Angiographic findings and survival in patients undergoing coronary angiography due to sudden cardiac arrest in western Sweden.

AIM: Sudden cardiac arrest (SCA) accounts for more than half of all deaths from coronary heart disease. Time to return of spontaneous circulation is the most important determinant of outcome but successful resuscitation also requires percutaneous coronary intervention in selected patients. However, proper selection of patients is difficult. We describe data on angiographic finding and survival from a prospectively followed SCA patient cohort. METHODS: We merged the RIKS-HIA registry (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) and SCAAR (Swedish Coronary Angiography and Angioplasty Registry) for patients hospitalized in cardiac care units in Western Sweden between January 2005 and March 2013. We performed propensity score-adjusted logistic and Cox proportional-hazards regression analyses on complete-case data as well as on imputed data sets. RESULTS: 638 consecutive patients underwent coronary angiography due to SCA. Severity of coronary artery disease was similar among SCA patients and patients undergoing coronary angiography due to suspected coronary artery disease (n=37,142). An acute occlusion was reported in the majority of SCA patients and was present in 37% of patients who did not have ST-elevation on the post resuscitation ECG. 31% of SCA patients died within 30 days. Long-term risk of death among patients who survived the first 30 days was higher in patients with SCA compared to patients with acute coronary syndromes (P<0.001). CONCLUSIONS: Coronary artery disease and acute coronary occlusions are common among patients who undergo coronary angiography after sudden cardiac arrest. These patients have a substantial mortality risk both short- and long-term.

Implementation of prehospital thrombolysis in Sweden: components of delay until delivery of treatment and examination of treatment feasibility.

OBJECTIVE: To evaluate the feasibility of prehospital thrombolysis in Sweden in terms of safety and to examine the various components of the delay between onset of symptoms and start of treatment. SETTING: A total of 16 hospitals in Sweden in both urban and less populated areas and the associated ambulance organisations. DESIGN: Prospective evaluation of patients with an ST-elevation infarction treated with reteplase. An ECG was recorded and transmitted to hospital. The ambulances were staffed by a physician in 1% of cases, a nurse in 67% and a staff nurse in 32%. RESULTS: Of the 148 patients who received treatment prior to hospital admission, six (4%) had a cardiac arrest prior to hospital admission and two (1%) died prior to arrival at hospital. One patient was given treatment despite an exclusion criterion (previous stroke) and died on the 1st day in hospital due to a cerebral haemorrhage. The overall 30-day mortality was 7.1% and 1-year mortality 9.8%. Treatment was initiated within 2 h after the onset of symptoms in 53% of patients and within 1 h in 17% of patients. The median interval between the arrival of the ambulance and sending an ECG was 13 min and the median interval between sending an ECG and the start of thrombolysis was 18 min. The delay was similar regardless of ambulance staff. CONCLUSION: Implementation of prehospital thrombolysis on a national basis in Sweden appears to be safe. More than half the patients can be given treatment less than 2 h after the onset of symptoms. There is potential for reducing this time still further.

Clinical and procedural characteristics associated with higher radiation exposure during percutaneous coronary interventions and coronary angiography.

BACKGROUND: We aim to study the clinical and procedural characteristics associated with higher radiation exposure in patients undergoing percutaneous coronary interventions (PCIs) and coronary angiography. METHODS AND RESULTS: Our present study included all coronary angiography and PCI procedures in 5 PCI centers in the Western part of Sweden, between January 1, 2008, and January 19, 2012. The radiation exposure and clinical data were collected prospectively in these 5 PCI centers in Sweden as part of the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). A prediction model was made for the radiation exposure (dose-area product) expressed in Gy·cm(2). A total of 20 669 procedures were included in the present study, consisting of 9850 PCI and 10 819 coronary angiography procedures. In multivariable analyses, body mass index (ß=1.04; confidence interval [CI], 1.04-1.04; P<0.001); history of coronary artery bypass graft surgery (ß=1.32; CI, 1.28-1.32; P<0.001); 2, 3, or 4 treated lesions (2 treated lesions: ß=1.95; CI, 1.84-2.03; P<0.001; 3 treated lesions: ß=2.34; CI, 2.16-2.53; P<0.001; and 4 treated lesions: ß=2.83; CI, 2.53-3.16; P<0.001); and chronic total occlusion lesions (ß=1.39; CI, 1.31-1.48; P<0.001) were associated with the highest radiation exposure. After adjusting for procedural complexity, radial access route was not associated with increased radiation exposure (ß=1.00; CI, 0.98-1.03; P=0.67). CONCLUSIONS: In the largest study population to assess radiation exposure, we found that high body mass index, history of coronary artery bypass graft surgery, number of treated lesions, and chronic total occlusions were associated with the highest patient radiation exposure. Radial access site was not associated with higher radiation exposure when compared with femoral approach.

Long-term results following switch from abciximab to eptifibatide during percutaneous coronary intervention.

BACKGROUND: The usage of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors improves the outcome during high-risk percutaneous coronary interventions (PCI). The aim of this study was to evaluate the long-term effects after a planned switch from abciximab to eptifibatide during PCI. HYPOTHESIS: A switch from the general use of abciximab to eptifibatide as a GP IIb/IIIa in connection with PCI would not have any negative effects on long-term clinical outcomes. METHODS: To reduce costs, a general switch from abciximab to eptifibatide was instituted in 2004 in 2 university hospitals in Sweden. All patients treated 6 months before and 6 months after the switch were followed for 30 months. During the study period, 1038 patients underwent PCI and received a GP IIb/IIIa receptor inhibitor, 481 (46%) before the switch (Group A) and 557 (54%) after the switch (Group B). The 2 groups had similar baseline characteristics. The primary endpoint was the composite of death, myocardial infarction, stroke, or new coronary revascularization (percutaneous or surgical); secondary endpoints were the individual components of this composite. A separate analysis was performed on patients treated for ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction/unstable angina, and diabetes, respectively. Data were collected from the Swedish Coronary Angiography and Angioplasty Registry. RESULTS: There were no differences between the groups in the primary endpoint (29.7% in Group A vs 29.3% in Group B; P = 0.48) or in any of the secondary endpoints. CONCLUSIONS: A switch from the general usage of abciximab to eptifibatide as a GP IIb/IIIa receptor inhibitor in connection with PCI did not seem to have any negative effects on long-term clinical outcomes.

Switch from abciximab to eptifibatide during percutaneous coronary intervention.

BACKGROUND: Treatment with glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary intervention (PCI) reduce ischemic complications and improve outcome. Of the GPIIb/IIIa inhibitors abciximab is better documented than eptifibatide, but the former is more expensive. The aim of this study was to monitor a switch from abciximab to eptifibatide with respect to clinical outcome up to six months after PCI. METHODS: All consecutive patients that six months before and six months after a switch from abciximab to eptifibatide received GPIIb/IIIa inhibitors during and after de novo PCIs were followed for six months with respect to clinical outcome. RESULTS: 310 patients received abciximab and 350 eptifibatide. Baseline characteristics were similar in the two groups. 55% of the patients underwent PCI for acute ST-elevation myocardial infarction and 41% for unstable coronary artery disease. There were trends for lower mortality among abciximab-treated than among the eptifibatide-treated patients during in-hospital stay (0.6% vs 2.0%:NS) as well as during the six month follow up (2.3% vs 3.7%:NS). The combined endpoint of death, myocardial infarction, stroke, repeated revascularisation and serious bleeding occurred in 14.9% in the abciximab group vs 16.8% in the eptifibatide group (NS). CONCLUSION: The study could not demonstrate any significant deterioration of clinical results after a switch from abciximab to eptifibatide as routine GPIIb/IIIa inhibition during PCI. With respect to the limited number of patients a clinical significant difference between the two GPIIb/IIIa inhibitors cannot, however, be excluded.

Safety and delay time in prehospital thrombolysis of acute myocardial infarction in urban and rural areas in Sweden.

Sixteen hospitals in Sweden, including those in urban and more sparsely populated areas, and the associated ambulance organizations were enrolled in a prospective evaluation of the feasibility of treating patients with a ST-elevation infarction with a thrombolytic agent (reteplase) before hospital admission. A physician staffed the ambulances in 1% of cases, a nurse in 67%, and a staff nurse in 32% of cases. In all, 64 patients in urban areas and 90 patients in rural areas were included. The occurrence of complications before hospital admission was low and similar in the 2 groups. The median interval between the onset of symptoms and the start of thrombolysis was 1 hour 44 minutes in urban areas versus 2 hours 14 minutes in rural areas (P = 0.03). The median arrival time (interval between onset of symptoms and arrival of the ambulance) tended to be shorter in urban areas (1 hr 10 min vs 1 hr 33 min; not significant) and the median interval between the arrival of the ambulance and the start of thrombolysis was shorter in urban areas (27 min vs 36 min; P < 0.0001). When comparing urban areas with the least-populated rural areas, differences in various delay times became even more marked. Patients in urban areas had a higher ejection fraction and fewer symptoms of heart failure after 30 days and a lower 1-year mortality.