Maaike Hermans

Healthcare and disease burden among refugees in long-stay refugee camps at Lesbos, Greece

ObjectivesTo assess current medical problems at two Greek refugee sites at Lesbos island (Camp Moria and Caritas hotel), to explore which care is needed and to assess how the provided healthcare can be improved.DesignIn this dynamic cohort study all consecutive patients who visited doctors from the Boat Refugee Foundation were included.OutcomeTreatment Rates (TR) with 95% Confidence Intervals (95% CI) were calculated for all major health issues. Additionally, the provided health care was evaluated using the SPHERE project standards.ResultsDuring the observation period of 30 March 2016 to 15 May 2016, 2291 persons were followed for a total of 289 person years (py). The median age of patients was 23.0 (IQR 8–38) years, 30.0% was aged <18. The healthcare demand was high with 3.6 patient visits per py. Upper respiratory tract infections were most commonly diagnosed with a TR of 89.6/100py (95% CI 78.7–10.1) followed by dental problems (TR 18.0/100py, 95% CI 13.1–22.9). The rate of suicide attempts was high at TR 1.4/100py (95% CI 0.03–2.8), and many psychological problems were diagnosed, TR 19.4/100py (95% CI 14.3–24.4). Major health care threats are the lack of a vaccination program, inadequate sanitation and hygiene, and severe overcrowding.ConclusionsThis study can help policy makers and Non-Governmental Organizations decide which health care is needed most in the current European refugee crisis. There is an urgent need for mental and dental healthcare. Furthermore, it is crucial that vaccination programs are initiated and “hotspot” camps should transform in camps designed for long-stay situations.

Prognosis of complete versus incomplete revascularisation of patients with STEMI with multivessel coronary artery disease: an observational study

Objective The best strategy in patients with acute ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease (CAD) regarding completeness of revascularisation of the non-culprit lesion(s) is still unclear. To establish which strategy should be followed, survival rates over a longer period should be evaluated. The aim of this study was to investigate whether complete revascularisation, compared with incomplete revascularisation, is associated with reduced short-term and long-term all-cause mortality in patients with first STEMI and multivessel CAD. Methods This retrospective study consisted of 518 patients with first STEMI with multivessel CAD. Complete revascularisation (45%) was defined as the treatment of any significant coronary artery stenosis (≥70% luminal narrowing) during primary or staged percutaneous coronary intervention prior to discharge. The primary end point was all-cause mortality. Results Incomplete revascularisation was not independently associated with 30-day all-cause mortality in patients with acute first STEMI and multivessel CAD (OR 1.98; 95% CI 0.62to6.37; p=0.25). During a median long-term follow-up of 6.7 years, patients with STEMI with multivessel CAD and incomplete revascularisation showed higher mortality rates compared with patients who received complete revascularisation (24% vs 12%, p<0.001), and these differences remained after excluding the first 30 days. However, in multivariate analysis, incomplete revascularisation was not independently associated with increased all-cause mortality during long-term follow-up in the group of patients with STEMI who survived the first 30 days post-STEMI (HR 1.53 95% CI 0.89-2.61, p=0.12). Conclusion In patients with acute first STEMI and multivessel CAD, incomplete revascularisation compared with complete revascularisation was not independently associated with increased short-term and long-term all-cause mortality.

Long-term prognostic value of single-photon emission computed tomography myocardial perfusion imaging after primary PCI for STEMI

Aims The aim of this study was to determine the long-term prognostic value of infarct size and myocardial ischaemia on single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Methods and results In total, 1092 STEMI patients who underwent primary PCI and SPECT MPI within 1-6 months were included (median follow-up time of 6.9 years). In the entire cohort, SPECT infarct size was independently associated with the composite of cardiac death or reinfarction [hazard ratio (HR) per 10% increase in summed rest score 1.33; 95% confidence interval (95% CI) 1.12-1.58; P = 0.001], whereas myocardial ischaemia was not (HR per 5% increase in summed difference score 1.18; 95% CI 0.94-1.48; P = 0.16). Addition of SPECT infarct size to a model including the clinical variables provided significant incremental prognostic value for the prediction of cardiac death or reinfarction (global χ2 13.8 vs. 24.2; P = 0.002), whereas addition of SPECT ischaemia did not add significantly (global χ2 24.2 vs. 25.6; P = 0.24). In the subgroup of patients with left ventricular ejection fraction (LVEF) ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction (HR 1.59; 95% CI 1.15-2.22; P = 0.006), whereas in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction (HR 1.28; 95% CI 1.00-1.63; P = 0.050). Conclusion In patients with first STEMI and primary PCI, SPECT infarct size was independently associated with cardiac death and/or reinfarction, whereas myocardial ischaemia was not. In patients with LVEF ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction, whereas myocardial ischaemia was not. Conversely, in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction.

PLASMA LDL-CHOLESTEROL LEVEL IS INDEPENDENTLY ASSOCIATED WITH INFARCT SIZE IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Introduction Hypercholesterolemia is a well-known risk factor for developing atherosclerosis and subsequently for the risk of a myocardial infarction (MI). Moreover, it might also be related to the extent of damaged myocardium in the event of a MI. The aim of this study was to evaluate the association of baseline low density lipoprotein-cholesterol (LDL-c) level with infarct size in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneously coronary intervention (pPCI).

Long-term mortality in patients with ST-segment elevation myocardial infarction is associated with anti-citrullinated protein antibodies

BACKGROUND Cardiovascular (CV) mortality is higher in patients with rheumatoid arthritis (RA), in particular when anti-citrullinated protein antibodies (ACPA) are present. Recently, ACPA have also been described in a cohort of patients without RA, but with coronary artery disease (CAD). It is however unknown if ACPA can consistently be found in patients with CAD, and if ACPA are associated with mortality in these patients. The purpose of this study was to assess the relationship between ACPA and long-term outcomes including mortality in patients with ST-elevation myocardial infarction (STEMI) without RA. METHODS All patients with STEMI from the MISSION! Intervention Study were analyzed. Patients with RA were excluded. The association between ACPA (anti-CCP3) at baseline and 10year mortality and re-infarction was investigated. RESULTS In total, 29 (11%) of 275 included patients were ACPA-positive, substantiating the previous description of ACPA in CAD patients. Increased cumulative cardiac mortality was observed in ACPA-positive patients in comparison with ACPA-negative patients. Moreover, after correction for other associated factors, ACPA-positivity was associated with long-term mortality (HR 3.1 [CI 1.4-7.1] p-value=0.01) and long-term combined endpoint of re-infarction and death (HR 2.4 [1.2-4.6] p-value=0.01). CONCLUSION In STEMI patients without RA, the presence of ACPA is independently associated with long-term mortality and the combined endpoint of re-infarction and death. ACPA in patients with and without RA might act as an independent pro-atherogenic factor.

Call-to-balloon time dashboard in patients with ST-segment elevation myocardial infarction results in significant improvement in the logistic chain

AIMS Timely reperfusion with primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) patients is associated with superior clinical outcomes. Aiming to reduce ischaemic time, an innovative system for home-to-hospital (H2H) time monitoring was implemented, which enabled real-time evaluation of ischaemic time intervals, regular feedback and improvements in the logistic chain. The objective of this study was to assess the results after implementation of the H2H dashboard for monitoring and evaluation of ischaemic time in STEMI patients. METHODS AND RESULTS Ischaemic time in STEMI patients transported by emergency medical services (EMS) and treated with pPCI in the Noordwest Ziekenhuis, Alkmaar before (2008-2009; n=495) and after the implementation of the H2H dashboard (2011-2014; n=441) was compared. Median time intervals were significantly shorter in the H2H group (door-to-balloon time 32 [IQR 25-43] vs. 40 [IQR 28-55] minutes, p-value <0.001, FMC-to-balloon time 62 [IQR 52-75] vs. 80 [IQR 67-103] minutes, p-value <0.001, and treatment delay 142 [IQR 103-221] vs. 159 [IQR 123-253] minutes, p-value <0.001). The H2H time dashboard was independently associated with shorter time delays. CONCLUSIONS Real-time monitoring and feedback on time delay with the H2H dashboard improves the logistic chain in STEMI patients, resulting in shorter ischaemic time intervals.

Gender-Specific Differences in All-Cause Mortality Between Incomplete and Complete Revascularization in Patients With ST-Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease

The best revascularization strategy (complete vs incomplete revascularization) in patients with ST-elevation myocardial infarction (STEMI) is still debated. The interaction between gender and revascularization strategy in patients with STEMI on all-cause mortality is uncertain. The aim of the present study was to evaluate gender-specific difference in all-cause mortality between incomplete and complete revascularization in patients with STEMI and multi-vessel coronary artery disease. The study population consisted of 375 men and 115 women with a first STEMI and multi-vessel coronary artery disease without cardiogenic shock at admission or left main stenosis. The 30-day and 5-year all-cause mortality was examined in patients categorized according to gender and revascularization strategy (incomplete and complete revascularization). Within the first 30 days, men and women with incomplete revascularization were associated with higher mortality rates compared with men with complete revascularization. However, the gender-strategy interaction variable was not independently associated with 30-day mortality after STEMI when corrected for baseline characteristics and angiographic features. Within the survivors of the first 30 days, men with incomplete revascularization (compared with men with complete revascularization) were independently associated with all-cause mortality during 5 years of follow-up (hazard ratios 3.07, 95% confidence interval 1.24;7.61, p = 0.016). In contrast, women with incomplete revascularization were not independently associated with 5-year all-cause mortality (hazard ratios 0.60, 95% confidence interval 0.14;2.51, p = 0.48). In conclusion, no gender-strategy differences occurred in all-cause mortality within 30 days after STEMI. However, in the survivors of the first 30 days, incomplete revascularization in men was independently associated with all-cause mortality during 5-year follow-up, but this was not the case in women.

AB0086 Anti-Citrullinated Protein Antibodies in Patients with Cardiovascular Disease without RA

Background Anti-citrullinated protein antibodies (ACPA) are thought to be highly specific for RA. ACPA are associated with risk factors for RA and with joint destruction, and are therefore presumed to be involved in RA pathogenesis. ACPA-positive RA patients also have increased cardiovascular mortality (1). In cardiovascular disease, inflammatory changes occur in vessel walls, raising the question whether ACPA (presumed to be pro-inflammatory) may contribute to this process. Objectives To investigate the prevalence and prognostic implications of ACPA in patients with cardiovascular disease without RA. Methods ACPA were determined by anti-CCP3 commercial assay in baseline sera from 290 patients with ST-elevation myocardial infarction participating in the MISSION intervention study (2). Patients with RA were excluded. The association between ACPA and long-term mortality was investigated. Results 30/290 (10.3%) of the non-RA patients with cardiovascular disease were ACPA-positive. ACPA-positive non-RA patients had a significantly increased long-term cardiac mortality compared to ACPA-negative non-RA patients (Figure). Corrected for age, ACPA positivity was independently associated with long-term mortality [HR 2.4 (CI 1.1–5.4) p-Value=0.026]. Conclusions ACPA can be detected in a considerable proportion of non-RA patients with cardiovascular disease. This challenges the presumed specificity of ACPA for RA. In both RA and cardiovascular disease, ACPA are associated with a worse disease outcome possibly by an ACPA-specific enhancement of inflammation. Future studies into ACPA in patients with cardiovascular disease offer the opportunity to dissect which risk factors are associated with ACPA in RA versus non-RA patients. This may supply crucial insights into the development of this autoimmune reaction. References Humphreys JH et al. Arthritis care & research 2014;66(9):1296–301. Liem et al. American Heart Journal 2007;153(1):11. Disclosure of Interest None declared