Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Strategies to improve outcome in patients with ST elevation myocardial infarction treated with primary PCI
Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: ST elevation myocardial infarction (STEMI) caused by a ruptured atherosclerotic plaque with overlying thrombosis leads to ischemia and progressively to the death of the myocardial cells supplied by the affected coronary artery. Rapid reperfusion with primary Percutaneous Coronary Intervention (PCI) in an experienced centre is the preferred therapy for these patients. The aim of the research program on which this thesis is based was to study the effect of antiplatelet therapy with abciximab on coronary patency  when administered early to an unselected cohort of patients with STEMI intended for primary PCI, to study the impact of health care delay time on infarct size measured with contrast enhanced Magnetic Resonance Imaging (ceMRI), and to evaluate if time delays could be reduced through reorganisation of logistics and personal feedback to staff involved in the care of STEMI patients. Finally measures of wall motion on cine MRI were evaluated to elucidate if functional measurements of the left ventricular wall could detect scar tissue visualised on ceMRI in a post-acute phase of primary PCI.

Material and results: In paper I we report on a study of all consecutive patients who sustained a STEMI in 2005 in the county of Östergötland and who were to be treated with primary PCI. Abciximab given as pretreatment before (n=133) or at the cath-lab after a diagnostic angiography (n=109) was associated with a patent Infarct Related Artery (IRA), i.e. Thrombolysis in Myocardial Infarction (TIMI) flow 2-3, in 45.9% of patients in the early group versus 20.2% in the cath-lab group, p=0.0001. There were no statistically significant differences in bleeding or mortality rate during the initial hospital stay, nor were there any significant differences between the groups during one-year follow up regarding a Major Adverse Cardiac Event (MACE).

Paper II is based on an examination of 30 patients in a stable clinical condition with ceMRI 4-8 weeks after they had been treated with primary PCI because of STEMI. Patients were selected on the presence of extensive myocardial scar in the anteroseptal segments (n=17) or no scar visible at all in this area or in any other part of the myocardium (n=13). The purpose of the study was to evaluate the ability of a new feature tracking software to measure functional parameters of the heart. The left ventricular wall was divided into 18 segments and myocardial contraction was measured with velocity, displacement and strain in the longitudinal and radial direction. The software calculated a mean value for the 18 segments for each parameter. Receiver-operatorcharacteristics curves (ROC) were constructed. The best area-under-curve (AUC) was for radial strain where a cut-off value of 38.8% had 80% sensitivity and 86% specificity to detect segments with scar>50%.

The impact of health care delay was examined in paper III based on a study in which 89 STEMI patients treated with primary PCI had their infarct size measured with ceMRI in the post-acute phase. Time from First Medical Contact (FMC) to a patent artery correlated weakly with infarct size, r=0.27, p=0.01. However, multivariable analysis showed the LAD as the Infarct Related Artery (IRA), active smoking and occlusion of the IRA at the time of the diagnostic angiogram were correlated with infarct size and that time from FMC to patent artery was not so correlated.

Finally, in the study leading to paper IV, extensive measurements on time delays were performed on 67 consecutive patients with STEMI treated with primary PCI. Through collaboration with different stakeholders in the treatment of STEMI in the catchment area the following types of targeted refining of logistics were done; 1. Ambulance staff prioritise ECG recording, 2. Central evaluation of ECG in all patients with suspected STEMI, and 3. PCI team is ready to accept the patient when two out of three members are on site. Moreover, personal feedback on time delays for each STEMI patient was given to all staff involved in the treatment of the patient. Thereafter, all the time delays for a similar group of consecutive STEMI patients (n=89) were analysed and compared with the delays for the former group. Improvements seen in the post-intervention group were a reduction in time from ECG to cath-lab arrival by 11 minutes, p=0.02 and a non-significant decrease of FMC to a patent artery by six minutes. The main part of this improvement could probably be ascribed to the decision to see to it that an attending cardiologist was present 24/7 and to central evaluation of ECG.

Conclusion: Abciximab given as pre-treatment to patients with STEMI intended for primary PCI was associated with a patent artery in 46% of patients. Moreover, we demonstrated a relationship between health care delay time and infarct size. This delay time could be reduced by a reorganisation of logistics and personal feedback on time delays. Finally, feature tracking analysis of cine MR images could detect segments with extensive myocardial scar in anterior infarction with 80% sensitivity and 86% specificity.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. , 78 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1327
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-85808ISBN: 978-91-7519-798-2 (print)OAI: oai:DiVA.org:liu-85808DiVA: diva2:572754
Public defence
2012-12-14, Berzeliussalen, Universitetssjukhuset, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2012-11-28 Created: 2012-11-28 Last updated: 2014-03-07Bibliographically approved
List of papers
1. Early treatment with abciximab in patients with ST elevation myocardial infarction results in a high rate of normal or near normal blood flow in the infarct related artery
Open this publication in new window or tab >>Early treatment with abciximab in patients with ST elevation myocardial infarction results in a high rate of normal or near normal blood flow in the infarct related artery
Show others...
2010 (English)In: Acute cardiac care, ISSN 1748-295X, Vol. 12, no 1, 10-17 p.Article in journal (Refereed) Published
Abstract [en]

There is debate whether early treatment with GpIIb/IIIa inhibitors is of clinical benefit in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). This study explored the effects of early given abciximab on coronary blood flow and major adverse cardiac events (MACE) in patients with STEMI treated with primary PCI and adjunctive abciximab. We studied all consecutive patients from our catchment area with STEMI undergoing acute angiography with the intention of primary PCI during 2005. Abciximab was given as early pre-treatment before, (n = 133) or at the cath. lab. after a diagnostic angiography (n = 109). Pre-procedural TIMI 2-3 flow was observed in 45.9 % of patients in the early group versus 20.2 % in the cath. lab. group, P = 0.0001. Mortality rates were 3.8 % versus 3.7% inhospital and 8.3 % versus 7.3% at one year in the early respectively the cath. lab. group, both P = NS. The MACE rate (death, non fatal myocardial infarction, unplanned revascularization) at one year was 19.5 % (early group) and 26.6 % (cath. lab. group), P = 0.19. CONCLUSION: In this single centre registry study of unselected patients with STEMI early given abciximab was associated with a significantly higher rate of TIMI 2-3 flow compared to abciximab given after the acute angiography.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-58764 (URN)10.3109/17482940903505926 (DOI)20201657 (PubMedID)
Available from: 2010-08-26 Created: 2010-08-26 Last updated: 2013-09-11
2. Functional measurements based on feature tracking of cine magnetic resonance images identify left ventricular segments with myocardial scar.
Open this publication in new window or tab >>Functional measurements based on feature tracking of cine magnetic resonance images identify left ventricular segments with myocardial scar.
Show others...
2009 (English)In: Cardiovascular Ultrasound, ISSN 1476-7120, E-ISSN 1476-7120, Vol. 7, no 53, 1-14 p.Article in journal (Refereed) Published
Abstract [en]

Background

The aim of the study was to perform a feature tracking analysis on cine magnetic resonance (MR) images to elucidate if functional measurements of the motion of the left ventricular wall may detect scar defined with gadolinium enhanced MR.

Myocardial contraction can be measured in terms of the velocity, displacement and local deformation (strain) of a particular myocardial segment. Contraction of the myocardial wall will be reduced in the presence of scar and as a consequence of reduced myocardial blood flow.

Methods

Thirty patients (3 women and 27 men) were selected based on the presence or absence of extensive scar in the anteroseptal area of the left ventricle. The patients were investigated in stable clinical condition, 4-8 weeks post ST-elevation myocardial infarction treated with percutaneous coronary intervention. Seventeen had a scar area >75% in at least one anteroseptal segment (scar) and thirteen had scar area <1% (non-scar). Velocity, displacement and strain were calculated in the longitudinal direction, tangential to the endocardial outline, and in the radial direction, perpendicular to the tangent.

Results

In the scar patients, segments with scar showed lower functional measurements than remote segments. Radial measurements of velocity, displacement and strain performed better in terms of receiver-operator-characteristic curves (ROC) than the corresponding longitudinal measurements. The best area-under-curve was for radial strain, 0.89, where a cut-off value of 38.8% had 80% sensitivity and 86% specificity for the detection of a segment with scar area >50%. As a percentage of the mean, intraobserver variability was 16-14-26% for radial measurements of displacement-velocity-strain and corresponding interobserver variability was 13-12-18%.

Conclusion

Feature tracking analysis of cine-MR displays velocity, displacement and strain in the radial and longitudinal direction and may be used for the detection of transmural scar. The accuracy and repeatability of the radial functional measurements is satisfactory and global measures agree.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-52269 (URN)10.1186/1476-7120-7-53 (DOI)000272351700001 ()
Note

Original Publication: Eva Maret, Tim Tödt, Lars Brudin, Eva Nylander, Eva Swahn, Jan Ohlsson and Jan Engvall, Functional measurements based on feature tracking of cine magnetic resonance images identify left ventricular segments with myocardial scar, 2009, Cardiovascular Ultrasound, (7), 53, 7120. http://dx.doi.org/10.1186/1476-7120-7-53 Licensee: BioMed Central http://www.biomedcentral.com/

Available from: 2009-12-14 Created: 2009-12-14 Last updated: 2017-12-12Bibliographically approved
3. Relationship between treatment delay and final infarct size in STEMI patients treated with abciximab and primary PCI
Open this publication in new window or tab >>Relationship between treatment delay and final infarct size in STEMI patients treated with abciximab and primary PCI
Show others...
2012 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 12, no 9, 1-9 p.Article in journal (Refereed) Published
Abstract [en]

Background

Studies on the impact of time to treatment on myocardial infarct size have yielded   conflicting results. In this study of ST-Elevation Myocardial Infarction (STEMI) treated   with primary percutaneous coronary intervention (PCI), we set out to investigate the   relationship between the time from First Medical Contact (FMC) to the demonstration   of an open infarct related artery (IRA) and final scar size.

Between February 2006 and September 2007, 89 STEMI patients treated with primary PCI   were studied with contrast enhanced magnetic resonance imaging (ceMRI) 4 to 8 weeks   after the infarction. Spearman correlation was computed for health care delay time   (defined as time from FMC to PCI) and myocardial injury. Multiple linear regression   was used to determine covariates independently associated with infarct size.

Results

An occluded artery (Thrombolysis In Myocardial Infarction, TIMI flow 0-1 at initial   angiogram) was seen in 56 patients (63%). The median FMC-to-patent artery was 89 minutes.   There was a weak correlation between time from FMC-to-patent IRA and infarct size,   r = 0.27, p = 0.01. In multiple regression analyses, LAD as the IRA, smoking and an occluded vessel   at the first angiogram, but not delay time, correlated with infarct size.

Conclusions

In patients with STEMI treated with primary PCI we found a weak correlation between   health care delay time and infarct size. Other factors like anterior infarction, a   patent artery pre-PCI and effects of reperfusion injury may have had greater influence   on infarct size than time-to-treatment per se.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-80591 (URN)10.1186/1471-2261-12-9 (DOI)000304351000001 ()
Available from: 2012-08-27 Created: 2012-08-27 Last updated: 2017-12-07
4. Strategies TO reduce time delays in patients with AcuTe coronary heart diasease treated with primary PCI - the STOP WATCH study: a multistage action research project
Open this publication in new window or tab >>Strategies TO reduce time delays in patients with AcuTe coronary heart diasease treated with primary PCI - the STOP WATCH study: a multistage action research project
Show others...
2013 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 3, no 3493Article in journal (Refereed) Published
Abstract [en]

Objective

To identify, evaluate and reduce system delay times in an ST-elevation myocardial infarction (STEMI) network by targeted reorganisation of logistics and personal feedback to staff on time delays.

Design

Multistage action research project. Three study phases were used (exploration, tailored intervention and evaluation).

Setting

Single centre study, Sweden.

Patients

Consecutive patients (N=156) with prehospital STEMI onset treated with primary percutaneous coronary intervention (PCI).

Interventions

Areas of delays were identified through participant observations and collaborative discussions. To increase the awareness of delay factors, continuous feedback on time delays was given. Elements of the logistics’ reorganisation were (1) prioritised ECG recording by emergency medical services personnel, (2) central evaluation of ECG in all patients and (3) start of PCI procedure when two of three PCI team members were on site. Multiple key time measurements were made before (N=67) and after (N=89) the intervention.

Main outcomes

Time difference (minutes) in system delay between the preintervention and postintervention phases.

Results

Time from first medical contact (FMC) to a patent artery and time from FMC-to-catheter laboratory (cath-lab) arrival decreased by 6 and 12 min, respectively (ns). Time from FMC-to-ECG recording remained unchanged after the intervention. Time from ECG to decision for primary PCI was reduced by 6 min, p=0.004 and time from ECG-to-cath-lab arrival by 11 min, p=0.02. Total time from diagnosis to a patent artery decreased by 11 min (ns).

Conclusions

Identification of time delays in an STEMI network with awareness of delay factors, reorganisation of logistics and continuous feedback can reduce system delay times significantly.

Place, publisher, year, edition, pages
BMJ Publishing Group, 2013
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-99863 (URN)10.1136/bmjopen-2013-003493 (DOI)000330541900066 ()
Available from: 2013-10-22 Created: 2013-10-22 Last updated: 2017-12-06Bibliographically approved

Open Access in DiVA

Strategies to improve outcome in patients with ST elevation myocardial infarction treated with primary PCI(997 kB)1004 downloads
File information
File name FULLTEXT01.pdfFile size 997 kBChecksum SHA-512
ae163370daaa292e403f1c241d5e45dae4c380dc8471d6f38e2891cdd1c8d7c82b36f8553b424b09292cf813bd3f926f70e65067a23e7de4c3a41f2e44b1b09c
Type fulltextMimetype application/pdf
omslag(318 kB)65 downloads
File information
File name COVER01.pdfFile size 318 kBChecksum SHA-512
533e9009586d47f05a668a957b6e3a8bd16f620e02452f14a66d4cfe2b532429c4ac2a5a5ce3f9232f34a7e0b5834e815464154404d97bec337763ab187240aa
Type coverMimetype application/pdf

Search in DiVA

By author/editor
Tödt, Tim
By organisation
Department of Medical and Health SciencesFaculty of Health Sciences
Medical and Health Sciences

Search outside of DiVA

GoogleGoogle Scholar
Total: 1004 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 822 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf