Changes in treatment for NSTEMI in women and the elderly over the past 16 years in a large real-world population.

AIMS: This study investigates the changes in therapy for Non-ST-Elevation Myocardial Infarction (NSTEMI) over the past 16 years in a large German registry. In particular, the high-risk population of female and elderly patients was analyzed. METHODS: In total, 19.383 patients presenting with NSTEMI were included in this study. Patients were stratified by age groups <75 years and ≥75 years and by sex. Four different time periods from 2000-2004, 2005-2008, 2009-2012 and 2013-2016 were compared. Influence on hospital mortality as the primary outcome measure was assessed by logistic regression analysis. Secondary outcome measures included percutaneous coronary intervention (PCI), the use of drug eluting stents (DES), radial access route and major adverse cardiovascular events (MACE), defined as all-cause mortality, stroke, re-infarction, percutaneous re-intervention, intervention-related bleeding, cardiopulmonary resuscitation and new onset of cardiogenic shock or need for mechanical ventilation. RESULTS: Mortality decreased in all age groups between the initial time period and the most recent one (8.9% vs. 4.5%, p < 0.01), particularly in female patients ≥75 years (18.2% in 2000-2004 vs. 7.9% in 2013-2016, p < 0.01). Revascularization rates differed by gender (68.3% in women vs. 78.1% in men, p < 0.01) and by age (64.2% for ≥75 years vs. 80.9% for <75 years, p < 0.01). PCI rates in elderly female patients increased from 28.7% to 69.8% (p < 0.01) from the initial to the latest period. CONCLUSIONS: The present study demonstrates, that revascularization rates improved in all patient groups over the study period. However, females and elderly patients still remain less likely to be treated according to current guidelines.

The Emergency Medical Care of Patients With Acute Myocardial Infarction.

BACKGROUND: Optimizing the emergency medical care chain might shorten the time to treatment of patients with ST-elevation myocardial infarction (STEMI). The initial care by a physician, and, in particular, correct ECG interpretation, are critically important factors. METHODS: From 1999 onward, data on the care of patients with myocardial infarction have been recorded and analyzed in the Berlin Myocardial Infarction Registry. In the First Medical Contact Study, data on initial emergency medical care were obtained on 1038 patients who had been initially treated by emergency physicians in 2012. Their pre-hospital ECGs were re-evaluated in a blinded fashion according to the criteria of the European Society of Cardiology. RESULTS: The retrospective re-evaluation of pre-hospital ECGs revealed that 756 of the 1038 patients had sustained a STEMI. The emergency physicians had correctly diagnosed STEMI in 472 patients (62.4%), and they had correctly diagnosed ventricular fibrillation in 85 patients (11.2%); in 199 patients (26.3%), the ECG interpretation was unclear. The pre-hospital ECG interpretation was significantly associated with the site of initial hospitalization and the ensuing times to treatment. In particular, the time from hospital admission to cardiac catheterization was longer in patients with an unclear initial ECG interpretation than in those with correctly diagnosed STEMI (121 [54; 705] vs. 36 [19; 60] minutes, p <0.001). After multivariate adjustment, this corresponded to a hazard ratio* of 2.67 [2.21; 3.24]. CONCLUSION: Pre-hospital ECG interpretation in patients with STEMI was a trigger factor with a major influence on the time to treatment in the hospital. The considerable percentage of pre-hospital ECGs whose interpretation was unclear implies that there is much room for improvement.

Complications in the clinical course of tako-tsubo cardiomyopathy.

OBJECTIVE: This study evaluated the frequency, severity and outcome of complications in the clinical course of tako-tsubo cardiomyopathy (TTC). BACKGROUND: TTC is regarded as a benign disease since left ventricular (LV) function returns to normal within a short time. However, severe complications have been reported in selected patients. METHODS: From 37 hospitals, 209 patients (189 female, age 69 ± 12 years) were prospectively included in a TTC registry. RESULTS: Complications developed in 108/209 patients (52%); 23 (11%) had >2 complications. Complications occurred median 1 day after symptom onset, and 77% were seen within 3 days. Arrhythmias were documented in 45/209 patients (22%) including atrial fibrillation in 32 (15%) and ventricular tachycardia in 17 (8%). Of 8 patients resuscitated (4%), 6 survived. Additional complications were right ventricular involvement (24%), pulmonary edema (13%), cardiogenic shock (7%), transient intraventricular pressure gradients (5%), LV thrombi (3%) and stroke (1%). During hospitalization, 5/209 patients (2.5%) died. Patients with complications were older (70 ± 13 vs 67 ± 10 years, p=0.012), had a higher heart rate (91 ± 26 vs 83 ± 19/min, p=0.025), more frequently Q\ waves on the admission ECG (36% vs 21%, p=0.019) and a lower LV ejection fraction (47 ± 15 vs 54 ± 14%, p = 0.002). Multivariate regression analysis identified Q-waves on admission (OR 2.49, 95% CI 1.23-5.05, p=0.021) and ejection fraction ≤ 30% (OR 4.03, 95% CI 1.04-15.67, p=0.022) as independent predictors for complications. CONCLUSIONS: TTC may be associated with severe complications in half of the patients. Since the majority of complications occur up to day 3, monitoring is advisable for this time period.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome in the real world: Data from the Berlin AFibACS Registry.

BACKGROUND: Guidelines for the management of atrial fibrillation (AFib) recommend antithromboembolic treatment strategies for patients with AFib and acute coronary syndrome (AFibACS). Our study assessed how current guidelines are implemented in the metropolitan area of Berlin and which therapeutic options were chosen in light of stroke and bleeding riskin everyday practice. METHODS AND RESULTS: Between April 2008 and January 2012, we included 1,295 AFibACS patients in the AFibACS Registry, as part of the Berlin Myocardial Infarction Registry. Meanage of the patients was 76 years with numerous comorbidities (15.4% former stroke, 35.0% renal failure, 43.5% diabetes, 92.8% hypertension). Of all the patients, 888 were treated with stent implantation, 91 with balloon angioplasty, and 316 conservatively. Overall mortality was 11.6%, and 8.3% in stented patients. At hospital discharge, triple therapy was administered to 49.9% of stented cases. After adjustment, odds of receiving triple therapy were lower within creasing age and renal failure. Odds were higher after stent implantation, with a higher CHA2DS2-VASc score, and with any AFib category compared to initially diagnosed AFib. Between 2008 and 2011, triple therapy increased from 33.3% to 49.8% for stented patients and did not change significantly for those treated conservatively or with balloon angioplasty. CONCLUSIONS: These data suggest that in AFibACS patients, antithrombotic treatment focused on dual antiplatelet therapy for ACS, rather than on anticoagulation therapy for stroke prevention. Factors influencing therapy at discharge were age, renal failure, stent implantation, AFib category, and CHA2DS2-VASc score. During the study period, triple therapy increased for stented patients.

Gender differences in the manifestation of tako-tsubo cardiomyopathy.

OBJECTIVE: This study evaluated if there are gender differences in the manifestation of tako-tsubo cardiomyopathy (TTC). BACKGROUND: TTC predominantly occurs in elderly females and mimics acute myocardial infarction (AMI) where men and women are known to have a different clinical profile. METHODS: 324 patients from 37 hospitals were prospectively included in a TTC registry. Clinical, electrocardiographic, angiographic and outcome data from male and female patients were compared. RESULTS: Of 324 patients 296 (91%) were female and 28 (9%) male. Mean age (68 ± 12 vs 66 ± 12 years) and prehospital delay were similar. A triggering event preceded TTC onset in 76% of women and 86% of men. Physical stress was more frequent in men (30% vs 57%, p=0.005) whereas more women experienced emotional or no stress. The prevalence of angina and dyspnea did not differ. Fewer females were admitted in cardiogenic shock and/or after out of hospital cardiac arrest (1% vs 14%, p=0.0006), and cardiac troponin was lower (median 7.2 vs 10.7 times the upper limit of normal, p=0.03). The QTc interval was longer in females than in males only on the day of admission (468 ± 52 vs 441 ± 51 ms, p=0.047). Overall, complications during the acute course (53% vs 40%) were comparable in both sexes. CONCLUSIONS: In this large TTC registry, males and females showed a similar clinical profile. In males, physical stress as a trigger event and shock or cardiac arrest as presenting symptoms were more frequent. The QTc interval was longer in females only on admission but similar in males and females during the following days.

Routine early invasive strategy and in-hospital mortality in women with non-ST-elevation myocardial infarction: results from the Berlin Myocardial Infarction Registry (BMIR).

BACKGROUND: It is under discussion whether female patients with non-ST-elevation myocardial infarction (NSTEMI) benefit from routine invasive treatment strategy. We accordingly applied our data from the Berlin Myocardial Infarction Registry (BMIR) to analyze the association between early percutaneous coronary intervention (PCI) and hospital mortality in NSTEMI patients. METHODS: Data prospectively collected in the BMIR between 2004 and 2008 from 2808 patients (m=1820/w=988) directly admitted to hospitals with 24-h PCI facilities were included in the analysis. After adjustment for confounding variables, we compared in-hospital mortality for patients of both sexes with vs. without early PCI. RESULTS: Women with NSTEMI were, on average, 7years older than men and demonstrated significantly more comorbidities. A GPIIb/IIIa antagonist was applied in women less often than in men (31.4% vs. 38.4%, p=0.001), and an early PCI was also performed less often in women than in men (64.0% vs. 76.2%, p<0.001). In-hospital mortality was higher in women than in men (5.4% vs. 3.6%, p=0.027). In female patients with NSTEMI, after adjustment for differences in patients' characteristics, hospital mortality did not differ between those treated with early PCI and those managed conservatively (OR: 1.24, 95% CI 0.53-2.91). In contrast, hospital mortality in male patients was lower in those treated with an early PCI (OR: 0.41, 95% CI 0.21-0.78). CONCLUSION: In our clinical registry, early PCI in female patients with NSTEMI was not associated with lower hospital mortality. Further randomized-controlled trials are needed to better understand which women may benefit from early invasive therapy, and under which conditions such benefits are possible.

Time of admission, quality of PCI care, and outcome of patients with ST-elevation myocardial infarction.

OBJECTIVE: Our study aimed to analyse the hospital mortality of patients admitted in- and off-regular working hours with ST-elevation myocardial infarction (STEMI) within the special logistical setting of the urban area of the city of Berlin. BACKGROUND: There is a debate whether patients with acute myocardial infarction admitted to hospital outside regular working hours experience higher mortality rates than those admitted within regular working hours. METHODS: This study analyses data from the Berlin Myocardial Infarction Registry and comprises 2,131 patients with STEMI and treated with percutaneous coronary intervention (PCI) in 2004-2007. Data of patients admitted during in- and off-regular working hours were compared. RESULTS: There was significant difference in door-to-balloon time (median in-hours: 79 min; median off-hours: 90 min, p < 0.001) and in hospital mortality (in-hours: 4.3%; off-hours: 6.8%, p = 0.020) between STEMI patients admitted in- and off-hours for treatment with PCI. After adjustment, admission off-hours remained an independent predictor for in-hospital death for patients (OR = 2.50; 95% CI 1.38-4.56). In patients with primary care from physician-escorted Emergency Medical Services (EMS), door-to-balloon time was reduced by 10 min for in-hours as well as off-hours patients. The difference in hospital mortality between off-hour and in-hour admission was reduced to a non-significant OR = 1.61 (95% CI 0.79-3.27). CONCLUSIONS: In conclusion, patients admitted off-hours experienced longer door-to-balloon times and higher hospital mortality than did those admitted in-hours. The differences observed between patients admitted in-hours and off-hours were reduced through physician-escorted EMS reflecting the influence of optimized STEMI care.

Improved therapy and outcome for patients with acute myocardial infarction--data of the Berlin Myocardial Infarction Registry from 1999 to 2004.

BACKGROUND: Guidelines for treatment of patients with myocardial infarction (MI) have been regularly updated. In addition, a new definition for acute MI has been recently established. The aim of our study was to evaluate development of treatment and effects on patient outcome. METHODS: We prospectively collected data from MI patients who were treated in 22 hospitals in Berlin, Germany, during the years 1999 to 2004. In the study we consecutively included 6080 MI patients presenting with (STEMI, n=4314) and without persistent ST-segment elevation (NSTEMI, n=1766). RESULTS: STEMI and NSTEMI patients showed an increase over time in arterial hypertension, smoking, hypercholesterolaemia, history of congestive heart failure, and renal failure. The application of acute percutaneous coronary intervention increased from 15.3% to 62.3% (p<0.001) for NSTEMI and from 24.7% to 71.8% (p<0.001) for STEMI patients. Concomitant therapy with beta-blockers, ACE inhibitors, statins, GP IIb/IIIa, and aspirin increased in parallel in both groups. The decrease in hospital mortality was more pronounced for NSTEMI (13.5% vs. 4.6%, p<0.001) than with STEMI patients (13.0% vs. 9.4%, p=0.005). CONCLUSIONS: Adherence to guidelines has led to a higher level of hospital care for NSTEMI and STEMI patients. Hospital mortality decreased for both groups, with a greater impact on NSTEMI patients.