Jean Guillaume Dillinger

Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients

BACKGROUNDnDiagnosis of acute myocardial infarction (AMI) in out-of-hospital cardiac arrest (OHCA) patients is important because immediate coronary angiography with coronary angioplasty could improve outcome in this setting. However, the value of acute post-resuscitation electrocardiographic (ECG) data for the detection of AMI is debatable.nnnMETHODSnWe assessed the diagnostic characteristics of post-resuscitation ECG changes in a retrospective single centre study evaluating several ECG criteria of selection of patients undergoing AMI, in order to improve sensitivity, even at the expense of specificity. Immediate post resuscitation coronary angiogram was performed in all patients. AMI was defined angiographically using coronary flow and plaque morphology criteria.nnnRESULTSnWe included 165 consecutive patients aged 56 (IQR 48-67) with sustained return of spontaneous circulation after OHCA between 2002 and 2008. 84 patients had shockable, 73 non-shockable and 8 unknown initial rhythm; 36% of the patients had an AMI. ST-segment elevation predicted AMI with 88% sensitivity and 84% specificity. The criterion including ST-segment elevation and/or depression had 95% sensitivity and 62% specificity. The combined criterion including ST-segment elevation and/or depression, and/or non-specific wide QRS complex and/or left bundle branch block provided a sensitivity and negative predictive value of 100%, a specificity of 46% and a positive predictive value of 52%.nnnCONCLUSIONnIn patients with OHCA without obvious non-cardiac causes, selection for coronary angiogram based on the combined criterion would detect all AMI and avoid the performance of the procedure in 30% of the patients, in whom coronary angiogram did not have a therapeutic role.

Favourable 5-year postdischarge survival of comatose patients resuscitated from out-of-hospital cardiac arrest, managed with immediate coronary angiogram on admission:

Aims: On-admission coronary angiogram (CA) with angioplasty (percutaneous coronary intervention, PCI) may improve survival in patients resuscitated from out-of-hospital cardiac arrest (OHCA), but long-term survival data are scarce. We assessed long-term survival in OHCA patients managed with on-admission CA and PCI if indicated and compared survival rates in patients with/without acute coronary syndrome (ACS). Methods: Retrospective single-centre study including patients aged ≥18 years resuscitated from an OHCA without noncardiac cause, with sustained return of spontaneous circulation, undergoing on-admission CA with PCI if indicated. ACS was diagnosed angiographically. Survival was recorded at hospital discharge and at 5-year follow up. Survival probability was estimated by Kaplan–Meier survival curves. Results: A total of 300 comatose patients aged 56 years (IQR 48–67 years) were included, 36% with ST-segment elevation. All had on-admission CA; 31% had ACS. PCI was attempted in 91% of ACS patients and was successful in 93%. Hypothermia was performed in 84%. Survival to discharge was 32.3%. After discharge, 5-year survival was 81.7±5.4%. Survival from admission to 5 years was 26.2±2.8%. ACS patients had better survival to discharge (40.8%) compared with non-ACS patients (28.5%, p=0.047). After discharge, 5-year survival was 92.2±5.4% for patients with ACS and 73.4±8.6% without ACS (hazard ratio, HR, 2.7, 95% CI 0.8–8.9, p=0.1). Survival from admission to 5 years was 37.4±5.2% for ACS patients, 20.7±3.0%, for non-ACS patients (HR 1.5, 95% CI 1.12–2.0, p=0.0067). Conclusions: OHCA patients undergoing on-admission CA had a very favourable postdischarge survival. Patients with OHCA due to ACS had better survival to discharge at 5-year follow up than patients with OHCA due to other causes.

Wall Shear Stress in the Feeding Native Conduit Arteries of Superficial Arteriovenous Malformations of the Lower Face is a Reliable Marker of Disease Progression

PURPOSEnu2002To assess the prognostic value of the wall shear stress (WSS) measured in the feeding native arteries upstream from facial superficial arteriovenous malformations (sAVMs). Reliable prognostic criteria are needed to distinguish progressive from stable sAVMs and thus support the indication for an aggressive or a conservative management to avoid severe facial disfigurement.nnnMATERIALS AND METHODSnu2002We prospectively included 25 patients with untreated facial sAVMs, 15 patients with surgically resected sAVMs and 15 controls. All had undergone Doppler ultrasound examination (DUS) with measurements of inner diameters, blood flow velocities, computation of blood flow and WSS of the feeding arteries. Based on the absence or presence of progression in clinical and imaging examinations 6 months after, we discriminated untreated patients as stable or progressive.nnnRESULTSnu2002WSS in the ipsilateral external carotid artery was higher in progressive compared to stable sAVMs (15.8u200a±u200a3.3dynes/cm² vs. 9.6u200a±u200a2.0dynes/cm², mean±SD, pu200a<u200a0.0001) with a cut-off of 11.5dynes/cm² (sensitivity: 92u200a%, specificity: 92u200a%, AUC: 0.955, [95u200a%CI: 0.789u200a-u200a0.998], pu200a=u200a0.0001). WSS in the ipsilateral facial artery was also higher in progressive compared to stable sAVMs (50.7u200a±u200a14.5dynes/cm² vs. 25.2u200a±u200a7.1dynes/cm², pu200a<u200a0.0001) with a cut-off of 34.0dynes/cm² (sensitivity: 100u200a%, specificity: 92u200a%, AUC: 0.974, [95u200a%CI: 0.819u200a-u200a1.000], pu200a=u200a0.0001). The hemodynamic data of operated patients were not different from those of the control group.nnnCONCLUSIONnu2002WSS measured in the feeding arteries of an sAVM may be a simple reliable criterion to distinguish stable from progressive sAVMs. This value should be considered to guide the therapeutic strategy as well as the long-term follow-up of patients with facial sAVMs.

Synchronized Pulsatile Flow With Low Systolic Output From Veno-Arterial Extracorporeal Membrane Oxygenation Improves Myocardial Recovery After Experimental Cardiac Arrest in Pigs: SYNCHRONIZED PULSATILE FLOW

Circulatory failure following cardiac arrest (CA) requires catecholamine support and occasionally veno-arterial extracorporeal membrane oxygenation (vaECMO). VaECMO-generated blood flow is continuous and retrograde, increasing ventricular stroke work. Our aim was to assess the benefit of a device generating a pulsatile vaECMO flow synchronized with the heart rhythm lowering systolic vaECMO output on the left ventricular ejection fraction (LVEF) and pulmonary capillary pressure (Pcap) after CA. This experimental randomized study in pigs compared standard nonpulsatile vaECMO (control) with pulsatile synchronized vaECMO (study) group using a pulsatility-generating device. After sedation and intubation, ventricular fibrillation was induced by pacing. After 10-min ventricular fibrillation, cardiopulmonary resuscitation was performed for 20 min then vaECMO, defibrillation and 0.15 µg/kg/min intravenous epinephrine infusion were initiated. Hemodynamics, Pcap, LVEF by echocardiography and angiography were measured at baseline and every 30 min after the vaECMO start until vaECMO and epinephrine were stopped (at 120 min), and 30 min later. Baseline hemodynamics did not differ between groups; 120 min after vaECMO initiation, LVEF by echocardiography and angiography was significantly higher in the study than control group 55u2009±u200919% versus 34u2009±u200913% (Pu2009=u20090.042), 50u2009±u200916% versus 33u2009±u200912% (Pu2009=u20090.043), respectively. Pcap decreased from baseline by 4.2u2009±u20098.6 mm Hg in the study group but increased by 5.6u2009±u20095.9 mm Hg in the control group (Pu2009=u20090.043). Thirty minutes later, LVEF remained higher in the study group 44u2009±u20097% versus 26u2009±u200911% (Pu2009=u20090.008) while Pcap did not differ. A synchronized pulsatile device decreasing systolic output from vaECMO improved LVEF and Pcap in a pig model of CA and resuscitation.

Mega-giant coronary aneurysm: antithrombotic therapy is an option

A 69-year-old man with a history of hypercholesterolaemia presented to the emergency department with atypical chest pain. Physical examination was normal and ECG showed no evidence of ischaemic changes. Laboratory studies were notable for a D-dimer level of 1842 ng/mL (reference valuexa0<500u2009ng/mL) and the troponin I level was normal.nnChest X-ray was normal. Chest CT angiography ruled out a pulmonary embolism but showed a giant and extensive aneurysm of the right coronary artery (RCA) up to 45u2009mm inxa0diameter with a partly thrombosed lumen and evidence of right ventricle compression …

0289: Inflammation is the main predictor of high-on aspirin platelet reactivity in stable vascular patients treated with monotherapy

Background High platelet reactivity (HPR) despite antiplatelet treatment is related to ischemic events in patients with coronary artery disease (CAD), but cannot be assessed routinely in all patients. The aim of the study was to identify clinical and biological predictive factors of HPR on aspirin. Methods 333 consecutive patients chronically treated with aspirin for CAD or cerebrovascular disease with potential high risk of ischemic events (complex angioplasty, diabetes, recurrence), in whom platelet reactivity was assessed between 2011 and 2013, were retrospectively analysed. HPR was evaluated just before the next aspirin intake, defined as aggregation ≥20% using light transmission aggregometry with arachidonic acid 0.5xa0mg/mL (LTA) and closure time Results Median age was 63 years old, 65% were male, with a median BMI of 25.5xa0kg/m 2 , 28% had diabetes mellitus and 15% moderate to severe chronic renal failure. Median dose of aspirin was 100mg/day (range 75 to 160) and 11% had aspirin twice daily. LTA found HPR in 8.7% patients and PFA in 20.1%. In a multivariate analysis, predictor factors associated with HPR using LTA were fibrinogen (OR: 1.51, p=0.01), CRP (OR: 1.01, p 3.0xa0mg/mL had a higher rate of HPR (14.6% versus 2.6%, p 3.0xa0mg/mL) were also associated with a 2.6-fold increased risk of HPR using PFA. Conclusion Inflammation is the main predictor of HPR on aspirin in stable CAD and cerebrovascular patients treated with monotherapy. Further clinical investigations assessing platelet reactivity should focus on patients with inflammatory states.

335 Sensitivity and specificity of post-resuscitation ECG for the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrests

Coronary angioplasty can decrease mortality in patients with acute myocardial infarction (AMI) and out-of-hospital cardiac arrest (OHCA). Sensitivity (Se) and specificity (Sp) of electrocardiogram (ECG) for AMI diagnosis in these patients are debated. Purpose to determine the Se and Sp of immediate post-resuscitation ECG for AMI diagnosis in patients resuscitated from an OHCA. Methods We screened in a prospective single centre study, 210 consecutive patients admitted for OHCA regardless of ECG abnormalities and medical history, between January 2002 and June 2008. All patients underwent coronary angiogram with angioplasty on arrival at the hospital. Exclusion criteria were: obvious non-cardiac cause of OHCA, age 90 years, unstable or absence of return of spontaneous circulation. AMI was characterized at angiography by a significant stenosis (>80% lumen diameter) and TIMI 3 or 2 flow with intracoronary fresh thrombus, or TIMI 1 or 0 flow due to an occlusion easily crossed by a guide wire. Results are expressed as meanxa0±xa0SD [range]. Results Among the 170 patients included, 77% were male and mean age was 58xa0±xa013 [26-90]. On post-resuscitation ECG, 41% presented with ST segment elevation, 15% with ST depression only (≥1mm), 12% with large QRS complex only (>120 ms with left bundle branch block or atypical morphology), and 32% with no significant ECG changes. AMI was diagnosed in 38% of the patients: in 76% of the patients with ST segment elevation, in 15% with ST depression, in 15% with large QRS, and in 0% with none of the above. Se and Sp for AMI diagnosis of ST elevation, ST elevation or depression and ST elevation or depression or large QRS were 88% and 83%, 95% and 63%, 100% and 46% respectively. Conclusion ST elevation on ECG after a resuscitated OHCA has a moderate Se and Sp for AMI diagnosis. The combined criterion of ST elevation or depression or large QRS has 100% sensitivity in our study and could identify all patients with AMI in the setting of OHCA.

291 An active strategy based on mandatory nicotine replacement coupled with a behavioral approach can dramatically decrease the rate of smoking 6 months after an acute coronary syndrome. The PATPAC trial

Background Although smoking continuation after an acute coronary syndrome (ACS) is associated with a poor prognosis, in-hospital smoking cessation strategies for such patients are not well defined. We evaluated an in-hospital initiated smoking cessation program based on mandatory nicotine replacement and a cognitive behavioral approach in ACS patients. Methods All consecutive eligible active smoker patients (mean >5 cig/day) hospitalized for ACS in our CCU were included. Main exclusion criteria were unstable hemodynamic status, the presence of another dependence (mainly alcohol or drug) and planned re-hospitalization after discharge. The patients were randomized into two groups: an active group receiving mandatory nicotine replacement on day 1 after hospitalization coupled with a behavioral approach based on “exposure” on day 2 and 3 and after discharge on week 1, 2, 3, 4 and month 3; a control group where patients received counseling and were proposed nicotine replacement during hospitalization. The main endpoint was the rate of non-smoking patients in each group (self-declaration + CO measurement) at 6 months after inclusion. Results 52 patients were studied: 25 (mean age 51± 7 y.o., 76% male) in the active group and 27 (mean age 54xa0±xa08 y.o. 100% male) in the control group. In the active and control groups respectively, mean duration of smoking was 31xa0±xa09 and 35xa0±xa09 years, mean number of cigarettes/day 24xa0±xa06 and 23xa0±xa010, Fargestrom score 5.0 ±2.0 and 5.4±2.4, anxiety and depression score (HAD) 13.8± 6.9 and 14.4xa0±xa04.8, and BMI 26xa0±xa03 and 27±3 (all NS). After 6 months, 41.7% patients had stopped smoking in the control group as compared to 85.0% in the active grouo. Conclusion A strategy based on mandatory nicotine replacement coupled with a behavioral approach can markedly decrease the rate of smoking in patients 6 months after ACS. The impact of such a strategy on major cardiac events as secondary prevention in smokers remains to be evaluated.