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Fibrinolysis or Primary PCI in ST-segment Elevation Myocardial Infarction
The Journal of Emergency Medicine, Vol. 45, No. 2, pp. 308–313, 2013 Copyright Ó 2013 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter
Abstracts , DIAGNOSTIC ACCURACY AND RADIATION DOSE OF CT CORONARY ANGIOGRAPHY IN ATRIAL FIBRILLATION: SYSTEMATIC REVIEW AND METAANALYSIS. Vorre MM, Abdulla J. Radiology 2013;267:376–86. In this meta-analysis of seven studies with a total of 247 patients, authors assessed the diagnostic accuracy of computed tomography (CT) coronary angiography compared with conventional angiography among patients with atrial fibrillation. There was a mean age of 64 years, and 49% were male. Among this population there was a 28% prevalence of coronary artery disease (CAD). Compared with the gold standard of conventional coronary angiography, CT coronary angiography had a 94% sensitivity and 91% specificity in the diagnosis of CAD. In a second meta-analysis including 574 patients (158 patients with atrial fibrillation and 416 patients with sinus rhythm), the authors compared the relative diagnostic accuracy and mean effective radiation dose of CT coronary angiography in atrial fibrillation compared with sinus rhythm. The mean age of these patients was 67 years, and the population was 70% male. There was a trend toward, although no significant increase in, the number of non-diagnostic segments among patients with atrial fibrillation compared with patients in sinus rhythm. There was a significant increase in the mean effective radiation dose among patients with atrial fibrillation compared with those in sinus rhythm. [Jesse Loar, MD Denver Health Medical Center, Denver, CO]
using no antibiotics, there was a significant increase in the rate of cardiovascular death among those currently using azithromycin (defined by usage in the last 1–5 days) with a rate ratio of 2.85 (confidence interval 1.13–7.24). The actual incidence of events was relatively low (1.1/1000 cardiovascular deaths among patient’s using azithromycin compared with 0.4/1000 cardiovascular deaths among patient’s using no antibiotics). There was no increase in risk of cardiovascular death for those with recent azithromycin (defined as use in the last 6–10 days) or past azithromycin (defined as use in the last 11–35 days) usage compared with no antibiotics. A propensity score-adjusted analysis of 1 million episodes of azithromycin usage compared with 7 million episodes of penicillin usage demonstrated no significant difference between incidences of cardiovascular death. These results held regardless of whether this represented current, recent, or past antibiotic usage. Additional subgroup analysis showed no significant difference in the incidence of cardiovascular death between azithromycin and penicillin usage regardless of gender, age (< or > 45 years old) or prior history of cardiovascular disease. [Jesse Loar, MD Denver Health Medical Center, Denver, CO] Comment: This study represents an important follow-up to a previously published study in the New England Journal of Medicine in May 2012, which demonstrated an increase in cardiovascular mortality among azithromycin users in a Tennessee Medicaid cohort. Overall, the results of this study are reassuring in that they demonstrate no real increase in risk of cardiovascular death related to azithromycin usage when compared with a common control antibiotic (in this case, Penicillin V). Although there is some increase in cardiovascular death with azithromycin compared with no antibiotics, this is likely related to the condition requiring antibiotic usage and not to the choice of antibiotic. Although additional studies are needed to further establish the safety profile of azithromycin, the results of this quite large cohort study are reassuring concerning the safety of this drug.
Comments: Coronary artery disease is an important comorbid condition in patients with atrial fibrillation. Up until now, these patients were generally excluded from the non-invasive evaluation of coronary anatomy afforded by CT coronary angiography. This meta-analysis provides reassurance as to the diagnostic accuracy of CT angiography compared with the gold standard of standard coronary angiography, albeit with an added risk of increased radiation and some increase in the number of non-diagnostic segments. , USE OF AZITHROMYCIN AND DEATH FROM CARDIOVASCULAR CAUSES. Svanstrom H, Pasternak B, Hviid A. N Engl J Med 2013;368:1704–12. In this cohort analysis involving millions of Danish citizens aged 18–64 years, authors assessed the incidence of cardiovascular death related to azithromycin usage compared with no antibiotics and Penicillin V. Data were obtained from the Danish National Prescription Registry and from the Danish Register of Causes of Death. In a propensity score-matched analysis of 1 million episodes of azithromycin usage compared with equal numbers of controls
, FIBRINOLYSIS OR PRIMARY PCI IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION. Armstrong PW, Gershlick AH, Goldstein P, et al. N Engl J Med 2013; 368:1379–87. In this open-label, prospective, randomized, multinational study involving 1892 patients from 99 sites in 15 countries, the authors sought to compare the efficacy of prehospital fibrinolysis (by tenecteplase) with primary percutaneous coronary intervention (PCI) in preventing a 30-day composite end point of all-cause mortality, shock, congestive heart failure (CHF), 308
The Journal of Emergency Medicine or re-infarction. Eligible patients were adults with up to 3 h of symptoms related to myocardial infarction, evidence of myocardial infarction (as noted by at least 2 mm of ST elevation in at least two contiguous leads), and the inability to undergo primary PCI within 1 h of symptom onset. Nine-hundred forty-four patients underwent fibrinolysis and 948 underwent primary PCI. Median time to reperfusion by fibrinolysis was significantly shorter at 100 min, compared with 178 min for reperfusion by PCI. Thirty-six percent (339) of patients who underwent primary reperfusion by fibrinolysis required rescue/urgent PCI for the following indications: < 50% ST-segment resolution, clinical evidence of failed reperfusion, hemodynamic instability, electrical instability, or worsening ischemia. Median time to urgent/rescue PCI was 2.2 h. All patients who underwent primary fibrinolysis ultimately underwent cardiac catheterization with a median time of 17 h after symptom onset. There was no significant difference between fibrinolysis (12.4%) and primary PCI (14.3%) with regards to the composite end point (all-cause mortality, CHF, re-infarction). Additional subgroup analysis including: patient age > 75 years, delayed time to randomization (> 2 h), infarct location, comorbid hypertension, comorbid diabetes, and TIMI risk score showed no significant difference between fibrinolysis and primary PCI. In addition, there was no difference between fibrinolysis and primary PCI with regards to individual components of the composite end point, including: death from any cause, death from cardiovascular causes, CHF, or reinfarction; nor were there differences in percentage of patients requiring rehospitalization for cardiac cause, or developing cardiogenic shock. There was no significant difference between fibrinolysis and primary PCI with regards to measured adverse events within 30 days, including intracranial hemorrhage, other hemorrhage, or primary ischemic stroke. [Jesse Loar, MD Denver Health Medical Center, Denver, CO] Comments: A growing body of evidence demonstrates the importance of timely reperfusion in patients undergoing STelevation myocardial infarction (STEMI). There is little question about the benefit of emergent PCI within 60-90 min when possible. This study shows similar outcomes among patients with acute onset of STEMI but without ability for PCI within 60 min regardless of whether they undergo fibrinolysis, which in this prehospital environment can occur relatively quickly, as noted by median time to reperfusion of 100 min, compared with delayed primary PCI, which in this study occurred with a median time of 178 min. In addition, urgent/rescue PCI was indicated in one-third of patients undergoing primary fibrinolysis due to persistent evidence of infarction or instability. For these reasons, PCI remains the intervention of choice for patients with acute STEMI regardless of their ability to undergo PCI within the recommended time frame. , SYSTEMATIC REVIEW OF ACCURACY OF DUALSOURCE CARDIAC CT FOR DETECTION OF ARTERIAL STENOSIS IN DIFFICULT TO IMAGE PATIENT GROUPS. Westwood ME, Raatz HDI, Misso K, et al. Radiology 2013;267:387–95.
309 The objective of this study was to evaluate the ability of dualsource cardiac (DSC) computed tomography (CT) to assess coronary artery disease among individuals who are difficult to image with 64-section CT, specifically those with irregular rhythm (e.g., atrial fibrillation) or fast heart rate (rate > 65 beats/min or intolerance to beta-blockers), obese individuals (body mass index $ 30 kg/m2), and those in whom high coronary calcium (> 400) or history of coronary artery stents or bypass graft may affect image quality. This was a systematic review of the literature from 2000 to 2011 and included studies in which either a SOMATOM Definition, SOMATOM Definition Flash (Siemens, Malvern, PA), or Aquilion ONE CT scanner (Toshiba, Irvine, CA) was used to assess $ 50% coronary stenosis in difficult-to-image persons > 18 years of age and that used invasive conventional angiography as the reference standard. Sensitivities and specificities as well as summary receiver operating curves were calculated using bivariate modeling. Heterogeneity between studies and total variation across studies were evaluated with c2 test and the I2 statistic, respectively. Of the 4407 identified references, 4278 were excluded based on title and abstract, and of the remaining 129 studies, 25 were included. The sensitivity of DSC CT for detecting coronary stenosis among those with dysrhythmias or heart rate $ 65 beats/ min was 97.7% (95% confidence interval [CI] 88.0–99.9) and 97.7% (95% CI 93.2–99.3), respectively, and specificity was 81.7% (95% CI 71.6–89.4) and 86.3% (95% CI 80.2–90.7), respectively. DSC CT was 100% sensitive among those with a high calcium score. Among obese individuals, the sensitivity and specificity for identifying coronary stenosis per segment was 90.4% (95% CI 83.8–94.9) and 92.1% (95% CI 89.1– 94.5). Among those with stents or bypass grafts, sensitivities and specificities for patient, graft, segment, or lesion ranged from 93.4% to 100% and 89.5% to 100%, respectively. In conclusion, use of DSC CT may be useful in identifying coronary stenosis in individuals that have been identified as difficult to image with 64-section CT. [Lauren M. Abbate, MD, PHD Denver Health Medical Center, Denver, CO] Comment: This is a systematic review that provides interesting data for the use of a new imaging modality for historically difficult-to-image groups. Compared to coronary angiography, DSC CT seems to be both sensitive and specific for the detection of coronary stenosis. Future studies should be designed to directly compare the ability of DSC CT to that of 64-section CT to detect coronary artery stenosis and then to determine if DSC CT has a direct advantage over 64-section CT in specific subgroups. , PENICILLIN TO PREVENT RECURRENT LEG CELLULITIS. Thomas KS, Crook AM, Nunn AJ, et al. N Engl J Med 2013;368:1695–703. The objective of this study was to evaluate the effectiveness of low-dose penicillin compared to placebo for the prevention of recurrent leg cellulitis. This was a double-blind, randomized, controlled trial comparing 12 months of low-dose (250 mg twice daily) penicillin
Abstracts , DIAGNOSTIC ACCURACY AND RADIATION DOSE OF CT CORONARY ANGIOGRAPHY IN ATRIAL FIBRILLATION: SYSTEMATIC REVIEW AND METAANALYSIS. Vorre MM, Abdulla J. Radiology 2013;267:376–86. In this meta-analysis of seven studies with a total of 247 patients, authors assessed the diagnostic accuracy of computed tomography (CT) coronary angiography compared with conventional angiography among patients with atrial fibrillation. There was a mean age of 64 years, and 49% were male. Among this population there was a 28% prevalence of coronary artery disease (CAD). Compared with the gold standard of conventional coronary angiography, CT coronary angiography had a 94% sensitivity and 91% specificity in the diagnosis of CAD. In a second meta-analysis including 574 patients (158 patients with atrial fibrillation and 416 patients with sinus rhythm), the authors compared the relative diagnostic accuracy and mean effective radiation dose of CT coronary angiography in atrial fibrillation compared with sinus rhythm. The mean age of these patients was 67 years, and the population was 70% male. There was a trend toward, although no significant increase in, the number of non-diagnostic segments among patients with atrial fibrillation compared with patients in sinus rhythm. There was a significant increase in the mean effective radiation dose among patients with atrial fibrillation compared with those in sinus rhythm. [Jesse Loar, MD Denver Health Medical Center, Denver, CO]
using no antibiotics, there was a significant increase in the rate of cardiovascular death among those currently using azithromycin (defined by usage in the last 1–5 days) with a rate ratio of 2.85 (confidence interval 1.13–7.24). The actual incidence of events was relatively low (1.1/1000 cardiovascular deaths among patient’s using azithromycin compared with 0.4/1000 cardiovascular deaths among patient’s using no antibiotics). There was no increase in risk of cardiovascular death for those with recent azithromycin (defined as use in the last 6–10 days) or past azithromycin (defined as use in the last 11–35 days) usage compared with no antibiotics. A propensity score-adjusted analysis of 1 million episodes of azithromycin usage compared with 7 million episodes of penicillin usage demonstrated no significant difference between incidences of cardiovascular death. These results held regardless of whether this represented current, recent, or past antibiotic usage. Additional subgroup analysis showed no significant difference in the incidence of cardiovascular death between azithromycin and penicillin usage regardless of gender, age (< or > 45 years old) or prior history of cardiovascular disease. [Jesse Loar, MD Denver Health Medical Center, Denver, CO] Comment: This study represents an important follow-up to a previously published study in the New England Journal of Medicine in May 2012, which demonstrated an increase in cardiovascular mortality among azithromycin users in a Tennessee Medicaid cohort. Overall, the results of this study are reassuring in that they demonstrate no real increase in risk of cardiovascular death related to azithromycin usage when compared with a common control antibiotic (in this case, Penicillin V). Although there is some increase in cardiovascular death with azithromycin compared with no antibiotics, this is likely related to the condition requiring antibiotic usage and not to the choice of antibiotic. Although additional studies are needed to further establish the safety profile of azithromycin, the results of this quite large cohort study are reassuring concerning the safety of this drug.
Comments: Coronary artery disease is an important comorbid condition in patients with atrial fibrillation. Up until now, these patients were generally excluded from the non-invasive evaluation of coronary anatomy afforded by CT coronary angiography. This meta-analysis provides reassurance as to the diagnostic accuracy of CT angiography compared with the gold standard of standard coronary angiography, albeit with an added risk of increased radiation and some increase in the number of non-diagnostic segments. , USE OF AZITHROMYCIN AND DEATH FROM CARDIOVASCULAR CAUSES. Svanstrom H, Pasternak B, Hviid A. N Engl J Med 2013;368:1704–12. In this cohort analysis involving millions of Danish citizens aged 18–64 years, authors assessed the incidence of cardiovascular death related to azithromycin usage compared with no antibiotics and Penicillin V. Data were obtained from the Danish National Prescription Registry and from the Danish Register of Causes of Death. In a propensity score-matched analysis of 1 million episodes of azithromycin usage compared with equal numbers of controls
, FIBRINOLYSIS OR PRIMARY PCI IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION. Armstrong PW, Gershlick AH, Goldstein P, et al. N Engl J Med 2013; 368:1379–87. In this open-label, prospective, randomized, multinational study involving 1892 patients from 99 sites in 15 countries, the authors sought to compare the efficacy of prehospital fibrinolysis (by tenecteplase) with primary percutaneous coronary intervention (PCI) in preventing a 30-day composite end point of all-cause mortality, shock, congestive heart failure (CHF), 308
The Journal of Emergency Medicine or re-infarction. Eligible patients were adults with up to 3 h of symptoms related to myocardial infarction, evidence of myocardial infarction (as noted by at least 2 mm of ST elevation in at least two contiguous leads), and the inability to undergo primary PCI within 1 h of symptom onset. Nine-hundred forty-four patients underwent fibrinolysis and 948 underwent primary PCI. Median time to reperfusion by fibrinolysis was significantly shorter at 100 min, compared with 178 min for reperfusion by PCI. Thirty-six percent (339) of patients who underwent primary reperfusion by fibrinolysis required rescue/urgent PCI for the following indications: < 50% ST-segment resolution, clinical evidence of failed reperfusion, hemodynamic instability, electrical instability, or worsening ischemia. Median time to urgent/rescue PCI was 2.2 h. All patients who underwent primary fibrinolysis ultimately underwent cardiac catheterization with a median time of 17 h after symptom onset. There was no significant difference between fibrinolysis (12.4%) and primary PCI (14.3%) with regards to the composite end point (all-cause mortality, CHF, re-infarction). Additional subgroup analysis including: patient age > 75 years, delayed time to randomization (> 2 h), infarct location, comorbid hypertension, comorbid diabetes, and TIMI risk score showed no significant difference between fibrinolysis and primary PCI. In addition, there was no difference between fibrinolysis and primary PCI with regards to individual components of the composite end point, including: death from any cause, death from cardiovascular causes, CHF, or reinfarction; nor were there differences in percentage of patients requiring rehospitalization for cardiac cause, or developing cardiogenic shock. There was no significant difference between fibrinolysis and primary PCI with regards to measured adverse events within 30 days, including intracranial hemorrhage, other hemorrhage, or primary ischemic stroke. [Jesse Loar, MD Denver Health Medical Center, Denver, CO] Comments: A growing body of evidence demonstrates the importance of timely reperfusion in patients undergoing STelevation myocardial infarction (STEMI). There is little question about the benefit of emergent PCI within 60-90 min when possible. This study shows similar outcomes among patients with acute onset of STEMI but without ability for PCI within 60 min regardless of whether they undergo fibrinolysis, which in this prehospital environment can occur relatively quickly, as noted by median time to reperfusion of 100 min, compared with delayed primary PCI, which in this study occurred with a median time of 178 min. In addition, urgent/rescue PCI was indicated in one-third of patients undergoing primary fibrinolysis due to persistent evidence of infarction or instability. For these reasons, PCI remains the intervention of choice for patients with acute STEMI regardless of their ability to undergo PCI within the recommended time frame. , SYSTEMATIC REVIEW OF ACCURACY OF DUALSOURCE CARDIAC CT FOR DETECTION OF ARTERIAL STENOSIS IN DIFFICULT TO IMAGE PATIENT GROUPS. Westwood ME, Raatz HDI, Misso K, et al. Radiology 2013;267:387–95.
309 The objective of this study was to evaluate the ability of dualsource cardiac (DSC) computed tomography (CT) to assess coronary artery disease among individuals who are difficult to image with 64-section CT, specifically those with irregular rhythm (e.g., atrial fibrillation) or fast heart rate (rate > 65 beats/min or intolerance to beta-blockers), obese individuals (body mass index $ 30 kg/m2), and those in whom high coronary calcium (> 400) or history of coronary artery stents or bypass graft may affect image quality. This was a systematic review of the literature from 2000 to 2011 and included studies in which either a SOMATOM Definition, SOMATOM Definition Flash (Siemens, Malvern, PA), or Aquilion ONE CT scanner (Toshiba, Irvine, CA) was used to assess $ 50% coronary stenosis in difficult-to-image persons > 18 years of age and that used invasive conventional angiography as the reference standard. Sensitivities and specificities as well as summary receiver operating curves were calculated using bivariate modeling. Heterogeneity between studies and total variation across studies were evaluated with c2 test and the I2 statistic, respectively. Of the 4407 identified references, 4278 were excluded based on title and abstract, and of the remaining 129 studies, 25 were included. The sensitivity of DSC CT for detecting coronary stenosis among those with dysrhythmias or heart rate $ 65 beats/ min was 97.7% (95% confidence interval [CI] 88.0–99.9) and 97.7% (95% CI 93.2–99.3), respectively, and specificity was 81.7% (95% CI 71.6–89.4) and 86.3% (95% CI 80.2–90.7), respectively. DSC CT was 100% sensitive among those with a high calcium score. Among obese individuals, the sensitivity and specificity for identifying coronary stenosis per segment was 90.4% (95% CI 83.8–94.9) and 92.1% (95% CI 89.1– 94.5). Among those with stents or bypass grafts, sensitivities and specificities for patient, graft, segment, or lesion ranged from 93.4% to 100% and 89.5% to 100%, respectively. In conclusion, use of DSC CT may be useful in identifying coronary stenosis in individuals that have been identified as difficult to image with 64-section CT. [Lauren M. Abbate, MD, PHD Denver Health Medical Center, Denver, CO] Comment: This is a systematic review that provides interesting data for the use of a new imaging modality for historically difficult-to-image groups. Compared to coronary angiography, DSC CT seems to be both sensitive and specific for the detection of coronary stenosis. Future studies should be designed to directly compare the ability of DSC CT to that of 64-section CT to detect coronary artery stenosis and then to determine if DSC CT has a direct advantage over 64-section CT in specific subgroups. , PENICILLIN TO PREVENT RECURRENT LEG CELLULITIS. Thomas KS, Crook AM, Nunn AJ, et al. N Engl J Med 2013;368:1695–703. The objective of this study was to evaluate the effectiveness of low-dose penicillin compared to placebo for the prevention of recurrent leg cellulitis. This was a double-blind, randomized, controlled trial comparing 12 months of low-dose (250 mg twice daily) penicillin