Zulfiquar Adam

Primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: changing patterns of vascular access, radial versus femoral artery

Objective: To examine the safety and efficacy of emergency transradial primary percutaneous coronary intervention for ST-elevation myocardial infarction. Design: Single-centre observational study with prospective data collection. Setting: A regional cardiac centre, United Kingdom. Patients: 1051 consecutive patients admitted with ST-elevation myocardial infarction, without cardiogenic shock, between November 2004 and October 2008. Interventions: Percutaneous coronary interventions by radial and femoral access Main outcome measures: The primary outcome measures were procedural success, major vascular complication and failed initial access strategy. Secondary outcomes were in-hospital mortality and major adverse cardiac and cerebrovascular events, needle-to-balloon times, contrast volume used, radiation dose absorbed and time to discharge. Multiple regression analysis was used to adjust for potential differences between the groups. Results: 571 patients underwent radial access and 480 femoral. A variable preference for radial access was observed among the lead operators (between 21% and 90%). Procedural success was similar between the radial and femoral groups, but major vascular complications were more frequent at the site of femoral access (0% radial versus 1.9% femoral, p = 0.001). Failure of the initial access strategy was more frequent in the radial group (7.7% versus 0.6%, p<0.001). Adjustment for other procedural and clinical predictors did not alter these findings. Needle-to-balloon time, as a measure of procedural efficiency, was equal for radial and femoral groups. Conclusions: In the setting of acute ST-elevation myocardial infarction without cardiogenic shock, transradial primary angioplasty is safe, with comparable outcomes to a femoral approach and a lower risk of vascular complications.

Could we use abdominal compressions rather than chest compression in patients who arrest after cardiac surgery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether abdominal cardiopulmonary resuscitation (CPR) could be used instead of external cardiac massage either to protect the recent sternotomy or while chest compressions are not possible whilst a sternotomy is being performed. Altogether 386 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Patients who arrest after cardiac surgery and require chest reopening will have a period of no external chest compression and therefore, no cerebral or coronary perfusion. In addition, if a patient arrests prior to cardiac surgery there will be a period of time performing the sternotomy during which there will be no external compressions. We found only one paper in a porcine model that looked at the effectiveness of abdominal only CPR although it did show that abdominal CPR was actually 60% better than chest CPR. Interposed abdominal and chest compressions has been much more extensively studied and has been shown to be significantly better in return of spontaneous circulation than chest compressions alone. We conclude that currently there is very little evidence to support abdominal only CPR although these studies may support the concept that it may potentially increase the coronary and cerebral perfusion pressure.

Resuscitation after cardiac surgery: results of an international survey

OBJECTIVE A survey was conducted on CTSNet, the cardiothoracic network website in order to ascertain an international viewpoint on a range of issues in resuscitation after cardiac surgery. METHODS From 40 questions, 19 were selected by the EACTS clinical guidelines committee. Respondents were anonymous but their location was determined by their Internet protocol (IP) address. The responses were checked for duplication and completion errors and then the results were presented either as percentages or median and range. RESULTS From 387 responses, 349 were suitable for inclusion from 53 countries. The median size of unit of respondents performed 560 cases per year. The incidence of cardiac arrest reported was 1.8%, emergency resternotomy after arrest 0.5% and emergency reinstitution of bypass 0.2%. Only 32% of respondents follow current guidelines on resuscitation in their unit and an additional 25% of respondents have never read these guidelines. Respondents indicated that they would perform three attempts at defibrillation for ventricular fibrillation without intervening external cardiac massage and for all arrests perform emergency resternotomy within 5 min if within 24h of the operation. Fifty percent of respondents would give adrenaline immediately, 58% of respondents would be happy for a non-surgeon to perform an emergency resternotomy and 76% would allow a surgeons assistant and 30% an anaesthesiologist to do this. Only 7% regularly practise for arrests, but 80% thought that specific training in this is important. CONCLUSION This survey supports the EACTS guideline for resuscitation in cardiac arrest after cardiac surgery published in this issue of the journal.

Bronchogenic stress cardiomyopathy: a case series.

Despite a growing awareness of stress (takotsubo) cardiomyopathy, the diversity in precipitants beyond emotional distress remains under-appreciated. Emerging data implicate a differential influence of precipitant type on the variable presentations of stress cardiomyopathy. We outline 5 cases of stress cardiomyopathy where the precipitant was an acute exacerbation of chronic obstructive pulmonary disease treated with high-dose bronchodilator therapy. In this setting, an atypical and insidious presentation of the stress cardiomyopathy was consistently observed that was difficult to distinguish from the acute airway exacerbation itself, with an absence of chest pain in particular. Scrutiny of published single-case reports reveals a similar atypical presentation; this supports the existence of a novel bronchogenic subgroup of stress cardiomyopathy. A key role of repeat ECG evaluation in distinguishing protracted but uncomplicated bronchospasm from bronchogenic stress cardiomyopathy is highlighted. Further data are now required to examine whether high-dose β-agonist therapy is implicated in this association.

The SSTARS (STeroids and Stents Against Re-Stenosis) Trial: Different stent alloys and the use of peri-procedural oral corticosteroids to prevent in-segment restenosis after percutaneous coronary intervention

BACKGROUND Stent design and technological modifications to allow for anti-proliferative drug elution influence restenosis rates following percutaneous coronary intervention (PCI). We aimed to investigate whether peri-procedural administration of corticosteroids or the use of thinner strut cobalt alloy stents would reduce rates of binary angiographic restenosis (BAR) after PCI. METHODS This was a two centre, mixed single and double blinded, randomised controlled trial using a factorial design. We compared (a) the use of prednisolone to placebo, starting at least six hours pre-PCI and continued for 28days post-PCI, and (b) cobalt chromium (CoCr) to stainless steel (SS) alloy stents, in patients admitted for PCI. The primary end-point was BAR at six months. RESULTS 315 patients (359 lesions) were randomly assigned to either placebo (n=145) or prednisolone (n=170) and SS (n=160) or CoCr (n=160). The majority (58%) presented with an ACS, 11% had diabetes and 287 (91%) completed angiographic follow up. BAR occurred in 26 cases in the placebo group (19.7%) versus 31 cases in the prednisolone group (20.0%) respectively, p=1.00. For the comparison between SS and CoCr stents, BAR occurred in 32 patients (21.6%) versus 25 patients (18.0%) respectively, p=0.46. CONCLUSION Our study showed that treating patients with a moderately high dose of prednisolone for 28days following PCI with BMS did not reduce the incidence of BAR. In addition, we showed no significant reduction in 6month restenosis rates with stents composed of CoCr alloy compared to SS (http://www.isrctn.com/ISRCTN05886349).

1 Route of admission in stemi: do patients who present directly to a PCI-capable hospital differ from inter-hospital transfers?

Background Rapid delivery of reperfusion therapy with PPCI is the gold standard treatment in STEMI. Systems have been developed, such as direct admission to a PCI-capable hospital, to minimise the time from diagnosis to PPCI. Despite this, a significant minority of patients are initially admitted to non-PCI capable hospitals. The aim of this study was to determine whether patients differed in their characteristics, time to PPCI, and outcome by route of admission. Methods The study was performed in a single tertiary centre in North England. Data are collected routinely on all patients undergoing PPCI and include demographic, clinical and procedural variables. In-hospital MACCE (death, re-infarction or CVA) and mortality are collected providing relevant outcome measures. Baseline clinical variables by route of admission were compared and unadjusted in-hospital MACCE rates determined. One-year mortality by route of admission was calculated using the K-M product limit estimate. In-hospital and 1-year outcomes were analysed after adjustment for factors known to be predictors of early mortality following STEMI (models 1 and 3). To determine the relative importance of delays in treatment, call-to-balloon time was added (models 2 and 4). Logistic regression was used for the adjusted in-hospital outcomes, and Cox-proportional regression for adjusted 1-year mortality. Results 2268 patients were included in the analysis. 510 patients (22.5%) were treated with PPCI following transfer from a non-PCI capable centre. Analysis of baseline variables (Abstract 1 table 1) showed the transfer group were more likely to have an LAD occlusion treated, and previous MI. Despite shorter DTB times, the transfer group had a greater median CTB time (52 minutes longer) compared with direct admissions. Other baseline variables were statistically no different between groups. There were 110 in-hospital MACCE events, and 168 deaths within 1-year follow-up. The transfer group had significantly higher unadjusted in-hospital MACCE rates (2.4% absolute, 58% relative increase (Abstract 1 table 2)). At 1 year, the transfer group had significantly higher unadjusted mortality (2.7% absolute, 48% relative increase (Abstract 1 table 2)). After adjustment for relevant co-variates (models 1 and 3) route of admission remained a significant predictor of in-hospital and 1-year mortality. With the addition of call-to-balloon time, no significant difference in outcome was noted by route of admission for either in-hospital or 1-year events.Abstract 1 Table 1 Direct Transfer p Age (years±SD) 64.3 (12.7) 63.9 (12.4) 0.17 Male 1252 (71.2) 367 (72.0) 0.74 Diabetes 177 (10.1) 55 (10.8) 0.68 Previous MI 225 (12.6) 89 (17.3) 0.001 Treated vessel 0.001  LMS 24 (1.4) 13 (2.5)  LAD 630 (36.1) 218 (42.9)  LCx 249 (14.3) 83 (16.3)  RCA 812 (46.6) 188 (37.0)  Graft 28 (1.7) 5 (1.1) Cardiogenic shock 28 (1.7) 35 (6.9) 0.61 Smoking (ex/current) 1331 (75.7) 377 (73.9) 0.42 Call-to-balloon time 102 (82–135) 154 (107–235) <0.001 Door-to-balloon time 44 (29–76) 34 (24–50) <0.001Abstract 1 Table 2 Direct Transfer OR (±95% CI) p In-hospital MACCE 4.3% 6.7% 1.58 (1.04 to 2.39) 0.03 Adjusted in-hospital MACCE (model 1) 1.64 (1.00 to 2.28) 0.05 Adjusted in-hospital MACCE (model 2) 1.34 (0.79 to 2.29) 0.27 Direct Transfer HR (±95% CI) p 1-year mortality 7% 9.7% 1.48 (1.06 to 2.07) 0.02 Adjusted 1-year mortality (model 3) 1.41 (0.99 to 2.01) 0.05 Adjusted 1-year mortality (model 4) 1.29 (0.87 to 1.89) 0.20 Conclusion In this study, patients who presented directly had superior in-hospital and 1-year outcomes compared with those who required transfer from other hospitals. Adjustment for longer call-to-balloon times attenuated the finding of poorer outcomes in these patients, suggesting that delays in treatment are critical. Systems of care should be designed to avoid admission of STEMI patients to non-PCI hospitals, and facilitate more rapid transfer of patients where this has not been possible.

Authors' Reply to the Letter by Madias Entitled '"Bronchogenic Stress Cardiomyopathy", a subset of Takotsubo Syndrome'.

leads in 50%, high lateral leads in 25%, anterior leads in 25%, and aVR in 25%). We are unable to systematically evaluate for resolution of attenuation, however, as ECGs were not routinely captured at outpatient follow-up. Whether these two ECG criteria can help distinguish stress cardiomyopathy from type I myocardial infarction is an intriguing hypothesis, although myocardial oedema might be expected in both processes. In our series of patients with bronchogenic stress cardiomyopathy, transthoracic echocardiography (TTE) was prompted by an abnormal ECG. It may also be reasonable to consider TTE where clinical suspicion is high despite an ostensibly normal ECG, although registries have documented ECG abnormalities in 99% of cases [4] . However, whether a more frequent and early implementation of TTE is appropriate is less clear. Ten to 30% of patients with apparent chronic obstructive pulmonary disease exacerbation do not respond to treatment [5] . The resource implications of a routine use of TTE in this setting are likely to be substantial and would therefore require demonstration of a clear advantage over simple bedside tests such as ECG. Following our recently reported novel observations concerning COPD exacerbation and stress cardiomyopathy [1] , we acknowledge with great interest the observations of Madias [2] with respect to electrocardiographic manifestations of stress cardiomyopathy and possible indicators of myocardial oedema. These comments align with our own impression that the ECG is a key investigation in the detection of bronchogenic stress cardiomyopathy, whose clinical features may be difficult to distinguish from the precipitating bronchospasm. We were able to retrieve all ECGs in 4 out of 5 patients. Low QRS complex voltages, as described by Madias [3] , were detectable in all patients in at least one group of leads (inferiorly in 50%, anteriorly in 75%, laterally in 25%, high laterally in 75%, and aVR in 50%). However, in 50% of patients we also noted low QRS complex voltages in ECGs remote in time to the clinical episode. Patient characteristics that might influence QRS voltage such as body habitus and lung hyperinflation may be relevant. Using the qualitative criteria set out by Madias [3] , transient attenuation of the QRS voltage during serial ECG analyses was also detectable in all 4 patients (lateral Received: February 23, 2015 Accepted: February 24, 2015 Published online: May 6, 2015

146 CRT Optimisation: Our Four Years Experience and Outcomes

Introduction The response to cardiac resynchronisation therapy (CRT) can be heterogeneous. Most studies aim to improve patient selection in order to achieve better outcomes.However, the adjustment of device timing intervals in conjunction with optimisation of medical therapy may maximise the effectiveness of CRT. This approach provides a new paradigm in the management of advance heart failure where not only medical therapies but also CRT timing intervals are tailored to individual needs. We describe our four years experience with CRT optimisation performed in a consultant-run heart failure (HF) clinic. Methods All patients attending the combined CRT optimisation and HF clinic during the period of 2008–2012 had a clinical assessment followed by echocardiography guided optimisation of their device. A-V optimisation was performed using the Iterative method on a pre-set sequence of paced and sensed AV delays. V-V optimisation was based on the maximal left ventricular outflow tract VTI as a surrogate for stoke volume.The following end-points were used: EuroQol (EQ visual analogue score (VAS)) health questionnaire, 6-minute walk test (6MWT), regional wall motion abnormality scoring (RWMA), left ventricular ejection fraction (LVEF), Yu Index (SD of time to peak systole in a 12 segment LV model as a measure of intra-ventricular dyssynchrony) and the difference between aortic and pulmonary ejection times (IVMD) a marker of inter-ventricular dyssynchrony. Patients were re-assessed after 8–12 weeks at which point optimisations of medical therapy were performed. Results 87 patients underwent CRT optimisation (68 (78%) were males). 92% of patients had NYHA Class II or III. CRT optimisation was performed at a mean 36 weeks post implantation and the follow-up visit took place at a mean of 9 weeks later. Post CRT optimisation there were reduction in intra-ventricular dyssynchrony (Yu Index decreased from 36 to 30ms (p = 0.02)) and inter-ventricular dyssynchrony (IVMD from 20 to 12 ms (P < 0.01). There were improvements in LVEF (from 31 to 34% (p = 0.05)) and RWMA (from 2.1 to 1.9 (P < 0.01)). Clinically there were trends toward an increase in 6MWT (from 274 to 311 m (p = 0.10)), improvement in NYHA from class III to II (p = 0.12) and EQ VAS health questionnaire score (from 60 to 66 (p = 0.07)). Conclusions This study suggests echocardiography guided CRT optimisation results in an improvement in measures of dyssynchrony and LV systolic function with a trend towards clinical improvement. This lends support to the individualisation of CRT timing intervals rather than relying on standard box settings as part of a heart failure service.