Use of the Sheathless Eaucath Is an Effective Strategy to Overcome Resistant Severe Radial Spasm.

Objectives: We aimed to assess the effectiveness of the sheathless Eaucath guiding catheter (SEGC) in overcoming severe spasm. Background: Radial spasm is a frequent challenge in transradial access (TRA) and can be difficult to manage. Methods: We performed a prospective observational study of 1000 consecutive patients undergoing coronary angiography with or without percutaneous coronary intervention. Patients with primary transfemoral access (TFA) or primary use of a sheathless guide catheter were excluded. Patients who developed angiographically confirmed severe spasm were treated with further sedation and vasodilators. If the conventional catheter would still not advance, it was exchanged for a SEGC. The primary endpoint was the successful passage of the SEGC through the radial with successful engagement of the coronary artery in patients with resistant severe spasm. Results: Primary TFA access was used in 58 (5.8%) and primary radial access with a SEGC in 44 (4.4%) patients. Of the remaining 898 patients, 888 (98.9%) had a radial sheath successfully inserted. Of these, 49 (5.5%) developed severe radial spasm with inability to advance the catheter. Following treatment with additional sedation and vasodilators, the severe spasm resolved in 5 (10.2%) patients. Passage of a SEGC was attempted in the remaining 44 patients with resistant severe spasm. Passage of the SEGC and engagement of coronary arteries were successful in all cases. There were no complications related to use of the SEGC. Conclusions: Our findings suggest that use of the SEGC for resistant severe spasm is highly effective, safe, and may reduce the need for conversion to TFA.

High flow oxygen and risk of mortality in patients with a suspected acute coronary syndrome: pragmatic, cluster randomised, crossover trial.

OBJECTIVE: To determine the association between high flow supplementary oxygen and 30 day mortality in patients presenting with a suspected acute coronary syndrome (ACS). DESIGN: Pragmatic, cluster randomised, crossover trial. SETTING: Four geographical regions in New Zealand. PARTICIPANTS: 40 872 patients with suspected or confirmed ACS included in the All New Zealand Acute Coronary Syndrome Quality Improvement registry or ambulance ACS pathway during the study periods. 20 304 patients were managed using the high oxygen protocol and 20 568 were managed using the low oxygen protocol. Final diagnosis of ST elevation myocardial infarction (STEMI) and non-STEMI were determined from the registry and ICD-10 discharge codes. INTERVENTIONS: The four geographical regions were randomly allocated to each of two oxygen protocols in six month blocks over two years. The high oxygen protocol recommended oxygen at 6-8 L/min by face mask for ischaemic symptoms or electrocardiographic changes, irrespective of the transcapillary oxygen saturation (SpO2). The low oxygen protocol recommended oxygen only if SpO2 was less than 90%, with a target SpO2 of less than 95%. MAIN OUTCOME MEASURE: 30 day all cause mortality determined from linkage to administrative data. RESULTS: Personal and clinical characteristics of patients managed under both oxygen protocols were well matched. For patients with suspected ACS, 30 day mortality for the high and low oxygen groups was 613 (3.0%) and 642 (3.1%), respectively (odds ratio 0.97, 95% confidence interval 0.86 to 1.08). For 4159 (10%) patients with STEMI, 30 day mortality for the high and low oxygen groups was 8.8% (n=178) and 10.6% (n=225), respectively (0.81, 0.66 to 1.00) and for 10 218 (25%) patients with non-STEMI was 3.6% (n=187) and 3.5% (n=176), respectively (1.05, 0.85 to 1.29). CONCLUSION: In a large patient cohort presenting with suspected ACS, high flow oxygen was not associated with an increase or decrease in 30 day mortality. TRIAL REGISTRATION: ANZ Clinical Trials ACTRN12616000461493.

Triple Therapy Versus Dual Antiplatelet Therapy for Patients with Atrial Fibrillation and Acute Coronary Syndromes: A Systematic Literature Review.

BACKGROUND: Patients with acute coronary syndromes (ACS) and a history of atrial fibrillation (AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines. We examined studies comparing clinical outcomes on DAPT versus TT for patients with AF and ACS. METHODS: We searched Medline, Medline pending, EMBASE and Evidence-Based Medicine Reviews databases for studies published between January 2000 to December 2016 in AF patients with ACS that compared DAPT and TT that reported ischaemic and/or bleeding outcomes. Studies that were not purely an AF population were excluded. RESULTS: Ten studies were included in the review, all of which were observational, 8 of which were retrospective. None of the studies detailed the specifics of treatment allocation. All but one were of AF patients with a mix of stable coronary disease and ACS patients. TT was associated with increased bleeding when compared to DAPT, with adjusted odds ratios ranging from 1.25 to 6.84. While the largest study reported a reduction in stroke associated with TT (odds ratio 0.67), two other studies reported non-significant increases in stroke with TT. Variable composite ischaemic endpoints were reported, none showing a statistical significant difference between DAPT and TT. CONCLUSION: In patients with ACS and AF, TT is likely to be associated with increased risk of bleeding, without a clear reduction in ischaemic endpoints. The quality of the evidence to support current guidelines for this patient group was generally poor.

Initiation of ß-blocker therapy and depression after acute myocardial infarction.

INTRODUCTION: Although ß-blockers reduce mortality after acute myocardial infarction (AMI), early reports linking ß-blocker use with subsequent depression have potentially limited their use in vulnerable patients. We sought to provide empirical evidence to support or refute this concern by examining the association between ß-blocker initiation and change in depressive symptoms in AMI patients. METHODS: Using data from 2 US multicenter, prospective registries of AMI patients, we examined 1-, 6-, and 12-month changes in depressive symptoms after the index hospitalization among patients who were ß-blocker-naïve on admission. Depressive symptoms were assessed using the validated 8-item Patient Health Questionnaire (PHQ-8), which rates depressive symptoms from 0 to 24, with higher scores indicating more depressive symptoms. A propensity-matched repeated-measures linear regression model was used to compare change in depressive symptoms among patients who were and were not initiated on a ß-blocker after AMI. RESULTS: Of 3,470 AMI patients who were ß-blocker-naïve on admission, 3,190 (91.9%) were initiated on a ß-blocker and 280 (8.1%) were not. Baseline PHQ-8 scores were higher in patients not initiated on a ß-blocker (mean 5.78 ± 5.45 vs 4.88 ± 5.11, P = .005). PHQ-8 scores were progressively lower at 1, 6, and 12 months in both the ß-blocker (mean decrease at 12 months 1.16, P < .0001) and no-ß-blocker groups (mean decrease 1.71, P < .0001). After propensity matching 201 untreated patients with 567 treated patients, initiation of ß-blocker therapy was not associated with a difference in mean change in PHQ-8 scores at 1, 6, or 12 months after AMI (absolute mean difference with ß-blocker initiation at 12 months of 0.08, 95% CI -0.81 to 0.96, P = .86). CONCLUSIONS: Initiation of ß-blocker therapy after AMI was not associated with an increase in depressive symptoms. Restricting ß-blocker use because of concerns about depression appears unwarranted and may lead to undertreatment of AMI patients.

High-concentration versus titrated oxygen therapy in ST-elevation myocardial infarction: a pilot randomized controlled trial.

BACKGROUND: The optimal approach to oxygen therapy in ST-elevation myocardial infarction (STEMI) is uncertain. METHODS: A randomized controlled trial was undertaken in which 136 patients presenting with their first STEMI uncomplicated by cardiogenic shock or marked hypoxia were randomized to receive high-concentration (6 L/min via medium concentration mask) or titrated oxygen (to achieve oxygen saturation 93%-96%) for 6 hours after presentation. The main outcome variables were 30-day mortality and infarct size assessed by troponin T level at 72 hours. Secondary outcomes included a meta-analysis of mortality data from this study and previous randomized controlled trials, and infarct size was assessed by magnetic resonance imaging at 4 to 6 weeks. RESULTS: There were 1 of 68 and 2 of 68 deaths in the high-concentration and titrated oxygen groups, respectively; a meta-analysis including these data with those from the 2 previous studies showed an odds ratio for mortality of high-concentration oxygen compared with room air or titrated oxygen of 2.2 (95% CI 0.8-6.0). There was no significant difference between high-concentration versus titrated oxygen in troponin T (ratio of mean levels 0.74, 95% CI 0.50-1.1, P = .14), infarct mass (mean difference -0.8 g, 95% CI -7.6 to 6.1, P = .82), or percent infarct mass (mean difference -0.6%, 95% CI -5.6 to 4.5, P = .83). CONCLUSION: This study found no evidence of benefit or harm from high-concentration compared with titrated oxygen in initially uncomplicated STEMI. However, our estimates have wide CIs, and as a result, large randomized controlled trials are required to resolve the clinical uncertainty.

A randomised controlled trial of the effect of high concentration oxygen on myocardial ischaemia during exercise.

BACKGROUND: International guidelines recommend the use of oxygen for angina, based on Level C evidence. We aimed to determine whether high concentration oxygen influences the time to exercise-induced ischaemia or angina in patients with stable ischaemic heart disease (IHD). METHODS: 22 subjects with IHD and a positive exercise treadmill test (ETT) awaiting coronary angiography were randomised to two further ETTs according to a double-blind, crossover study design, during which they breathed oxygen or air at 15 L/min via a non-rebreather mask. Subjects in whom significant coronary artery disease was not subsequently confirmed by coronary angiography were excluded from analysis. The primary outcome was time to exercise-induced myocardial ischaemia, defined as ≥ 1 mm ST depression on contiguous electrocardiographic (ECG) leads. The secondary outcome was time to onset of angina. RESULTS: Exercise-induced myocardial ischaemia occurred in 17 of the 19 subjects with coronary artery disease, with the remaining two stopping due to shortness of breath. The mean (SD) time to inducible ischaemia was 35 (47) s longer (95% CI 11 to 59, P=0.007) with oxygen compared to air. Exercise-induced angina occurred in 9 subjects and started a mean 19 (32) s later (95% CI -6 to 43, P=0.12) with oxygen compared to air. All subjects who developed myocardial ischaemia or angina did so during both of the study ETTs. CONCLUSION: High concentration oxygen increases the time to onset of exercise-induced myocardial ischaemia in patients with stable IHD.

Same-day discharge is feasible and safe in the majority of elderly patients undergoing elective percutaneous coronary intervention.

BACKGROUND: Same-day discharge after elective percutaneous coronary intervention (PCI) is safe in the majority of patients. However, the elderly have more comorbidities and less favorable coronary and peripheral arterial anatomy, which may preclude safe same-day discharge after PCI. We assessed the feasibility and safety of same-day discharge in an elderly cohort of patients. METHODS: A total of 1,580 consecutive patients undergoing elective PCI in a single center between January 2001 and January 2009 were included in the study. We compared the outcomes of elderly patients aged 75 or older to control patients under the age of 75 years. Patients were examined 6 hours post procedure and discharged if there were no complications. RESULTS: Of the 1,580 study patients 212 (13.4%) were elderly and 1,365 (86.6%) were younger controls. The elderly were more likely to be female, hypertensive and to have had previous coronary artery bypass graft (CABG) surgery and less likely to be smokers or to have hyperlipidemia (all p < 0.05). The number of lesions treated and their complexity were similar in both groups. Procedural success, in-hospital major adverse cardiac events (MACE) and the rates of same-day discharge were also similar in both groups. Same-day discharge was achieved in the majority (84%) of the elderly. There were no deaths within 24 hours of discharge. Readmission within 24 hours of discharge was rare (< 0.7%) in both groups. The 30-day MACE rate was low in both the elderly (3.3%) and control groups (3.6%; p = 1.0). CONCLUSIONS: Same-day discharge is safe and feasible in the majority of elderly patients following elective PCI.

Paramedic-administered prehospital thrombolysis is safe and reduces time to treatment.

INTRODUCTION: The Kapiti Coast region is remote from Wellington Hospital with an ambulance transport time of 1 hour. To reduce delays in the treatment of myocardial infarction (MI), a prehospital thrombolysis (PHT) programme was initiated in 2003. METHODS: This study evaluated outcomes of the Kapiti PHT programme between 2003 and 2007. Paramedics attending patients with suspected MI-transmitted electrocardiograms to our Coronary Care Unit where a physician made the decision whether or not to thrombolyse. Thrombolysis was then administered by a paramedic. Patients from the Kapiti region treated with in-hospital thrombolysis (IHT) between 1999 and 2003 formed the control group. RESULTS: A total of 50 Kapiti patients received PHT. The group receiving IHT were older than those receiving PHT but other baseline characteristics were similar. No patients without MI or with a contraindication received PHT. In the PHT group there was one minor bleed but no major bleeding, stroke or death occurred during transport to hospital. The median scene to thrombolytic time for PHT was 89 minutes faster (44 minutes versus 133, P<0.0001) than in patients transferred for IHT. The median scene to thrombolytic time for PHT was similar to the door to thrombolytic time for IHT (P=0.13). In-hospital mortality in the PHT group (8.0%) was similar to the IHT group (6.0%, P=1.0) but heart failure was reduced (10% vs. 26%, P=0.04) CONCLUSIONS: Prehospital thrombolysis administered by paramedics is safe and reduces the time to treatment and was associated with a reduction in heart failure.

Systematic review of studies of the effect of hyperoxia on coronary blood flow.

BACKGROUND: International guidelines recommend the routine use of oxygen in the initial treatment of myocardial infarction, yet it is uncertain what effect this might have on physiologic and clinical outcomes. METHODS: We undertook a systematic search of Medline, Cochrane Database of Systematic Reviews, EMBASE, and CINHAL using the key words "oxygen," "coronary blood flow," "hyperoxia," and "coronary circulation" to identify human studies involving a measure of coronary blood flow while breathing oxygen and room air. The primary outcome measure was coronary blood flow; secondary outcomes included coronary vascular resistance and myocardial oxygen consumption. RESULTS: From 2,072 potential publications, there were 6 studies from 4 publications that met the inclusion criteria, with 6 healthy subjects and 61 subjects with cardiac disease. It was not possible to undertake a meta-analysis due to methodological limitations. In the 6 studies, high-concentration oxygen therapy resulted in hyperoxia, with a range in mean Pao(2) of 273 to 425 mm Hg. Hyperoxia caused a significant reduction in coronary blood flow (mean change -7.9% to -28.9%, n = 6 studies). Hyperoxia caused a significant increase in coronary vascular resistance (mean change 21.5% to 40.9%, n = 4 studies) and a significant reduction in myocardial oxygen consumption (mean change -15.3% to -26.9%, n = 3 studies). CONCLUSIONS: Hyperoxia from high-concentration oxygen therapy causes a marked reduction in coronary blood flow and myocardial oxygen consumption. These physiologic effects may have the potential to cause harm and are relevant to the use of high-concentration oxygen therapy in the treatment of cardiac and other disorders.

International medical graduates' training needs: perceptions of New Zealand hospital staff.

OBJECTIVE: To determine the opinion of New Zealand doctors and nurses on the possible training needs of international medical graduates (IMGS) in New Zealand hospitals. DESIGN: A postal questionnaire sent to hospital doctors and nurses. METHODS: All doctors working at Wellington, Kenepuru, and Hutt Hospitals in the greater Wellington region, and nurses working in acute medical wards at the same hospitals, were asked to complete a questionnaire based on the Northern Clinical Training Network and Capital Coast District Health Board resident medical officer assessment forms regarding an overseas-trained doctor they had worked with in the last year. RESULTS: The response rate for the doctor's questionnaires was 68/174 (39.1%), with 51 of these from New Zealand doctors rating an international medical graduate. The response rate for the nurses was 58/60 (96.7%). Areas where the median score of the questionnaire was unsatisfactory (less than three out of five on an ordinal scale rating performance) were clinical documentation; communication with patients, families, and other health professionals; knowledge of hospital policies and procedures, and medicolegal matters; and some aspects of patient management. There was no difference in median ratings between doctors and nurses. CONCLUSIONS: More specific training may improve the performance of overseas-trained doctors in the New Zealand health system. A further study of the perceived needs of the overseas-trained doctors themselves may be useful.