RESUMO
AIMS: The present acute myocardial infarction (AMI) rule-out strategies are challenged by the late temporal release of cardiac troponin. Copeptin is a non-specific biomarker of endogenous stress and rises early in AMI, covering the early period where troponin is still normal. An accelerated dual-marker rule-out strategy combining prehospital copeptin and in-hospital high-sensitivity troponin T could reduce length of hospital stay and thus the burden on the health care systems worldwide. The AROMI trial aimed to evaluate if the accelerated dual-marker rule-out strategy could safely reduce length of stay in patients discharged after early rule-out of AMI. METHODS AND RESULTS: Patients with suspected AMI transported to hospital by ambulance were randomized 1:1 to either accelerated rule-out using copeptin measured in a prehospital blood sample and high-sensitivity troponin T measured at arrival to hospital or to standard rule-out using a 0 h/3 h rule-out strategy. The AROMI study included 4351 patients with suspected AMI. The accelerated dual-marker rule-out strategy reduced mean length of stay by 0.9 h (95% confidence interval 0.7-1.1 h) in patients discharged after rule-out of AMI and was non-inferior regarding 30-day major adverse cardiac events when compared to standard rule-out (absolute risk difference -0.4%, 95% confidence interval -2.5 to 1.7; P-value for non-inferiority = 0.013). CONCLUSION: Accelerated dual marker rule-out of AMI, using a combination of prehospital copeptin and first in-hospital high-sensitivity troponin T, reduces length of hospital stay without increasing the rate of 30-day major adverse cardiac events as compared to using a 0 h/3 h rule-out strategy.
Assuntos
Serviços Médicos de Emergência , Infarto do Miocárdio , Humanos , Troponina , Troponina T , Infarto do Miocárdio/diagnóstico , Glicopeptídeos , Biomarcadores , Hospitais , Valor Preditivo dos Testes , Dor no PeitoRESUMO
BACKGROUND: Smaller randomized studies have reported conflicting results regarding the optimal electrode position for cardioverting atrial fibrillation. However, anterior-posterior electrode positioning is widely used as a standard and believed to be superior to anterior-lateral electrode positioning. Therefore, we aimed to compare anterior-lateral and anterior-posterior electrode positioning for cardioverting atrial fibrillation in a multicenter randomized trial. METHODS: In this multicenter, investigator-initiated, open-label trial, we randomly assigned patients with atrial fibrillation scheduled for elective cardioversion to either anterior-lateral or anterior-posterior electrode positioning. The primary outcome was the proportion of patients in sinus rhythm after the first shock. The secondary outcome was the proportion of patients in sinus rhythm after up to 4 shocks escalating to maximum energy. Safety outcomes were any cases of arrhythmia during or after cardioversion, skin redness, and patient-reported periprocedural pain. RESULTS: We randomized 468 patients. The primary outcome occurred in 126 patients (54%) assigned to the anterior-lateral electrode position and in 77 patients (33%) assigned to the anterior-posterior electrode position (risk difference, 22 percentage points [95% CI, 13-30]; P<0.001). The number of patients in sinus rhythm after the final cardioversion shock was 216 (93%) assigned to anterior-lateral electrode positioning and 200 (85%) assigned to anterior-posterior electrode positioning (risk difference, 7 percentage points [95% CI, 2-12]). There were no significant differences between groups in any safety outcomes. CONCLUSIONS: Anterior-lateral electrode positioning was more effective than anterior-posterior electrode positioning for biphasic cardioversion of atrial fibrillation. There were no significant differences in any safety outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03817372.
Assuntos
Fibrilação Atrial/terapia , Cardioversão Elétrica/métodos , Eletrodos/normas , Feminino , Humanos , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do TratamentoRESUMO
BACKGROUND: To investigate if acute pulmonary vasodilation by sildenafil improves right ventricular function in patients with acute intermediate-high risk pulmonary embolism (PE). METHODS: Single center, explorative trial. Patients with PE were randomized to a single oral dose of sildenafil 50 mg (n = 10) or placebo (n = 10) as add-on to conventional therapy. The time from hospital admission to study inclusion was 2.3 ± 0.7 days. Right ventricular function was evaluated immediately before and shortly after (0.5-1.5 h) randomization by right heart catheterization (RHC), trans-thoracic echocardiography (TTE), and cardiac magnetic resonance (CMR). The primary efficacy endpoint was cardiac index measured by CMR. RESULTS: Patients had acute intermediate-high risk PE verified by computed tomography pulmonary angiography, systolic blood pressure of 135 ± 18 (mean ± SD) mmHg, increased right ventricular/left ventricular ratio 1.1 ± 0.09 and increased troponin T 167 ± 144 ng/L. Sildenafil treatment did not improve cardiac index compared to baseline (0.02 ± 0.36 l/min/m2, p = 0.89) and neither did placebo (0.00 ± 0.34 l/min/m2, p = 0.97). Sildenafil lowered mean arterial blood pressure (- 19 ± 10 mmHg, p < 0.001) which was not observed in the placebo group (0 ± 9 mmHg, p = 0.97). CONCLUSION: A single oral dose of sildenafil 50 mg did not improve cardiac index but lowered systemic blood pressure in patients with acute intermediate-high risk PE. The time from PE to intervention, a small patient sample size and low pulmonary vascular resistance are limitations of this study that should be considered when interpreting the results. TRIAL REGISTRATION: The trial was retrospectively registered at www.clinicaltrials.gov (NCT04283240) February 2nd 2020, https://clinicaltrials.gov/ct2/show/NCT04283240?term=NCT04283240&draw=2&rank=1 .
Assuntos
Pressão Arterial/efeitos dos fármacos , Ventrículos do Coração/efeitos dos fármacos , Embolia Pulmonar/tratamento farmacológico , Citrato de Sildenafila/uso terapêutico , Vasodilatação/efeitos dos fármacos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Citrato de Sildenafila/farmacologia , Resultado do Tratamento , Resistência Vascular/efeitos dos fármacosRESUMO
BACKGROUND: Chest pain is common in acute ambulance transports. This study aims to characterize and compare ambulance-transported chest pain patients to non-chest pain patients and evaluate if patient characteristics and accompanying symptoms accessible at the time of emergency call can predict cause and outcome in chest pain patients. METHODS: Retrospective, observational population-based study, including acute ambulance transports. Patient characteristics and symptoms are included in a multivariable risk model to identify characteristics, associated with being discharged without an acute cardiac diagnosis and surviving 30 days after chest pain event. RESULTS: In total, 10,033 of 61,088 (16.4%) acute ambulance transports were due to chest pain. In chest pain patients, 30-day mortality was 2.1% (95%CI 1.8-2.4) compared to 6.0% (95%CI 5.7-6.2) in non-chest pain patients. Of chest pain patients, 1054 (10.5%) were diagnosed with acute myocardial infarction, and 5068 (50.5%) were discharged without any diagnosis of disease. This no-diagnosis group had very low 30-day mortality, 0.4% (95%CI 0.2-0.9). Female gender, younger age, chronic pulmonary disease, absence of accompanying symptoms of dyspnoea, radiation, severe pain for > 5 min, clammy skin, uncomfortable, and nausea were associated with being discharged without an acute cardiac diagnosis and surviving 30 days after a chest pain event. CONCLUSION: Chest pain is a common reason for ambulance transport, but the majority of patients are discharged without a diagnosis and with a high survival rate. Early risk prediction seems to hold a potential for resource downgrading and thus cost-saving in selected chest pain patients.
Assuntos
Ambulâncias , Dor no Peito/epidemiologia , Adulto , Idoso , Dinamarca , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Prevalência , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
The optimal timing of coronary angiography (CAG) in high-risk patients with acute coronary syndrome without persisting ST-segment elevation (NST-ACS) remains undetermined. The NON-ST-Elevation Myocardial Infarction trial aimed to compare outcomes in NSTE-ACS patients randomized to acute CAG (STEMI-like approach) with patients randomized to medical therapy and subacute CAG. We randomized 496 patients with suspected NST-ACS based on symptoms and significant regional ST depressions and/or elevated point-of-care troponin T (POC-cTnT) (≥50 ng/l) to either acute CAG (<2 hours, nâ¯=â¯245) or subacute CAG (<72 hours, nâ¯=â¯251). The primary end point was a composite of all-cause death, reinfarction, and readmission with congestive heart failure within 1 year from randomization. A final acute coronary syndrome (ACS) diagnosis was assigned to 429 (86.5%) patients. The median time from randomization to revascularization was 1.3 hours in the acute CAG group versus 51.1 hours in the subacute CAG group (p <0.001). The composite end point occurred in 25 patients (10.2%) in the acute CAG group and 29 (11.6%) in the subacute CAG group, pâ¯=â¯0.62. The acute CAG group had a 1-year all-cause mortality of 5.7% compared with 5.6% in the subacute CAG group, pâ¯=â¯0.96. In conclusion, neither the composite end point of all-cause death, reinfarction, and readmission with congestive heart failure nor mortality differed between an acute and subacute CAG approach in NSTE-ACS patients. However, identification of NSTE-ACS patients in the prehospital phase and direct triage to an invasive center is feasible, safe and may facilitate early diagnosis and revascularization.
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Síndrome Coronariana Aguda/diagnóstico , Angiografia Coronária/métodos , Vasos Coronários/diagnóstico por imagem , Eletrocardiografia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Idoso , Dinamarca/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Taxa de Sobrevida/tendências , Fatores de Tempo , Troponina TRESUMO
BACKGROUND: Suspicion of acute myocardial infarction (AMI) is among the most common reasons for admission to hospital in Denmark. Owing to this suspicion, an estimated 50,000 patients are admitted every year. Only 15-20% are finally diagnosed with AMI, whereas 40% are discharged after rule-out of AMI and without initiation of any treatment or need for further admission. In patients discharged after rule-out, the current diagnostic protocol, using consecutive troponin measurements, results in an average length of stay (LOS) of 8-12 h. This leads to overcrowding in both the emergency departments and coronary care units. Measuring copeptin and high-sensitivity cardiac troponin (hs-cTn) upon hospital arrival has shown potential for early rule-out of AMI. However, the diagnostic performance may be improved by accelerating the copeptin measurement of blood sampled already in the pre-hospital phase. Additional evidence on LOS reduction and safety of the rule-out strategy in a large cohort of all-comers is needed. METHODS/DESIGN: The rule-out potential is being evaluated in a randomized controlled trial including 4800 patients admitted to hospital for suspicion of AMI. Patients are randomized to either standard rule-out (consecutive troponin measurements) or accelerated rule-out (copeptin measured in a blood sample acquired before hospital admission, combined with troponin measured in the first blood sample upon admission). DISCUSSION: Sampling blood for copeptin analysis already in the pre-hospital phase and combining this with a later hs-cTn measurement may be the optimal timing for achieving the best diagnostic performance in an AMI rule-out protocol/strategy. Moreover, we are directly comparing pre-hospital and in-hospital blood sample results to address this issue of timing, and we also are comparing single-marker strategies with dual-marker strategies. If the combination of copeptin and hs-cTn is confirmed to rule out AMI safely, implementation of this fast rule-out protocol could optimize patient flow, reduce health care expenses and enable allocation of resources to patients with confirmed illness. In future, when point-of-care analyses of copeptin and hs-cTn are available, hospitalization of the large proportion of patients with symptoms raising suspicion of AMI could potentially be avoided. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02666326 . Registered on January 24, 2016.
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Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Glicopeptídeos/sangue , Infarto do Miocárdio/diagnóstico , Troponina/sangue , Biomarcadores/sangue , Dinamarca , Diagnóstico Precoce , Estudos de Equivalência como Asunto , Hospitalização , Humanos , Estudos Multicêntricos como Assunto , Infarto do Miocárdio/sangue , Valor Preditivo dos Testes , Prognóstico , Fatores de TempoRESUMO
BACKGROUND: Currently, no pharmacological treatment can modify the natural history of aortic valve stenosis (AS). This underlines the critical need to explore novel treatment strategies, which could postpone or prevent the need for aortic valve replacement in patients with asymptomatic AS. The objectives of this study were to investigate whether metoprolol reduce the hemodynamic and metabolic burden imposed by AS. METHODS AND RESULTS: In a double-blinded design, 40 patients with moderate-severe asymptomatic AS (aortic valve area, 0.5±0.1 cm2/m2; peak gradient, 53±19 mm Hg) were randomized to placebo or metoprolol treatment for 22 weeks. Patients were evaluated by echocardiography, cardiovascular magnetic resonance, and 11C-acetate positron emission tomography. Compared with placebo, metoprolol (100±53 mg/d) decreased heart rate; mean difference (95% confidence interval) -8 minute-1 (-13, -3; P=0.003) and increased ejection time 26 ms (2, 50; P=0.03). Furthermore, metoprolol reduced aortic valve peak -7 mm Hg (-13, 0; P=0.05) and mean -4 mm Hg (-7, -1; P=0.03) gradients, without affecting stroke volume 3 mL/m2 (-2, 8; P=0.16). Valvuloarterial impedance (ie, global afterload) and myocardial oxygen consumption were reduced by -11% and -12% (P=0.03 and 0.01), respectively; and decreased heart rate correlated with lower valvuloarterial impedance, myocardial oxygen consumption, and improved myocardial efficiency defined as stroke work/myocardial oxygen consumption (r=0.63-0.65; all P<0.01). There were 2 adverse cardiovascular events in the metoprolol group and none in the placebo group. CONCLUSIONS: In patients with asymptomatic AS, metoprolol increases systolic ejection time and reduces aortic valve gradients, global afterload, and myocardial oxygen requirements. Thus, metoprolol displays favorable hemodynamic and metabolic effects and could improve outcome in patients with asymptomatic AS. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02076711.
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Antagonistas de Receptores Adrenérgicos beta 1/uso terapêutico , Estenose da Valva Aórtica/tratamento farmacológico , Valva Aórtica/efeitos dos fármacos , Metabolismo Energético/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Metoprolol/uso terapêutico , Antagonistas de Receptores Adrenérgicos beta 1/efeitos adversos , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/metabolismo , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/metabolismo , Estenose da Valva Aórtica/fisiopatologia , Doenças Assintomáticas , Dinamarca , Método Duplo-Cego , Ecocardiografia Doppler , Feminino , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Metoprolol/efeitos adversos , Pessoa de Meia-Idade , Consumo de Oxigênio/efeitos dos fármacos , Tomografia por Emissão de Pósitrons , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Myocardial oxygen consumption (MVO2) and its coupling to contractile work are fundamentals of cardiac function and may be involved causally in the transition from compensated left ventricular hypertrophy to failure. Nevertheless, these processes have not been studied previously in patients with aortic valve stenosis (AS). METHODS AND RESULTS: Participants underwent 11C-acetate positron emission tomography, cardiovascular magnetic resonance, and echocardiography to measure MVO2 and myocardial external efficiency (MEE) defined as the ratio of left ventricular stroke work and the energy equivalent of MVO2. We studied 10 healthy controls (group A), 37 asymptomatic AS patients with left ventricular ejection fraction ≥50% (group B), 12 symptomatic AS patients with left ventricular ejection fraction ≥50% (group C), and 9 symptomatic AS patients with left ventricular ejection fraction <50% (group D). MVO2 did not differ among groups A, B, C, and D (0.105±0.02, 0.117±0.024, 0.129±0.032, and 0.104±0.026 mL/min per gram, respectively; P=0.07), whereas MEE was reduced in group D (21.0±1.6%, 22.3±3.3%, 22.1±4.2%, and 17.3±4.7%, respectively; P<0.05). Similarly, patients with global longitudinal strain greater than -12% and paradoxical low-flow, low-gradient AS had impaired MEE (P<0.05 versus controls). The ability to discriminate between symptomatic and asymptomatic patients was superior for global longitudinal strain compared with MVO2 and MEE (area under the curve 0.98, 0.48, and 0.61, respectively; P<0.05). CONCLUSIONS: AS patients display a persistent ability to maintain normal MVO2 and MEE (ie, the ability to convert energy into stroke work); however, patients with left ventricular ejection fraction <50%; global longitudinal strain greater than -12%; or paradoxical low-flow, low-gradient AS demonstrate reduced MEE. These findings suggest that mitochondrial uncoupling contributes to the dismal prognosis in patients with reduced contractile function or paradoxical low-flow, low-gradient AS.
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Estenose da Valva Aórtica/metabolismo , Insuficiência Cardíaca/metabolismo , Ventrículos do Coração/fisiopatologia , Miocárdio/metabolismo , Consumo de Oxigênio , Volume Sistólico/fisiologia , Idoso , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Progressão da Doença , Ecocardiografia , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons , Prognóstico , Índice de Gravidade de Doença , Função Ventricular EsquerdaRESUMO
BACKGROUND: Systematic management of patients suffering high-risk symptoms is essential in emergency medical services. Patients with chest pain receive algorithm-based work-up and treatment. Though dyspnea is recognized as an independent predictor of mortality, no generally accepted prehospital treatment algorithm exists and this may affect outcome. The objective of this study was to compare mortality in patients suspected of myocardial infarction (MI) presenting with dyspnea versus chest pain in the ambulance. METHODS: Follow-up study in patients undergoing electrocardiogram-based telemedical triage because of suspected MI in an ambulance in the Central Denmark Region from 1 June 2008 to 1 January 2013. Primary outcome was 30-day mortality. Secondary outcomes were 4-year mortality and mortality rates in subgroups of patients with and without a confirmed MI. Absolute risk differences adjusted for comorbidity, age, systolic blood pressure and heart rate were calculated by a generalized linear regression model. RESULTS: Of 17,398 patients, 12,230 (70%) suffered from chest pain, 1464 (8%) from dyspnea, 3540 (20%) from other symptoms and 164 (1%) from cardiac arrest. Among patients with dyspnea, 30-day mortality was 13% (CI 12-15) and 4-year mortality was 50% (CI 47-54) compared to 2.9% (CI 2.6-3.2) and 20% (CI 19-21) in patients with chest pain. MI was confirmed in 121 (8.3%) patients with dyspnea and in 2319 (19%) with chest pain. Patients with dyspnea and confirmed MI had a 30-day and 4-year mortality of 21 % (CI 15-30) and 60% (CI 50-70) compared to 5.0% (CI 4.2-5.8) and 23% (CI 21-25) in patients with chest pain and confirmed MI. Adjusting for age, comorbidity, systolic blood pressure and heart rate did not change these patterns. CONCLUSION: Patients suspected of MI presenting with dyspnea have significantly higher short- and long-term mortality than patients with chest pain irrespective of a confirmed MI diagnosis. Future studies should examine if supplementary prehospital diagnostics can improve triage, facilitate early therapy and improve outcome in patients presenting with dyspnea.
Assuntos
Ambulâncias , Comorbidade , Dispneia/diagnóstico , Infarto do Miocárdio , Idoso , Idoso de 80 Anos ou mais , Dinamarca , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Medição de Risco , TriagemRESUMO
OBJECTIVES: Guidelines recommend initiating primary prevention with statins to those at highest cardiovascular risk. We assessed the gender-specific implementation and effectiveness of this risk-guided approach. METHODS: We identified 1399 consecutive patients without known cardiovascular disease or diabetes hospitalized with a first myocardial infarction (MI) in Denmark. Statin use before MI was assessed, and cardiovascular risk was calculated using SCORE (Systematic COronary Risk Evaluation). RESULTS: Among patients with first MI, 36% were women. Compared with men, they were older (mean 72 vs. 65years) but had a lower estimated risk (median 3.4% vs. 6.7%, SCORE high-risk model in the statin-naïve patients). Statin therapy had been initiated in 12% of women and 10% of men prior to MI. After adding 1.5mmol/L to the total cholesterol concentration of those already on statins, the estimated pre-treatment risk was much lower in women than men (median 3.8% vs. 9.2%, SCORE high-risk model), and only 29% of women would have passed the risk-based treatment threshold defined by the European guidelines (SCORE ≥5%). Estimated risk and statin use correlated directly in men but not in women. Only ~5% of first MI are prevented by the current use of statins in people without diabetes. CONCLUSION: In people destined for a first MI, statin therapy is uncommon and prevents few events. Lower-risk women receive as much statins as higher risk men. This gender disparity and inefficient targeting of statins to those at highest risk indicate that risk scoring is not widely used in routine clinical practice in Denmark.
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Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Infarto do Miocárdio/prevenção & controle , Idoso , Dinamarca , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevenção Primária , Medição de Risco , Fatores SexuaisRESUMO
OBJECTIVE: European ST-segment elevation myocardial infarction (STEMI) guidelines recommend prehospital diagnosis to facilitate early reperfusion in patients with STEMI, and they provide recommendations regarding optimal system delay (time from first medical contact (FMC) to the primary percutaneous coronary intervention (PPCI)). There are limited data on achievable system delays in an optimal STEMI system of care using prehospital diagnosis to triage patients with STEMI directly to percutaneous coronary intervention (PCI) centres. We examined the proportion of tentative prehospital STEMI diagnoses established by telemedicine confirmed on hospital arrival, and we determined system delay in patients diagnosed before hospital arrival and triaged directly to the catheterisation laboratory. DESIGN: Population-based follow-up study. SETTING: Central Denmark Region. PARTICIPANTS: 15 992 patients diagnosed using telemedicine. RESULTS: During the study period, a tentative diagnosis of STEMI was established in 1061 patients, of whom 919 were triaged directly to the PCI centre. In 771 (84%) patients, a diagnosis of STEMI was confirmed. Patients transported <10 km had a mean system delay of 82 min; this delay rose to 103 min for patients transported 50-75 km. Data on system delay was achievable in 682 patients in whom 553 (81%) were treated within 120 min of the FMC, and a system delay of <120 min was achievable in 89% of patients living up to 95 km from the PCI centre. Even for patients living <10 km from the PCI centre, only 16 (14%) had a system delay of 60 min or less. CONCLUSIONS: The use of telemedicine for prehospital diagnosis and triage of patients directly to the catheter laboratory is feasible and allows 89% of patients living up to 95 km from the invasive centre to be treated with PPCI within 120 min of the emergency medical service call. The study confirms that a recommendation of a system delay <60 min is unachievable if the FMC is the emergency medical call.