Marc C. Newell

A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Background— Percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is superior to fibrinolysis when performed in a timely manner in high-volume centers. Recent European trials suggest that transfer for PCI also may be superior to fibrinolysis and increase access to PCI. In the United States, transfer times are consistently long; therefore, many believe a transfer for PCI strategy for STEMI is not practical. Methods and Results— We developed a standardized PCI-based treatment system for STEMI patients from 30 hospitals up to 210 miles from a PCI center. From March 2003 to November 2006, 1345 consecutive STEMI patients were treated, including 1048 patients transferred from non-PCI hospitals. The median first door-to-balloon time for patients <60 miles (zone 1) and 60 to 210 miles (zone 2) from the PCI center was 95 minutes (25th and 75th percentiles, 82 and 116 minutes) and 120 minutes (25th and 75th percentiles, 100 and 145 minutes), respectively. Despite the high-risk unselected patient population (cardiogenic shock, 12.3%; cardiac arrest, 10.8%; and elderly [≥80 years of age], 14.6%), in-hospital mortality was 4.2%, and median length of stay was 3 days. Conclusions— Rapid transfer of STEMI patients from community hospitals up to 210 miles from a PCI center is safe and feasible using a standardized protocol with an integrated transfer system.

Causes of Delay and Associated Mortality in Patients Transferred With ST-Segment–Elevation Myocardial Infarction

Background— Regional ST-segment–elevation myocardial infarction systems are being developed to improve timely access to primary percutaneous coronary intervention (PCI). System delays may diminish the mortality benefit achieved with primary PCI in ST-segment–elevation myocardial infarction patients, but the specific reasons for and clinical impact of delays in patients transferred for PCI are unknown. Methods and Results— This was a prospective, observational study of 2034 patients transferred for primary PCI at a single center as part of a regional ST-segment–elevation myocardial infarction system from March 2003 to December 2009. Despite long-distance transfers, 30.4% of patients (n=613) were treated in ⩽90 minutes and 65.7% (n=1324) were treated in ⩽120 minutes. Delays occurred most frequently at the referral hospital (64.0%, n=1298), followed by the PCI center (15.7%, n=317) and transport (12.6%, n=255). For the referral hospital, the most common reasons for delay were awaiting transport (26.4%, n=535) and emergency department delays (14.3%, n=289). Diagnostic dilemmas (median, 95.5 minutes; 25th and 75th percentiles, 72–127 minutes) and nondiagnostic initial ECGs (81 minutes; 64–110.5 minutes) led to delays of the greatest magnitude. Delays caused by cardiac arrest and/or cardiogenic shock had the highest in-hospital mortality (30.6%), in contrast with nondiagnostic initial ECGs, which, despite long treatment delays, did not affect mortality (0%). Significant variation in both the magnitude and clinical impact of delays also occurred during the transport and PCI center segments. Conclusions— Treatment delays occur even in efficient systems for ST-segment–elevation myocardial infarction care. The clinical impact of specific delays in interhospital transfer for PCI varies according to the cause of the delay.

Impact of age on treatment and outcomes in ST-elevation myocardial infarction.

OBJECTIVES We hypothesized that older patients in a regional ST-elevation myocardial infarction (STEMI) transfer program would attain comparable treatment to younger patients. BACKGROUND Older patients have been either excluded or underrepresented in STEMI clinical trials. Observational studies suggest that these patients are less likely to receive adjunctive pharmacologies and reperfusion therapy-thrombolysis or percutaneous coronary intervention (PCI)-and therapy is frequently delayed. METHODS We identified a consecutive series of 2,262 STEMI patients (March 2003-December 2008) who either presented or were transferred to Abbott Northwestern Hospital for PCI (<65 years [n = 1285], 65-74 years [n = 436], 75-84 years [n = 381], and ≥85 years [n = 160]). Main outcome measures included time-to-reperfusion therapy, adjunctive medications received, and all-cause mortality. RESULTS Overall time-to-reperfusion therapy was similar across age strata-94 minutes (<65 years), 101 minutes (65-74 years), 106 minutes (75-84 years), and 103 minutes (≥85 years). No difference in adjunctive antiplatelet or anticoagulant medications was seen at hospital admission, and only slight differences in standard post-myocardial infarction medication use were seen by age at hospital discharge. Age was an independent predictor of in-hospital and yearly mortality up to 5 years (1-year mortality 3.4% [<65 years], 9.2% [65-74 years], 15.2% [75-84 years], and 28.9% [≥85 years]; P < .0001). CONCLUSIONS Older patients receive similar care to younger patients when treated in a regional STEMI transfer program. Although all-cause mortality in the elderly is increased, the absolute rates are lower than previously established. Our data suggest primary PCI (including transfer) can be applied to all appropriate STEMI patients, regardless of age.

Use of cardiac CT angiography to assist in the diagnosis and treatment of aortic prosthetic paravalvular leak: a practical guide.

Percutaneous repair of aortic paravalvular regurgitation can help avoid the need for repeat valve surgery. Although the initial diagnosis of paravalvular regurgitation is usually made with echocardiography, cardiac CT angiography helps to determine the site and morphology of these leaks. The utility of CT is highly dependent on the quality of the data. Herein, we describe a systematic approach to image acquisition and interpretation of cardiac CT angiography in patients with aortic paravalvular regurgitation, which integrates findings from echocardiography. This approach can be used to minimize inaccuracies in the diagnosis and enhance the procedural success for percutaneous repair of aortic paravalvular regurgitation.

Comparison of Functional Recovery Following Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction in Three Age Groups (<70, 70 to 79, and ≥80 Years)

Functional outcomes of elderly patients ≥80 years who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) are unknown. Registry data indicate that up to 55% of elderly patients with STEMI do not receive reperfusion therapy despite a suggested mortality benefit, and only limited data are available regarding outcomes in elderly patients treated with primary PCI. Therefore, prospective data from a regional STEMI transfer program were analyzed to determine major adverse cardiac events, length of stay, and discharge status of consecutive patients with STEMI ≥80 years from March 2003 to November 2006. Of the 1,323 consecutive patients with STEMI treated in this regional STEMI system from March 2003 to November 2006, 199 (15.0%) were ≥80 years old. In-hospital mortality in elderly patients was 11.6%, with a 1-year mortality rate of 25.6%. Of the 166 patients with age ≥80 who lived independently or in assisted living before hospital admission and survived, 150 (90.4%) were discharged to a similar living situation or projected to such a living situation after temporary nursing home care. The median length of hospital stay was 4 days for these patients. In conclusion, elderly patients with age ≥80 receiving PCI for STEMI in a regional STEMI program have short hospital stays and excellent functional recovery on the basis of a very high rate of return to a similar previous living situation.

Internal medicine point-of-care ultrasound assessment of left ventricular function correlates with formal echocardiography

Although focused cardiac ultrasonographic (FoCUS) examination has been evaluated in emergency departments and intensive care units with good correlation to formal echocardiography, accuracy for the assessment of left ventricular systolic function (LVSF) when performed by internal medicine physicians still needs independent evaluation.

Coronary Computed Tomographic Angiographic Findings in Patients With Kawasaki Disease

Kawasaki disease (KD) is the leading cause of acquired coronary disease in children and may lead to subsequent myocardial ischemia and infarction. Because coronary computed tomographic angiography (CTA) is the most sensitive noninvasive test in patients with atherosclerosis, the aim of this study was to retrospectively evaluate coronary CTA performed in patients with KD for aneurysm, stenosis, and calcified and noncalcified coronary artery disease (CAD). Clinical histories and prior stress and imaging test results were reviewed. Thirty-two patients underwent coronary CTA for KD, and 385 coronary segments were evaluated. Twenty-three of 32 patients had ≥1 diseased coronary segment. There were 20 aneurysms, 7 lesions, and 75 segments (20%) with nonobstructive CAD (16% noncalcified, 2% calcified, and 2% mixed). All nonobstructive and obstructive CAD was in patients with histories of acute-phase coronary artery dilatation or aneurysm (echocardiographic z score 4 to 44), and were almost always associated with normal stress imaging test results on follow-up. No lesion or CAD was found in coronary computed tomographic angiographic studies performed in a control group referred for other indications (n = 32, 422 segments evaluated). The median coronary computed tomographic angiographic dose-length product was 59 mGy cm (interquartile range 32 to 131), the median unadjusted radiation dose was 0.8 mSv (interquartile range 0.4 to 1.8), and the median age- and size-adjusted radiation dose was 1.3 mSv (interquartile range 0.7 to 2.3). In conclusion, high-risk patients with histories of KD had nonobstructive and obstructive CAD not visualized by other noninvasive imaging tests. In properly selected high-risk patients with KD, coronary CTA may identify a subset at increased risk for future coronary pathology who may benefit from medical therapy.

Primary PCI in the elderly: 75 may be the new 55!

Age is a powerful independent predictor of mortality in patients with ST-elevation myocardial infarction (STEMI). According to the GRACE registry, the expected mortality from acute coronary syndromes increases by an odds ratio of 1.7 for each 10 year increment over the age of 65 years [1]. Despite this knowledge, there is a clear paucity of objective data regarding the epidemiology, diagnosis, and treatment of myocardial infarction in the elderly, particularly STEMI, in large part due to under-representation in clinical trials [2]. When GUSTO-I trial criteria were applied to the National Registry of Myocardial Infarction (NRMI) database, only 15.4% of patients over the age of 65 met trial eligibility [3]. Primary percutaneous coronary intervention (PCI) is of clear benefit in the general population, but has not been well studied in elderly patients. As the population ages, it is increasingly important to understand the optimal method of reperfusion and outcomes in elderly patients with STEMI. In this edition of Catheterization and Cardiovascular Interventions (CCI), Sakai et al. aim to close the gap in reporting elderly outcomes in STEMI [4]. They report on 947 consecutive STEMI patients undergoing PCI who presented to a single center, of which 616 patients were aged 50–75 compared to 331 patients 75 years old. The results are notable for several reasons: (1) as expected, elderly patients remain high risk. Elderly patients in this study were more likely to be female, and had more renal insufficiency, more prior stroke, and more cardiogenic shock. Because of these differences, outcomes continue to be very challenging compared to younger patients. (2) Contrary to prior reports, elderly patients had similar door-to-balloon (DTB) times and procedural success as younger patients. (3) Overall, 30-day outcomes were improved compared to prior reports. Several limitations to the study are also worth noting. First, outcomes were only reported for 30 days. Secondly, very long ‘‘chest pain to balloon’’ times were seen. Finally, as the authors suggest, we could likely expect even better outcomes with more proven strategies, including: standardized treatment protocols, pre-cath lab thienopyridines, drug-eluting stents, aspiration catheters, and bivalirudin. The overall premise and results are consistent with our recently published outcomes in 2,262 consecutive STEMI patients, with 541 patients aged >75 years [5]. In a high risk cohort (>12% cardiogenic shock in the patients >75), we showed identical DTB times across age strata, similar rates of preand post-PCI medication use, and also improved outcomes in five years post intervention. DTB times in elderly patients presenting to our facility were <70 min (median). Elderly patients were safely transferred, even to distances of 200 miles, with median DTB <120 min. Significant mortality reduction, when compared to historical controls, was also seen. The importance of treating elderly patients in standardized protocols and with ‘‘gold standard’’ therapies, such as PCI for STEMI, cannot be understated. We agree with the findings reported here that elderly patients have reduced mortality and overall improved outcomes, despite being higher risk, when treated rapidly with PCI. With an aging worldwide population, elderly outcomes deserve further attention. As seen, they can be improved. Once these strategies are systematically implemented, then 75 can truly be the new 55!

Radiation dose and image quality of 70 kVp functional cardiovascular computed tomography imaging in congenital heart disease

BACKGROUND The use of cardiac computed tomography (CT) for quantification of ventricular function is limited by relatively high radiation dose. OBJECTIVES The goal of this study was to describe the radiation exposure and image quality of 70 kVp functional cardiac CT in patients with congenital heart disease (CHD). METHODS A retrospective review of 70 kVp ECG gated functional CT scans using tube current modulation was performed in CHD patients at a single institution. Quantitative and qualitative (assessed by myocardial segment, 1-4; 1 = optimal) image quality was determined. Per segment image quality was compared between thin (1.5 mm) and thick (8 mm) reconstructions and by patient age and size. Scan DLP was used to estimate radiation dose. RESULTS 72 scans were performed during the time of review (7/2013-6/2015). Median patient age was 19.5 years (8.0, 27.1) and BMI was 20.1 (16.6, 24.5) kg/m(2). Median functional scan DLP was 78.8 (45.5, 98) and unadjusted and adjusted procedural mSv were 1.10 (0.64, 1.37) and 1.13 (0.90, 1.37). Image quality of 1 was achieved in all myocardial segments in >75% of scans. Patients with a weight ≥75 kg were more likely to have a scan achieve optimal image when using thick reconstructions compared to thin (81.3% vs. 43.8%; p = 0.028). CONCLUSIONS Imaging of ventricular function with 70 kVp in CHD patients can be done with low radiation doses and provides diagnostic image quality, particularly for patients <75 kg. In larger patients, thicker slice reconstruction improved image quality.

Statin Eligibility and Outpatient Care Prior to ST‐Segment Elevation Myocardial Infarction

Background The impact of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines on statin eligibility in individuals otherwise destined to experience cardiovascular disease (CVD) events is unclear. Methods and Results We analyzed a prospective cohort of consecutive ST‐segment elevation myocardial infarction (STEMI) patients from a regional STEMI system with data on patient demographics, low‐density lipoprotein cholesterol levels, CVD risk factors, medication use, and outpatient visits over the 2 years prior to STEMI. We determined pre‐STEMI eligibility according to American College of Cardiology/American Heart Association guidelines and the prior Third Report of the Adult Treatment Panel guidelines. Our sample included 1062 patients with a mean age of 63.7 (13.0) years (72.5% male), and 761 (71.7%) did not have known CVD prior to STEMI. Only 62.5% and 19.3% of individuals with and without prior CVD were taking a statin before STEMI, respectively. In individuals not taking a statin, median (interquartile range) low‐density lipoprotein cholesterol levels in those with and without known CVD were low (108 [83, 138] mg/dL and 110 [87, 133] mg/dL). For individuals not taking a statin, only 38.7% were statin eligible by ATP III guidelines. Conversely, 79.0% would have been statin eligible according to American College of Cardiology/American Heart Association guidelines. Less than half of individuals with (49.2%) and without (41.1%) prior CVD had seen a primary care provider during the 2 years prior to STEMI. Conclusions In a large cohort of STEMI patients, application of American College of Cardiology/American Heart Association guidelines more than doubled pre‐STEMI statin eligibility compared with Third Report of the Adult Treatment Panel guidelines. However, access to and utilization of health care, a necessity for guideline implementation, was suboptimal prior to STEMI.