Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times. METHODS AND RESULTS: We developed a standardized treatment and transfer protocol for ST-segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time-to-treatment outcomes during the pre- and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI-capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P=0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes (P<0.001). There was a similar significant reduction in median time from receiving center door to balloon of 11 minutes less than the baseline time (P<0.01). CONCLUSIONS: Rural systems of care for ST-segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.

The effect of interhospital transfers, emergency medical services, and distance on ischemic time in a rural ST-elevation myocardial infarction system of care.

BACKGROUND: Regional myocardial infarction systems of care have been shown to improve timely access to primary percutaneous coronary intervention (PCI). However, there is a relatively sparse research on rural "frontier" regions. Arrival mode, high rates of interhospital transfers, long transport times, low population density, and mostly volunteer emergency medical services (EMS) distinguish this region from metropolitan systems of care. We sought to assess the effect of interhospital transfers, distance, and arrival mode on total ischemic times for patients with ST-elevation myocardial infarctions undergoing primary PCI. METHODS: We assessed patient data from our observational cohort of 395 patients with ST-elevation myocardial infarction with PCI as their primary treatment strategy. Data came from the 10 PCI hospitals participating in the Wyoming Mission: Lifeline program from January 2013 to September 2014. We performed both regression and tests of differences. RESULTS: Median total ischemic time was nearly 2.7 times greater in transferred patients than those presenting directly (379 vs 140 minutes). Distance in miles traveled between patient's home and PCI facility was 2.5 times larger in transfer patients (51 vs 20 miles). Emergency medical services arrival was associated with 23% shorter total ischemic times than self-arrival. CONCLUSIONS: Transfer patients from referral hospitals had significantly greater total ischemic time, and use of EMS was associated with significantly lower times. Transport distance was mixed in its effect. These findings suggest a continued focus on improving transitions between referral and receiving centers and enhancing coordination in rural systems of care to reduce the multiplier effect of transfers on total ischemic time.

Severe stress in an elderly woman causes a temporary "broken" heart.

This novel cardiac syndrome has clinical features that mimic those of acute myocardial infarction. The typical patient is a postmenopausal woman.

Routine functional testing after percutaneous coronary intervention: results of the aggressive diagnosis of restenosis in high-risk patients (ADORE II) trial.

BACKGROUND: It is unclear whether routine or selective functional testing is optimal following percutaneous coronary intervention (PCI) in high-risk patients. OBJECTIVES: The aim of this trial was to compare exercise endurance, functional status, and quality of life (QOL) among high-risk patients randomized to either routine or selective functional testing following PCI. METHODS: We randomized 84 patients to either routine or selective functional testing. Patients had one or more of the following: multivessel PCI, diabetes mellitus, left ventricular ejection fraction < 35%, and/or PCI of the proximal left anterior descending artery. Patients in the routine arm (n = 41) underwent maximum endurance exercise treadmill testing (ETT) with nuclear perfusion imaging at 1.5 and 6 months. Patients in the selective arm (n = 43) only underwent functional testing for a clinical indication. All patients underwent a maximum endurance ETT at 9 months. Exercise endurance, functional status, and QOL were assessed at 9 months. RESULTS: Most patients were middle-aged men (58 +/- 10 years old; 87% male) who underwent PCI with stenting (94%). Among routine functional testing patients, 27.0% and 41.9% had a positive functional test at 1.5 and 6 months, respectively. Exercise endurance was improved in the routine vs. selective arm at 9 months (metabolic equivalents: 10.3 +/- 2.6 vs. 8.6 +/- 3.0, P = 0.013). There was no difference in improvement from baseline for the Duke Activity Status Index, the Seattle Angina Questionnaire, or the SF-36. Nine-month cumulative incidences of cardiac procedures and clinical events were not significantly different. CONCLUSIONS: Routine functional testing following PCI in high-risk patients may lead to improved exercise endurance but not improved QOL.

Infection control guidelines for the cardiac catheterization laboratory: society guidelines revisited.

In the early years of diagnostic cardiac catheterization, strict sterile precautions were required for cutdown procedures. Thirteen years ago, when the original guidelines were written, the brachial arteriotomy was still frequently utilized, femoral closure devices were uncommon, "implantables," such as intracoronary stents and PFO/ASD closure devices, were in their infancy, and percutaneous valve replacement was not a consideration. In 2005, the cardiac catheterization laboratory is a complex interventional suite with percutaneous access routine and device implantation standard. Despite frequent device implantation, strict sterile precautions are often not observed. Reasons for this include a decline in brachial artery cutdown, limited postprocedure follow-up with few reported infections, limited use of hats and masks in televised cases, and lack of current guidelines. Proper sterile technique has the potential to decrease the patient infection rate. Hand washing remains the most important procedure for preventing infections. Caps, masks, gowns, and gloves help to protect the patient by maintaining a sterile field. Protection of personnel may be accomplished by proper gowning, gloving, and eye wear, disposal of contaminated equipment, and prevention and care of puncture wounds and lacerations. With the potential for acquired disease from blood-borne pathogens, the need for protective measures is as essential in the cardiac catheterization laboratory as is the standard Universal Precautions, which are applied throughout the hospital. All personnel should strongly consider vaccination for hepatitis B. Maintenance of the cardiac catheterization laboratory environment includes appropriate cleaning, limitation of traffic, and adequate ventilation. In an SCAI survey, members recommended an update on guidelines for infection control in the cardiac catheterization laboratory. The following revision of the original 1992 guidelines is written specifically to address the increased utilization of the catheterization laboratory as an interventional suite with device implantation. In this update, infection protection is divided into sections on the patient, the laboratory personnel, and the laboratory environment. Additionally, specific CDC recommendation sections highlight recommendations from other published guidelines.

The role of limited echocardiography and electrocardiography in screening physicals for amateur athletes.

Sudden cardiac death in seemingly healthy young people during exertion has led to preparticipation assessment of athletes. Typically, cardiac evaluation is limited to auscultation by a primary care provider. Screening electrocardiography is controversial. The value of limited echocardiography is unknown. High school athletes undergoing preparticipation evaluation for organized athletics completed a medical history questionnaire and were examined with standardized history and physical, 12-lead electrocardiogram, and a limited two-dimensional echocardiogram. The studies were interpreted by cardiologists. Of 95 subjects recruited, there were 55 females and 40 males. There were 10 abnormalities detected requiring further evaluation, two by electrocardiogram and eight by echocardiography. Only one abnormality was found with screening physical examination. Abnormalities occurred with similar frequency (13% vs. 9%) in those with and without cardiovascular symptoms. Screening echocardiography and electrocardiography are of benefit in identification of cardiac anomalies not appreciated on routine physical examinations. Further study of these screening modalities is warranted.