A. Hutchison

Prehospital 12-lead ECG to triage ST-elevation myocardial infarction and emergency department activation of the infarct team significantly improves door-to-balloon times: ambulance Victoria and MonashHEART Acute Myocardial Infarction (MonAMI) 12-lead ECG project.

Background—American College of Cardiology/American Heart Association guidelines recommend >75% of patients with an ST-elevation myocardial infarction receive primary percutaneous coronary interventions (PPCI) within 90 minutes. Despite these recommendations, this goal has been difficult to achieve. Methods and Results—We conducted a prospective interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infarct team on door-to-balloon time (D2BT). The median D2BT of all patients (n=107) who underwent PPCI after field ECG and emergency department activation of the infarct team (MonashHEART Acute Myocardial Infarction [MonAMI] group) was 56 minutes (interquartile range, 36.5 to 70) compared with the median time of a contemporary group (n=122) undergoing PPCI during the same period but not receiving field triage (non-MonAMI group) of 98 minutes (73 to 126.45). The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project (pre-MonAMI group) was 101.5 minutes (72.5 to 134; P<0.001). The proportion of patients who achieved a D2BT of ≤90 minutes increased from 39% in the pre-MonAMI group and 45% in the non-MonAMI group to 93% in the MonAMI group (P<0.001). Conclusions—The performance of prehospital 12-lead ECG triage and emergency department activation of the infarct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations.

Prehospital 12-Lead ECG to Triage ST-Elevation Myocardial Infarction and Emergency Department Activation of the Infarct Team Significantly Improves Door-to-Balloon Times

Background—American College of Cardiology/American Heart Association guidelines recommend >75% of patients with an ST-elevation myocardial infarction receive primary percutaneous coronary interventions (PPCI) within 90 minutes. Despite these recommendations, this goal has been difficult to achieve. Methods and Results—We conducted a prospective interventional study involving 349 patients undergoing PPCI at a single tertiary referral institution to determine the impact of prehospital 12-lead ECG triage and emergency department activation of the infarct team on door-to-balloon time (D2BT). The median D2BT of all patients (n=107) who underwent PPCI after field ECG and emergency department activation of the infarct team (MonashHEART Acute Myocardial Infarction [MonAMI] group) was 56 minutes (interquartile range, 36.5 to 70) compared with the median time of a contemporary group (n=122) undergoing PPCI during the same period but not receiving field triage (non-MonAMI group) of 98 minutes (73 to 126.45). The median D2BT time of 120 consecutive patients who underwent PPCI before initiation of the project (pre-MonAMI group) was 101.5 minutes (72.5 to 134; P<0.001). The proportion of patients who achieved a D2BT of ≤90 minutes increased from 39% in the pre-MonAMI group and 45% in the non-MonAMI group to 93% in the MonAMI group (P<0.001). Conclusions—The performance of prehospital 12-lead ECG triage and emergency department activation of the infarct team significantly improves D2BT and results in a greater proportion of patients achieving guideline recommendations.

Pre-hospital 12 Lead ECG to Triage ST Elevation Myocardial Infarction and Long Term Improvements in Door to Balloon Times: The First 1000 Patients From the MonAMI Project

BACKGROUND Pre-hospital ECG is one strategy to improve door to balloon times (D2BT), however its long term effectiveness to sustain reductions in D2BT has not been evaluated. METHODS From 2007 to 2011 we conducted a prospective interventional study involving 1000 patients undergoing primary PCI (PPCI) at a single tertiary referral institution to determine the long term impact of pre-hospital 12 lead ECG on D2BT. RESULTS The median D2BT of patients (n=414) who underwent PPCI following field 12-lead ECG was 54 min [IQR: 37-71 min] compared to the median time of a contemporary group (n=586) undergoing PPCI during the same period but not presenting via field triage of 100 min [74-134] (p<0.001). The proportion of patients who achieved a D2BT of ≤90 min in the pre-hospital ECG group was greater than that in the contemporary group (90% vs 42%, p<0.001). A comparison of the first 250 patients compared to subsequent 250 patient blocks showed no change in D2BT. CONCLUSIONS Introduction of pre-hospital ECG in the triage of STEMI resulted in a sustained reduction in D2BT.

Guideline recommended door-to-balloon time can be achieved in transradial primary PCI — the usefulness of a dedicated radial guide catheter

BACKGROUND Radial access for primary percutaneous coronary intervention (PPCI) is well established in terms of safety and efficacy. However, there are limited data on the impact of the use of a single dedicated radial guide catheter in primary PCI using radial access. AIMS To determine the overall cardiac catheterisation laboratory to balloon time (CCL2BT) and door to balloon (D2BT) time in transradial PPCI. To determine the impact of a single dedicated radial guide catheter on CCLD2BT and D2BT in transradial PPCI compared to conventional transfemoral PPCI. METHODS The procedural and clinical outcomes of consecutive patients who had transradial primary PCI between 2005 and 2009 were included in this study and compared with a matched cohort who underwent transfemoral primary PCI. RESULTS Overall D2BT and inpatient MACE were similar between the radial (n=53) and femoral (n=53) groups (85 and 82 min, P=0.889; 0% and 1.8% P=0.317 respectively). An increase in the CCL2BT and procedural times was noted in the radial compared to the femoral group (34 min versus 29 min P=0.028; 15.8 min versus 11.6 min P=0.001). When a single radial guide catheter was used for the entire procedure, there was no difference in CCL2BT, D2BT and procedural times between the radial and femoral groups (31 min versus 29 min P=0.599; 74 min versus 82 min P=0.418; 50 min versus 47 min P=0.086). CONCLUSION The radial approach is safe and results in guideline recommended D2BT in STEMI. The use of a dedicated radial guide catheter reduces treatment time, demonstrating equivalent times to a femoral approach.

Assessing Suitability for Early Discharge Following Primary PCI for STEMI

Background: Recent literature suggests primary PCI patients can be safely discharged at 72 h, yet there remains a reluctance to do so. Methods: We retrospectively reviewed 47 patients admitted to a coronary care unit after undergoing primary PCI. We examined documented early complication rates (arrhythmias, heart failure, haemodynamic instability, ischaemia and bleeding requiring treatment) and representation to hospital at 30 days and identified those that would have been suitable for early discharge (72 h) using the Zwolle Risk Score (a validated tool to predict early outcomes following STEMI). Results: Fourteen out of 47 patients were discharged between 72 and 96h following primary PCI, with the remainder discharged >96h (no patients were discharged at 96-h group. The overall per-patient complication ratewas 62%.All complications except onewere identified within 72h of procedure. The patient with a complication occurringbetween72and96hwouldhavebeenunsuitable for early discharge using the Zwolle score. Three patients (6.3%) re-presented with complications within the first 30 days, all of whom identified as high risk on the Zwolle score. Conclusions: Most complications identified following primary PCI were within 72h of admission. A validated scoring system appears to identify patients as suitable for early discharge post primary PCI.

Novel Thrombus Burden Guided Thrombus Aspiration Catheter Use During Primary Percutaneous Coronary Intervention in the Management of ST Elevation Myocardial Infarction

index derived. Troponin (TnT) was measured at admission, and daily until peak. Results: Infarct size mean 20± 11% (range 0–48.3%), Edema volume 35± 12.9% of LVmass. Myocardial salvage 15.59± 12.5% (range−1 to 46.5%).Myocardial hemorrhage present in 12 (20%), only in the largest 2 quartiles of IS. Infarct size correlated with peak Tn, as is well-recognized, p= 00001. The difference between Admission and Peak troponin (delta-Tn) correlated to the degree of myocardial salvage, p= 0.04. Admission troponin correlated with perfusion score, p= 0.016, as has been previously demonstrated by our group. Conclusions: CMR provides a powerful tool for quantitation of myocardial salvage. Delta-Tn correlates to myocardial salvage by CMR, whereas admission troponin correlates more strongly to resting perfusion defect. This sheds greater light on the relationship between biomarkers and myocardial salvage after STEMI. doi:10.1016/j.hlc.2010.06.738