Browsing by Subject "ST-SEGMENT ELEVATION"

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  • Stassen, Willem; Wallis, Lee; Castren, Maaret; Vincent-Lambert, Craig; Kurland, Lisa (2019)
    The incidence of cardiovascular disease and STEMI is on the rise in sub-Saharan Africa. Timely treatment is essential to reduce mortality. Internationally, prehospital 12 lead ECG telemetry has been proposed to reduce time to reperfusion. Its value in South Africa has not been established. The aim of this study was to determine the effect of prehospital 12 lead ECG telemetry on the PCI-times of STEMI patients in South Africa. A multicentre randomised controlled trial was attempted among adult patients with prehospital 12 lead ECG evidence of STEMI. Due to poor enrolment and small sample sizes, meaningful analyses could not be made. The challenges and lessons learnt from this attempt at Africa's first prehospital RCT are discussed. Challenges associated with conducting this RCT related to the healthcare landscape, resources, training of paramedics, rollout and rando-misation, technology, consent and research culture. High quality evidence to guide prehospital emergency care practice is lacking both in Africa and the rest of the world. This is likely due to the difficulties with performing prehospital clinical trials. Every trial will be unique to the test intervention and setting of each study, but by considering some of the challenges and lessons learnt in the attempt at this trial, future studies might experience less difficulty. This may lead to a stronger evidence-base for prehospital emergency
  • Koivula, Kimmo; Nikus, Kjell; Viikilä, Juho; Lilleberg, Jyrki; Huhtala, Heini; Birnbaum, Yochai; Eskola, Markku (2019)
    Background Both Q waves and T-wave inversion (TWI) in the presenting ECG are associated with a progressed stage of myocardial infarction, possibly with less potential for myocardial salvage with reperfusion therapy. Combining the diagnostic information from the Q- and T-wave analyses could improve the prognostic work-up in ST-elevation myocardial infarction (STEMI) patients. Methods We sought to determine the prognostic impact of Q waves and TWI in the admission ECG on patient outcome in STEMI. We formed four groups according to the presence of Q waves and/or TWI (Q+TWI+; Q-TWI+; Q+TWI-; Q-TWI-). We studied 627 all-comers with STEMI derived from two patient cohorts. Results The patients with Q+TWI+ had the highest and those with Q-TWI- the lowest 30-day and one-year mortality. One-year mortality was similar between Q-TWI+ and Q+TWI-. The survival analysis showed higher early mortality in Q+TWI- but the higher late mortality in Q-TWI+ compensated for the difference at 1 year. The highest peak troponin level was found in the patients with Q+TWI-. Conclusion Q waves and TWI predict adverse outcome, especially if both ECG features are present. Q waves and TWI predict similar one-year mortality. Extending the ECG analysis in STEMI patients to include both Q waves and TWI improves risk stratification.
  • Chioncel, Ovidiu; Parissis, John; Mebazaa, Alexandre; Thiele, Holger; Desch, Steffen; Bauersachs, Johann; Harjola, Veli-Pekka; Antohi, Elena-Laura; Arrigo, Mattia; Gal, Tuvia B.; Celutkiene, Jelena; Collins, Sean P.; DeBacker, Daniel; Iliescu, Vlad A.; Jankowska, Ewa; Jaarsma, Tiny; Keramida, Kalliopi; Lainscak, Mitja; Lund, Lars H.; Lyon, Alexander R.; Masip, Josep; Metra, Marco; Miro, Oscar; Mortara, Andrea; Mueller, Christian; Mullens, Wilfried; Nikolaou, Maria; Piepoli, Massimo; Price, Susana; Rosano, Giuseppe; Vieillard-Baron, Antoine; Weinstein, Jean M.; Anker, Stefan D.; Filippatos, Gerasimos; Ruschitzka, Frank; Coats, Andrew J. S.; Seferovic, Petar (2020)
    Cardiogenic shock (CS) is a complex multifactorial clinical syndrome with extremely high mortality, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large spectrum of CS presentations resulting from the interaction between an acute cardiac insult and a patient's underlying cardiac and overall medical condition. Phenotyping patients with CS may have clinical impact on management because classification would support initiation of appropriate therapies. CS management should consider appropriate organization of the health care services, and therapies must be given to the appropriately selected patients, in a timely manner, whilst avoiding iatrogenic harm. Although several consensus-driven algorithms have been proposed, CS management remains challenging and substantial investments in research and development have not yielded proof of efficacy and safety for most of the therapies tested, and outcome in this condition remains poor. Future studies should consider the identification of the new pathophysiological targets, and high-quality translational research should facilitate incorporation of more targeted interventions in clinical research protocols, aimed to improve individual patient outcomes. Designing outcome clinical trials in CS remains particularly challenging in this critical and very costly scenario in cardiology, but information from these trials is imperiously needed to better inform the guidelines and clinical practice. The goal of this review is to summarize the current knowledge concerning the definition, epidemiology, underlying causes, pathophysiology and management of CS based on important lessons from clinical trials and registries, with a focus on improving in-hospital management.
  • Koivula, Kimmo; Eskola, Markku; Viikilä, Juho; Lilleberg, Jyrki; Huhtala, Heini; Birnbaum, Yochai; Nikus, Kjell (2018)
    Background: Grade 3 ischemia (G3I) in the 12 lead electrocardiogram (ECG) predicts poor outcome in patients with ST-elevation myocardial infarction (STEMI). The outcome of G3I in "real-life" patient cohorts is unclear. Methods: The aim of the study was to establish the prognostic significance of grade 2 ischemia (G2I), G3I and the STEMI patients excluded from ischemia grading (No grade of ischemia, NG) in a real-life patient population. We assessed in-hospital, 30-day and 1-year mortality as well as other endpoints. Results: The NG patients had more comorbidities and longer treatment delays than the two other groups. Shortterm and 1-year mortality were highest in patients with NG and lowest in patients with G2I. Maximum troponin level was highest in G3I, followed by NG and G2I. In logistic regression multivariable analysis, NG was independently associated with 1-year mortality. Conclusions: NG predicted poor outcome in STEMI patients. G2I predicted relatively favorable outcome. (C) 2018 Elsevier Inc. All rights reserved.
  • Stassen, Willem; Wallis, Lee; Lambert, Craig; Castren, Maaret; Kurland, Lisa (2017)
    Introduction: The incidence of myocardial infarction is rising in Sub-Saharan Africa. In order to reduce mortality, timely reperfusion by percutaneous coronary intervention (PCI) or thrombolysis followed by PCI is required. South Africa has historically been characterised by inequities in healthcare access based on geographic and socioeconomic status. We aimed to determine the coverage of PCI-facilities in South Africa and relate this to access based on population and socio-economic status. Methods: This cross-sectional study obtained data from literature, directories, organisational databases and correspondence with Departments of Health and hospital groups. Data was analysed descriptively while Spearman's Rho sought correlations between PCI-facility resources, population, poverty and medical insurance status. Results: South Africa has 62 PCI-facilities. Gauteng has the most PCI-facilities (n = 28) while the Northern Cape has none. Most PCI-facilities (n = 48; 77%) are owned by the private sector. A disparity exists between the number of private and state-owned PCI-facilities when compared to the poverty (r = 0.01; p = 0.17) and insurance status of individuals (r = -0.4; p = 0.27). Conclusion: For many South Africans, access to PCI-facilities and primary PCI is still impossible given their socio-economic status or geographical locale. Research is needed to determine the specific PCI-facility needs based on geographic and epidemiological aspects, and to develop a contextualised solution for South Africans suffering a myocardial infarction. (C) 2017 African Federation for Emergency Medicine. Publishing services provided by Elsevier B.V.
  • Saarinen, Sini; Puolakka, Jyrki; Boyd, James; Vayrynen, Taneli; Luurila, Harri; Kuisma, Markku (2011)