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Background: Despite data showing that time to treatment is very important in ST-elevation myocardial infarct patients, unacceptable long delays to reperfusion remain present in daily life practice. We sought to evaluate the feasibility and effect of improving logistics by early infarct diagnosis in the ambulance and immediate triage to a percutaneous coronary intervention (PCI) center performed by paramedics only without interference of a physician. Methods: In the On-TIME study, 209 patients were included after prehospital infarct diagnosis and triage in the ambulance (ambulance group, n = 209). Infarct diagnosis was made by highly trained paramedics with the help of a computerized electrocardiographic algorithm. The accuracy of diagnosis, time to treatment, left ventricular function, and clinical outcome were compared with the patients who were diagnosed and triaged at a referral non-PCI center (referred group, n = 258). Left ventricular function was assessed before discharge using a nuclear technique. Results: Acute myocardial infarction was accurately diagnosed in 95% of patients in the ambulance group, as compared with 99% in the referred group (P = .01). The percentage of patients in whom pharmacologic pretreatment (heparin, aspirin, tirofiban, or placebo) was initiated in the ambulance within 90 minutes after the onset of symptoms was 59% in the ambulance group versus 43% in the referred group (P < .01). A left ventricular ejection fraction of <40% was present in 25% in the ambulance group, as compared with 38% in the referred group (P = .013). After multivariate analysis, ambulance triage was independently associated with a left ventricular ejection fraction >40% and a favorable long-term clinical outcome. Conclusions: Early, prehospital infarct diagnosis, triage, and therapy in the ambulance with direct transportation to the nearest PCI center, performed by trained paramedics only, is feasible in 95% of patients. Ambulance triage resulted in earlier diagnosis and initiation of therapy and was independently associated with a better left ventricular function and clinical outcome, as compared with triage and transportation from a referral non-PCI center. [Copyright &y& Elsevier]

Background: To evaluate the impact of adjunctive high-dose glucose-insulin-potassium (GIK) on ST-segment elevation resolution in patients with ST-segment elevation myocardial infarction (MI). Methods: As part of a randomized controlled trial of GIK versus no GIK in patients treated with primary percutaneous coronary intervention (PCI) for ST-elevation MI in a tertiary referral center, we analyzed ST-segment elevation resolution. Paired electrocardiographic recordings (baseline and 3 hours after primary PCI) were available in 612 (65%) of 940 patients. Results: We analyzed paired electrocardiograms of 310 patients randomized to GIK and 302 control patients. Baseline characteristics of the groups were comparable. Combined complete (>70%) and partial (30%-70%) resolution was more commonly observed in the GIK group (87%) when compared with the control group (78%), odds ratio 1.92 (95% CI 1.23-3.02, P = .004); 1-year mortality was lower in patients with combined complete and partial resolution compared with patients without resolution (3.8% vs 10.3%, P = .011). There was no difference in 1-year mortality between GIK and control patients (5.5% vs 4.3%, P = .58). Conclusions: In patients with ST-elevation MI treated with primary PCI, addition of GIK is associated with improved ST-segment elevation resolution. ST-segment elevation resolution is related to improved 1-year survival. No benefit of GIK on 1-year outcome was observed. Future trials should investigate whether GIK-induced improvement of ST-segment elevation resolution results in more favorable clinical outcome. [Copyright &y& Elsevier]

Decreased left ventricular (LV) function is a strong predictor of mortality. Although current guidelines recommend prophylactic implantable cardioverter-defibrillator (ICD) implantation after ST-elevation myocardial infarction and a depressed LV ejection fraction for 1 month, the prognoses of these patients may be better than those observed in randomized trials of ICDs (1-year mortality 6.8% to 19%), particularly because reperfusion treatment has improved, and the use of life-saving drugs is higher. To assess 1-year mortality in patients with depressed LV ejection fractions after primary percutaneous coronary intervention, a prospective, observational study was performed. Data from all patients who survived ≥30 days after primary percutaneous coronary intervention and had LV ejection fractions ≤30% from 1994 to 2004 were recorded. Of 2,544 patients, 342 (13%) had LV ejection fractions ≤30%. One-year mortality was 5.8%. Sudden death was the most common cause of death (40%). Patients who died more often had multivessel disease and a higher incidence of recurrent myocardial infarction within 1 year. In conclusion, current mortality in patients with depressed LV ejection fractions after primary percutaneous coronary intervention is much better than that observed in previous ICD trials, and the benefits of ICD therapy in these patients should be further evaluated. [Copyright &y& Elsevier]

Abstract: Background: The prognostic importance of elevated cardiac enzymes after elective percutaneous coronary intervention has been debated. Therefore, we performed a prospective observational study to evaluate the prognostic value of postprocedural rise of troponin T and creatine kinase. Methods: Troponin T (cut-off value 0.05 ng/ml) and creatine kinase (cut-off value 180 IU/l with muscle-brain fraction >4%) were measured 12 h after elective percutaneous coronary intervention in 713 consecutive patients without elevated troponin before the procedure. Primary endpoint was the combined incidence of death, myocardial infarction, stroke, repeat angiography or re-admission because of anginal symptoms during the follow-up period. Results: Troponin was elevated after the procedure in 150 patients (21%) and creatine kinase in 66 pts (9%), with a strong association between increased troponin and creatine kinase. After a mean follow-up of 10.9 months, mortality was low (1%) and not associated with increased troponin or creatine kinase. There was, however, a strong relation between postprocedural troponin and re-admission for angina (p =0.001) or myocardial infarction (p =0.001). Furthermore, troponin rise was significantly associated with an increased risk of the primary endpoint (relative risk 1.55 95% confidence interval 1.01–2.38). After multivariate analysis, troponin elevation but not increased creatine kinase was associated with an increased risk of the primary endpoint (relative risk 1.59 95% confidence interval 1.02–2.47 for troponin elevation versus 1.16 95% confidence interval 0.62–2.15 for increased creatine kinase). Conclusion: Increase of troponin T after elective percutaneous coronary intervention has stronger prognostic implication when compared to increased creatine kinase. [Copyright &y& Elsevier]

Percutaneous coronary intervention is not successful in all patients whose acute myocardial infarction is controlled with primary angioplasty, and, after an initial successful procedure, reperfusion is not always sustained due to subacute (stent) thrombosis. In a studied population that had acute myocardial infarction, failed mechanical reperfusion occurred in 108 patients (6.9%). Killip’s class >I at admission, a left anterior descending artery as the infarct-related vessel, or a preprocedural Thrombolysis In Myocardial Infarction grade 0 or 1 flow was an independent predictor of failed reperfusion. Outcome after successful early and sustained mechanical reperfusion is excellent. Failure of the initial procedure and reocclusion of the infarct-related vessel are important determinants of adverse outcome. [Copyright &y& Elsevier]

Patients with diabetes mellitus (DM) have an adverse prognosis after ST-segment elevation myocardial infarction (STEMI). Whether DM was associated with impaired myocardial reperfusion after successful primary percutaneous coronary intervention for STEMI was investigated. Myocardial reperfusion was assessed by ST-segment resolution and myocardial blush grade (MBG). A total of 386 patients were studied, of whom 64 (17%) had DM. These patients more frequently had reduced MBG (20% vs 10%, p = 0.02) and incomplete ST-segment resolution (55% vs 35%, p = 0.02) compared with patients without DM. After multivariate analysis, DM was still associated with impaired ST resolution (odds ratio 2.1, p = 0.03) and reduced MBG (odds ratio 2.2, p = 0.03). [Copyright &y& Elsevier]