarian Myocardial Infarction Registry. Between 1 January 2014 and 31 March 2016, 27 157 patients with 28 408 myocardial infarction events were recorded. To investigate TIT, 7146 STEMI patients were selected who were treated with percutaneous coronary intervention (PCI) within 24 hours of the beginning of the complaint and all of its components were known. RESULTS: Average follow-up was 740 ± 346 days. The median time of the TIT is 260 minutes, within which the earliest prehospital time was found (median 205 minutes). The TIT influenced survival: if this time was less than 400 minutes, the 30-day and the 1-year deaths were 7.5% and 12.2%, respectively. In longer TIT, higher mortality rate was found (9.2% versus 19.7%, respectively). Multivariate analysis was performed for short (<30 days), medium (30-364 days) and long-term (≥365 days) survival. Diabetes mellitus is a short-term prognostic factor, abnormal creatinine, and severe coronary status have affected short and medium survival. PCI was significant in terms of medium and long-term survival. Previous myocardial infarction and TIT influenced the long-term survival significantly. CONCLUSIONS: In Hungary, TIT is too long, and its dominant part falls within the prehospital period. The TIT is an independent prognostic factor, so reducing this time can improve the long-term prognosis of patients with ST-elevation myocardial infarction. Orv Hetil. 2018; 159(27): 1113-1120.

Real-life clinical outcomes with everolimus eluting platinum chromium stent with an abluminal biodegradable polymer in patients from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

BACKGROUND: No previous studies have evaluated the performance of the Synergy stent in a large real-life population. OBJECTIVES: To describe the initial real-life experience with a novel everolimus eluting platinum chromium stent with abluminal biodegradable polymer (SYNERGY) in unselected patients from a nationwide registry. METHODS: All implanted Synergy stents were compared with other new generation drug eluting stents (n-DES) with >1,000 implantations in Sweden between March 2013 and October 2015. Restenosis, definite stent thrombosis (ST), myocardial infarction (MI) and death rates were assessed using propensity score and Cox regression analyses. RESULTS: A total of 7,886 of Synergy stents and 64,429 other n-DES (BioMatrix, N = 1,953; Orsiro, N = 4,946; Promus Element Plus, N= 2,543; Promus Premier, N= 20,414; Xience Xpedition, N= 7,971, Resolute/Resolute Integrity, N = 19,021; Ultimaster, N = 1,156; Resolute Onyx, N = 6,425) were implanted in 42,357 procedures. Restenosis and stent thrombosis occurred in 642 and 314 cases, respectively, in the overall population at 1 year. The cumulative rate of restenosis (1.1% vs. 1.0%, adjusted HR: 1.24 95% CI: 0.88-1.75; P = 0.21) and ST (0.4% vs. 0.5%, adjusted HR: 0.97; 95% CI: 0.63-1.50; P = 0.17) up to 1 year was low in both the Synergy group and the other n-DES group. Death occurred in 5.2% versus 4.5% (adjusted HR: 1.14; 95% CI: 0.96-1.36; P = 0.11) and MI in 3.2% versus 3.5%, (adjusted HR: 1.11; 95% CI: 0.93-1.33; P = 0.24) up to 1 year. CONCLUSIONS: In a large real-life population the Synergy stent appears to be safe and effective with a low rate of restenosis and ST comparable with other n-DES. © 2017 Wiley Periodicals, Inc.

Vitamin C supplementation for the primary prevention of cardiovascular disease.

BACKGROUND: Vitamin C is an essential micronutrient and powerful antioxidant. Observational studies have shown an inverse relationship between vitamin C intake and major cardiovascular events and cardiovascular disease (CVD) risk factors. Results from clinical trials are less consistent. OBJECTIVES: To determine the effectiveness of vitamin C supplementation as a single supplement for the primary prevention of CVD. SEARCH METHODS: We searched the following electronic databases on 11 May 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (Ovid); Embase Classic and Embase (Ovid); Web of Science Core Collection (Thomson Reuters); Database of Abstracts of Reviews of Effects (DARE); Health Technology Assessment Database and Health Economics Evaluations Database in the Cochrane Library. We searched trial registers on 13 April 2016 and reference lists of reviews for further studies. We applied no language restrictions. SELECTION CRITERIA: Randomised controlled trials of vitamin C supplementation as a single nutrient supplement lasting at least three months and involving healthy adults or adults at moderate and high risk of CVD were included. The comparison group was no intervention or placebo. The outcomes of interest were CVD clinical events and CVD risk factors. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, abstracted the data and assessed the risk of bias. MAIN RESULTS: We included eight trials with 15,445 participants randomised. The largest trial with 14,641 participants provided data on our primary outcomes. Seven trials reported on CVD risk factors. Three of the eight trials were regarded at high risk of bias for either reporting or attrition bias, most of the 'Risk of bias' domains for the remaining trials were judged as unclear, with the exception of the largest trial where most domains were judged to be at low risk of bias.The composite endpoint, major CVD events was not different between the vitamin C and placebo group (hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.89 to 1.10; 1 study; 14,641 participants; low-quality evidence) in the Physicians Health Study II over eight years of follow-up. Similar results were obtained for all-cause mortality HR 1.07, 95% CI 0.97 to 1.18; 1 study; 14,641 participants; very low-quality evidence, total myocardial infarction (MI) (fatal and non-fatal) HR 1.04 (95% CI 0.87 to 1.24); 1 study; 14,641 participants; low-quality evidence, total stroke (fatal and non-fatal) HR 0.89 (95% CI 0.74 to 1.07); 1 study; 14,641 participants; low-quality evidence, CVD mortality HR 1.02 (95% 0.85 to 1.22); 1 study; 14,641 participants; very low-quality evidence, self-reported coronary artery bypass grafting (CABG)/percutaneous transluminal coronary angioplasty (PTCA) HR 0.96 (95% CI 0.86 to 1.07); 1 study; 14,641 participants; low-quality evidence, self-reported angina HR 0.93 (95% CI 0.84 to 1.03); 1 study; 14,641 participants; low-quality evidence.The evidence for the majority of primary outcomes was downgraded (low quality) because of indirectness and imprecision. For all-cause mortality and CVD mortality, the evidence was very low because more factors affected the directness of the evidence and because of inconsistency.Four studies did not state sources of funding, two studies declared non-commercial funding and two studies declared both commercial and non-commercial funding. AUTHORS' CONCLUSIONS: Currently, there is no evidence to suggest that vitamin C supplementation reduces the risk of CVD in healthy participants and those at increased risk of CVD, but current evidence is limited to one trial of middle-aged and older male physicians from the USA. There is limited low- and very low-quality evidence currently on the effect of vitamin C supplementation and risk of CVD risk factors.

[Patient care of patients with myocardial infarction in Hungary. Analysis of National Myocardial Infarction Registry data collecting in 2015]. / A szívinfarktus miatt kezelt betegek ellátása Magyarországon. A Nemzeti Szívinfarktus Regiszter 2015. évi adatainak elemzése.

The authors summarize the most relevant data of myocardial infarction patients according to the National Myocardial Infarction Registry data base. In 2015 12,681 patients had 12,941 acute myocardial infarctions. Less than half of patients (44.4%) were treated with ST elevation myocardial infarction. National Ambulance Service was the first medical contact of more than half (51.4%) of patients with ST elevation infarction. Prehospital thrombolysis was occasionally done (0.23%), but 91.6% of the patients were treated in hospital with invasive facilities. The median of the ischaemic time (time between onset of symptoms and arrival at the invasive laboratory) was 223 minutes. Most of the patients (94%) with positive coronary arteriography were treated with percutaneous coronary intervention. The 30 day mortality of the whole group was 12.8% vs. 8.6% of patients treated with an invasive procedure. CONCLUSION: comparing the national and international registry data we conclude that we should analyse and decrease the prehospital delay time to improve the patient care in Hungary. Orv. Hetil., 2017, 158(3), 90-93.

Impact of the implementation of the Infarction Code strategy in patients with acute myocardial infarction diagnosis in the Hospital de Cardiología of the Centro Médico Nacional Siglo XXI / Impacto de la implementación de Código Infarto en pacientes con infarto agudo de miocardio con elevación del segmento ST en el Hospital de Cardiología del Centro Médico Nacional Siglo XXI.

Objective: To evaluate the impact of the implementation of the Infarction Code strategy in patients with acute myocardial infarction diagnosis. Methods: Consecutive patients with ST-elevation acute myocardial infarction ≤12 hours of evolution, were included in the infarction code strategy, before (Group I) and after (Group II). Times of medical attention and major cardiovascular events during hospitalization were analyzed. Results: 1227 patients were included, 919 men (75%) and 308 women (25%) with an average age of 62 ± 11 years. Among Group I and Group II, percutaneous coronary intervention reperfusion therapy changed (16.6% to 42.6%), fibrinolytic therapy (39.3% to 25%), and patients who did not receive any form of reperfusion therapy (44% to 32.6%; p < 0.0001). Times of medical attention decreased significantly (door-to-needle time decreased from 92 to 72 minutes, p = 0.004; door-to-balloon time decreased from 140 to 92 minutes, p < 0.0001). Kidney failure (24.6% vs. 17.9%; p = 0.006), major complications (35.3% to 29.3%), and death (21% vs. 12%; odds ratio: 0.52; 95% confidence interval: 0.38-0.71; p = 0.004). also decreased. Conclusion: The Infarction Code strategy improved treatment, times of medical attention and decreased complications and death in these patients.

Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.

BACKGROUND: Recent reductions in average door-to-balloon (D2B) times have not been associated with decreases in mortality at the population level. We investigated this seemingly paradoxical finding by assessing components of this association at the individual and population levels simultaneously. We postulated that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently decreased mortality in individual patients with shorter D2B times. METHODS: This was a retrospective study of ST-elevation myocardial infarction (STEMI) patients who underwent pPCI between Jan 1, 2005, and Dec 31, 2011, in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. We looked for catheterisation laboratory visits associated with STEMI. We excluded patients not undergoing pPCI, transfer patients for pPCI, patients with D2B times less than 15 min or more than 3 h, and patients at hospitals that did not consistently report data across the study period. We assessed in-hospital mortality in the entire cohort and 6-month mortality in elderly patients aged 65 years or older matched to data from the Centers for Medicare and Medicaid Services. We built multilevel models to assess the relation between D2B time and in-hospital and 6-month mortality, including both individual and population-level components of this association after adjusting for patient and procedural factors. FINDINGS: 423 hospitals reported data on 150,116 procedures with a 55% increase in the number of patients undergoing pPCI at these facilities over time, as well as many changes in patient and procedural factors. Annual D2B times decreased significantly from a median of 86 min (IQR 65-109) in 2005 to 63 min (IQR 47-80) in 2011 (p<0·0001) with a concurrent rise in risk-adjusted in-hospital mortality (from 4·7% to 5·3%; p=0·06) and risk-adjusted 6-month mortality (from 12·9% to 14·4%; p=0·001). In multilevel models, shorter patient-specific D2B times were consistently associated at the individual level with lower in-hospital mortality (adjusted OR for each 10 min decrease 0·92; 95% CI 0·91-0·93; p<0·0001) and 6-month mortality (adjusted OR for each 10 min decrease, 0·94; 95% CI 0·93-0·95; p<0·0001). By contrast, risk-adjusted in-hospital and 6-month mortality at the population level, independent of patient-specific D2B times, rose in the growing and changing population of patients undergoing pPCI during the study period. INTERPRETATION: Shorter patient-specific D2B times were consistently associated with lower mortality over time, whereas secular trends suggest increased mortality risk in the growing and changing pPCI population. The absence of association of annual D2B time and changes in mortality at the population level should not be interpreted as an indication of its individual-level relation in patients with STEMI undergoing primary PCI. FUNDING: National Heart, Lung, and Blood Institute.

Geographic and socioeconomic differences in access to revascularization following acute myocardial infarction.

BACKGROUND: Geographic and socioeconomic barriers may hinder fair access to healthcare. This study assesses geographic and socioeconomic disparities in access to reperfusion procedures in acute myocardial infarction (AMI) patients residing in Piedmont (Italy). METHODS: Coronary Care Units (CCUs) were geocoded with a geographic information system (GIS) and the shortest drive time from CCUs to patients' residence was computed and categorized as 0 to <20, 20 to <40 and ≥40 min. Using data on AMI emergency hospitalizations in 2004-2012, we employed a log-binomial regression model to evaluate the relation between drive time and use of Percutaneous Transluminal Coronary Angioplasty (PTCA) occurring within 2 days after a hospitalization for an episode of AMI, and whether this relation varied depending on the period of hospitalization. RESULTS: A total of 29% of all cases with a diagnosis of AMI (n = 66 097), were revascularized within 2 days from the index admission. The further AMI patients lived from CCUs, the less likely they were to receive revascularization: compared with distance <20 min, RRs were respectively 0.84 [95% CI 0.80-0.88] and 0.78 [95% CI 0.71-0.86]. Findings also showed that less educated people had a lower relative risk of being revascularized compared to more educated people (RR = 0.78; 95% CI = 0.74-0.82). Both inequalities have reduced in recent years. CONCLUSION: This study provides evidence of reduced geographical and socioeconomic differences in revascularization use over time. Geography and socioeconomic status should not determine the type of treatment received for life-threatening conditions such as AMI.

[Is the introduction of innovative methods in cardiovascular diagnostics and therapy to quick?]. / Sind wir zu schnell mit der Einführung neuer Methoden in die kardiovaskuläre Diagnostik und Therapie?

Andreas Grüntzig can be regarded as the pioneer of modern cardiology. Based on the previous experiences of Charles Dotter in Portland, Oregon, and after many years of preparation as a young 38-year-old physician and consultant he carried out the first percutaneous transluminal coronary angioplasty (PTCA) in a 38-year-old patient in Zurich in 1977, supported by the cardiac surgeons A. Senning and M. Turina. Despite high ranking publications and early preparedness to share his experiences the development of PTCA stagnated and was met with great scepticism. The technique was new, technically difficult and aimed at aortocoronary bypass surgery, which was itself still in its infancy 10 years after the introduction in Cleveland in 1968. Even after several years only two patients per week were admitted for treatment in Zurich. In a similar way the young cardiac surgeon H.R. Andersen was a pioneer in Denmark whose ideas and own experiments with a balloon catheter-assisted aortic valve implantation were not initially taken up by the leading companies of the time and publication of the data suffered lengthy delays. It took 10 years before Prof. A. Cribier in Rouen followed up his ideas and carried out the first valve implantation again in pioneer work after many years of preparation in 2002. Again, the new method for treatment of very old and high risk patients needed many years before it was accepted. The breakthrough only became possible when this new technique began to be used in cardiac surgery after the introduction of hybrid cardiac catheter operating rooms. Despite evidence-based studies innovative methods are not subject to the same criteria throughout Europe with respect to the timely introduction of innovative and validated procedures also in consideration of reimbursement and this has become an important initiative of the European Society of Cardiology (ESC).

Coordinated Digital-Assisted Program Improved Door-to-Balloon Time for Acute Chest Pain Patients.

Emergency care for patients with chest pain can be a challenge in remote areas. Digital communication technology has the potential to improve outcomes by allowing early diagnosis and faster treatment. The aim of the present study was to investigate whether implementation of a coordinated digital-assisted program (CDAP) for Chinese hospitals can reduce the door-to-balloon (D2B) time for percutaneous coronary intervention (PCI) in acute chest pain patients in China. From March to December 2011, 609 patients (CDAP group) requiring an emergency response for acute chest pain were evaluated using this CDAP. The results were compared in terms of time interval reduction (including D2B) and economic indices with those of 528 patients (non-CDAP group) previously treated by conventional protocols after admission. We screened 154 and 127 eligible patients under PCI in the CDAP and non-CDAP groups, respectively. PCI patients achieved a D2B time < 90 minutes using CDAP (82.5 versus 26.0%, P < 0.001). CDAP reduced D2B time under PCI and reduced hospitalization lengths and costs (all P < 0.001).

[Angioplasty, coronarography and coronary artery bypass in France: a geographical approach]. / Angioplastie coronaire, coronarographie et pontage aorto-coronarien en France: une approche géographique.

There are major geographic disparities in the practice of coronary angioplasty and coronarography in France. Their study shows that the frequency of these procedures is linked to the density of private medical practice (cardiologist's offices or clinics). This is not observed as far as coronary artery bypass surgery is concerned. This indicates an induction effect from simply on demand. However, this cannot give indication on the pertinence of those acts since this induction effect may as well be beneficial to patients. Nevertheless, this study gives an insight to the regulatory authorities (Regional Health Agencies and the National "Direction Générale de l'Offre de Soins") which have to manage health care system performance on the basis of the principles set out and international guidelines so as to provide equal access for all to a quality healthcare system.

Reperfusion times and in-hospital outcomes among patients with an isolated posterior myocardial infarction: insights from the National Cardiovascular Data Registry (NCDR).

BACKGROUND: A posterior myocardial infarction (PMI) is associated with significant morbidity and delays in recognition may prevent the timely revascularization of these patients. The present study sought to evaluate the reperfusion times and in-hospital outcomes among patients with an isolated PMI. METHODS: Clinical characteristics and reperfusion times were compared between those with an isolated PMI and those with all other ST-elevation myocardial infarctions (STEMI) in the NCDR ACTION-GWTG Registry from 2007 to 2012. Logistic generalized estimating equations were used to examine risk-adjusted mortality. RESULTS: Among 117,739 subjects with a STEMI, 824 (0.7%) had evidence of an isolated PMI. The median time between patient arrival and initial electrocardiogram was similar between those with an isolated PMI and those with a non-PMI STEMI (6 vs. 6 minutes, P = .48). However, the median time from initial electrocardiogram to percutaneous coronary intervention was significantly longer among subjects with a PMI (69 vs 61 minutes, P < .01) and fewer patients achieved a door-to-balloon time less than 90 minutes (83% vs 89%, P < .01). After multivariable adjustment, in-hospital mortality was similar for PMI patients compared to those with a non-PMI STEMI (AOR: 1.11, 95% CI: 0.83-1.50). CONCLUSION: The door-to-balloon times are significantly longer for those with an isolated PMI resulting in fewer patients receiving reperfusion within the guideline recommended time period. Ongoing educational initiatives to increase recognition of a PMI are needed to improve the reperfusion times and outcomes associated with this condition.