B. Hadley Wilson

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.

Demonstration of myocardial reperfusion injury in humans: Results of a pilot study utilizing acute coronary angioplasty with perfluorochemical in anterior myocardial infarction☆

Reperfusion may limit the amount of potentially salvageable myocardium through the introduction of cellular elements into previously ischemic but viable myocardium (reperfusion injury). It has been demonstrated that intracoronary infusion of a 20% intravascular perfluorochemical emulsion (Fluosol) significantly reduces infarct size and results in improved left ventricular function in the canine model. This pilot study was performed to explore the existence of myocardial reperfusion injury in humans. Utilizing Fluosol as a probe in conjunction with emergency coronary angioplasty, 26 patients presenting within 4 h with a first anterior myocardial infarction were randomized to emergency angioplasty or angioplasty followed by a 30-min intracoronary infusion of Fluosol at 40 ml/min. Global and regional ventricular function were assessed immediately and a mean of 12 days after successful angioplasty with contrast ventriculography. Infarct size was semiquantitated with thallium-201 single-photon emission computed tomography (SPECT) images before discharge. Twelve patients (six undergoing angioplasty alone, six treated with angioplasty and Fluosol) had an occluded infarct-related vessel (Thrombolysis in Myocardial Infarction [TIMI] grade 0 to 1) at the time of emergency catheterization and were included in the final analysis. At 12 days after successful angioplasty, the improvement in regional ventricular function was greater in patients receiving adjunctive therapy with intracoronary Fluosol versus those undergoing angioplasty alone utilizing both the radial shortening and centerline method, respectively (23 +/- 3.1% vs. 8 +/- 2.3%, p less than 0.02; and -1.6 +/- 0.4 vs. -2.9 +/- 0.2 SD/chord, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Beneficial long-term effect of intracoronary perfluorochemical on infarct size and ventricular function in a canine reperfusion model.

The administration of a drug soon after reperfusion that could enhance myocardial salvage would have important clinical application. The aim of this study was to assess the long-term effect of the perfluorochemical, Fluosol DA 20%, on infarct size, infarct morphology, ventricular ectopic activity and serial regional ventricular function in a 2 week closed chest canine model. After 90 minutes of proximal left anterior descending artery occlusion, animals randomly received either oxygenated Fluosol DA (n = 9) or saline solution (n = 9) intracoronary at 15 ml/kg body weight over 20 to 30 minutes. Hemodynamic variables were similar in the two groups except for transient elevation of left ventricular filling pressure immediately after infusion in the treated group. Infarct size was markedly reduced in the perfluorochemical-treated animals when expressed as a percent of the risk region (10.8 +/- 1.8% versus 28.9 +/- 5.5%, p less than 0.02) or as a percent of the total left ventricle (3.7 +/- 1% versus 10.8 +/- 8%, p less than 0.006). This was associated with greater improvement in radial shortening in the jeopardized zone at 2 weeks after reperfusion (15.3 +/- 2.8% versus 5.2 +/- 2.1%, p less than 0.01). Histologic examination revealed adequate healing in the treated animals with an increased number of swollen mononuclear cells in the border zones. Holter electrocardiographic recordings demonstrated a low frequency of ventricular ectopic beats in both groups. This study suggests that the perfluorochemical, Fluosol DA, may be a potentially useful agent in enhancing myocardial salvage after successful reperfusion.

Expansion of a Regional ST-Segment Elevation Myocardial Infarction System to an Entire State

Background— Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer. Methods and Results— One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment–elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment–elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non–percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% (P=0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a “transfer for percutaneous coronary intervention” reperfusion strategy fell from 117 to 103 minutes (P=0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes (P=0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P<0.001). Emergency medical services–transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations (P<0.001). Conclusion— Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment–elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.

Infective perivalvular abscess of the aortic ring: Echocardiographic features and clinical course

Abstract Aortic ring abscess is a serious complication of infective endocarditis that may be diagnosed by 2-dimensional echocardiography when an echocardiographic-free space or focal aortic root thickening is shown.1–4 Two related complications that markedly worsen prognosis in endocarditis are new atrioventricular conduction block and pseudoaneurysm formation.5–7 Using 2-dimensional echocardiography prospectively in 10 patients with endocarditis, we correlated the location of aortic ring abscesses with the development of atrioventricular conduction block and observed the development of 6 aortic ring pseudoaneurysms.

Out-of-hospital management of cardiac arrest by basic emergency medical technicians

The outcome in 126 consecutive patients with nontraumatic out-of-hospital cardiac arrest was analyzed to determine the effectiveness of a standard ambulance system over 22 months. Therapy was limited to basic life support (that is, administration of oxygen by mask, i.v. fluids, closed-chest massage and artificial respiration) by emergency medical technicians in a community in which less than 1% of the population had been trained in cardiopulmonary resuscitation (CPR). Analyses of patient data were performed to determine the relations between survival to hospital admission or discharge and 6 variables; response time, prior CPR, initial rhythm, acute myocardial infarction, initial blood pressure and initial pulse. Of 126 patients, 28 (22%) survived to hospital admission and 11 (9%) to hospital discharge. Two patient subgroups had a higher discharge rate: those with an initial rhythm of ventricular tachycardia or fibrillation (7 of 50, 14%), and those with an initial blood pressure greater than or equal to 90 mm Hg and a pulse rate of greater than 50 beats/min (3 of 6, 50%). For patients in arrest before ambulance arrival, there was no difference in outcome between those who did or those who did not receive prior CPR. Results of this study can be used as a basis for evaluating and comparing interventions directed toward stabilization of patients during the prehospital phase of cardiac arrest.

Right ventricular myocardial infarction in patients with chronic lung disease: possible role of right ventricular hypertrophy.

To determine the relation between right ventricular hypertrophy and right ventricular myocardial infarction in patients with chronic lung disease, the records of 28 patients with chronic lung disease, inferior myocardial infarction and significant coronary artery disease (group I) and 20 patients with right ventricular hypertrophy, chronic lung disease without inferior myocardial infarction or significant coronary artery disease (group II) were reviewed. Chronic lung disease was diagnosed by clinical criteria, chest radiographs and pulmonary function tests. All patients had postmortem examinations. Patients in group I were classified into two subgroups: group Ia (without right ventricular hypertrophy) and group Ib (with right ventricular hypertrophy). Right ventricular wall thickness was 3.3 mm ± 0.5 in group la, 6.0 mm ± 1.1 in group Ib and 8.8 mm ± 2.4 in group II (group Ia versus Ib, p Patients with right ventricular hypertrophy as a result of chronic lung disease are prone to right ventricular myocardial infarction in the setting of inferior myocardial infarction. Isolated right ventricular myocardial infarction may occur in patients with chronic lung disease, right ventricular hypertrophy and insignificant coronary artery disease. Both increased myocardial oxygen demand and a decreased supply may play a role in this relation.

Right ventricular hypertrophy is an important determinant of right ventricular infarction complicating acute inferior left ventricular infarction

To explore the role of right ventricular hypertrophy and chronic obstructive pulmonary disease in the pathogenesis of right ventricular infarction, 27 consecutive patients with a first inferior left ventricular infarction were prospectively studied. Right ventricular infarction was diagnosed using established hemodynamic criteria. Right ventricular hypertrophy was defined as right ventricular free wall thickness greater than or equal to 5 mm. Patients were classified into two groups: Group I patients with right ventricular infarction (n = 15), and Group II patients without right ventricular infarction (n = 12). The ratio of forced expiratory volume over forced vital capacity (FEV1/FVC) and forced expiratory flow between 25 and 75% expired volume (FEF) as a percent of predicted values were significantly reduced in Group I versus Group II (90 +/- 5 versus 105 +/- 6% and 63 +/- 13 versus 103 +/- 15%, respectively; p less than 0.05). This was associated with increased right ventricular wall thickness (Group I 5.5 +/- 0.3 mm versus Group II 3.9 +/- 0.2 mm, p less than 0.001). Multiple logistic regression analysis demonstrated that right ventricular wall thickness was the strongest predictor of right ventricular infarction (p less than 0.0005). No significant difference was found in the site of right coronary occlusion, collateral blood supply or extent of coronary artery disease between the two groups. These findings suggest that right ventricular hypertrophy predisposes patients with acute inferior myocardial infarction to right ventricular infarction independent of the site or extent of coronary artery disease.

Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator.

Background: Up to 50% of patients fail to meet ST-segment–elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact–to–device time of <90 minutes for patients directly presenting to percutaneous coronary intervention–capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. Methods: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. Results: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P <0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact–to–device time, including those directly presenting via EMS (50% to 55%; P <0.001) and transferred patients (44%−48%; P =0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P <0.001) and 38% to 50% (transfers; P <0.001). Conclusions: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact–to–device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals. # Clinical Perspective {#article-title-31}Background: Up to 50% of patients fail to meet ST-segment–elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact–to–device time of <90 minutes for patients directly presenting to percutaneous coronary intervention–capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. Methods: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. Results: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact–to–device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%−48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). Conclusions: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact–to–device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.

Bypassing the Emergency Department and Time to Reperfusion in Patients With Prehospital ST-Segment Elevation Findings From the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments Project

Background—Among patients identified prehospital with ST-segment–elevation myocardial infarction, emergency medical service transport from the field directly to the catheterization laboratory, thereby bypassing the emergency department (ED), may shorten time to reperfusion. Methods and Results—We studied 1687 patients identified prehospital with ST-segment–elevation myocardial infarction from the Reperfusion in Acute Myocardial Infarction in Carolina Emergency Departments (RACE) project, transported via emergency medical service directly to 21 North Carolina hospitals for primary percutaneous coronary intervention between July 2008 and December 2009. Treatment time intervals were compared between patients evaluated in the ED (ED evaluation) and those transported directly to the catheterization laboratory (ED bypass). Emergency medical service transported 1401 (83.0%) patients to the ED, whereas the ED was bypassed for 286 (17.0%) patients. Overall, first medical contact to device activation within 90 minutes was achieved in 913 (54.1%) patients. Among patients evaluated in the ED, median time (25th–75th percentiles) from ED arrival to catheterization laboratory arrival was 30 (20–41) minutes. First medical contact to device activation occurred faster (75 [59–93] versus 90 [76–109] minutes; P<0.001) and was more frequently achieved within 90 minutes (74.1% versus 50.1%; P<0.001) among ED bypass patients. Conclusions—Among patients identified prehospital with ST-segment–elevation myocardial infarction and transported directly to a percutaneous coronary intervention hospital, only 1 in 2 achieve device activation within 90 minutes. A median of 30 minutes is spent in the ED, contributing significantly to the failure to achieve timely reperfusion. The strategy to bypass the ED is used infrequently and represents a potential opportunity to improve reperfusion times.