Alfred Kaff

Implementation of Guidelines Improves the Standard of Care The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI Registry)

Background— The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area. Methods and Results— We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours’ duration. Conclusions— Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.

Prediction of survival after out-of-hospital cardiac arrest: results of a community-based study in Vienna

The objective of this study was the assessment of out-of-hospital cardiac arrest and the definition of possible predictive factors for final hospital discharge. Out of a database of 89,557 consecutive missions of the Vienna emergency medical system (EMS) during 1990, there were 623 missions due to a collapse of non-traumatic origin: in 374 cases (60.0%) the patients were declared dead without further attempts at resuscitation. The remaining 249 patients were analysed for predictive factors at site. Survival to hospital admission: 109 patients survived to hospital admission (43.7%); bystander support had a small impact (P < 0.05) on survival to hospital arrival whereas age and gender had no predictive power. Most patients with ventricular tachycardia/fibrillation (VT/VF) survived primarily (69 of 117, i.e. 59.0%). Survival to hospital discharge: 27 patients were discharged from hospital care (10.8%). ECG findings on arrival of the EMS physician at the site proved to be the only powerful predictor for survival: 24 of 117 patients with VT/VF survived compared with only one of 81 with primary asystole, two of 39 with severe bradycardia, and no patient with electromechanical dissociation.

Out of hospital cardiac arrest in Vienna: Incidence and outcome

AIM OF THE STUDY To determine the incidence of out-of-hospital cardiac arrest and the survival rate of those patients who received CPR in the city of Vienna. METHODS A cohort of patients with out-of-hospital cardiac arrests and who were treated by the Vienna Ambulance Service between January 1, 2009, and December 31, 2010, were followed up until either death or hospital discharge. The associations of survival and neurological outcome with their potential predictors were analysed using simple logistic regression models. Odds ratios were estimated for each factor. RESULTS During the observation period, a total of 7030 (206.8/100,000 inhabitants/year) patients without signs of circulation were assessed by teams of the Vienna Ambulance Service, and 1448 adult patients were resuscitated by emergency medical service personnel. A sustained return of spontaneous circulation was reported in 361 (24.9%) of the treated patients, and in all 479 (33.0%) of the patients were taken to the emergency department. A total of 164 (11.3%) of the patients were discharged from the hospital alive, and 126 (8.7%) of the patients showed cerebral performance categories of 1 or 2 at the time of discharge. Younger age, an arrest in a public area, a witnessed arrest and a shockable rhythm were associated with a higher probability of survival to hospital discharge. CONCLUSION Survival rates for out-of-hospital cardiac arrests remain low. Efforts should be focused on rapidly initiating basic life support, early defibrillation, and high-quality CPR by emergency medical services and state-of-the art post-resuscitation care.

Increased occurrence of out-of-hospital cardiac arrest on Mondays in a community-based study.

Acute myocardial infarction and sudden cardiac death are more common on Mondays than other days of the week. The stress of returning to work at the beginning of the week has been postulated as a possible trigger factor. This project examined the weekly variation of out‐of‐hospital cardiac arrests of nontraumatic origin for the entire case series as well as for selected subgroups. A retrospective analysis of 1,498 incidences between January 1, 1995 and December 31, 1996 revealed a distinct Monday peak in occurrence irrespective of age, gender, presence of witnesses, primary survival, or primary ECG. This finding, however, was most pronounced in retired patients, subjects living alone, and persons found unconscious outside buildings or in public places. One important trigger of cardiac arrest is going to work after weekends; however, resumption of social and other activities on Mondays is another possible trigger. Other factors, such as endogenous biological rhythms, may contribute to an increased risk at this particular time even in elderly.

Analysing calls by lay persons reporting cardiac arrest

Prior to establishing a protocol for pre-arrival instructions for cardio-pulmonary resuscitation in the Vienna emergency medical system dispatch centre, a study was performed to determine whether any problems exist which may compromise guidance for basic life-support on the telephone. To evaluate the feasibility of prearrival instructions, a retrospective analysis of cardiac arrest calls was performed. We reviewed the Vienna emergency medical services dispatch centre tape recordings, ambulance run sheets and the hospital charts of 114 patients suffering from atraumatic cardiac arrest. Analysis showed that in 59 cases the arrest occurred in the victims home. The telephone and the patient were either in the same or in adjoining rooms in 55% of the calls. We did not experience any technical or language difficulties. The caller and victim were related in 51 cases. The callers were completely calm in 77% and fairly calm in an additional 15%. Not one caller was distraught. Our data show that most objections to the feasibility of pre-arrival instructions can be refuted. We conclude that in Vienna the setting and location of arrest will impose few problems on the performance of bystander-cardio-pulmonary resuscitation using pre-arrival instructions given by dispatchers.

Maßnahmen durch Ersthelfer am Unfallort Eine prospektive, epidemiologische Studie im Raum Wien

SummaryThe object of this prospective, epidemiological study was to determine whether bystanders provided necessary first aid measures in the prehospital trauma setting, whether they performed these measures correctly, and whether the level of first aid training affected the quality of first aid measures performed. Data were collected by means of a questionnaire, which was filled out between March and July 2000 for all cases attended to by the Vienna Ambulance Service. A total of 2812 cases were documented. The most frequent causes of trauma were falls from heights less than 1 meter (50%) and traffic accidents (17%). The most frequent injuries were injuries to the extremities (59%) and head and traumatic brain injuries (42%). Most patients were “moderately” or “severely” injured (69% and 29%,. respectively), but life-threatening injuries were rare (2%). Bystanders were present in 57% of the cases. The most frequently required first aid measures were “application of a dressing” and “positioning” of the patient, “Control of haemorrhage”, “ensuring accident site safety” and “extrication” of the patient were less frequently required. “Clearing of the airway”, “precautions against hypothermia” and cardio-pulmonary resuscitation were very rarely required. Bystanders were most frequently policemen, relatives or friends of the patient, and strangers. The vast majority of bystanders had no training in first aid or had only attended the first aid course required to attain a driving licence. We found a clear relationship between the level of first aid training and the quality of first aid measures provided. It would be advisable to offer an increased amount of refresher courses in first aid to improve bystander trauma care.ZusammenfassungZiel dieser prospektiven, epidemiologischen Studie war es, zu erheben, ob Erste-Hilfe-Maßnahmen am Unfallort notwendig waren und ob sie von Ersthelfern geleistet und korrekt durchgeführt wurden. Weiters sollten Angaben zu den Ersthelfern erhoben und festgestellt werden, ob der Ausbildungsstand die Qualität der Erste-Hilfe-Maßnahmen beeinflusst. Die Erhebung erfolgte mittels eines Fragebogens, der zwischen März und Juli 2000 bei allen Einsätzen der Wiener Rettung ausgefüllt wurde. Insgesamt wurden 2812 Einsätze erfasst. Die häufigsten Unfallursachen waren Sturz aus <1 m Höhe (50%) und Verkehrsunfälle (17%). Die häufigsten Verletzungen waren Extremitätenverletzungen (59%) und Schädel- und Schädel-Hirn-Traumen (42%). Die meislen Patienten waren „mäßig schwer” (69%) oder „schwer” (29%) verletzt, aber lebensbedrohliche Verletzungen waren selten (2%). Ersthelfer waren in 57% der Unfälle anwesend. Die am häufigsten indizierten Erste-Hilfe-Maßnahmen waren „Anlegen eines Verbands” und „Lagerung”. Seltener waren „Stillung einer Bluttung”, „Absicherung der Unfallstelle” und „Bergung” indiziert „Freimachen der Atemwege”, „Schutz gegen Unterkühlung” und „Atemspende und Herzmassage” waren sehr selten indiziert. Die häufigsten Ersthelfer waren Polizisten. Verwandte oder Freunde des Verunfallten, und Unbetelligte. Die überwiegende Mehrzahl aller Ersthelfer hatte keine Erste-Hilfe-Ausbildung oder nur den für den Erwerb des Führerscheins notwendigen Kurs. Es bestand ein deutlicher Zusammenhang zwischen Ausbildungsstand und Qualität der Erste-Hilfe-Maßnahmen. Es wäre sinnvoll, vermehrt Wiederholungskurse anzubieten, um bestehende Defizite zu beheben.

Randomized placebo controlled trial of furosemide on subjective perception of dyspnoea in patients with pulmonary oedema because of hypertensive crisis.

Eur J Clin Invest 2011; 41 (6): 627–634

Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality

Background: While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality. Methods: The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003–2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: ‘early presenters’ versus ‘late presenters’); and for (b) onset of pain-to-FMC (min) as a continuous variable. Results: After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013–1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001–1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368–0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex (p=0.003), anterior infarction (p=0.004) and diabetes mellitus (p=0.035) were independently associated with longer delay, while hyperlipidaemia (p=0.002) and cardiogenic shock (p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% (p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999–1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676–1.573; p=0.886). Conclusion: In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

Hurrah—we are still alive! A different dimension in post-resuscitative care: the annual gathering of cardiac arrest survivors at a typical Viennese wine tavern

The Vienna area has a population of about 1.6 million spread over an area of approximately 400 square kilometers. About 16 000 people (1% of the population) receive basic life support training every year. The medical emergency services are centralised: one emergency number (144) serves the whole city. All emergency calls are routed to a dispatch center run by municipal authorities. Dispatchers in the centre co-ordinate the movements of ambulances manned by doctors and emergency medical technicians, a helicopter and standard ambulances with regular crews. The proportion of patients resuscitated successfully after cardiac arrest is about 15%. The Department of Emergency Medicine at the Vienna General University Hospital was opened in the early summer of 1991. Within the 2000-bed hospital complex, the Department is an independent unit in both academic and administrative terms. It treats most types of lifeand non-life-threatening medical emergencies, except trauma and pediatric patients. In addition to its function, related to patient care, the Department has an academic role in emergency medicine (American College of Emergency Physicians Practice Management Committee, 1991; Task Force on Guidelines: Society of Critical Care Medicine, 1991). Approximately 160 patients a year are treated for cardiac arrest and care is provided for those who have undergone out-of hospital cardiopulmonary resuscitation (CPR) provided by the emergency services. Following primary stabilisation, most of the patients are transferred to intensive care units within one or two days. Active follow-up after petients are transferred from the emergency department is frequently difficult, but essential to our aim of bringing about an improvement in the patients outcome and quality of life. In our experience, many survivors of cardiac arrest experience difficulties in returning to a normal lifestyle after the incident. Fear, loneliness and depression are common symptoms and close family members are sometimes unable to improve matters. On the other hand, we have seen patients in the post-resuscitation phase who regain the will to live, with resilience and good spirits. Some patients see the incident as an opportunity to start life anew and generate a new mental capacity. They view life from a different perspective and are able to enjoy the time at their disposal more than ever before. In our attempts to get to know as many facets of life after resuscitation as possible, we have managed to involve an appreciable number of cardiac arrest survivors and their families in specific projects. For the most part, the projects are related to CPR training, including the family use of an automated external defibrillator (AED). This year, we also initiated the foundation of a support group for cardiac arrest survivors and immediate members of their families. This group is led by four patients. For close on a decade now, the Department has organised a special annual event that is looked forward to awaited with enthusiasm by patients, ambulance crews and emergency department staff alike. * Corresponding author. Address: Universitatsklinik fur Notfallmedizin, Wahringergutel 18-20/6D, 1090 Wien, Austria. Tel.: + 43-1-40-400-1964; fax: +43-1-40-400-1965. E-mail address: fritz.sterz@akh-wien.ac.at (F. Sterz).

Gender differences in short- and long-term mortality in the Vienna STEMI registry

BACKGROUND Data obtained from registries have shown that women diagnosed with STEMI are older, have more co-morbidities and a worse clinical outcome than men. Aim of this study was to investigate potential gender differences in in-hospital and long-term mortality in patients from Vienna STEMI registry (2003-2009). PATIENTS AND METHODS Data from 4593 patients who were enrolled from January 2003 until December 2009 into the Vienna STEMI registry were analyzed. Gender-related differences in patient characteristics, time delays, reperfusion therapy, as well as short- and long-term all-cause mortality were investigated. A landmark analysis was performed to assess long-term all-cause mortality in patients after discharge. Multivariate regression analysis was performed in order to correct for confounders. RESULTS Mean age, history of hypertension, diabetes mellitus and shock at presentation were significantly higher in women compared to men, whereas men were more frequently smokers, had more frequently a positive family history, a history of previous myocardial infarction and received more often GbIIb/IIIa inhibitors and reperfusion therapy. Overall the only significant difference in time delays was found in the onset of pain-to first medical contact time, which was significantly prolonged in women. Unadjusted in-hospital mortality, long-term mortality and long-term mortality for in-hospital survivors were statistically higher for women. After adjustment for confounders, multivariate analysis revealed no differences in mortalities between males and females. CONCLUSION The higher risk profile and the prolonged delay between onset of pain-to-first medical contact are responsible for the higher unadjusted mortality rates in women. Difference in short and long-term mortalities is no more existent after statistical correction for confounders such as age, co-morbidities and significantly different time delay.