Aaron D. Berman

Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: impact on Door-to-Balloon times across 10 independent regions.

OBJECTIVES The aim of this study was to evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks. BACKGROUND The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a >75% rate of D2B <or=90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis of STEMI and immediate transport to a SRC (designated PPCI-capable hospital). METHODS A pooled analysis of 10 independent, prospective, observational registries involving 72 hospitals was performed. Data were collected on all consecutive patients with a PH-ECG diagnosis of STEMI. The D2B and emergency medical services (EMS)-to-balloon (E2B) times were recorded. RESULTS Paramedics transported 2,712 patients with a PH-ECG diagnosis of STEMI directly to the nearest SRC. A PPCI was performed in 2,053 patients (76%) with an 86% rate of D2B <or=90 min (95% confidence interval: 84.4% to 87.4%). Secondary analyses of this cohort demonstrated a 50% rate of D2B <or=60 min (n = 1,031), 25% rate of D2B <or=45 min (n = 517), and an 8% rate of D2B <or=30 min (n = 155). A tertiary analysis restricted to 762 of 2,053 (37%) cases demonstrated a 68% rate of E2B <or=90 min. CONCLUSIONS Ten independent regional SRC networks demonstrated a combined 86% rate of D2B <or=90 min, and each region individually surpassed the American College of Cardiology D2B Alliance benchmark. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care.

Obesity and Age of First Non–ST-Segment Elevation Myocardial Infarction

OBJECTIVES Because excess adiposity is one of the most important determinants of adipokines and inflammatory factors associated with coronary plaque rupture, we hypothesized that obesity was associated with myocardial infarction at earlier ages. BACKGROUND The developing obesity pandemic of the past 50 years has gained considerable attention as a major public health threat. METHODS The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) registry was a voluntary observational data collection and quality improvement initiative that began in November 2001, with retrospective data collection from January 2001 to January 2007. The CRUSADE initiative included high-risk patients with unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). We retrospectively examined, among 189,065 patients with acute coronary syndrome (between January 2001 and September 2006) in the CRUSADE initiative, the relationship of body mass index (BMI) with patient age of first NSTEMI. RESULTS A total of 111,847 patients with NSTEMI were included in the final analysis. There was a strong, inverse linear relationship between BMI and earlier age of first NSTEMI. The mean patient ages (+/- SD) of first NSTEMI were 74.6 +/- 14.3 years and 58.7 +/- 12.5 years for the leanest (BMI <or=18.5 kg/m(2)) and most obese (BMI >40.0 kg/m(2)) cohorts, respectively (p < 0.0001). After adjustment for baseline demographic data, cardiac risk factors, and medications, the age of first NSTEMI occurred 3.5, 6.8, 9.4, and 12.0 years earlier with ascending levels of adiposity (BMI 25.1 to 30.0, 30.1 to 35.0, 35.1 to 40.0, and >40.0 kg/m(2), respectively; referent 18.6 to 25.0 kg/m(2)) (p < 0.0001 for each estimate). CONCLUSIONS Excess adiposity is strongly related to first NSTEMI occurring prematurely.

Hospital Process Intervals, not Ems Time Intervals, are the Most Important Predictors of Rapid Reperfusion in Ems Patients with St-Segment Elevation Myocardial Infarction

Abstract Objective. To assess the relationship of emergency medical services (EMS) intervals and internal hospital intervals to the rapid reperfusion of patients with ST-segment elevation myocardial infarction (STEMI). Methods. We performed a secondary analysis of a prospectively collected database of STEMI patients transported to a large academic community hospital between January 1, 2004, and December 31, 2009. EMS and hospital data intervals included EMS scene time, transport time, hospital arrival to myocardial infarction (MI) team activation (D2Page), page to catheterization laboratory arrival (P2Lab), and catheterization laboratory arrival to reperfusion (L2B). We used two outcomes: EMS scene arrival to reperfusion (S2B) ≤90 minutes and hospital arrival to reperfusion (D2B) ≤90 minutes. Means and proportions are reported. Pearson chi-square and multivariate regression were used for analysis. Results. During the study period, we included 313 EMS-transported STEMI patients with 298 (95.2%) MI team activations. Of these STEMI patients, 295 (94.2%) were taken to the cardiac catheterization laboratory and 244 (78.0%) underwent percutaneous coronary intervention (PCI). For the patients who underwent PCI, 127 (52.5%) had prehospital EMS activation, 202 (82.8%) had D2B ≤90 minutes, and 72 (39%) had S2B ≤90 minutes. In a multivariate analysis, hospital processes EMS activation (OR 7.1, 95% CI 2.7, 18.4], Page to Lab [6.7, 95% CI 2.3, 19.2] and Lab arrival to Reperfusion [18.5, 95% CI 6.1, 55.6]) were the most important predictors of Scene to Balloon ≤ 90 minutes. EMS scene and transport intervals also had a modest association with rapid reperfusion (OR 0.85, 95% CI 0.78, 0.93 and OR 0.89, 95% CI 0.83, 0.95, respectively). In a secondary analysis, Hospital processes (Door to Page [OR 44.8, 95% CI 8.6, 234.4], Page 2 Lab [OR 5.4, 95% CI 1.9, 15.3], and Lab arrival to Reperfusion [OR 14.6 95% CI 2.5, 84.3]), but not EMS scene and transport intervals were the most important predictors D2B ≤90 minutes. Conclusions. In our study, hospital process intervals (EMS activation, door to page, page to laboratory, and laboratory to reperfusion) are key covariates of rapid reperfusion for EMS STEMI patients and should be used when assessing STEMI care.

Determinants of markedly increased B-type natriuretic peptide in patients with ST-segment elevation myocardial infarction

BACKGROUND A modestly increased plasma B-type natriuretic peptide (BNP) level of greater than 80 pg/mL has been associated with increased mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, the prognostic significance of larger increases in BNP during STEMI has not been reported. METHODS A total of 420 patients with STEMI were identified from an administrative database, and 91 were found to have a BNP level measured within 24 hours of hospitalization. All patients underwent detailed angiographic and echocardiographic evaluation. Charts were abstracted in a blinded fashion to the BNP results. RESULTS The mean ± SD age of the participants was 64 ± 13 years, and 53 (58%) of the participants were men. The median, 25th percentile, and 75th percentile of the BNP value were 366, 142, and 1011 pg/mL, respectively. The BNP level increased progressively in 1-, 2-, and 3-vessel coronary disease with medians of 253, 351, and 818 pg/mL, respectively (P = .009). Patients with grade 3/4 diastolic dysfunction had significantly increased median BNP values vs all others, 786 vs 306 pg/mL (P = .03). Eight (9%) patients died during their hospitalization. The median BNP values for 83 (91%) survivors and 8 (9%) nonsurvivors were 344 and 1420 pg/mL, respectively (P = .007). By multiple logistic regression, BNP level more than 500 pg/mL was independently associated with female sex, increased number of vessels diseased (>75% stenosis), lower ejection fraction, higher creatine kinase level, and lower body mass index. CONCLUSION In patients with STEMI, markedly increased BNP level seems to reflect the extent of coronary disease, the degree of associated systolic and diastolic dysfunction, and a higher risk of in-hospital mortality.

Body Weight Limitations of United States Cardiac Catheterization Laboratories Including Restricted Access for the Morbidly Obese

A telephone survey was performed to determine the current weight limits of cardiovascular catheterization laboratories (n = 94) in the United States. The minimum, mean, and maximum weight limits of the catheterization laboratories in this survey were 160, 198.9, and 250 kg (350, 437.5, and 550 lb), respectively. Twenty-two percent of respondents (n = 21) referred to other institutions when asked what they did when patients were too heavy, and 70% of respondents (n = 66) could not provide an answer. In this population, 5.2 +/- 3.4 patients/hospital/year were rejected for being over the weight limit. In conclusion, these results provide useful information for the future management of this growing population.

Balloon Aortic Valvuloplasty

The role of surgical aortic valve replacement (SAVR) for aortic stenosis (AS) is well established as a lifesaving therapy, conferring improved survival, improved symptomatic status, decreases in left ventricular hypertrophy, and improvement in left ventricular systolic function. However, there remain a group of patients with clinical risk factors in whom the risk of SAVR is felt to be prohibitive due to comorbidities. Such risk factors include advanced age, advanced renal and pulmonary disease, and severe left ventricular dysfunction. Of particular concern were patients with “low gradient” AS in the presence of severe LV dysfunction and low cardiac output. The natural history of this group, treated medically, is dismal, with a 3 year survival of 25 %.

Tracheobronchial wallstents for degenerated saphenous vein bypass grafts

The tracheobronchial Wallstent was employed as an endoluminal prosthesis in degenerated saphenous vein bypass grafts in three patients. This Wallstent has unique characteristics that make it potentially useful in patients with vein graft disease.