Increased mortality after a first myocardial infarction in human immunodeficiency virus-infected patients; a nested cohort study.

AIMS: HIV infection may be associated with an increased recurrence rate of myocardial infarction. Our aim was to determine whether HIV infection is a risk factor for worse outcomes in patients with coronaray artery disease. METHODS: We compared data aggregated from two ongoing cohorts: (i) the Acute Myocardial Infarction in Switzerland (AMIS) registry, which includes patients with acute myocardial infarction (AMI), and (ii) the Swiss HIV Cohort Study (SHCS), a prospective registry of HIV-positive (HIV+) patients. We included all patients who survived an incident AMI occurring on or after 1st January 2005. Our primary outcome measure was all-cause mortality at one year; secondary outcomes included AMI recurrence and cardiovascular-related hospitalisations. Comparisons used Cox and logistic regression analyses, respectively. RESULTS: There were 133 HIV+, (SHCS) and 5,328 HIV-negative [HIV-] (AMIS) individuals with incident AMI. In the SHCS and AMIS registries, patients were predominantly male (72% and 85% male, respectively), with a median age of 51 years (interquartile range [IQR] 46-57) and 64 years (IQR 55-74), respectively. Nearly all (90%) of HIV+ individuals were on successful antiretroviral therapy. During the first year of follow-up, 5 (3.6%) HIV+ and 135 (2.5%) HIV- individuals died. At one year, HIV+ status after adjustment for age, sex, calendar year of AMI, smoking status, hypertension and diabetes was associated with a higher risk of death (HR 4.42, 95% CI 1.73-11.27). There were no significant differences in recurrent AMIs (4 [3.0%] HIV+ and 146 [3.0%] HIV- individuals, OR 1.16, 95% CI 0.41-3.27) or in hospitalization rates (OR 0.68 [95% CI 0.42-1.11]). CONCLUSIONS: HIV infection was associated with a significantly increased risk of all-cause mortality one year after incident AMI.

Characteristics and Outcome in Acute Coronary Syndrome Patients with and without Established Modifiable Cardiovascular Risk Factors: Insights from the Nationwide AMIS Plus Registry 1997-2010.

OBJECTIVES: Little is known about patients without known modifiable risk factors presenting initially with acute coronary syndrome (ACS). This study assessed baseline characteristics and outcomes of ACS patients with and without the known modifiable risk factors arterial hypertension, dyslipidemia, obesity, smoking or diabetes. METHODS: All ACS patients enrolled in the AMIS Plus Registry between 1997 and 2010 were analyzed until hospital discharge; a subgroup was re-assessed at the 1-year follow-up. Outcome measures were in-hospital mortality and major adverse cardiac or cerebrovascular events (MACCE) defined as a composite outcome of mortality, re-infarction and cerebrovascular events. RESULTS: Of 33,306 patients, 2,125 (6.4%) had none of these modifiable risk factors. They were older (males), had less moderate or severe comorbidities and were more frequently in Killip class I on admission. Treatment of ACS patients with or without modifiable risk factors was similar with regard to interventional therapies and use of antiplatelet agents. In-hospital mortality was lower in patients without modifiable risk factors but in-hospital MACCE and 1-year survival was similar. CONCLUSION: Lack of modifiable risk factors was an independent predictor of lower in-hospital mortality but not of MACCE in patients who presented with ACS.

Optimized Treatment of Refractory Hypercholesterolemia in Patients With Atherosclerotic Cardiovascular Disease or Heterozygous Familial Hypercholesterolemia With Alirocumab (OPTIMIZE).

Background: Low-density lipoprotein cholesterol (LDL-C) is a major risk factor for atherosclerotic cardiovascular disease (ASCVD). In confirmatory trials, proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab substantially lowered LDL-C and reduced cardiovascular morbidity and mortality. However, the routine clinical use of alirocumab in Switzerland has not yet been studied. Methods: In this prospective nation-wide cohort study, we aimed to investigate the patient profile and routine clinical efficacy and safety of alirocumab in 207 patients with ASCVD or heterozygous familial hypercholesterolemia and increased LDL-C despite maximally tolerated statin therapy. LDL-C was measured at baseline and after 3-months follow-up. Results: Overall, mean age was 63 ± 11 years, 138 (67%) were men, and 168 (81%) had statin intolerance (SI). Patients with SI had a higher baseline LDL-C (4.3 ± 1.4 vs. 3.3 ± 1.4 mmol/l; p < 0.001) and less frequently ASCVD (71% vs. 95%; p = 0.002). After 3 months of treatment with alirocumab, LDL-C was reduced from 4.1 ± 1.5 to 2.0 ± 1.2 mmol/l (50.5%; p < 0.001). Mean absolute and relative reductions in LDL-C were similar in patients with vs. without SI (2.2 ± 1.2 vs. 1.9 ± 1.3 mmol/l; p = 0.24 and 49.0 vs. 56.6%; p = 0.11, respectively). In total, adverse events were recorded in 25 (12%) patients, with no new safety signals. Conclusions: In routine clinical practice, alirocumab was predominantly used in patients with SI suggesting that the great majority of patients with insufficient LDL-C control who would be candidates for alirocumab are not receiving this therapeutic option in Switzerland. LDL-C lowering was potent and similar in patients with and without SI, replicating the favorable efficacy-safety profile of alirocumab from randomized trials.

[A Swiss multicentric project to improve the prevention of cardiovascular event recurrence after acute coronary syndromes]. / Un projet multicentrique suisse pour améliorer la prévention et la récidive après un syndrome coronarien aigu.

Recurrence of cardiovascular events and mortality remain high after acute coronary syndromes. A Swiss multicentric study, "Inflammation and acute coronary syndromes (ACS)--Novel strategies for prevention and clinical managements", is currently underway with the support of the Swiss National Science Foundation. The study includes a clinical research subproject of which the aim is to assess the impact of the ELIPS program (multi-dimEnsionaL prevention Program after acute coronary Syndrome) on the recurrence of cardiovascular events after an ACS. The basic research sub-projects aim to investigate novel cardiovascular risk biomarkers and genetic determinants of recurrence and to study the role of stem cells after an ACS. Another sub-project will evaluate intracoronary imaging techniques and the efficacy of different types of stents.

Clinical impact of a structured secondary cardiovascular prevention program following acute coronary syndromes: A prospective multicenter healthcare intervention.

BACKGROUND: Structured secondary cardiovascular prevention programs (SSCP) following acute coronary syndromes (ACS) may reduce major adverse cardiovascular events (MACE) through better adherence to post-ACS recommendations. METHODS: Through a prospective multicenter cohort study, we compared the outcomes of two sequential post-ACS patient cohorts, the initial one receiving standard care (SC) followed by one receiving additional interventions (SSCP) aimed at improving patient education as well as healthcare provider and hospital systems. The primary endpoint was MACE at one year. Secondary endpoints included adherence to recommended therapies, attendance to cardiac rehabilitation (CR) and successful achievement of cardiovascular risk factor (CVRF) targets. RESULTS: In total, 2498 post-ACS patients from 4 Swiss university hospitals were included: 1210 vs 1288 in the SC and SSCP groups, respectively. The SSCP group demonstrated a significant increase in attendance to CR programs (RR 1.08, 95%CI 1.02-1.14, P = 0.006), despite not achieving the primary MACE endpoint (HR 0.97, 95%CI 0.77-1.22, P = 0.79). After age-stratification, significant reductions in cardiac death, MI and stroke events (HR 0.53, 95%CI 0.30-0.93, P for interaction = 0.016) were observed for SSCP patients ≤ 65 years old. The SSCP group also scored significantly better for the LDL cholesterol target (RR 1.07, 95%CI 1.02-1.13, P = 0.012), systolic blood pressure target (RR 1.06, 95%CI 1.01-1.13, P = 0.029) and physical activity (RR 1.10, 95%CI 1.01-1.20, P = 0.021). CONCLUSIONS: The implementation of an SSCP post ACS was associated with an improvement in the control of CVRF and attendance to CR programs, and was also associated with significant reductions in cardiac death, MI and stroke at one year for patients ≤65years old.

Biatrial anatomical reverse remodelling after radiofrequency catheter ablation for atrial fibrillation: evidence from real-time three-dimensional echocardiography.

AIMS: Reports using two-dimensional echocardiography have indicated that radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) results in a reduction in the left atrial (LA) size. Furthermore, the effect of pulmonary vein isolation (PVI) on right atrial (RA) anatomical remodelling has not been studied. Three-dimensional echocardiography (3DE) allows us to more precisely quantify atrial volume. Our aim was to assess the effect of PVI on biatrial anatomical remodelling using real-time 3DE. METHODS AND RESULTS: We prospectively studied 91 patients (age 59 +/- 8 years, 79 males) referred for RFCA of paroxysmal (n = 79) or chronic (n = 19) AF. Left atrial and RA volumes were measured using real-time 3DE at baseline and after 6 months of follow-up. Data on AF recurrences were also collected. Left atrial volume was significantly reduced at follow-up when compared with baseline (51 +/- 16 vs. 60 +/- 21 mL, P < 0.001). The same occurred with RA volume (43 +/- 17 vs. 50 +/- 20 mL, P = 0.001). The reduction in the LA volume was more marked in patients with chronic than in those with paroxysmal AF (17 +/- 16 vs. 6 +/- 17 mL, P = 0.017). Patients with AF recurrence (23%) showed similar atrial volume reduction compared with those who were seemingly cured. CONCLUSION: Three-dimensional echocardiography shows evidence of biatrial anatomical reverse remodelling after RFCA for AF. A reduction in the atrial volume occurs despite recurrence of AF.

Biomarkers and arrhythmia recurrence following radiofrequency ablation of atrial fibrillation.

OBJECTIVE: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and radiofrequency catheter ablation of AF (RCAAF) has become increasingly popular. Cardiac stress and inflammation have been associated with AF. This study was performed to determine whether the pre- or post-AF ablation levels of high-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are predictive of AF recurrence. METHODS: This multicenter prospective cohort study involved patients undergoing RCAAF in Switzerland and Canada. The primary endpoint was the recurrence of AF or atrial flutter at 6 months. RESULTS: Of 202 patients, 195 completed follow-up (age, 57.5 ± 9 years; mean left ventricular ejection fraction, 62%; mean left atrial size, 19.4 cm2). Patients with AF recurrence had larger atrial surfaces and longer total RCAAF times. Both the pre-ablation hs-CRP level and 1-day post-RCAAF NT-proBNP level were significantly associated with an increased risk of recurrence. CONCLUSIONS: The pre-ablation hs-CRP level and immediate post-ablation NT-proBNP level were markers for atrial arrhythmia recurrence after RCAAF. This confirms growing evidence of the role of inflammation in the pathogenesis of AF. These biomarkers appear to be promising stratification tools for selection and management of patients undergoing RCAAF.

Long-term safety of intravascular ultrasound in nontransplant, nonintervened, atherosclerotic coronary arteries.

OBJECTIVES: The goal of this study was to demonstrate that intravascular ultrasound (IVUS) examination of native coronary arteries does not result in an acceleration of the atherosclerotic process. BACKGROUND: Intravascular ultrasound is increasingly used to assess the effects of pharmacologic agents on atherosclerosis. METHODS: Intravascular ultrasound examinations of one coronary artery and coronary angiography were performed in 525 patients at baseline. Patients then underwent a follow-up angiogram 18 to 24 months later. All end points were evaluated in IVUS-related and non-IVUS arteries using quantitative coronary analysis. The study end points were the coronary change score (per-patient mean of minimum lumen diameter changes for all lesions measured), occurrence of new coronary lesions, and progression of preexistent lesions at follow-up. Acute angiographic and clinical complications were also analyzed. RESULTS: Coronary change score was -0.06 +/- 0.23 mm and -0.05 +/- 0.21 mm for IVUS-related and non-IVUS arteries, respectively (p = 0.35). The increase in percent diameter stenosis from baseline to follow-up was 0.8 +/- 6.7% and 1.2 +/- 7.0% in the IVUS-related and non-IVUS arteries (p = 0.29). New lesions occurred in 3.6% and 3.9% of IVUS-related and non-IVUS arteries, respectively (p = 0.84). When all coronary lesions were considered, the incidence of lesion progression was not significantly different between IVUS-related (11.6%) and non-IVUS (9.8%) arteries. Coronary spasm occurred in 1.9% of IVUS procedures, and there was one case of acute occlusion with no long-term sequelae. CONCLUSIONS: Intravascular ultrasound does not significantly accelerate atherosclerosis in native coronary arteries and can be used safely to assess progression/regression in clinical trials.

Effect of atherosclerotic regression on total luminal size of coronary arteries as determined by intravascular ultrasound.

We assessed vascular changes during atherosclerosis regression. Compensatory enlargement of coronary arteries accommodates plaque burden during atherosclerosis development. Lipid-lowering therapy has altered the natural history of coronary atherosclerosis, but the arterial changes that occur during disease regression need to be clarified. Intravascular ultrasound was performed at baseline and after approximately 18 months in 432 patients with coronary disease. Mean plaque, lumen, and total vessel area were computed in a 30-mm coronary segment of interest. Mean low-density lipoprotein cholesterol level was 2.4 mmol/L, and 88% of patients received statins. Overall, changes in plaque and total vessel areas were highly correlated (r = 0.82, p <0.0001). Among the 227 patients with plaque regression, the plaque area decrease was -0.58 +/- 0.54 mm(2), and changes in total vessel and lumen areas were -1.02 +/- 1.10 and -0.44 +/- 0.86 mm(2), respectively. The decrease in plaque area correlated better with the change in total vessel area (r = 0.64, p <0.0001) than with the change in lumen area (r = 0.20, p = 0.003). The relation between plaque regression and decrease in total vessel area was significantly better (p = 0.019) for patients with a >40% atheroma area (r = 0.72; p <0.0001) than for those with

Angiotensin-converting enzyme inhibition in hypertensive patients is associated with a reduction in the occurrence of atrial fibrillation.

OBJECTIVE: The objective of this study was to determine the effects of angiotensin-converting enzyme inhibition (ACEI) versus long-acting calcium-channel blockade (CCB) on atrial fibrillation (AF) in patients with hypertension. BACKGROUND: Atrial fibrillation is the most common significant cardiac arrhythmia, and angiotensin II has been implicated in its pathophysiology. METHODS: This was a retrospective, longitudinal cohort study from a database of 8 million people in the U.S. Patients age > or =18 years with hypertension were eligible if they filled a prescription for either an ACEI or a CCB between January 1995 and June 1999. The use of all other antihypertensive medications was permitted. Patient chronic disease burden was assessed using a modified Charlson index. Patients were matched on a propensity score generated from a logistic regression model. A survival analysis approach was used to compare the incidence of AF between groups. The final cohorts were evaluated until June 2002, and the average follow-up was 4.5 years. RESULTS: After cohort matching, 10,926 patients were included in the analysis and divided equally into the ACEI and CCB groups. Mean patient age was 65 years. The adjusted hazards ratio (95% confidence interval [CI]) in the ACEI versus CCB groups for the entire follow-up period was 0.85 (95% CI: 0.74 to 0.97) for new-onset AF, and the adjusted incidence ratio for AF-related hospitalizations was 0.74 (95% CI: 0.62 to 0.89). CONCLUSIONS: Angiotensin-converting enzyme inhibition was associated with a reduced incidence of AF for patients with hypertension in a usual care setting. These results need to be confirmed in a large-scale randomized clinical trial.

The drug-based pipeline against restenosis.

More than 1 million percutaneous coronary interventions (PCIs) are performed yearly worldwide. Restenosis is the recurrent narrowing that can occur within 6 months following an initially successful PCI. Although drug-eluting stents have accomplished remarkable success, restenosis has not been eliminated and optimisation of both the polymers and drugs associated with them is desirable. This article reviews the presently available and potential preventive approaches against restenosis, including the sirolimus and paclitaxel drug-eluting stents.

Acute respiratory and cardiovascular admissions after a public smoking ban in Geneva, Switzerland.

BACKGROUND: Many countries have introduced legislations for public smoking bans to reduce the harmful effects of exposure to tobacco smoke. Smoking bans cause significant reductions in admissions for acute coronary syndromes but their impact on respiratory diseases is unclear. In Geneva, Switzerland, two popular votes led to a stepwise implementation of a state smoking ban in public places, with a temporary suspension. This study evaluated the effect of this smoking ban on hospitalisations for acute respiratory and cardiovascular diseases. METHODS: This before and after intervention study was conducted at the University Hospitals of Geneva, Switzerland, across 4 periods with different smoking legislations. It included 5,345 patients with a first hospitalisation for acute coronary syndrome, ischemic stroke, acute exacerbation of chronic obstructive pulmonary disease, pneumonia and acute asthma. The main outcomes were the incidence rate ratios (IRR) of admissions for each diagnosis after the final ban compared to the pre-ban period and adjusted for age, gender, season, influenza epidemic and secular trend. RESULTS: Hospitalisations for acute exacerbation of chronic obstructive pulmonary disease significantly decreased over the 4 periods and were lowest after the final ban (IRR=0.54 [95%CI: 0.42-0.68]). We observed a trend in reduced admissions for acute coronary syndromes (IRR=0.90 [95%CI: 0.80-1.00]). Admissions for ischemic stroke, asthma and pneumonia did not significantly change. CONCLUSIONS: A legislative smoking ban was followed by a strong decrease in hospitalisations for acute exacerbation of chronic obstructive pulmonary disease and a trend for reduced admissions for acute coronary syndrome. Smoking bans are likely to be very beneficial for patients with chronic obstructive pulmonary disease.

Diagnostic accuracy of pocket-size handheld echocardiographs used by cardiologists in the acute care setting.

AIMS: Pocket-size echographs may be useful for bedside diagnosis in acute cardiac care, but their diagnostic accuracy in this setting has not been well tested. Our aim was to evaluate this tool in patients requiring an urgent echocardiogram. METHODS: Trained cardiologists performed echocardiograms with a pocket-size echograph (Vscan) in consecutive patients requiring urgent echocardiography. The exams were then compared in a blinded manner with echocardiograms performed with a high-end standard echocardiograph. RESULTS: A total of 104 patients were studied. There was an excellent agreement between the Vscan and the high-end echocardiograph for the left ventricular systolic function and pericardial effusion (Kappa: 0.89 and 0.81, respectively), and the agreement was good or moderate for evaluating the aortic, mitral, and tricuspid valve function and the left ventricular size (Kappa: 0.55-0.66). Visualization of the Vscan images in full-screen format on a PC did not in general confer added value. CONCLUSION: The Vscan used by a trained cardiologist has good diagnostic accuracy in the emergency setting compared with a high-end echocardiograph, despite small screen size and lack of pulse-wave and continuous Doppler.

AngioJet rheolytic thrombectomy in patients presenting with high-risk pulmonary embolism and cardiogenic shock: a feasibility pilot study.

AIMS: Pulmonary embolism (PE) associated with haemodynamic instability has exceedingly high mortality. While intravenous thrombolysis is considered the therapy of choice, percutaneous mechanical thrombectomy may represent an alternative treatment. METHODS AND RESULTS: The impact of AngioJet® rheolytic thrombectomy (RT) in PE associated with cardiogenic shock was assessed in a single-centre prospective pilot study. Ten consecutive PE patients in cardiogenic shock were included in the study. Six patients had thrombolysis contraindications, eight were intubated before the RT procedure and six had experienced cardiac arrest prior to the RT procedure. The RT procedure was technically successful in all cases. The Miller index improved from 25 to 20 (p=0.002). The shock index decreased from 1.22 to 0.9 (p=0.129). Thrombolytic agents were administered during or after the procedure in four patients because of progressive clinical deterioration. Seven patients died in the first 24 hours: two from multi-organ failure, one from post-anoxic cerebral oedema, and four from progressive right heart failure. The three survivors had favourable outcomes at one year. CONCLUSIONS: This study suggests that the AngioJet® RT procedure may be safely performed in PE patients with cardiogenic shock. However, despite angiographic and haemodynamic improvements, the procedure does not appear to influence the dismal prognosis of these high-risk patients.

Transjugular intravascular ultrasound for the evaluation of hepatic vasculature and parenchyma in patients with chronic liver disease.

BACKGROUND: The evaluation of the hepatic parenchyma in patients with chronic liver disease is important to assess the extension, localization and relationship with adjacent anatomical structures of possible lesions. This is usually performed with conventional abdominal ultrasound, CT-scan or magnetic resonance imaging. In this context, the feasibility and the safety of intravascular ultrasound in the liver have not been assessed yet. METHODS: We tested the safety and performance of an intracardiac echography (ICE) catheter applied by a transjugular approach into the hepatic veins in patients with chronic liver disease undergoing hepatic hemodynamic measurements. RESULTS: Five patients were enrolled in this pilot study. The insertion of the ICE catheter was possible into the right and middle, but not into the left hepatic vein. The position of the ICE was followed using fluoroscopy and external conventional ultrasound. Accurate imaging of focal hepatic parenchymal lesions, Doppler ultrasound of surrounding blood vessels and assessment of liver surface and ascites were achieved without complications. CONCLUSIONS: This study demonstrated that a diagnostic approach using an ICE device inserted in the hepatic veins is feasible, safe and well tolerated. However, it remains for the moment only an experimental investigative tool. Whether ICE adds further information regarding parenchymal lesions and associated vascular alterations as compared to other techniques, needs additional investigation.

Fondaparinux versus enoxaprin in the management of acute coronary syndromes in Switzerland: A cost comparison analysis.

QUESTION UNDER STUDY: Anticoagulation therapy is routinely used in cases of non ST-segment elevation acute coronary syndromes (NSTE-ACS). The most commonly used drug in such events is enoxaparin, a low molecular weight heparin. Fondaparinux, a synthetic pentasaccharide, is as effective as enoxaparin in terms of survival or residual angina pectoris and significantly reduces bleeding complications. The purpose of this study was to assess the magnitude of cost reductions if enoxaparin were replaced by fondaparinux in Switzerland. METHODS: Costs of hospital stay for NSTE-ACS with or without bleeding complications at the Geneva University Hospitals were determined for patients admitted between July 1st, 2007 and June 30th, 2008. These costs were applied to subjects recruited in the AMIS Plus registry, which gathers information on ACS in Swiss hospitals, using three scenarios. Firstly, using the baseline incidence of bleeding episodes observed in the AMIS plus registry. Secondly, using the baseline incidence of haemorrhagic episodes observed in the Geneva University Hospitals sample and thirdly, using the incidence of haemorrhagic episodes observed in the OASIS-5 study. These results and costs were then extrapolated to the national level. RESULTS: At the Swiss national level, replacement of enoxaparin by fondaparinux would generate annual savings ranging from 854,000 Swiss Francs (scenario 1) to 3,400,000 Swiss Francs (scenario 2) and 2,845,000 Swiss Francs (scenario 3). Estimated savings accounted for 55 to 63% of total hospital costs. CONCLUSIONS: Use of fondaparinux instead of enoxaparin in patients with NSTE-ACS could yield substantial savings at the local as well as the national level in Switzerland.

Present and future of secondary prevention after an acute coronary syndrome.

Despite a marked improvement of in-hospital outcome of patients with Acute Coronary Syndrome (ACS), long-term outcome remains poor. There remains a high risk of complications, Non ST-Elevation ACS (NSTE-ACS) patients being at higher risk than those with ST-elevation ACS, in part due to more diffuse coronary artery disease. Whether with conservative medical management or an early invasive approach, of which they less frequently benefit, NSTE-ACS patients are less frequently treated according to guidelines. Therapeutic adhesion within the months following hospital discharge is low and associated with an increase in one-year mortality. The next step in the improvement of care of ACS patients will be to use multi-dimensional prevention programs that use didactic information tools and improve patient motivation, aimed at reinforcing the use of guidelines, promoting in-hospital therapeutic education, creating patient-health care provider partnerships and including discharge programs that ensure the prescription of recommended therapies.

Acute coronary syndromes in young patients: presentation, treatment and outcome.

BACKGROUND: Acute coronary syndromes (ACS) in very young patients have been poorly described. We therefore evaluate ACS in patients aged 35 years and younger. METHODS: In this prospective cohort study, 76 hospitals treating ACS in Switzerland enrolled 28,778 patients with ACS between January 1, 1997, and October 1, 2008. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). RESULTS: 195 patients (0.7%) were 35 years old or younger. Compared to patients>35 years, these patients were more likely to present with chest pain (91.6% vs. 83.7%; P=0.003) and less likely to have heart failure (Killip class II to IV in 5.2% vs. 23.0%; P<0.001). STEMI was more prevalent in younger than in older patients (73.1% vs. 58.3%; P<0.001). Smoking, family history of CAD, and/or dyslipidemia were important cardiovascular risk factors in young patients (prevalence 77.2%, 55.0%, and 44.0%). The prevalence of overweight among young patients with ACS was high (57.8%). Cocaine abuse was associated with ACS in some young patients. Compared to older patients, young patients were more likely to receive early percutaneous coronary interventions and had better outcome with fewer major adverse cardiac events. CONCLUSIONS: Young patients with ACS differed from older patients in that the younger often presented with STEMI, received early aggressive treatment, and had favourable outcomes. Primary prevention of smoking, dyslipidemia and overweight should be more aggressively promoted in adolescence.

Prehospital emergency physician activation of interventional cardiology team reduces door-to-balloon time in ST-elevation myocardial infarction.

QUESTION UNDER STUDY: To explore whether early activation of an interventional cardiology team, by prehospital emergency physicians, reduces door-to-balloon time (DTBT) in patients with ST-elevation myocardial infarction (STEMI) diagnosed with prehospital ECG. DESIGN: before-after comparison. SETTING: emergency department (ED) of an urban teaching hospital with a catheterisation laboratory open continuously. STUDY SUBJECTS: patients with STEMI diagnosed in the prehospital setting or in the ED within 12 hours of symptoms. INTERVENTION: a paging system or "STEMI alarm", activated by prehospital physicians, which simultaneously notified both the catherisation laboratory and cardiology teams before the patient's arrival to the ED. OUTCOME MEASURES: DTBT and the proportion of patients with DTBT <90 minutes. RESULTS: A total of 196 patients were included; 77 before and 119 after implementation of the "STEMI alarm". Between the two periods, median DTBT decreased from 109 to 76 minutes (p <0.001) and the proportion of patients treated within 90 minutes increased from 36% to 66% (p <0.001). During intervention, the STEMI alarm was activated in 67 patients (56%). In these cases the median DTBT was 50 minutes, with 96% within 90 minutes. The alarm was inappropriately activated in 9 cases (11%). CONCLUSIONS: Catheterisation laboratory activation by a prehospital emergency physician markedly reduces DTBT in STEMI patients.