There is little clear evidence as to the optimal energy levels for initial and subsequent shocks in biphasic waveform defibrillation. The present study compared fixed lower- and escalating higher-energy regimens for out-of-hospital cardiac arrest.
The Randomized Controlled Trial to Compare Fixed Versus Escalating Energy Regimens for Biphasic Waveform Defibrillation (BIPHASIC Trial) was a multicenter, randomized controlled trial of 221 out-of-hospital cardiac arrest patients who received > or = 1 shock given by biphasic automated external defibrillator devices that were randomly programmed to provide, blindly, fixed lower-energy (150-150-150 J) or escalating higher-energy (200-300-360 J) regimens. Patient mean age was 66.0 years; 79.6% were male. The cardiac arrest was witnessed in 63.8%; a bystander performed cardiopulmonary resuscitation in 23.5%; and initial rhythm was ventricular fibrillation/ventricular tachycardia in 92.3%. The fixed lower- and escalating higher-energy regimen cases were similar for the 106 multishock patients and for all 221 patients. In the primary analysis in multishock patients, conversion rates differed significantly (fixed lower, 24.7%, versus escalating higher, 36.6%; P=0.035; absolute difference, 11.9%; 95% CI, 1.2 to 24.4). Ventricular fibrillation termination rates also were significantly different between groups (71.2% versus 82.5%; P=0.027; absolute difference, 11.3%; 95% CI, 1.6 to 20.9). For the secondary analysis of first shock success, conversion rates were similar between the fixed lower and escalating higher study groups (38.4% versus 36.7%; P=0.92), as were ventricular fibrillation termination rates (86.8% versus 88.8%; P=0.81). There were no distinguishable differences between regimens for survival outcomes or adverse effects.
This is the first randomized trial to compare fixed lower and escalating higher biphasic energy regimens in out-of-hospital cardiac arrest, and it demonstrated higher rates of ventricular fibrillation conversion and termination with an escalating higher-energy regimen for patients requiring multiple shocks. These results suggest that patients in ventricular fibrillation benefit from higher biphasic energy levels if multiple defibrillation shocks are required.
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Comment In: Evid Based Med. 2007 Oct;12(5):14217909233
Comment In: Circulation. 2007 Nov 6;116(19):e522; author reply e52317984386
As many as 70 patients were examined under conditions of a cardio resuscitation unit to gain insight into relatedness of time of development of acute of myocardial infarction (AMI) to its forms and particular clinical picture. The highest risk of AMI development was recordable within the time interval of 6-12 hours with the existing dependence for morning probability of microfocal AMI, daytime probability of microfocal and transmural AMI, with significant reduction thereof within the interval of 18-24 hours. Lesser probability of AMI development within 18-24 hours was closely related to reduction of levels of aspartate aminotransferases, lactatdegidrogenases, and creatinphosphokinases in AMI patients within this time interval.
Clinical characteristics and role of early cardiac magnetic resonance imaging in patients with suspected ST-elevation myocardial infarction and normal coronary arteries.
A variety of conditions other than acute myocardial infarction may cause ST-elevation. Our objective was to evaluate the impact of cardiac magnetic resonance (CMR) on differential diagnosis from a prospective series of patients with suspected ST-elevation myocardial infarction (STEMI) and completely normal coronary arteries. Among 1,145 patients with suspected STEMI, 49 patients had completely normal coronary arteries and entered a prospective registry. CMR was done within 24 h, if possible, and included function analyses, T2-weighted imaging (T2 ratio), T1-weighted imaging before and after gadolineum administration (global relative enhancement; gRE), and late gadolineum enhancement (LGE). All patients were asked for a follow-up CMR after approximately 3 months. The incidence of patients with suspected STEMI and normal coronary arteries was 4.3% and mean age was 45 ± 14 years (STEMI group 64 ± 13 years; P
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Cites: N Engl J Med. 2003 Mar 6;348(10):933-4012621138
Cites: Int J Cardiol. 2011 Jan 21;146(2):207-1219664828
Cites: N Engl J Med. 2003 Nov 27;349(22):2128-3514645641
In this, the 1st part of a 2-part review, we discuss how plaque rupture is the most common underlying pathophysiologic cause of unstable angina and non-ST-segment-elevation myocardial infarction and how early risk stratification is vital in the timely diagnosis and treatment of acute coronary syndrome. Part 2 of this review (to be published in a later issue of this journal) will focus mainly on the various pharmacologic agents and treatment approaches (early invasive vs early conservative) to the management of unstable angina and non-ST-segment-elevation myocardial infarction.
[Criteria of appropriate incomplete revascularization in patients with ST-segment elevation myocardial infarction in multivessel lesion of the coronary bed].
The study was aimed at analysing the outcomes of multivessel revascularization by means of percutaneous coronary intervention (PCI) in a total of 190 patients presenting with ST segment elevation myocardial infarction (STEMI) and multivessel lesion (MVL) of coronary arteries. Patients with unsuccessful PCI or those having received no planned second stage of revascularization for any reason were excluded from the study. The patients were subdivided into two groups: Group One comprised those having received appropriate complete revascularization (CR) within the framework of multivessel stenting (MVS) during primary PCI or a stagewise approach (n=137), Group Two included patients with the so-called appropriate incomplete revascularization (AIR) after MVS or stagewise PCI (n=53). In all cases IR was considered appropriate due to the presence of the corresponding anatomical and/or functional criteria used in the literature but not studied in relation to the cohort of patients with STEMI: (1) small arterial diameter (
University of Toronto, Toronto, Ontario, Canada ; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada ; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Printed educational materials for clinician education are one of the most commonly used approaches for quality improvement. The objective of this pragmatic cluster randomized trial was to evaluate the effectiveness of an educational toolkit focusing on cardiovascular disease screening and risk reduction in people with diabetes.
All 933,789 people aged =40 years with diagnosed diabetes in Ontario, Canada were studied using population-level administrative databases, with additional clinical outcome data collected from a random sample of 1,592 high risk patients. Family practices were randomly assigned to receive the educational toolkit in June 2009 (intervention group) or May 2010 (control group). The primary outcome in the administrative data study, death or non-fatal myocardial infarction, occurred in 11,736 (2.5%) patients in the intervention group and 11,536 (2.5%) in the control group (p?=?0.77). The primary outcome in the clinical data study, use of a statin, occurred in 700 (88.1%) patients in the intervention group and 725 (90.1%) in the control group (p?=?0.26). Pre-specified secondary outcomes, including other clinical events, processes of care, and measures of risk factor control, were also not improved by the intervention. A limitation is the high baseline rate of statin prescribing in this population.
The educational toolkit did not improve quality of care or cardiovascular outcomes in a population with diabetes. Despite being relatively easy and inexpensive to implement, printed educational materials were not effective. The study highlights the need for a rigorous and scientifically based approach to the development, dissemination, and evaluation of quality improvement interventions.
http://www.ClinicalTrials.gov NCT01411865 and NCT01026688.
Department of Medical and Health Sciences, Division of Cardiovascular Medicine, Linköping University Hospital, SE-581 85 Linköping, Sweden. sofla@imv.liu.se
OBJECTIVE: Previous data on young patients with acute coronary syndrome (ACS) have indicated higher rates of normal coronary angiograms but higher mortality in women than men. However, ST-elevation myocardial infarction (STEMI) differs from non-ST-elevation ACS in many aspects. We elucidated sex differences in risk factors, angiographic findings and outcome in consecutive STEMI patients below 46 years of age. DESIGN: Retrospective cohort study. SETTING: The Swedish registers for CCU care and coronary angioplasty; RIKS-HIA and SCAAR. PATIENTS: 2132 STEMI patients below 46 years of age admitted to intensive coronary care units in Sweden between 1995 and 2006 and followed for at least 1 year. MAIN OUTCOME MEASURES: Angiographic findings and short-term and long-term mortality. RESULTS: Risk factors were more common in women. Significant coronary lesions were equally common (92.1% vs 93.1%, p=0.64) while single vessel disease was more common (72.9% vs 59.3%; p
The excess risk of major coronary events (acute myocardial infarction (AMI) or death from coronary heart disease (CHD)) in individuals with type 1 diabetes (T1D) in relation to glycaemic control and renal complications is not known.
Individuals with T1D in the Swedish National Diabetes Registry after 1 January 1998, without a previous MI (n=33?170) and 1?64?698 controls matched on age, sex and county were followed with respect to non-fatal AMI or death from CHD. Data were censored at death due to any cause until 31 December 2011.
During median follow-up of 8.3 and 8.9 years for individuals with T1D and controls, respectively, 1500 (4.5%) and 1925 (1.2%), experienced non-fatal AMI or died from CHD, adjusted HR 4.07 (95% CI 3.79 to 4.36). This excess risk increased with younger age, female sex, worse glycaemic control and severity of renal complications.The adjusted HR in men with T1D with updated mean haemoglobin A1c (HbA1c) 9.7%?and renal complications.
The excess risk of AMI in T1D is substantially lower with good glycaemic control, absence of renal complications and men compared with women. In women, the excess risk of AMI or CHD death persists even among patients with good glycaemic control and no renal complications.
Although rare, life-threatening complications requiring emergency cardiac surgery do occur after diagnostic and therapeutic cardiac catheterization procedures. The operative mortality has been persistently reported to remain high. The purpose of this observational study was to evaluate and report the outcomes, with particular emphasis on early mortality, of these risky operations that were performed in a single highly specialized cardiac centre.
Between June 1997 and August 2007, 100 consecutive patients, 13 after diagnostic complicated cardiac catheterization (0.038% of 34,193 angiographies) and 87 after crashed percutaneous coronary intervention (PCI; 0.56% of 15,544 PCIs), received emergency operations at the Feiring Heart Center. In the same period, 10,192 other patients underwent open cardiac surgery. Early outcome data were analysed and compared between the cohorts. Follow-up was 100% complete.
The preoperative status of the 100 patients was that 4 had ongoing external cardiac massage, 24 were in cardiogenic shock, 32 had frank enduring ST-segment infarction but without shock and 40 had threatened acute myocardial infarction. There was 1% (1 patient) 30-day mortality in the study group, which is equal (0.9%, P=0.60) to that of all other operations. Postoperative myocardial infarction and prolonged ventilator use were significantly higher in the crash group, whereas the rate of stroke, renal failure, reopening for bleeding and mediastinitis were similar between the groups.
With rapid transfer to an operation room, minimizing the time of warm myocardial ischaemia, and by performing complete coronary revascularization, it is possible to obtain equally low operative mortality in patients with life-threatening cardiac catheterization-associated complications, as is the case with open cardiac operations in general.
