Rob Adams

Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands

Objective:To describe the effect of implementation of a rapid response system on the composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death. Design:Pragmatic prospective Dutch multicenter before-after trial, Cost and Outcomes analysis of Medical Emergency Teams trial. Setting:Twelve hospitals participated, each including two surgical and two nonsurgical wards between April 2009 and November 2011. The Modified Early Warning Score and Situation-Background-Assessment-Recommendation instruments were implemented over 7 months. The rapid response team was then implemented during the following 17 months. The effects of implementing the rapid response team were measured in the last 5 months of this period. Patients:All patients 18 years old and older admitted to the study wards were included. Measurements and Main Results:In total, 166,569 patients were included in the study representing 1,031,172 hospital admission days. No differences were observed in patient demographics between periods. The composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death per 1,000 admissions was significantly reduced in the rapid response team versus the before phase (adjusted odds ratio, 0.847; 95% CI, 0.725–0.989; p = 0.036). Cardiopulmonary arrests and in-hospital mortality were also significantly reduced (odds ratio, 0.607; 95% CI, 0.393–0.937; p = 0.018 and odds ratio, 0.802; 95% CI, 0.644–1.0; p = 0.05, respectively). Unplanned ICU admissions showed a declining trend (odds ratio, 0.878; 95% CI, 0.755–1.021; p = 0.092), whereas severity of illness at the moment of ICU admission was not different between periods. Conclusions:In this study, introduction of nationwide implementation of rapid response systems was associated with a decrease in the composite endpoint of cardiopulmonary arrests, unplanned ICU admissions, and mortality in patients in general hospital wards. These findings support the implementation of rapid response systems in hospitals to reduce severe adverse events.

Low molecular weight heparin as an adjunct to thrombolysis for acute myocardial infarction: the FATIMA study

Objective To investigate the feasibility of fixed dose, weight adjusted subcutaneous low molecular weight heparin (LMWH), with monitoring of anti-Xa levels and assessment of coronary patency rates after three to five days, thereby giving an initial indication of its safety and efficacy. Design In 30 patients with acute myocardial infarction, LMWH (nadroparine) was given as a body weight adjusted intravenous bolus with thrombolysis (rt-PA infusion) and in weight adjusted subcutaneous doses at six hours, and every 12 hours thereafter for 72 hours. The target range was defined prospectively as 0.35–0.70 anti-factor Xa activity (aXa) units. The aXa level was measured every six hours. Coronary angiography was performed in all patients within five days after the start of thrombolytic treatment to determine patency (TIMI 2 and 3 flow) of the infarct related artery. Results The mean (SEM) aXa level over 72 hours was 0.52 (0.08) U/ml; from 12 hours onwards 88% of all aXa measurements were within the target range. At angiography, a patent infarct related artery was present in 24 of the 30 patients. No major bleeding complications occurred, though minor bleeding complications were observed in two patients. Conclusions This small study indicates that LMWH is feasible as an adjunct to thrombolysis in patients with acute myocardial infarction. The aXa levels were within the target range and patency rates at three to five days were around 80%, with no major bleeding complications.

Clinical evaluation of the CARDIAC STATus, a rapid immunochromatographic assay for simultaneous detection of elevated concentrations of CK-MB and myoglobin in whole blood

Abstract We studied the performance of the CARDIAC STATusTM, a new rapid, easy to perform qualitative whole blood bedside test for detection of elevated CK-MB and myoglobin in the emergency room. Blood samples from 182 consecutive patients with chest pain were drawn on admission and at five and seven hours after the onset of symptoms. The CARDIAC STATusTM tests were performed by coronary care unit nurses and, independently, by a trained laboratory technician. The results were compared with quantitative assays for CK-MB mass and myoglobin. At the end of the study, a second test series using a new lot number of cartridges was performed on the same blood samples because of possible elution buffer contamination. Nurses produced more false negative results than the technician (CK-MB 43 vs. 27 %, p=0.01, myoglobin 31 vs. 13 %, p<0.0001), but the technician produced more false positive myoglobin results (9.3 vs. 5.5 %, p=0.0001). In the second test series, the nurses produced significantly fewer false negative tests both for CK-MB (19 %, p<0.0001) and myoglobin (13 %, p=0.0002). The false negative rate for the technician was not different between the first and the second test series. The CARDIAC STATusTM yields a substantial number of false negative results both for CK-MB and myoglobin when compared to a quantitative assay, and therefore at present has limited value for ruling out an acute myocardial infarction.

Implementation of a Prehospital Triage System for Patients With Chest Pain and Logistics for Primary Percutaneous Coronary Intervention in the Region of Amsterdam, The Netherlands

We aimed to describe the logistics of a prehospital triage system for patients with acute chest pain in the region of Amsterdam, The Netherlands. Ambulance electrocardiograms (ECGs) were evaluated immediately in 1 of the percutaneous coronary intervention (PCI)-capable centers. Patients accepted for primary PCI (PPCI) were directly transferred to the catheterization laboratory. Two thousand three hundred fifty ECGs of 2,192 patients were transmitted to the regions intervention centers. Median duration of chest complaints before ambulance dispatch was 67 minutes; ambulance crews recorded the first ECG within 7 minutes after arrival. Actual transmission of the ECG took an additional (median) 10 minutes. Seven hundred eleven patients (32.4%) were transported to the catheter laboratory and were treated with PPCI. Time between first prehospital ECG and start of PPCI procedure was 66 minutes. The PPCI procedure started 36 minutes after ambulance arrival at the hospital. In conclusion, the results of this study compare favorably to other reported performances of prehospital triage systems of PPCI for ST-segment elevated myocardial infarction and demonstrate that the European Society of Cardiology and American Heart Association guidelines for treatment of patients with ST-segment elevated myocardial infarction can be met.

Precordial junctional ST-segment depression with tall symmetric T-waves signifying proximal LAD occlusion, case reports of STEMI equivalence.

Timely reperfusion therapy by means of primary percutaneous coronary intervention (PCI) is the preferred treatment for patients with ST-segment elevation myocardial infarction. A significant number of patients with large acute myocardial infarction, caused by occlusion of an epicardial coronary artery, do not show ST-elevation on the electrocardiogram. Other ECG abnormalities may be present, the so called STEMI-equivalents. One such STEMI equivalent, junctional ST-segment depression followed by tall symmetrical T-waves in the precordial leads, often in combination with slight ST-elevation in lead AVR, has been associated with proximal occlusion of the left anterior descending coronary artery. Recognition of this ECG pattern by ambulance staff, emergency physicians and interventional cardiologists envolved in STEMI networks, is important to ensure timely reperfusion therapy in these patients. In this paper we present three patients with typical symptoms of acute myocardial infarction and the ECG pattern with slight J-point depression combined with tall, symmetrical T-waves.

Prevalence of junctional ST-depression with tall symmetrical T-waves in a pre-hospital field triage system for STEMI patients

INTRODUCTION The prevalence of the junctional ST-depression with tall symmetrical T-waves in a field triage system for ST-Elevation Myocardial Infarction (STEMI) is unknown. MATERIAL AND METHODS We prospectively collected all transmitted 12-lead electrocardiograms (ECGs) from the STEMI field triage system in Amsterdam from 2011 to 2013. Electrocardiograms with junctional ST-depression with tall symmetrical T-waves were recognized and angiographic documentation and clinical follow up were collected. RESULTS A total of 5588 patients with at least 1 transmitted field ECG were identified from the database. ST-elevation infarction was present on the field ECG in 1864 patients (33%) and 701 ECGs (12,5%) showed anterior infarction. In 11 patients, junctional ST-depression with tall symmetrical T-waves was identified (0,2% of total transmitted ECGs and 1,6% of anterior infarctions). The 11 angiograms invariably showed involvement of the proximal Left Anterior Descending (LAD) artery (segment 5,6 and 7). Mortality was 27% within the first week. CONCLUSIONS An ECG with junctional ST-depression with tall symmetrical T-waves is an infrequent finding. Because this pattern of STEMI equivalent is associated with LAD occlusions, it is important to recognize this pattern, so patients can be transported to the catheterization laboratory without delay.