NHLBI-Sponsored Randomized Trial of Postconditioning During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction.

RATIONALE: Postconditioning at the time of primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction may reduce infarct size and improve myocardial salvage. However, clinical trials have shown inconsistent benefit. OBJECTIVE: We performed the first National Heart, Lung, and Blood Institute-sponsored trial of postconditioning in the United States using strict enrollment criteria to optimize the early benefits of postconditioning and assess its long-term effects on left ventricular (LV) function. METHODS AND RESULTS: We randomized 122 ST-segment-elevation myocardial infarction patients to postconditioning (4, 30 seconds PTCA [percutaneous transluminal coronary angioplasty] inflations/deflations)+PCI (n=65) versus routine PCI (n=57). All subjects had an occluded major epicardial artery (thrombolysis in myocardial infarction=0) with ischemic times between 1 and 6 hours with no evidence of preinfarction angina or collateral blood flow. Cardiac magnetic resonance imaging measured at 2 days post-PCI showed no difference between the postconditioning group and control in regards to infarct size (22.5±14.5 versus 24.0±18.5 g), myocardial salvage index (30.3±15.6% versus 31.5±23.6%), or mean LV ejection fraction. Magnetic resonance imaging at 12 months showed a significant recovery of LV ejection fraction in both groups (61.0±11.4% and 61.4±9.1%; P<0.01). Subjects randomized to postconditioning experienced more favorable remodeling over 1 year (LV end-diastolic volume =157±34 to 150±38 mL) compared with the control group (157±40 to 165±45 mL; P<0.03) and reduced microvascular obstruction ( P=0.05) on baseline magnetic resonance imaging and significantly less adverse LV remodeling compared with control subjects with microvascular obstruction ( P<0.05). No significant adverse events were associated with the postconditioning protocol and all patients but one (hemorrhagic stroke) survived through 1 year of follow-up. CONCLUSIONS: We found no early benefit of postconditioning on infarct size, myocardial salvage index, and LV function compared with routine PCI. However, postconditioning was associated with improved LV remodeling at 1 year of follow-up, especially in subjects with microvascular obstruction. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01324453.

Causes of delay and associated mortality in patients transferred with ST-segment-elevation myocardial infarction.

BACKGROUND: Regional ST-segment-elevation myocardial infarction systems are being developed to improve timely access to primary percutaneous coronary intervention (PCI). System delays may diminish the mortality benefit achieved with primary PCI in ST-segment-elevation myocardial infarction patients, but the specific reasons for and clinical impact of delays in patients transferred for PCI are unknown. METHODS AND RESULTS: This was a prospective, observational study of 2034 patients transferred for primary PCI at a single center as part of a regional ST-segment-elevation myocardial infarction system from March 2003 to December 2009. Despite long-distance transfers, 30.4% of patients (n=613) were treated in ≤ 90 minutes and 65.7% (n=1324) were treated in ≤ 120 minutes. Delays occurred most frequently at the referral hospital (64.0%, n=1298), followed by the PCI center (15.7%, n=317) and transport (12.6%, n=255). For the referral hospital, the most common reasons for delay were awaiting transport (26.4%, n=535) and emergency department delays (14.3%, n=289). Diagnostic dilemmas (median, 95.5 minutes; 25th and 75th percentiles, 72-127 minutes) and nondiagnostic initial ECGs (81 minutes; 64-110.5 minutes) led to delays of the greatest magnitude. Delays caused by cardiac arrest and/or cardiogenic shock had the highest in-hospital mortality (30.6%), in contrast with nondiagnostic initial ECGs, which, despite long treatment delays, did not affect mortality (0%). Significant variation in both the magnitude and clinical impact of delays also occurred during the transport and PCI center segments. CONCLUSIONS: Treatment delays occur even in efficient systems for ST-segment-elevation myocardial infarction care. The clinical impact of specific delays in interhospital transfer for PCI varies according to the cause of the delay.

Clopidogrel pretreatment in ST-elevation myocardial infarction patients transferred for percutaneous coronary intervention.

BACKGROUND: Pretreatment with clopidogrel reduces ischemic complications before percutaneous coronary intervention (PCI). Limited data exist regarding the effect of pretreatment for ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. METHODS: Prospective data were analyzed from a regional STEMI system using rapid transfer for primary PCI in 30 community hospitals. Zone 1 community hospitals are <60 miles and Zone 2 hospitals are 60 to 210 miles away from the PCI hospital. Compared with 63 minutes in the PCI hospital, median door-to-balloon times were 94 minutes in Zone 1 and 123 minutes in Zone 2 hospitals. All patients received aspirin, unfractionated heparin, and clopidogrel 600 mg in the emergency department of the presenting hospital within 15 minutes of diagnosis. RESULTS: From April 2003 through December 2008, 2,014 consecutive STEMI patients were pretreated with clopidogrel before PCI, with a median (25th-75th percentile) duration from pretreatment to PCI of 75 (58-93) minutes. Patients with longer pretreatment duration had significantly reduced reinfarction/reischemia at 30 days (Zone 1: 0.85%, Zone 2: 0.9%) compared with nontransferred patients (3.2%, P = .001) as well as reduced stent thrombosis (Zone 1: 0.6%, Zone 2: 0.6% vs Abbott Northwestern: 2.0%; P = .04). Similarly, pretreatment duration of >60 minutes before PCI had reduced 30-day reinfarction/reischemia (1.0% vs 2.9%, P = .003). There were no significant differences in mortality or major bleeding. CONCLUSION: ST-segment elevation myocardial infarction patients undergoing primary PCI in a regional STEMI network who received earlier pretreatment with a 600-mg loading dose of clopidogrel had less ischemic complications without increased bleeding or mortality.

Sleep Deprivation in Cardiology: A Multidisciplinary Survey.

BACKGROUND: The burden and impact of sleep deprivation in cardiology has received limited study. METHODS: A multidisciplinary, online survey on sleep health patterns and sleep deprivation involving 44 closed-ended questions was distributed via email list to cardiovascular workers. RESULTS: The survey was circulated among 6683 individuals, of whom 481 (7.2%) completed the survey; 80% of the respondents were men and 70% were interventional cardiologists. Nearly all (91%) had call responsibilities, with 43% doing ≥7 call-nights per month. Sleep disorders were reported in 25%, with 25% using sleep-inducing medications (8.4% at least once per week). The main factors diminishing the quality and/or quantity of sleep were related to work (66%), family and/or personal activities (56%), and staying up late at night writing or studying (48%). Sleep deprivation was associated with difficulty concentrating (58%), lack of motivation (56%), and irritability (68%). Work performance was felt to be hindered by 46% of participants and 8.6% reported an adverse event such as a complication and/ or negative patient outcome likely related to sleep deprivation. Many (56.5%) felt burnout and 85% opined that policies should exist allowing sleep-deprived individuals to go home early post call. CONCLUSIONS: Our survey provides insights into sleep health patterns among cardiovascular workers and potential factors contributing to sleep deprivation. Sleep deprivation may impact performance, with 8.6% of respondents describing sleep-deprivation related adverse events. Further study is required to both identify measures to attenuate the burden and better understand the impact of sleep deprivation on both health-care personnel and patient outcomes.

A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. METHODS AND RESULTS: We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [> or =80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. CONCLUSIONS: Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

Contemporary Arterial Access in the Cardiac Catheterization Laboratory.

Obtaining femoral and radial arterial access in the cardiac catheterization laboratory using state-of-the-art techniques is essential to optimize outcomes, patient satisfaction, and procedural efficiency. Although transradial access is increasingly used for coronary angiography and percutaneous coronary intervention, femoral access remains necessary for numerous procedures, many requiring large-bore access, including complex high-risk coronary interventions, structural procedures, and procedures involving mechanical circulatory support. For femoral access, contemporary access techniques should combine the use of fluoroscopy, ultrasound, micropuncture needle, femoral angiography, and vascular closure devices, when feasible. For radial access, ultrasound may reveal important anatomic features and expedite access. Despite randomized controlled trials supporting use of routine ultrasound guidance for femoral and/or radial arterial access, ultrasound remains underused in cardiac catheterization laboratories. This article reviews contemporary techniques to achieve optimal arterial access in the cardiac catheterization laboratory.

Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention.

BACKGROUND: Direct percutaneous coronary intervention (PCI) is the preferred method of reperfusion for ST-elevation myocardial infarction (STEMI). Transfer from community hospitals to PCI centers increases availability for direct PCI, which improves outcomes compared to fibrinolysis in Europe. It has been difficult to achieve similar door-to-balloon times for transfer patients in the United States. METHODS: We designed a standardized protocol and integrated system of transfer for patients with STEMI. We report the door-to-balloon times for the pre- and postpilot patients in the index hospital and describe the details of the current Level 1 MI Program. RESULTS: In the 15 months before the pilot project, the door-to-balloon time for patients receiving ad hoc transfer for direct PCI was 192 minutes, similar to the national average. The door-to-balloon time for the patients receiving rescue PCI after failed thrombolysis was 221 minutes. The standardized protocol decreased door-to-balloon time to 98 minutes in the pilot trial (P < .01) and has now been applied successfully in 29 community hospitals. CONCLUSIONS: Rapid transfer of patients with STEMI is feasible in the United States using a standardized protocol and integrated transfer system. This requires a team approach with cooperation between cardiologists, emergency physicians, nurses, and the emergency medical system as well as various health care organizations.

Outcomes of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients with previous coronary bypass surgery.

OBJECTIVES: This study sought to determine the contemporary clinical characteristics and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and previous coronary artery bypass graft (CABG), including those with a saphenous vein graft culprit lesion. BACKGROUND: The outcome of STEMI patients with previous CABG is reported to be inferior to those without previous CABG, but limited data is available from the primary percutaneous coronary intervention era. METHODS: Data was extracted from a large, regional STEMI system's prospective database, which contained 3,542 unique STEMI episodes from March 4, 2003 through April 22, 2012. RESULTS: Previous CABG was present in 249 patients (7%). Despite higher comorbidity, patients with versus those without previous CABG had similar in-hospital (4.8% vs. 5.2%; p = 0.82) and 1-year (10.8% vs. 9.1%; p = 0.36) mortality, but 5-year (24.9% vs. 14.2%; p < 0.001) mortality was higher. Patients with previous CABG have similar door-to-balloon times. The culprit vessel was the saphenous vein graft in 84 patients (34%), a native vessel in 104 (42%), with no clear culprit in 59 (24%). The left internal mammary artery graft was not a culprit in any patient. Mortality at 30 days (8.3% vs. 3.9% vs. 1.7%, p = 0.19) and 1 year (14.3% vs. 9.0% vs. 6.8%; p = 0.35) was higher (but not statistically) with a saphenous vein graft culprit and was equivalent at 5 years (25.0% vs. 26.0% vs. 20.3%; p = 0.71). CONCLUSIONS: Patients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.

Daughter-mother tako-tsubo cardiomyopathy.

The investigators describe the occurrence of an episode of acute tako-tsubo cardiomyopathy in a 51-year-old woman, which was followed, only days later, by an episode of acute tako-tsubo cardiomyopathy in her 74-year-old mother. The mother and daughter had distinctly different left ventricular contraction patterns, yet the left anterior descending coronary artery distribution was similar, extending beyond the left ventricular apex in both women. In conclusion, this unusual scenario suggests a familial predisposition to tako-tsubo cardiomyopathy. Furthermore, the daughter's event may have contributed to (or triggered) the tako-tsubo episode in her mother.

Catheter-induced left internal mammary artery dissection: a report of two cases and review of the literature.

Coronary artery dissection is a well-described but rare complication of diagnostic angiography. With increased numbers of patients undergoing coronary artery bypass grafting, the number of patients undergoing repeat angiography for chest pain should likewise increase. The authors report two cases of catheter-induced left internal mammary (LIMA) dissection and review the existing literature.