Impact of Helicopter Transport on Reperfusion Times and Long-Term Outcomes in Acute Myocardial Infarction Patients in Rural Areas: A Report From the Mie Acute Coronary Syndrome Registry.

OBJECTIVE: Helicopter emergency medical services (HEMS) are effective for time-sensitive conditions, such as stroke and trauma. However, prognostic data on helicopter transport for acute myocardial infarction (AMI) patients are insufficient. METHODS: We registered 2,681 AMI patients in the Mie Acute Coronary Syndrome Registry and enrolled 163 patients from rural areas to HEMS base hospitals with HEMS or ground emergency medical services (GEMS). They were categorized into 4 groups according to the transportation method for interhospital transfer (direct HEMS: n = 52, direct GEMS: n = 54, interhospital HEMS: n = 32, and interhospital GEMS: n = 25). The primary end point was the emergency medical services (EMS) call-to-balloon time. The secondary end point was 2-year major adverse cardiac and cerebrovascular events. RESULTS: The direct HEMS group was younger than the direct GEMS group (P = .029). The EMS call-to-balloon time was shorter in the direct HEMS and interhospital HEMS groups than in each GEMS group (P = .015 and P = .046). The incidence of 2-year major adverse cardiac and cerebrovascular events tended to be lower in both HEMS groups than in each GEMS group. CONCLUSION: Direct HEMS for AMI in rural areas shortens the time from the EMS call to reperfusion when the transport distance is expected to exceed 30 km, which may result in a better patient prognosis. In addition, prehospital diagnostic modalities, such as 12-lead electrocardiography and echocardiography, may shorten the duration from the EMS call to reperfusion.

Advanced atrioventricular block induced by obstructive sleep apnea before oxygen desaturation.

We report a patient with transient advanced atrioventricular (AV) block induced by obstructive sleep apnea (OSA). This 54-year-old man was diagnosed as having severe OSA and AV block with ventricular asystole for more than 6 s during overnight polysomnography, which occurred just from the onset of OSA before oxygen desaturation had occurred. An electrophysiological study revealed normal AV conduction system function and normal His-Purkinje system function. The resolution of OSA with continuous positive airway pressure therapy improved the advanced AV block. Therefore, the bradyarrhythmia was determined to be an OSA-induced AV block that occurred before oxygen desaturation.

Impact of heart rate on mechanical dyssynchrony and left ventricular contractility in patients with heart failure and normal QRS duration.

AIMS: The quantification of mechanical dyssynchrony has important diagnostic value and may help to determine optimal therapy in heart failure (HF). We hypothesized that mechanical dyssynchrony may be augmented at increased heart rates in patients with HF and normal QRS duration. METHODS AND RESULTS: From online segmental conductance catheter signals, we derived indices to quantify temporal and spatial aspects of mechanical dyssynchrony during systole in 20 control subjects, 20 HF patients with normal QRS duration, and 12 HF patients with complete left bundle branch block (CLBBB). Data were collected at baseline, and then following a 40 bpm increase in heart rate induced by right atrial pacing. Mechanical dyssynchrony in HF patients with normal QRS duration or CLBBB was higher than that found in control subjects. In HF patients with normal QRS duration, mechanical dyssynchrony increased from 37.4+/-4.8% at baseline to 43.2+/-4.4% with increased heart rate (p<0.01), the resultant degree of mechanical dyssynchrony was similar to that at baseline in the HF patients with CLBBB. Increased heart rate did not affect dyssynchrony in the control patients. CONCLUSION: Mechanical dyssynchrony was augmented as heart rate increased by right atrial pacing in patients with HF and normal QRS duration.

Impact of nicorandil to prevent reperfusion injury in patients with acute myocardial infarction: Sigmart Multicenter Angioplasty Revascularization Trial (SMART).

BACKGROUND: Nicorandil in conjunction with percutaneous coronary intervention (PCI) has been reported to reduce reperfusion injury events and improve cardiac function in patients with acute myocardial infarction (AMI). This multicenter study was undertaken to determine the effectiveness and optimal administration of nicorandil in AMI patients. METHODS AND RESULTS: Ninety-two patients with first AMI were randomly assigned to 1 of 3 groups: intracoronary administration of nicorandil (Group A), combined intravenous and intracoronary administration of nicorandil (Group B), and no nicorandil administration (Group C). The primary endpoint was a composite of the incidence of reperfusion-induced arrhythmia, chest pain, and no-reflow/slow-reflow. The secondary endpoint was the combined rate of improvement in the Thrombolysis in Myocardial Infarction frame count (cTFC) and ST resolution (STR). A significant difference was observed in the primary endpoint for Group B as compared with Group C (p<0.05). In the meantime, a significant improvement was shown in the secondary endpoint for Group B compared with Group C (p=0.04 and 0.006 for cTFC and STR, respectively). CONCLUSIONS: Combined intravenous and intracoronary administration of nicorandil reduces reperfusion injury during PCI and improves the cTFC and STR in AMI, and appears to be preferable to intracoronary administration alone.

Impact of diabetes mellitus on angiographically silent coronary atherosclerosis.

Constrictive remodeling occurs in significant atherosclerotic lesions of the diabetic patient, but the impact of diabetes mellitus (DM) on the angiographically normal coronary artery is still unclear. Morphometric analysis using intravascular ultrasound (IVUS) prior to intervention evaluated 54 sites in 33 DM patients and 106 in 62 non-diabetic patients. Vessel area (VA) and lumen area (LA) were measured at angiographically normal sites in the vessel. Plaque area (PA) was calculated as VA - LA. Percentage plaque area (%PA) was calculated as PA VA. Even in the angiographically normal site, mild coronary atherosclerosis was detected by IVUS in both groups. In the patients with DM, VA and LA were significantly smaller than in the non-diabetic patient (15.5 vs 17.8 mm(2), p<0.01; and 10.1 vs 12.2 mm(2), p<0.01 respectively), whereas % PA was similar (34.5 vs 31.6%). At angiographically normal sites where mild coronary atherosclerosis is detected by IVUS, the coronary artery of diabetic patients is smaller than that of the non-diabetic. These results suggest impaired compensatory enlargement or some other constrictive mechanism has already occurred in the early stages of coronary atherosclerosis in patients with DM.