Shukri David

A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy: Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial

OBJECTIVES The purpose of this study was to determine if early triage angiography with revascularization, if indicated, favorably affects clinical outcomes in patients with suspected acute myocardial infarction who are ineligible for thrombolysis. BACKGROUND The majority of patients with acute myocardial infarction and other acute coronary syndromes are considered ineligible for thrombolysis and therefore are not afforded the opportunity for early reperfusion. METHODS This multicenter, prospective, randomized trial evaluated in a controlled fashion the outcomes following triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Eligible patients (n=201) with <24 h of symptoms were randomized to early triage angiography and subsequent therapies based on the angiogram versus conventional medical therapy consisting of aspirin, intravenous heparin, nitroglycerin, beta-blockers, and analgesics. RESULTS In the triage angiography group, 109 patients underwent early angiography and 64 (58%) received revascularization, whereas in the conservative group, 54 (60%) subsequently underwent nonprotocol angiography in response to recurrent ischemia and 33 (37%) received revascularization (p=0.004). The mean time to revascularization was 27+/-32 versus 88+/-98 h (p=0.0001) and the primary endpoint of recurrent ischemic events or death occurred in 14 (13%) versus 31 (34%) of the triage angiography and conservative groups, respectively (45% risk reduction, 95% CI 27-59%, p=0.0002). There were no differences between the groups with respect to initial hospital costs or length of stay. Long-term follow-up at a median of 21 months revealed no significant differences in the endpoints of late revascularization, recurrent myocardial infarction, or all-cause mortality. CONCLUSIONS Early triage angiography in patients with acute coronary syndromes who are not eligible for thrombolytics reduced the composite of recurrent ischemic events or death and shortened the time to definitive revascularization during the index hospitalization. Despite more frequent early revascularization after triage angiography, we found no long-term benefit in cardiac outcomes compared with conservative medical therapy with revascularization prompted by recurrent ischemia.

Effectiveness of Implantable Cardioverter- Defibrillators for the Primary Prevention of Sudden Cardiac Death in Women With Advanced Heart Failure A Meta-analysis of Randomized Controlled Trials

BACKGROUND Numerous clinical trials have established a role for implantable cardioverter-defibrillators in the prevention of sudden cardiac death in patients with heart failure. However, questions remain that regard the clinical benefit of these therapies in different patient subgroups. Specifically, the role of implantable cardioverter-defibrillators in women with heart failure for the primary prevention of sudden cardiac death has not been well established. Our objective is to determine whether implantable cardioverter-defibrillators reduce mortality in women with advanced heart failure. METHODS We searched MEDLINE (1950-2008), EMBASE (1988-2008, week 24), the Cochrane Controlled Trials Register (third quarter, 2008), the National Institute of Health ClinicalTrials.gov database, the Food and Drug Administration Web site, and various reports presented at scientific meetings (1994-2007). Eligible studies were randomized controlled trials of implantable cardioverter/defibrillators for the primary prevention of sudden cardiac death in patients with heart failure that reported all-cause mortality as an outcome for the female population. Of the 2619 reports identified, 5 trials that enroll 934 women were included in the meta-analysis. RESULTS Pooled data from the 5 trials revealed no statistically significant decrease in all-cause mortality in women with heart failure who receive implantable cardioverter-defibrillators (hazard ratio, 1.01; 95% confidence interval, 0.76-1.33). CONCLUSIONS Implantable cardioverter-defibrillator therapy for the primary prevention of sudden cardiac death in women does not reduce all-cause mortality. Further studies are needed to investigate the reasons for this ob servation and to define the population of women who may benefit most from implantable cardioverter-defibrillator therapy.

Initial experience with hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction: results of a pilot study utilizing intracoronary aqueous oxygen therapy.

OBJECTIVES The purpose of this study was to evaluate the feasibility and safety of intracoronary hyperoxemic reperfusion after primary angioplasty for acute myocardial infarction (MI). BACKGROUND Hyperoxemic therapy with aqueous oxygen (AO) attenuates reperfusion injury and preserves left ventricular (LV) function in experimental models of MI. METHODS In a multi-center study of patients with acute MI undergoing primary angioplasty (PTCA), hyperoxemic blood (pO(2): 600 to 800 mm Hg) was infused into the infarct-related artery for 60 to 90 min after intervention. The primary end points were clinical, electrical and hemodynamic stability during hyperoxemic reperfusion and in-hospital major adverse cardiac events. Global and regional LV function was evaluated by serial echocardiography after PTCA, after AO infusion, at 24 h and at one and three months. RESULTS Twenty-nine patients were enrolled (mean age: 58.9+/-12.6 years). Hyperoxemic reperfusion was performed successfully in all cases (mean infusion time: 80.8+/-18.2 min; mean coronary perfusate pO(2): 631+/-235 mm Hg). There were no adverse events during hyperoxemic reperfusion or the in-hospital period. Compared with baseline, a significant improvement in global wall motion score index was observed at 24 h (1.68+/-0.24 vs. 1.48+/-0.24, p < 0.001) with a trend toward an increase in ejection fraction (48.6+/-7.3% vs. 51.8+/-6.8%, p = 0.08). Progressive improvement in LV function was observed at one and three months, primarily due to recovery of infarct zone function. CONCLUSIONS Intracoronary hyperoxemic reperfusion is safe and well tolerated after primary PTCA. These preliminary data support the need for a randomized controlled trial to determine if hyperoxemic reperfusion enhances myocardial salvage or improves long-term outcome.

Impact of the prehospital ECG on door-to-balloon time in ST elevation myocardial infarction.

National guidelines have been set to achieve door‐to‐balloon time (D2B) is less than 90 minutes to improve outcomes for patients with STEMI. The purpose of this study is to see if a more aggressive approach utilizing prehospital ECGs could improve reperfusion times.

Feasibility of early emergency room notification to improve door-to-balloon times for patients with acute ST segment elevation myocardial infarction

An algorithm to lower time from first contact in the field by EMS personnel to in‐hospital mechanical reperfusion is described. ECG tracings were telemetered via cellular phone to an emergency room physician, who then activated the cardiac catheterization call team to bypass usual delays seen during ER triage. Seventy‐one ECGs were sent to the ER in the time interval from October 2003 to October 2004. Five ECGs (7.0%) failed to transmit due to failure of the cellular phone to receive an adequate signal. Sixty‐six patients (93.0%) had an adequate ECG transmitted to the ER and six patients with ST elevation myocardial infarction were identified. Door‐to‐balloon times were lowered to 44 ± 17.4 min, a substantial decrease over historical norms that range from 120 min (25th percentile) to 289 min (75th percentile).

Arrhythmias Associated with Intermittent Outpatient Dobutamine Infusion

The use of intermittent outpatient dobutamine infusion has recently been studied as an alternative therapy modality for patients with refractory conges tive heart failure. We studied the arrhythmogenic effects of intermittent outpa tient dobutamine infusion in two patients with NYHA class IV heart failure. The patients received dobutamine at 5mcg./kg./min. for four hours per day for an eight week period. Ambulatory Holter monitoring was obtained during the infusion periods and compared to infusion-free periods. A significant increase of complex ventricular- arrhythmias, including multifocal PVCs and ventricu lar tachycardias, was observed during the infusion period. The incidence of complex ventricular ectopy was dose related and could be suppressed to baseline levels with appropriate antiarrhythmic therapy. We concluded that dobutamine is extremely arrhythmogenic when used in patients with heart failure and that this effect was controllable with antiarrhythmics. Extreme caution and careful monitoring is required for this new therapeutic modality in the treatment of refractory heart failure.

Sustained consciousness during ventricular fibrillation: case report of cough cardiopulmonary resuscitation.

A 54-year-old male developed ventricular fibrillation during right coronary angiography. Cough cardiopulmonary resuscitation was performed for 30 sec allowing the patient to remain alert and hemodynamically stable. Cough cardiopulmonary resuscitation is a simple, often overlooked technique that can be utilized during resuscitation in the cardiac catheterization laboratory.

The comparative efficacy of bivalirudin is markedly attenuated by use of radial access: insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium

AIM The purpose of our study was to evaluate the relative impact of bivalirudin on bleeding outcomes associated with trans-radial interventions (TRI) in real world practice. METHODS AND RESULTS Data for patients undergoing percutaneous coronary intervention (PCI) between January 2010 and March 2014 at the 47 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) were utilized. Propensity matching was used within cohorts defined by access site. The impact of bivalirudin use on in-hospital outcomes was evaluated with Fishers exact tests. Among patients undergoing trans-femoral interventions (TFI), use of bivalirudin was associated with a reduction in bleeding compared with both glycoprotein IIb/IIIa inhibitors (GPI; 1.67 vs. 3.46%, absolute risk reduction (ARR) 1.79%, odds ratio, OR, 0.47, confidence interval, CI, 0.41-0.54, number needed to treat, NNT 56, P < 0.001) and heparin (1.26 vs. 1.76%, ARR 0.5%, OR 0.71, CI 0.61-0.82, NNT 197, P < 0.001). Among patients undergoing TRI, there was a more modest absolute reduction in bleeding with bivalirudin compared with GPI (0.79 vs. 1.41%, ARR 0.62%, OR 0.56, CI 0.34-0.90, NNT 161, P = 0.016) and no difference in bleeding compared with heparin (0.46 vs. 0.46%, OR 1, CI 0.54-1.84, P = 1). CONCLUSION Bivalirudin is markedly efficacious in reducing bleeding in patients undergoing TFI. The reduction in bleeding associated with bivalirudin use is minimal to absent in patients undergoing TRI. Given its lower cost and comparable outcomes, heparin should be the preferred anticoagulation strategy in those undergoing radial PCI.

Hereditary Hemorrhagic Telangiectasia Presenting as High Output Cardiac Failure during Pregnancy

High-output cardiac failure secondary to hepatic involvement is a rare complication of hereditary hemorrhagic telangiectasia (HHT). Here we report a 43-year-old woman who presented at 29 weeks gestation of her second pregnancy with complications of right-sided heart failure and preterm labor. After delivery via cesarean section, the patient was found to have intrahepatic arteriovenous malformations through non-invasive imaging. Subsequently, a family history of vascular malformations and epistaxis was elucidated and a diagnosis of HHT was made. This case is presented, along with a review of the literature and discussion of hepatic involvement in HHT with particular focus on the pregnant patient.

A forgotten devil; Rupture of mitral valve papillary muscle.

Summary Background: Papillary muscle rupture is one of the catastrophic mechanical complications following myocardial infarction. Rupture leads to acute mitral valve regurgitation, pulmonary edema, and cardiogenic shock. Survival is dependent on prompt recognition and surgical intervention. Cases Report: We present two cases where acute myocardial infarction was complicated by papillary muscle rupture resulting in severe mitral regurgitation and cardiogenic shock. In both cases rupture occurred within one week of infarction. Both patients did not receive coronary revascularization; one patient presented late after the onset of chest pain, the other patient percutaneous revascularization attempted and was not successful. Both patients suffered an inferior wall infarction. Echocardiogram demonstrated severe mitral regurgitation with a jet directed posteriorly. In both cases rupture of the posteromedial papillary muscle resulted in flail of the anterior mitral valve leaflet, thus serving as a reminder that both the anterior and the posterior leaflets attach to both papillary muscles. Conclusions: While one case had a good outcome, the other reinforces the fact that this is a very serious complication requiring prompt recognition and treatment.