A tale of two cities: STEMI interventions in developed and developing countries and the potential of telemedicine to reduce disparities in care.

OBJECTIVES: To utilize telemedicine as a foundation platform for creating population-based STEMI networks. BACKGROUND: Disparate acute myocardial infarction (AMI) management occurs in developed and developing countries on account of differences in infrastructure resources. As a result, developed countries utilize primary percutaneous coronary intervention (PCI) and second- and third-generation thrombolytic therapy, in contrast to developing countries, which primarily rely on earlier-generation thrombolytic therapy and basic medical management. Reducing the vast gap in AMI care between developed and developing countries is an abysmally slow process. METHODS: Remote access, telemedicine IT platforms, expert EKG interpretation, teleconsultation, and a strict quality assurance process are incorporated into a population-based AMI network. RESULTS: Lumen Americas Telemedicine Infarct Network (LATIN) is an applied hub-and-spoke strategy, which creates a telemedicine-based STEMI management network across large populations. Primary PCI with targeted door-to-balloon times is the preferred strategy for the hub sites. Telemedicine-guided accurate EKG interpretation and teleconsultation are applied at the spoke sites. An integrated IT platform is used to navigate an effective prehospital triage system. The pilot phase has created 100 LATIN sites in Brazil and Colombia. CONCLUSION: Telemedicine provides an attractive strategy to reduce the gaps that presently exist in managing AMI in developed and developing countries.

Optimal Anticoagulant Therapy in ST Elevation Myocardial Infarction Interventions.

Bivalirudin is a direct thrombin inhibitor. It is a new recommendation for the treatment of patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention. Bivalirudin combined with aspirin and P2Y12 inhibitors has proved to be an effective and safe choice for the management of thrombus in coronary artery disease. The use of bivalirudin compared with the combination of heparin plus glycoprotein IIb/IIIa inhibitors as anticoagulant therapy is associated with reduced severe bleeding and inpatient mortality, as well as diminished costs. There is only a slight increase of late stent thrombosis, which may be controlled with the use of thienopyridines.

Global Acute Myocardial Infarction Perspectives: Beyond Door-to-Balloon Interventions.

The goal in ST-elevation myocardial infarction (STEMI) intervention is achieving a door-to-balloon time of less than 90 minutes. Challenges in North America and Europe include patient education and implementing legislative mandates for STEMI guidelines. Globally, hurdles for primary percutaneous coronary intervention include limitations of access and financial constraints to providing STEMI care to vast populations. Adherence to North American and European guidelines globally remains an unrealistic goal given the unique cultural, demographic, and fiscal dynamics in poorer countries. The authors propose a four-phased population-based strategy for global acute myocardial infarction development and a pharmacoinvasive approach to STEMI care based on socioeconomic characteristics.

Compulsive Thrombus Management in STEMI Interventions.

Thrombus is a fundamental concept in the pathophysiology of ST-elevated myocardial infarction (STEMI). Distal embolization and no reflow are associated with less angiographic success, reduced myocardial blush, less ST resolution after primary percutaneous coronary intervention, larger enzymatic infarct size, lower left ventricular ejection fraction at discharge, and higher long-term mortality. We believe that with the use of thrombectomy devices, these shortcomings can be minimized. Based on our experience from the Single Individual Community Experience Registry (SINCERE) database, we formulated a selective thrombus burden management strategy (the Mehta classification) for thrombus management.

Door-to-Balloon ST-Elevation Myocardial Infarction Interventions: Illustrated Cases.

ST-elevation myocardial infarction (STEMI) intervention comprises 2 components, the STEMI procedure and the STEMI process, which have unique aspects that can be modified and improved, ultimately affecting patient outcome. The 15 illustrated cases in this article highlight suggested improvements mainly in the STEMI procedure, with some references as to how the authors practically improved the STEMI process for the described procedure. The illustrated procedures have been meticulously selected from more than 1000 short door-to-balloon STEMI interventions recorded in the Single Individual Community Experience Registry (SINCERE) database, and are aimed at educating the reader about unique STEMI skills.

Telemedicine: The Future of Global STEMI Care.

Telemedicine is an innovative tool in the setting of ST-elevation myocardial infarction (STEMI), because it addresses the greatest challenge-delivering optimal reperfusion therapies in a timely manner. Telemedicine targets delays related to geography, distance, and stated prehospital systems of care. Integration of telemedicine into prehospital STEMI management has been shown to yield cost-effective improvements in patient care. Despite socioeconomic constraints, a standard prehospital network based on telemedicine is globally feasible. This article proposes 2 models that enable the use of telemedicine in the STEMI management protocol.

Automated analysis of sleep-wake state in rats.

A fully automated computer-based sleep scoring system is described and validated for use in rats. The system was designed to emulate visual sleep scoring by using the same basic features of the electroencephalogram (EEG) and electromyogram (EMG), and a similar set of decision-making rules. State indices are calculated for each 5s epoch by combination of amplitudes (microVrms) of 6 filtered EEG frequency bands (EEGlo, d.c.-1.5Hz; delta, 1.5-6Hz; theta, 6-9Hz; alpha, 10.5-15Hz; beta, 22-30Hz; gamma, 35-45Hz; Sigma(EEG)=delta+theta+alpha+beta+gamma) and EMG (10-100Hz) yielding dimensionless ratios: WAKE-index=(EMGxgamma)/theta; NREM-index=(deltaxalpha)/gamma(2); REM-index=theta(3)/(deltaxalphaxEMG); artifact-index=[(2xEEG(lo))+beta]*(gamma/Sigma(EEG)). The index values are re-scaled and normalized, thereby dispensing with the need for animal-specific threshold values. The system was validated by direct comparison with visually scored data in 9 rats. Overall, the computer and visual scores were 96% concordant, which is similar to inter-rater agreement in visual scoring. False-positive error rate was <5%. A re-test protocol in 7 rats confirmed the long-term stability of the system in studies lasting 5 weeks. The system was implemented and further validated in a study of sleep architecture in 7 rats under a 12:12h LD cycle.

Amplification by long RT-PCR of near full-length norovirus genomes.

A long RT-PCR method was developed to amplify the norovirus genome. Starting from RNA extracted directly from clinical samples and using broadly reactive primers, it can generate near full-length amplicons that allow for easy determination of the near complete genomic sequence. Two norovirus isolates from Toronto, Canada, in 2002 and 2005 were sequenced. This approach will facilitate molecular epidemiology studies of noroviruses.