Introduction: Following ST-elevation myocardial infarction (STEMI) and treatment with Primary Percutaneous Coronary Intervention (PPCI), some patients re-present with potential ischaemic heart disease (IHD) symptoms. Symptoms may be related to cardiac ischaemia, reduced psychological health or a comorbid condition, which share similar symptoms and may lead patients to seek help via acute services. The purpose of the study was to investigate the proportion of PPCI patients who re-presented to acute services due to potential IHD symptoms within 6 months of STEMI, and to explore associated factors. Methods: An explanatory mixed methods study was conducted. Quantitative data were collected at baseline and 6 months from consecutive patients attending two centres in Manchester. Variables were carefully considered based on a conceptual model for re-presentation. These included potential IHD symptom and psychological health assessments using self-report measures: the Seattle Angina Questionnaire (SAQ) and the Hospital and Anxiety and Depression Scale (HADS). Physiological health was measured using the Global Registry of Acute Coronary Events (GRACE) and the Charleson Comorbidity Index (CCI) at baseline. At 6 months re-presentation data were collected using patient records, a telephone interview and a self-report diary card. The experiences of some who re-presented (purposeful sampling) were explored through semi-structured interviews conducted at least 6 months following PPCI. Framework analysis was adopted to analyse data. Results: 202 PPCI patients returned baseline questionnaires [mean age 59.7 years (SD 13.9), 75.7% male]; 38 (18.8%; 95% CI 14.0% to 24.8%) participants re-presented due to potential IHD symptoms at 6 months; 16 (42.1%) re-presented due to a cardiac event and 22 (57.9%) did not receive a diagnosis. At both baseline and 6 months, mean HADS anxiety scores were higher for the re-presentation group compared to the non-representation group (baseline 9.5 vs 7.1, p=0.006; 6 months 9.4 vs 6.0, p<0.001). Angina symptoms were stable and infrequent at both time points for the groups. Multivariate regression modelling with the inclusion of predictors HADS anxiety, SAQ angina stability, SAQ angina frequency, GRACE and CCI, determined HADS anxiety as a predictor of re-presentation with an adjusted odds ratio of 1.12 (95% CI 1.03 to 1.22, p=0.008). The qualitative interviews with re-presenters included 25 participants (14 men, 27-79 years). Four themes were identified: fear of experiencing a further heart attack, uncertainty and inability to determine cause of symptoms, insufficient opportunity to validate self-construction of illness and difficulty adapting to life after a heart attack. Conclusion: Elevated levels of anxiety at baseline were predictive of re-presentation with potential IHD symptoms at 6 months. Factors such as shock at experiencing a heart attack, hypervigilance of symptoms and difficulty with symptom attribution appeared to play a role in raised anxiety levels for the re-presentation group. Findings suggested that changes are needed to cardiac rehabilitation and post-STEMI follow-up to address educational needs and psychological issues and changes in STEMI treatment.

Current evidence regarding the effect of intravenous morphine administration on reperfusion injury and/or cardioprotection in patients with myocardial infarction is conflicting. The aim of this study was to evaluate the impact of morphine administration, on infarct size and reperfusion injury assessed by cardiac magnetic resonance imaging (CMR) in a large multicenter ST-elevation myocardial infarction (STEMI) population. In total, 734 STEMI patients reperfused by primary percutaneous coronary intervention <12 h after symptom onset underwent CMR imaging at eight centers for assessment of myocardial damage. Intravenous morphine administration was recorded in all patients. CMR was completed within one week after infarction using a standardized protocol. The clinical endpoint of the study was the occurrence of major adverse cardiac events (MACE) within 12 months after infarction. Intravenous morphine was administered in 61.8% (n = 454) of all patients. There were no differences in infarct size (17%LV, interquartile range [IQR] 8–25%LV versus 16%LV, IQR 8–26%LV, p = 0.67) and microvascular obstruction (p = 0.92) in patients with versus without morphine administration. In the subgroup of patients with early reperfusion within 120 min and reduced flow of the infarcted vessel (TIMI-flow ≤2 before PCI) morphine administration resulted in significantly smaller infarcts (12%LV, IQR 12–19 versus 19%LV, IQR 10–29, p = 0.035) and reduced microvascular obstruction (p = 0.003). Morphine administration had no effect on hard clinical endpoints (log-rank test p = 0.74) and was not an independent predictor of clinical outcome in Cox regression analysis. In our large multicenter CMR study, morphine administration did not have a negative effect on myocardial damage or clinical prognosis in acute reperfused STEMI. In patients, presenting early ( ≤120 min) morphine may have a cardioprotective effect as reflected by smaller infarcts; but this finding has to be assessed in further well-designed clinical studies

<p>In unstable coronary artery disease (CAD) it still is a matter of debate which patients should undergo early revascularisation. In the FRISC II study (n=2457) an early invasive strategy was, compared to a primarily non-invasive strategy, associated with reduced mortality and myocardial infarction (MI) rates. However, in this heterogeneous group of patients, tools for an appropriate selection to revascularisation are needed.</p><p>From the FRISC II study we evaluated the prognosis, the angiographic extent of CAD and the effects of an early invasive strategy in relation to risk variables on admission.</p><p>The occurrence of ST depression and/or elevated levels of Troponin T were associated with a higher risk for death and MI, more severe CAD and also with a reduction of death or MI by the early invasive strategy.</p><p>Elevated levels of the inflammatory markers C-reactive protein (CRP) and interleukin-6 (Il-6) were associated with a higher mortality but an unchanged MI rate. Elevated levels of Il-6, but not CRP, identified patients with a large reduction of mortality by the invasive strategy.</p><p>Age ≥ 70 years, male gender, diabetes, previous MI, ST depression and elevated levels of troponin and markers of inflammation were independently associated with an adverse outcome. The FRISC-score was constructed using these 7 variables. At FRISC-score ≥ 5 an early invasive strategy markedly reduced mortality and MI, at FRISC–score 3-4 death/MI was reduced, whereas in patients with a FRISC-score 0-2 neither mortality nor death/MI was influenced.</p><p>In unstable CAD, a non-invasive strategy seems justified only for patients at low risk, i.e. FRISC score < 2. In patients with intermediate and high risk, i.e. FRISC-score ≥ 3, an early invasive strategy is recommended.</p>

In unstable coronary artery disease (CAD) it still is a matter of debate which patients should undergo early revascularisation. In the FRISC II study (n=2457) an early invasive strategy was, compared to a primarily non-invasive strategy, associated with reduced mortality and myocardial infarction (MI) rates. However, in this heterogeneous group of patients, tools for an appropriate selection to revascularisation are needed. From the FRISC II study we evaluated the prognosis, the angiographic extent of CAD and the effects of an early invasive strategy in relation to risk variables on admission. The occurrence of ST depression and/or elevated levels of Troponin T were associated with a higher risk for death and MI, more severe CAD and also with a reduction of death or MI by the early invasive strategy. Elevated levels of the inflammatory markers C-reactive protein (CRP) and interleukin-6 (Il-6) were associated with a higher mortality but an unchanged MI rate. Elevated levels of Il-6, but not CRP, identified patients with a large reduction of mortality by the invasive strategy. Age ≥ 70 years, male gender, diabetes, previous MI, ST depression and elevated levels of troponin and markers of inflammation were independently associated with an adverse outcome. The FRISC-score was constructed using these 7 variables. At FRISC-score ≥ 5 an early invasive strategy markedly reduced mortality and MI, at FRISC–score 3-4 death/MI was reduced, whereas in patients with a FRISC-score 0-2 neither mortality nor death/MI was influenced. In unstable CAD, a non-invasive strategy seems justified only for patients at low risk, i.e. FRISC score &lt; 2. In patients with intermediate and high risk, i.e. FRISC-score ≥ 3, an early invasive strategy is recommended.

Background: This study aimed to evaluate the incremental prognostic value of infarct size, microvascular obstruction (MO), myocardial salvage index (MSI), and left ventricular ejection fraction (LV-EFCMR) assessed by cardiac magnetic resonance imaging (CMR) in comparison to traditional outcome markers in patients with ST-elevation myocardial infarction (STEMI) reperfused by primary percutaneous intervention (PCI). Methods: STEMI patients reperfused by primary PCI (n = 278) within 12 hours after symptom onset underwent CMR three days after the index event (interquartile range [IQR] two to four). Infarct size and MO were measured 15 minutes after gadolinium injection. T2-weighted and contrast-enhanced CMR were used to calculate MSI. In addition, traditional outcome markers such as ST-segment resolution, pre- and post-PCI Thrombolysis In Myocardial Infarction (TIMI)-flow, maximum level of creatine kinase-MB, TIMI-risk score, and left ventricular ejection fraction assessed by echocardiography were determined in all patients. Clinical follow-up was conducted after 19 months (IQR 10 to 27). The primary endpoint was defined as a composite of death, myocardial reinfarction, and congestive heart failure (MACE). Results: In multivariable Cox regression analysis, adjusting for all traditional outcome parameters significantly associated with the primary endpoint in univariable analysis, MSI was identified as an independent predictor for the occurrence of MACE (Hazard ratio 0.94, 95% CI 0.92 to 0.96, P <0.001). Further, C-statistics comparing a model including only traditional outcome markers to a model including CMR parameters on top of traditional outcome markers revealed an incremental prognostic value of CMR parameters (0.74 versus 0.94, P <0.001). Conclusions: CMR parameters such as infarct size, MO, MSI, and LV-EFCMR add incremental prognostic value above traditional outcome markers alone in acute reperfused STEMI.

Introduction Prior to percutaneous coronary intervention (PCI) guidelines recommend that patients with ST- elevation myocardial infarction (STEMI) receive dual antiplatelet therapy (DAPT) consisting of P2Y12 inhibition and acetylsalicylic acid (aspirin). However, in rare occasions, patients admitted with STEMI as preliminary diagnosis require acute thoracic surgery and oral P2Y12 inhibitors increases the bleeding risk over several hours. Cangrelor is an intravenous reversible P2Y12 antagonist with normal platelet function returning within 60 minutes and might therefore be an attractive alternative to oral P2Y12 inhibition.Aim Firstly, to quantify P2Y12 pre-treatment with ticagrelor in patients undergoing acute thoracic surgery and the mortality and morbidity rate associated with DAPT prior to surgery. Secondly, to estimate cost-benefit differences between cangrelor and ticagrelor pre-treatment.Material and Methods A descriptive cohort study using retrospective data. The inclusion criteria were patients undergoing acute thoracic surgery (≤ 24 hours) between January 2015 and December 2017, in the catchment area of Örebro University Hospital. Patients were stratified into groups depending on whether they had received pre-treatment with DAPT or not before surgery. Statistical analyses were made in SPSS and Excel.Results A total of 50 patients were included. 8 patients received DAPT before surgery. There was no mortality in patients receiving DAPT but TIMI major bleeding was more frequent compared to the group with no pre-treatment. The DAPT group required numerically more units of platelets and plasma, however the result was not significant. Direct treatment costs for ticagrelor was 20.14 SEK (the dosage is 2 tablets) and cangrelor was 3 059 SEK.Conclusions DAPT pre-treatment with ticagrelor was not associated with increased mortality but TIMI major bleeding was more frequent compared to the group with no pre-treatment. Direct treatment costs with cangrelor was higher compared to ticagrelor treatment. Further studies, with larger study samples, are needed to investigate complications associated with P2Y12 pre-treatment in patients undergoing acute thoracic surgery.

En så tidig reperfusionsbehandling som möjligt hos patienter med ST-höjningsinfarkt förbättrar prognosen både gällande kardiell status och minskad dödlighet. Arbetet runt patienten måste ske skyndsamt men samtidigt med hög kompetens. Trots tydliga riktlinjer och tidsmål för reperfusionsbehandling uppfylls inte alltid dessa. Med ökad förståelse för faktorer som påverkar tidsflödet från första vårdkontakt till reperfusionsbehandling skapas förutsättningar för ett mer tidseffektivt och därmed säkrare omhändertagande av patienter som drabbade av ST-höjningsinfarkt. Syftet var att identifiera faktorer som påverkar tidsflödet från första vårdkontakt till reperfusionsbehandling vid det akuta omhändertagandet av patienter med ST-höjningsinfarkt. Metoden var en icke systematisk litteraturöversikt. Totalt inkluderades 15 artiklar både av kvantitativ- och kvalitativ ansats. Artiklarna som inkluderades i resultatet kvalitetsgranskades utifrån Sophiahemmets bedömningsunderlag för att klassificera och kvalitetsbedöma de vetenskapliga artiklarna. Artiklarna analyserades med integrerad analysmetod där likheter och olikheter mellan artiklarna identifierades, sammanställdes och delades in i underrubriker samt kategorier. I resultatet framkom fyra huvudkategorier; “Patientrelaterade faktorer”, “System-och organisatoriska faktorer”, “Vårdpersonalens inflytande” och “Kommunikation”. Resultatet från litteraturöversikten visar faktorer som hade både positiv och negativ inverkan på tidsåtgången från första vårdkontakt till reperfusionsbehandling. Faktorer som associerades med förlängd tidsåtgång var: prehospitalt långa transporttider, ospecifika symtom och otillgängligt Percutant Coronar Interventions-lab (PCI-lab). Faktorerna som associerades med tidssparande effekt var: prehospitalt EKG, när patienten transporterades direkt till PCI-lab utan att gå via akuten, prehospital notifikation, fungerande teamarbete, standardiserade arbetssätt och protokoll, organisatoriskt engagemang med regelbunden feedback till personalen samt kompetensutbildning. Slutsatsen är att faktorer som associerades med förlängd tidsåtgång var prehospitalt långa transportavstånd, ospecifika symtom och otillgängligt PCI-lab. Faktorerna som associerades med tidssparande effekt var prehospitalt EKG, direkt transport till PCI-lab utan att passera akutmottagningen, fungerande teamarbete med god kommunikation, standardiserade arbetssätt, organisatoriskt engagemang med regelbunden feedback och utvärdering samt kompetensutbildning för berörd personal. För att identifiera faktorer som är tidsvinnande och skapa nya strategier krävs engagemang och samarbete från samtliga professioner som möter patienten. / As early reperfusion therapy as possible in patients with ST-elevation infarction, the prognosis improves both in terms of cardiac status and reduced mortality. The care around the patient must be done quickly but at the same time with high knowledge precision. Despite clear guidelines and goals for reperfusion, not everyone lives up to them. With an increased understanding of factors that affect the flow of time from initial care contact to reperfusion treatment, conditions are created for more time-efficient and safer care of patients suffering from ST-elevation myocardial infarction. The aim was to identify factors that affect the time flow from first medical contact to reperfusion therapy in the acute care of patients with ST-elevation myocardial infarction. The method was a literature study with a systematic search strategy. A total of 15 articles were included which were both quantitative and qualitative. The articles that were included in the results section were read through several times by both authors and quality reviewed with assessment data for literature studies. The articles were analyzed with an integrated analysis method and divided into subheadings and categories. The results revealed four main categories; "Patient-related factors", "System and organizational factors", "Influence of care staff" and "Communication". The results from the literature review show factors that had both a positive and negative impact on the time required from first medical contact to reperfusion therapy. Factors associated with prolonged time consumption were: prehospital transport times, nonspecific symptoms, and unavailable Percutaneous Coronary Intervention-lab (PCI-lab). The factors associated with the timesaving effect were: prehospital ECG, when the patient was transported directly to the PCI-lab without going through the emergency room, prehospital notification, functioning teamwork, standardized working methods and protocols, organizational commitment with regular feedback to staff and skills training The conclusion is that factors associated with prolonged time consumption were prehospital long transport distances, nonspecific symptoms and unavailable PCI lab. The factors associated with time-saving effect were prehospital ECG, direct transport to PCI-lab without passing the emergency room, functioning teamwork with good communication, standardized working methods, organizational commitment with regular feedback and evaluation and competence training for relevant staff. Identifying factors that are time-saving and creating new strategies requires commitment and cooperation from all professionals who meet the patient.

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfillment of the degree of Master of Science in Medicine, 2014 / The earliest possible initiation of reperfusion therapy is necessary to reduce morbidity and mortality from acute STEMI. Therefore improving the time to thrombolysis where percutaneous coronary interventional facilities are limited or do not exist is critical. The most effective system would integrate three key components to deliver continuous patient care, including: 1) from time of call for help through to emergency response; 2) transportation to and admission to hospital; 3) assessment and initiation of thrombolytic therapy. The purpose of this prospective study is: to develop a chest pain awareness education programme appropriate for the South African context; to assess safe initiation of thrombolytic therapy by emergency care practitioners for STEMI; and to compare the performance of emergency care practitioner thrombolysis with historical control data.

Με δεδομένο το γεγονός ότι η αιμοπεταλιακή αναστολή είναι θεμελιώδους σημασίας σε ασθενείς με οξύ έμφραγμα του μυοκαρδίου με ανάσπαση του ST τμήματος που υποβάλλονται σε πρωτογενή αγγειοπλαστική (PPCI), η αναγνώριση παραγόντων που σχετίζονται με την εμφάνιση στην οξεία φάση υψηλής αντιδραστικότητας των αιμοπεταλίων (HTPR) παρά τη θεραπεία με κλοπιδογρέλη μπορεί να είναι σημαντική. Σε ασθενείς με STEMI και επακόλουθη PPCI εκτιμήθηκε η αιμοπεταλιακή αντιδραστικότητα 2 ώρες μετά τη φόρτιση με 600mg κλοπιδογρέλης με τη χρήση της παρακλίνιας μεθόδου VerifyNow P2Y12. Το όριο ≥235 P2Y12 μονάδων αντιδραστικότητας (PRU) θεωρήθηκε ενδεικτικό HTPR. Από τους 92 ασθενείς με STEMI, 63 (68,5%) βρέθηκαν να έχουν υψηλή αιμοπεταλιακή αντιδραστικότητα στις 2 ώρεςμετά τη φόρτιση. Οι ασθενείς με την υψηλή αντιδραστικότητα είχαν λάβει ‘πρώιμη φόρτιση’ με κλοπιδογρέλη πιο συχνά, είχαν χαμηλότερη τιμή αιμοσφαιρίνης και έτειναν να έχουν επηρεασμένη νεφρική λειτουργία σε σε σχέση με αυτούς που είχαν ικανοποιητική απάντηση στην κλοπιδογρέλη. Στην πολυπαραγοντική ανάλυση, η ‘πρώιμη φόρτιση’ και η κάθαρση κρεατινίνης <60ml/min είχαν ανεξάρτητη συσχέτιση με υψηλότερο κίνδυνο εμφάνισης HTPR (σχετικός κίνδυνος [RR]=1,55 95% διάστημα εμπιστοσύνης [CI]:1,11-2,17 P=0,01 και RR=1,31 95% CI: 1,008-1,71 P=0,04 αντίστοιχα). Επομένως σε ασθενείς με STEMI που υποβάλλονται σε PPCI, η ‘πρώιμη φόρτιση’ με κλοπιδογρέλη και η επηρεασμένη νεφρική λειτουργία αποτελούν ανεξάρτητους προβλεπτικούς παράγοντες εμφάνισης υψηλής υπολειπόμενης αντιδραστικότητας των αιμοπεταλίων (εκτιμούμενης με τη μεθοδο VerifyNow) 2 ώρες μετά την αρχική φόρτιση με 600mg κλοπιδογρέλης / Given that platelet inhibition is crucial when ST-elevation myocardial infarction (STEMI) patients undergo primary PCI (PPCI), the identification of factors associated with early high on-treatment platelet reactivity may be important. Consecutive STEMI patients admitted for PPCI were considered for platelet reactivity assessment 2 h after loading with 600 mg clopidogrel using the VerifyNow point-of-care P2Y12 assay. A cut-off of ≥235 P2Y12 reaction units indicated high on-treatment platelet reactivity. Out of 92 STEMI patients, 63 (68.5%) were found to have high on-treatment platelet reactivity. Patients with high on-treatment platelet reactivity had received upstream clopidogrel loading more frequently, had lower admission hemoglobin and tended to have an impaired renal function compared to those with an adequate response to clopidogrel. On multivariate analysis, upstream clopidogrel loading and creatinine clearance <60 ml/min were independently associated with higher risk for high on-treatment platelet reactivity (relative risk [RR]=1.55, 95% confidence interval [CI]: 1.11–2.17, P=0.01; RR=1.31, 95% CI: 1.008–1.71, P=0.04, respectively). In patients with STEMI undergoing PPCI, use of upstream clopidogrel and impaired renal function independently predict high on-treatment platelet reactivity assessed as early as 2 h following 600 mg of clopidogrel loading dose on point-of-care P2Y12 function assay.

Background: This study aimed to evaluate the incremental prognostic value of infarct size, microvascular obstruction (MO), myocardial salvage index (MSI), and left ventricular ejection fraction (LV-EFCMR) assessed by cardiac magnetic resonance imaging (CMR) in comparison to traditional outcome markers in patients with ST-elevation myocardial infarction (STEMI) reperfused by primary percutaneous intervention (PCI). Methods: STEMI patients reperfused by primary PCI (n = 278) within 12 hours after symptom onset underwent CMR three days after the index event (interquartile range [IQR] two to four). Infarct size and MO were measured 15 minutes after gadolinium injection. T2-weighted and contrast-enhanced CMR were used to calculate MSI. In addition, traditional outcome markers such as ST-segment resolution, pre- and post-PCI Thrombolysis In Myocardial Infarction (TIMI)-flow, maximum level of creatine kinase-MB, TIMI-risk score, and left ventricular ejection fraction assessed by echocardiography were determined in all patients. Clinical follow-up was conducted after 19 months (IQR 10 to 27). The primary endpoint was defined as a composite of death, myocardial reinfarction, and congestive heart failure (MACE). Results: In multivariable Cox regression analysis, adjusting for all traditional outcome parameters significantly associated with the primary endpoint in univariable analysis, MSI was identified as an independent predictor for the occurrence of MACE (Hazard ratio 0.94, 95% CI 0.92 to 0.96, P <0.001). Further, C-statistics comparing a model including only traditional outcome markers to a model including CMR parameters on top of traditional outcome markers revealed an incremental prognostic value of CMR parameters (0.74 versus 0.94, P <0.001). Conclusions: CMR parameters such as infarct size, MO, MSI, and LV-EFCMR add incremental prognostic value above traditional outcome markers alone in acute reperfused STEMI.