M.M. Vis

Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion

Objective: To describe patients with a distinct electrocardiogram (ECG) pattern without ST-segment elevation in the presence of an acute occlusion of the proximal left anterior descending (LAD) artery. Design: Single-centre observational study. Patients: Patients with acute anterior wall myocardial infarction who were referred for primary percutaneous coronary intervention (PCI) between 1998 and 2008. Results: We identified patients with a static, distinct ECG pattern without ST-segment elevation and an occlusion of the proximal LAD artery during urgent coronary angiography before PCI. Of 1890 patients who underwent primary PCI of the LAD artery, we could identify 35 patients (2%) with this distinct ECG pattern. The ECG showed ST-segment depression at the J-point of at least 1 mm in precordial leads with upsloping ST-segments continuing into tall, symmetrical T-waves. Patients with this distinct ECG pattern were younger, more often male and more often had hypercholesterolaemia compared to patients with anterior myocardial infarction and ST-segment elevation. Conclusions: In patients presenting with chest pain, ST-segment depression at the J-point with upsloping ST-segments and tall, symmetrical T-waves in the precordial leads of the 12-lead ECG signifies proximal LAD artery occlusion. It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.

Prognostic value of post-procedural aPTT in patients with ST-elevation myocardial infarction treated with primary PCI

Unfractionated heparin is the most commonly used anticoagulant in ST-elevation myocardial infarction (STEMI) and its effect can be monitored with activated partial thromboplastin time (aPTT). However, the optimal aPTT range during heparin therapy after primary percutaneous coronary intervention (PCI) is yet to be defined. A mean aPTT was calculated of all aPTT measurements in the first 24 hours after pPCI in a total of 1,876 STEMI patients. Mean aPTT measurements were stratified into four categories; < 1.5 times the upper limit of normal (ULN), 1.5 - 2.0 times ULN (the therapeutic group), 2.01 - 3.99 times ULN, and ≥ 4 times ULN. Compared to patients with a therapeutic aPTT, patients with aPTTs < 1.5 times ULN had no increase in recurrent ischaemic events and had similar rates of bleeding complications. Patients with a mean aPTT ≥ 4 times ULN had higher rates recurrent ischaemic and haemorrhagic complications. After multivariable analyses, aPTT ratios ≥ 4 times ULN were no longer associated with recurrent ischaemic events, but remained a strong predictor of severe and moderate bleeding (hazard ratio [HR] 4.64, p = 0.016 and HR 2.27, p = 0.052). In conclusion, in 1,876 STEMI patients treated with pPCI, low aPTTs in the first 24 hours after PCI were not associated with an increase in ischaemic events, whereas high aPTT values were associated with more frequent bleeding complications. These results indicate no clear benefit as well as a safety concern with heparin treatment after primary PCI.

Guideline-defined futility or patient-reported outcomes to assess treatment success after TAVI: what to use? Results from a prospective cohort study with long-term follow-up

Objective Transcatheter aortic valve implantation (TAVI) provides a significant symptom relief and mortality reduction in most patients; however, a substantial group of patients does not experience the same beneficial results according to physician-determined outcomes. Methods Single-centre prospective design; the population comprises all consecutive patients undergoing TAVI in 2012–2017. TAVI futility was defined as the combined endpoint of either no symptomatic improvement or mortality at 1u2009year. We actively gathered telephone follow-up using a predefined questionnaire. Results Guideline defined TAVI futility was present in 212/741 patients. Multivariate regression showed lower albumin and non-transfemoral approach to be predictive for futility. In addition to these, chronic obstructive pulmonary disease, lower estimated glomerular filtration rate, atrial fibrillation, low-flow–low-gradient aortic stenosis and lower Body Mass Index were predictive for 1-year mortality. Patients who showed symptomatic benefit estimated the percentage in which their symptoms were remedied higher than patients who did not (80% vs 60%, p<0.001). Guideline-defined TAVI futility occurs frequently, contrasting with patient-reported outcome measures (PROMs). The vast majority in both groups would again choose for TAVI treatment. Conclusion Lower albumin and non-transfemoral access route were predictors for guideline-defined TAVI futility, defined as mortality within 1u2009year or no objective symptomatic improvement in New York Heart Association class. Futility according to this definition occurred frequently in this study, contrasting with much more positive PROMs. The majority of patients would undergo a TAVI again, underlining the patients’ experienced value of TAVI and putting the definition of TAVI futility further on debate. In the near future, less-strict criteria for TAVI futility, that is, using a shorter warranted life expectancy and incorporating patients’ perceived outcomes, should be used.

Premedication to reduce anxiety in patients undergoing coronary angiography and percutaneous coronary intervention

Aims In this study, we examined the effects of the routinely administration of benzodiazepines on reducing periprocedural anxiety versus no premedication. Methods In this open label study, we enrolled 1683 patients undergoing diagnostic coronary angiograms (CAG) or percutaneous coronary interventions (PCI). Randomisation was simulated by systematically allocating patients in monthly rotational periods to lorazepam 1 u2009mg/sl, oxazepam 10 u2009mg/po, diazepam 5 u2009mg/po, midazolam 7.5 u2009mg/po or no premedication. Anxiety was measured at four different time points using the one-item Visual Analogue Scale for Anxiety (VAS score) ranging from 0 to 10. The primary outcome was the difference in anxiety reduction (ΔVAS, preprocedure to postprocedure), between the different premedication strategies versus no premedication. Results Anxiety reduction was larger in patients premedicated with lorazepam (ΔVAS=−2.0, SE=1.6, P=0.007) or diazepam (ΔVAS=−2.0, SE=1.5, p=0.003) compared with patients without any premedication (ΔVAS=−1.4, SE=1.2). The use of midazolam or oxazepam did not lead to a significant reduction in anxiety compared with patients who did not receive premedication. Additionally, a high number of patients treated with midazolam (N=39, 19.8%) developed side effects. Conclusions In this study, the use of lorazepam or diazepam was associated with a significant, but modest anxiety reduction in patients undergoing CAG or PCI. This study does not support the standard use of oxazepam or midazolam as premedication to reduce anxiety.

Remote Monitoring of Patients Undergoing Transcatheter Aortic Valve Replacement: A Framework for Postprocedural Telemonitoring

Background The postprocedural trajectory of patients undergoing transcatheter aortic valve replacement (TAVR) involves in-hospital monitoring of potential cardiac rhythm or conduction disorders and other complications. Recent advances in telemonitoring technologies create opportunities to monitor electrocardiogram (ECG) and vital signs remotely, facilitating redesign of follow-up trajectories. Objective This study aimed to outline a potential set-up of telemonitoring after TAVR. Methods A multidisciplinary team systematically framed the envisioned telemonitoring scenario according to the intentions, People, Activities, Context, Technology (iPACT) and Functionality, Interaction, Content, Services (FICS) methods and identified corresponding technical requirements. Results In this scenario, a wearable sensor system is used to continuously transmit ECG and contextual data to a central monitoring unit, allowing remote follow-up of ECG abnormalities and physical deteriorations. Telemonitoring is suggested as an alternative or supplement to current in-hospital monitoring after TAVR, enabling early hospital dismissal in eligible patients and accessible follow-up prolongation. Together, this approach aims to improve rehabilitation, enhance patient comfort, optimize hospital capacity usage, and reduce overall costs. Required technical components include continuous data acquisition, real-time data transfer, privacy-ensured storage, automatic event detection, and user-friendly interfaces. Conclusions The suggested telemonitoring set-up involves a new approach to patient follow-up that could bring durable solutions for the growing scarcities in health care and for improving health care quality. To further explore the potential and feasibility of post-TAVR telemonitoring, we recommend evaluation of the overall impact on patient outcomes and of the safety, social, ethical, legal, organizational, and financial factors.

Associations of major bleeding and recurrent myocardial infarction with the incidence and timing of mortality in patients with ST-segment elevation myocardial infarction

Purpose: The purpose of the current analysis was to investigate the temporal mortality pattern after recurrent MI (reMI) and severe bleeding in STEMI patients.nnMethods: From 1-1-2003 to 31-7-2008, 2002 patients were treated with primary PCI for STEMI and followed for the occurrence of recurrent MI and GUSTO severe bleeding. Hazard ratios for 4 year mortality for discrete time intervals after bleeding or reMI were calculated in a time-dependent, covariate adjusted Cox model.nnResults: After a reMI, the risk of subsequent mortality was high in the first days after the reMI, gradually decreased over time, but remained elevated long after the reMI (see table). After a bleeding, the risk of mortality was high in the first days after the bleeding, but rapidly decreased to non-significant.nnView this table:nnTable 1. Impact of recurrent MI and GUSTO severe bleeding on subsequent mortality to 4 yearsnnnnnnConclusions: The occurrence of reMI and bleeding in the first year after STEMI are both associated with subsequent mortality. The risk implication of reMI however was greater and more sustained than that of severe bleeding.

Prognostic value of access site and non-access site bleeding in ST-segment elevation myocardial infarction

Purpose: The aim of the current analysis was to investigate the relative prognostic value of access and non-access site bleeding on recurrent ischemic outcomes and mortality in patients with ST-segment elevation myocardial infarction (STEMI).nnMethods: The prognostic value of access and non-access site bleeding for one year cardiac and non cardiac mortality, reinfarction, stent thrombosis and stroke was investigated in 2002 STEMI patients undergoing primary PCI in a high volume tertiary center. Access site related bleeding was defined as a GUSTO severe or moderate bleeding originating at the PCI related arterial puncture site or in the retroperitoneal cavity.nnHazard ratios for one year outcomes were calculated using Cox regression analyses, simultaneously including access and non-access site bleeding as time dependent covariates, adjusting for predictors of these outcomes in our dataset. We additionally performed a meta-analysis of adjusted hazard ratios of studies investigating the prognostic value of access- and non-access site bleedings using the generic inverse variance method (not shown).nnResults: Of the GUSTO severe or moderate bleedings within 30 days after PPCI, 52% was non-access site related and 63.2% was access-site related (some patients suffered both). After adjustment for relevant predictors, an access site bleeding was not associated with a higher risk of one year mortality (HR 1.03, p = 0.89), reinfarction (HR 1.16, p = 0.64), stent thrombosis (HR 0.55, p = 0.42) or stroke (HR 0.47, p = 0.31). Non-access site bleeding was associated with a higher risk of one year mortality (HR 2.77, p < 0.001), and stent thrombosis (HR 3.10 p = 0.021), but not of reinfarction (HR 1.46, p = 0.24) and stroke (no patients with non-access site bleeding suffered a stroke). Non-access site bleedings were associated with higher rates of premature discontinuation of antiplatelet therapy (clopidogrel 8.5 vs 1.7%, p=0.019, aspirin or clopidogrel 15.7 vs 4.8%, p=0.006).nnConclusion: Access site related bleeding was not associated with an increased risk of mortality and recurrent ischemic events, while bleedings occurring at non-access sites were associated with higher rates of premature cessation of antiplatelet therapy, increased risk of mortality and stent thrombosis.

525 The presence of mitral regurgitation is an independent predictor of 1-year mortality in STEMI patients with cardiogenic shock on admission

s S85 Eur J Echocardiography Abstracts Supplement, December 2006 Echocardiographic evaluation was focused on LV volumes, and indices of global (ejection fraction, global WMS) and regional function (WMSI for anterosepto-apical, posterior and inferior territories). Results: A different pattern of geographic distribution of dyssynergy was found between groups, despite similar end-diastolic volumes and global WMS. The degree of involvement of the posterior and inferior walls was the main determinant for the occurrence of mitral regurgitation see Table 1. Conclusions: Our results underscore the importance of posteroinferior wall asynergy over global remodeling and LV dysfunction for the occurrence of