Effectiveness and Safety of P2Y12 Inhibitors Pretreatment in Primary Percutaneous Coronary Intervention with Long Transfer Times.

BACKGROUND: Early initiation of a new P2Y12 inhibitor in ST-elevation myocardial infarction (STEMI) patients prior to primary percutaneous coronary intervention (PCI) is recommended over clopidogrel. However, comparative data remain limited, especially in semi-rural regions with subsequent longer transfer times. OBJECTIVES: We aimed to assess the determinants, effectiveness, and safety of pretreatment with new P2Y12 inhibitors compared with clopidogrel in a primary PCI regional network. METHODS: Outcomes of 1235 primary PCI patients pretreated with new P2Y12 inhibitors (n = 1050) or clopidogrel (n = 185) were evaluated using a prospective registry. Primary effectiveness endpoint was the composite of death, recurrent myocardial infarction, stroke, or new revascularization. Serious bleedings were defined as Bleeding Academic Research Consortium ≥ 2. RESULTS: Clopidogrel was more likely to be used in older and female patients with more comorbidities. Mean transfer time was longer in the clopidogrel group (123.3 ± 67.3 vs. 102.3 ± 57.2 min; p < 0.01). The primary endpoint was less frequent with new P2Y12 inhibitors compared with clopidogrel (14.9 vs. 30.3%; odds ratio 0.58, 95% confidence interval [CI] 0.39-0.87; p < 0.01), mostly driven by a reduced rate of death (4.5 vs. 26% respectively; hazard ratio 0.25, 95% CI 0.16-0.38; p < 0.01). Bleeding rates did not differ between groups (1 vs. 0.5%, respectively; p = 0.96). CONCLUSION: Compared with clopidogrel, pretreatment with new P2Y12 inhibitors seems to be associated with lower risks of mortality and ischemic outcomes, and similar risks of bleeding in a real-world registry. Our results are in line with the guidelines recommending the preferential pre-PCI administration of new P2Y12 inhibitors in STEMI patients referred for primary PCI.

Impact of a feedback device on chest compression quality during extended manikin CPR: a randomized crossover study.

PURPOSES: Chest compressions require physical effort leading to increased fatigue and rapid degradation in the quality of cardiopulmonary resuscitation overtime. Despite harmful effect of interrupting chest compressions, current guidelines recommend that rescuers switch every 2 minutes. The impact on the quality of chest compressions during extended cardiopulmonary resuscitation has yet to be assessed. BASIC PROCEDURES: We conducted randomized crossover study on manikin (ResusciAnne; Laerdal). After randomization, 60 professional emergency rescuers performed 2 × 10 minutes of continuous chest compressions with and without a feedback device (CPRmeter). Efficient compression rate (primary outcome) was defined as the frequency target reached along with depth and leaning at the same time (recorded continuously). MAIN FINDINGS: The 10-minute mean efficient compression rate was significantly better in the feedback group: 42% vs 21% (P< .001). There was no significant difference between the first (43%) and the tenth minute (36%; P= .068) with feedback. Conversely, a significant difference was evident from the second minute without feedback (35% initially vs 27%; P< .001). The efficient compression rate difference with and without feedback was significant every minute, from the second minute onwards. CPRmeter feedback significantly improved chest compression depth from the first minute, leaning from the second minute and rate from the third minute. PRINCIPAL CONCLUSIONS: A real-time feedback device delivers longer effective, steadier chest compressions over time. An extrapolation of these results from simulation may allow rescuer switches to be carried out beyond the currently recommended 2 minutes when a feedback device is used.

Improvement in chest compression quality using a feedback device (CPRmeter): a simulation randomized crossover study.

PURPOSES: Cardiac arrest survival depends on celerity and efficiency of life support action. Guidelines emphasized the chest compression (CC) quality and feedback devices are encouraged. The purpose is to study the impact of the CPRmeter feedback device on resuscitation performed by untrained rescuers. BASIC PROCEDURES: This is a prospective randomized crossover study on manikins (Resusci Anne). One hundred and forty four students inexperienced in cardiopulmonary resuscitation representing untrained rescuers were included. Participants performed 2 minutes of CC without interruption with (group G) or without (group B) feedback. Four months passed between the 2 crossover phases to avoid resilience effect. Data collected by the CPRmeter device were: CC rate, depth and release. MAIN FINDINGS: Efficient CC rate ([simultaneous and correct CC rate, depth and release] primary outcome) (absolute difference [95% CI]) was significantly improved in group G (71%) compared to group B (26%; [45 {36-55}]; P < .0001). Adequate depth rate (>38 mm) was significantly improved in group G (85%) compared to group B (43%; [42 {33-52}]; P < .0001). Adequate CC rate (90-120/min) was significantly improved in group G (81%) compared to group B (56%; [25 {15-35}]; P < .0001). The average CC rate and depth in group G were significantly less dispersed around the mean compared to group B (test of variance P < .007; P < .015 respectively). PRINCIPAL CONCLUSIONS: The use of the CPRmeter significantly improved CC quality performed by students inexperienced in cardiopulmonary resuscitation.

Mild hypothermia during advanced life support: a preliminary study in out-of-hospital cardiac arrest.

INTRODUCTION: Induction of mild hypothermia after cardiac arrest may confer neuroprotection. We assessed the feasibility, safety and effectiveness of therapeutic infusion of 2 l of normal saline at 4 degrees C before return of spontaneous circulation during cardiopulmonary resuscitation after out of hospital cardiac arrest. METHODS: This was a prospective, observational, multicenter clinical trial conducted in Emergency Medical Services units and in a medical intensive care unit at Caen University Hospital, Cen, France. RESULTS: In patients who had suffered out of hospital cardiac arrest, hypothermia was induced by infusing 2 l of 4 degrees C NaCl 0.9% over 30 minutes during advanced life support prior to arrival at the hospital. A total of 33 patients were included in the study. Eight patients presented with ventricular fibrillation as the initial cardiac rhythm. Mild hypothermia was achieved after a median of 16 minutes (interquartile range 11.5 to 25.0 minutes) after return of spontaneous circulation. After intravenous cooling, the temperature decreased by 2.1 degrees C (P < 0.0001) to a mean body temperature of 33.3 degrees C (interquartile range 32.3 to 34.3 degrees C). The only observed adverse event was pulmonary oedema, which occurred in one patient. CONCLUSION: We concluded that prehospital induction of therapeutic hypothermia using infusion of 2 l of 4 degrees C normal saline during advanced life support was feasible, effective and safe. Larger studies are required to assess the impact that this early cooling has on neurological outcomes after cardiac arrest.