Archive of Medical Research

A Rapid-Response Alphanumeric Paging Design Decreases Door-to-Balloon Times in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Acute Myocardial Infarction.

INTRODUCTION:: In acute ST elevation myocardial infarction (STEMI), rapid reperfusion of the infarcted artery improves cardiovascular outcomes; however, many hospitals have difficulty achieving recommended times. We hypothesized that a Rapid-Response Alphanumeric Paging Design (RAPiD) would reduce door-to-balloon time for primary percutaneous coronary intervention (PCI) in STEMI. METHODS:: A chest pain algorithm and interdisciplinary team was established in December 2000. In August 2002, RAPiD was instituted to transmit the diagnosis and location of a STEMI to the chest pain team through a speed-dial button. All patients presenting to our emergency department from February 2002 through July 2003 with STEMI were included. Exclusion criteria included lack of chest pain, cardiopulmonary arrest before PCI, and catheterization or PCI not performed. Outside-referral STEMI, in-patient STEMI, and failed thrombolysis patients were excluded. Data was obtained from medical records. Log transform of door-to-balloon (DTB) times was performed. RESULTS:: Forty-seven events satisfied inclusion and exclusion criteria with 32 occurring after RAPiD (post-RAPiD). Fifteen events occurred during on-hours (8 am to 7 pm on weekdays). Mean untransformed DTB times pre- and post-RAPiD were 162 +/- 137 (standard deviation) minutes and 112 +/- 41 minutes. The main effects analysis of variance model showed a significant reduction in post-RAPiD DTB time (P = 0.03) with a mean reduction of 26% during off-hours and 20% during on-hours. The post-RAPiD estimate of mean DTB time, derived from the antilog of the log transform, was 96.7 minutes (95% confidence interval, 83.7-111.7). CONCLUSIONS:: The institution of RAPiD in a hospital with a preexisting chest pain algorithm significantly decreases DTB times so as to satisfy current ACC/AHA guidelines.

Goyal NK, Giglio J, Lorberbaum M, Hurley E, Stant J, Esposito F, Sciacca R, Apfelbaum M, Rabbani LE.

From the *Division of Cardiology and the †Department of Emergency Medicine, Columbia University Medical Center, New York Presbyterian Hospital and Columbia University College of Physicians and Surgeons, Division of Cardiology, New York, NY; and ‡Hadassah University Hospital, Department of Medicine, Mount Scopus, Jerusalem, Israel.

Updated Algorithms for Using B-Type Natriuretic Peptide (BNP) Levels in the Diagnosis and Management of Congestive Heart Failure.

The growing popularity of BNP testing is a testimony to its usefulness for diagnosing and managing patients with congestive heart failure. The algorithms in this article are based on the most-up-to-date evidence-based medicine we have intermingled with clinical judgement of someone who has used BNP testing since its inception.

Maisel A.

From the Division of Cardiology and Department of Medicine, San Diego VA Healthcare System and University of California, San Diego.

Prevention of Contrast-Induced Nephropathy With Sodium Bicarbonate: An Evidence-Based Protocol.

Contrast-induced nephropathy has continued to plague interventional cardiology as an all-too-frequent complication of diagnostic and therapeutic procedures. We present an evidence-based protocol for prevention of this complication that uses infusion of NaHCO3 to effect urinary alkalinization and possibly decrease free-radical renal injury resulting from contrast exposure.

Merten GJ, Burgess WP, Rittase RA, Kennedy TP.

From the *Division of Nephrology, Mayo Clinic, Rochester, Minnesota; †Metrolina Nephrology Associates, Charlotte, North Carolina; the ‡Clinical Pharmacy, Carolinas Medical Center, Charlotte, North Carolina; and the §Department of Internal Medicine and Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina.

Act in Time to Heart Attack Signs: Update on the National Heart Attack Alert Program\’s Campaign to Reduce Patient Delay.

Outcomes of reperfusion treatment for acute myocardial infarction (MI) can be dramatically enhanced if patients present early after symptom onset. Yet delayed presentation by patients with acute coronary syndrome (ACS) symptoms (including MI and unstable angina) remains a tenacious challenge. The \”Act in Time to Heart Attack Signs\” is a public education campaign sponsored by the National Heart, Lung, and Blood Institute\’s (NHLBI\’s) National Heart Attack Alert Program (NHAAP) that addresses early recognition and response to ACS symptoms by patients, providers, and the general public. The campaign\’s materials and messages are based on those used in a multicenter research program, the Rapid Early Action for Coronary Treatment (REACT), funded by the National Heart, Lung, and Blood Institute from 1994-1998. Materials are available for providers, patients, and the public discussing heart attack risk, common heart attack symptoms, the importance of seeking early care, common misconceptions about how heart attacks present, and the importance of accessing care by calling 9-1-1. There is a critical need for all healthcare providers to relay this lifesaving information to the patients seen in their practice settings.

Hand MM.

From the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesdsa, Maryland.

Early and Aggressive Treatment of Patients With Acute ST Segment Elevation and Non-ST Segment Elevation Myocardial Infarction Leads to Improved Clinical Outcomes.

Acute myocardial infarction remains a significant burden to our society. Despite being the number 1 cause of mortality, there remains no uniform approach to treatment, which is unlike that of the triage and care of trauma victims. It is now well documented that acute reperfusion therapy has a profound benefit; however, many current strategies take too long to be performed and thus those potential benefits are often reduced. The emergence of prehospital treatment as a means to reducing time to reperfusion provides a new avenue for earlier therapy. With a coordinated aggressive treatment strategy and the identification of primary cardiovascular centers dedicated to the treatment of ST segment elevation myocardial infarctions (STEMI), we believe the mortality of an STEMI can be significantly reduced. Similarly, the treatment of non-ST segment elevation myocardial infarction has shifted to an aggressive approach. Although thrombolytic therapy is not indicated, the use of glycoprotein IIb/IIIa antagonists, as well as early interventional revascularization, is the current preferred treatment strategy. We review important current trials that shape the practice of treatment as well as introduce a novel concept of combined prehospital administration of thrombolytics with urgent culprit artery revascularization.

Smalling RW, Giesler GM.

From the University of Texas Health Sciences Center at Houston Medical School, Houston, Texas.

Early Exercise Testing for Risk Stratification of Low-Risk Patients in Chest Pain Centers.

Amsterdam EA, Kirk JD, Diercks DB, Turnipseed SD, Lewis WR.

From the Divisions of *Cardiovascular Medicine and †Emergency Medicine, Department of Internal Medicine, University of California School of Medicine (Davis) and Medical Center, Sacramento, California.

Emergency Department Evaluation and Treatment of Patients With ST-Segment Elevation Myocardial Infarction.

Acute coronary syndrome (ACS) identifies a set of clinical presentations with a common etiology. This entity accounts for more deaths in the United States than any other disease or form of injury. Early identification and management has been shown to substantially reduce the morbidity and mortality associated with ACS. As a result of efforts by several organizations to inform the public of the importance of immediately responding to signs and symptoms of ACS, a growing percentage of ACS patients are seeking emergency department care in a timely manner. Patients with ST segment elevation myocardial infarction (STEMI) are among the most vulnerable ACS patients. Immediate triage to a properly equipped and staffed ACS area within the ED is essential. Some therapeutic measures can be implemented while the initial assessment is underway. Additional therapeutic interventions will be dictated by the results of history, physical examination, electrocardiogram, serum marker measurements, radiologic and ultrasound results. Protocols designed to assist with the management of STEMI patients improve the speed and accuracy of treatment while helping to reduce medical errors. Protocols should include stimuli that will encourage timely, appropriate interfacility transfers, personal physician involvement, and cardiology consultation. The rapid pace of advancement in medical knowledge surrounding STEMI management necessitates monitoring of compliance with protocols and periodic revision to achieve optimal outcomes for patients.

Aghababian RV.

From the Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.

The future of cardiac markers in the emergency department.

The development of new cardiac marker strategies has the potential of improving the treatment and triage of patients in the emergency department with possible acute coronary syndrome. Although there has been a proliferation of new cardiac markers, at present rigorous studies demonstrating the incremental utility of many of these are lacking.

McCord JK.

From Henry Ford Hospital, Heart & Vascular Institute, Detroit, Michigan.

The final common pathway for community heart attack care: combining prevention through intervention when acute events are taking place with future prevention using the novel emerging cardiovascular risk factors.

Bahr RD.

From The Paul Dudley White Coronary Care System, St Agnes Health Care, Baltimore, MD.

Greater Benefit of Early Invasive Strategy for Unstable Angina and Non-ST Elevation Myocardial Infarction in United States Compared With Non-United States Patients: A TACTICS-TIMI 18 Substudy.

BACKGROUND:: The TACTICS-TIMI 18 (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy - Thrombolysis in Myocardial Infarction 18) trial compared routine invasive to conservative care for the management of patients with unstable angina and non ST-elevation myocardial infarction, and included the routine use of the platelet glycoprotein IIb/IIIa inhibitor tirofiban in the initial medical stabilization of all patients. METHODS:: Because previous trials utilizing IIb/IIIa inhibition for acute coronary syndrome (ACS) patients have demonstrated different outcomes in non-US and US patients, the authors sought to determine whether differences in baseline characteristics and practice patterns between 1844 US and 376 non-US patients and physicians would affect outcomes in the TACTICS-TIMI 18 trial. Event rates were stratified by treatment strategy and adjusted for baseline and treatment differences between cohorts. RESULTS:: Although US subjects were more likely women, hypertensive, and diabetic, the US and non-US patients did not differ with respect to low, intermediate, or high TIMI risk scores. For US patients, the primary composite end point of death, myocardial infarction (MI), and rehospitalization for ACS was reduced with an invasive strategy by 40% (95% CI: 0.43-0.83) at 30 days and by 30% (95% CI: 0.55-0.88) at 180 days. Non-US patients managed conservatively had 35% fewer events at 180 days than their invasive counterparts resulting in no benefit for the invasive strategy (P = 0.016 for the interaction term between country and treatment group). Similar results were observed for the additional outcome of death and MI, and in troponin-positive patients. Adjustment for baseline characteristics, medications during the initial hospitalization, and the use of cardiac procedures suggested that a higher cross-over rate from conservative to invasive care in non-US patients (59% versus 49%, P = 0.02) was the most likely explanation for the lower event rate in the conservatively managed patients outside the US. CONCLUSION:: US patients treated with tirofiban and early routine cardiac catheterization had a 30% reduction in major cardiac events by 6 months compared with those treated with tirofiban and a conservative (selective invasive) approach. Non-US patients treated conservatively had fewer events than US patients, which appears to be related to a higher rate of cross-over to invasive care. These findings emphasize the importance of both risk stratification and invasive management for ACS patients.

Herrmann HC, Murphy SA, Dibattiste PM, Delucca PT, Demopoulos LA, Gibson CM, Cannon CP.

From the *University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, †Brigham and Womenʼs Hospital, Boston, Massachusetts, and ‡Merck and Co., Inc., West Point, Pennsylvania.