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Survival and Neurologic Recovery in Patients With ST-Segment Elevation Myocardial Infarction Resuscitated From Cardiac Arrest
Abstracts
230 STRESS ECHOCARDIOGRAM AUDIT Boga 1 , Christian Emma L. Ivens 1,2 , Tau 1 1 Craig , Daryl Burstow , Darren Walters 1
Hamilton-
1 Prince 2 Holy
Charles Hospital, Brisbane, Australia Spirit Northside Hospital, Australia
Aim: An audit was performed of all patients who underwent stress echocardiography at the Prince Charles Hospital in 2007 in order to assess the safety of the procedure, analyse results and assess the accuracy of the test. Results and discussion: 611 patients have stress echocardiograms performed of which 491 (80%) were exercise stress echocardiograms, 93 (15%) Dobutamine stress echocardiograms and 27 (4%) contrast Dobutamine stress echocardiograms. 53% were female and 47% male. Mean age was 58 ± 14 years (range 12–81 years). 98% were outpatients and 2% inpatients. The major indications were chest pain (49%) and dyspnoea (14%). The average METS achieved was 9.9 and average maximum predicted heart rate 94%. There were no significant complications. 23% were reported as positive, 69% were reported as negative, 6% suboptimal heart rate and <1% equivocal. 13% of these patients had conventional invasive coronary angiography. Sensitivity for detecting significant coronary stenoses >50% was 93%, specifity 94% and negative predictive value (NPV) 99.5%. The positive predictive value was 51% and increased to 82% if chest pain and significant ECG changes were included. Three patients had a global reduction in left ventricular function with stress echocardiogram and none had significant disease on angiography. One patient with LBBB and an equivocal stress echocardiogram had no significant disease at angiography. No patient with a normal stress echocardiogram had significant stenoses at angiography. Discordance between positive stress echocardiograms and conventional angiography may reflect microvascular disease. Conclusion: Stress echocardiography is a satisfactory and safe test with a high sensitivity and high NPV. doi:10.1016/j.hlc.2009.05.232 231 STUDENT CARDIOVASCULAR EXAMINATION SKILLS: ASSESSMENT AND DEVELOPMENT OF A NOVEL WEB-BASED RESOURCE L.J. Chiang, C. Aspinall, T.P. Harland, H.C. Lowe Concord Repatriation General Hospital, University of Sydney, NSW, Australia Background: It has been suggested that cardiovascular examination (CE) skills are declining. Alternative teaching methods using multimedia may encourage more effective learning to complement traditional methods. We hypothesised that 2nd and 3rd year medical students would have specific perceived and actual deficiencies in the CE, and by designing a novel web-based resource targeting these deficiencies, CE skills could be improved.
S103
Methods: Students completed a questionnaire assessing their confidence in CE, a written competency test in CE, and an audio competency test in cardiac auscultation. We then developed an interactive web-based resource teaching CE techniques, with specific emphasis on students’ deficiencies, as identified by these competency tests. Students were then re-tested, and their confidence and competency re-assessed. Results: Sixty-two students were examined, and reported low confidence and exhibited low levels of competency in assessing the jugular venous pressure (JVP) and cardiac auscultation. Sixteen students were followed up. Students’ confidence in the areas of deficiency increased significantly (p < 0.05) after using the web-based resource. However, the overall written and cardiac auscultation competency tests showed only a non-significant (p = 0.07) trend towards improvement. Conclusions: (1) Medical students have important perceived and actual deficiencies in CE, mainly in assessing the JVP and cardiac auscultation. (2) Design and implementation of an interactive web-based resource is possible. (3) Use of this web-based resource has resulted in improved student confidence and a trend toward improved competency, indicating potential for such a resource to be used to support traditional bedside teaching among medical students. doi:10.1016/j.hlc.2009.05.233 232 SURVIVAL AND NEUROLOGIC RECOVERY IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION RESUSCITATED FROM CARDIAC ARREST D O h-Ici, C. Zakhem
Senanayake, K.
Harrison, Y.L.
Lim, B.
Centre for Cardiovascular Therapeutics, Western Hospital, Melbourne, Australia Objectives: The outcome of resuscitated patients after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction is poor. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation acute myocardial infarction (STEMI). In comatose survivors of OHCA, mild therapeutic hypothermia (MTH) improves neurological recovery. We investigated the feasibility and safety of combining primary PCI and MTH in comatose survivors of ventricular fibrillation with STEMI after return of spontaneous circulation (ROSC). Methods: Sixty consecutive patients undergoing primary PCI and MTH from July 1, 2004 to July 31, 2008 were compared to 30 consecutive patients who underwent primary PCI but no MTH between January 1, 2002 and June 20, 2004. There were no significant differences between the MTH and no MTH groups in general characteristics, time to ROSC and angiographic features. Mortality and neurologic recovery at discharge and at 30 days were assessed by individual chart review.
ABSTRACTS
Heart, Lung and Circulation 2009;18S:S1–S286
S104
Heart, Lung and Circulation 2009;18S:S1–S286
Abstracts
ABSTRACTS
Results: Hospital survival with full neurologic recovery was significantly better in the MTH group (62% vs 18%; p = 0.001). Conclusion: Primary PCI and MTH are feasible and may be combined safely in comatose survivors of ventricular fibrillation with signs of STEMI. This strategy may improve survival with good neurological recovery. doi:10.1016/j.hlc.2009.05.234 233 NEED FOR TRANSVENOUS TEMPORARY PACING IS ASSOCIATED WITH HIGH 12-MONTH MORTALITY—RESULTS FROM A 3-YEAR RETROSPECTIVE CLINICAL AUDIT Helena M.H. Choi, William Y.S. Wang, Harry C. Lowe Concord Repatriation General Hospital, Hospital Rd, Concord, NSW 2139 & The University of Sydney, Australia Background: Transvenous temporary pacemakers (TP) are commonly used for high-risk or symptomatic bradyarrhythmias. TP insertion is relatively straightforward and TPs have been used successfully for over 40 years. However, with changes in patient demographics, medical therapy and coronary intervention in recent years, the clinical outcomes of patients requiring TP is unclear. Objective: A retrospective 3-year analysis of TP was performed to clarify current practice, and associated morbidities and mortalities in a tertiary hospital in Sydney. Methods: Data were collected on patient characteristics, clinical indications, insertion procedures, complications, permanent pacemaker use, in-patient morbidities and mortalities, and 12-months out-of-hospital mortality. Results: All procedures in Concord Hospital between January 2005 and December 2007 were included. Eightytwo patients (49% females) required a total of 119 TP insertions. The median age was 80. TP was associated with acute coronary syndromes in 15 patients (18%). Most common indications were complete AV block with (29%) or without (15%) ventricular escape, junctional rhythm from any cause (17%) and sinus node disease (15%). Over half of the patients (51%) were on negative chronotropic medications including beta-blockers (38%) and digoxin (12%). Overall complication rate was 8%, including one case of right ventricular perforation. Sixty-one patients (74%) proceeded to a permanent pacemaker in the same presentation. The hospital in-patient mortality rate was 12% with 4 patients dying due to a direct cardiac cause. Moreover, the 12-month mortality rate was also high at 21%. Conclusions: Although TP insertion is relatively safe, patients requiring TP insertion have high in-hospital and 12-month mortality rates. doi:10.1016/j.hlc.2009.05.235
234 THE ABSENCE OF STRESS IN PATIENTS WITH “STRESS CARDIOMYOPATHY” C.W. Wong 1 , A. Khan 1,2 , J.L. Looi 1 , I. Zeng 3 , A.J. Kerr 1 1 Department of Cardiology Middlemore Hospital, Auckland, New Zealand 2 Department of Cardiology, North Shore Hospital, Auckland, New Zealand 3 CCREP, Middlemore Hospital, Auckland, New Zealand
Background: Apical Ballooning Syndrome (ABS) otherwise known as “Stress Cardiomyopathy” is classically preceded by exposure to a severe emotional or physical stressor. Presentation mimics that of myocardial infarction. A number of patients presented with ABS who had no clear preceding stressor. Aim: To investigate the frequency of preceding stressors in ABS presentation and compare the clinical characteristics of those with and without stress. Methods: Cohort study of 60 consecutive Auckland region patients who fulfilled the 2004 Mayo Clinic proposed diagnostic criteria for ABS between March 2004 and February 2009. Because of the subjectivity of “stress” we subdivided patients into three groups: A, major stressor [n = 20]; B, minor stressor [n = 17]; and C, no identifiable stressor [n = 23]. Results: The Cohorts are predominantly European (75%) and female (95%) with mean age of 65 years. Triggering factors were physical stress in 17 patients and emotional stress in 20 patients. There were no statistically significant differences between the three groups separately, or between the two groups with any stress (61.6%) and that with no identifiable stress (38.3%), with regards to patient demographics, left ventricular ejection fraction or outcome. Serum potassium was significantly lower in the group with preceding stress (3.69 vs 4.13, p = 0.02). Conclusion: Only one-third of patients had a severe physical or emotional stressor identified by clinicians at the time of their admission. The absence of a preceding stressor should not deter clinicians from suspecting ABS particularly in women presenting with suspected MI. doi:10.1016/j.hlc.2009.05.236 235 THE IMPACT OF RENAL DYSFUNCTION ON MORTALITY IN PATIENTS WITH INFECTIVE ENDOCARDITIS D. Isacson, R. Sy, A. Yong, T. Chung, L. Kritharides Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia Background: Renal dysfunction is commonly seen in patients with infective endocarditis (IE). We aimed to assess the impact of renal dysfunction on mortality in patients with this condition. Methods: We retrospectively reviewed the case records of 254 consecutive patients admitted with IE to two ter-
230 STRESS ECHOCARDIOGRAM AUDIT Boga 1 , Christian Emma L. Ivens 1,2 , Tau 1 1 Craig , Daryl Burstow , Darren Walters 1
Hamilton-
1 Prince 2 Holy
Charles Hospital, Brisbane, Australia Spirit Northside Hospital, Australia
Aim: An audit was performed of all patients who underwent stress echocardiography at the Prince Charles Hospital in 2007 in order to assess the safety of the procedure, analyse results and assess the accuracy of the test. Results and discussion: 611 patients have stress echocardiograms performed of which 491 (80%) were exercise stress echocardiograms, 93 (15%) Dobutamine stress echocardiograms and 27 (4%) contrast Dobutamine stress echocardiograms. 53% were female and 47% male. Mean age was 58 ± 14 years (range 12–81 years). 98% were outpatients and 2% inpatients. The major indications were chest pain (49%) and dyspnoea (14%). The average METS achieved was 9.9 and average maximum predicted heart rate 94%. There were no significant complications. 23% were reported as positive, 69% were reported as negative, 6% suboptimal heart rate and <1% equivocal. 13% of these patients had conventional invasive coronary angiography. Sensitivity for detecting significant coronary stenoses >50% was 93%, specifity 94% and negative predictive value (NPV) 99.5%. The positive predictive value was 51% and increased to 82% if chest pain and significant ECG changes were included. Three patients had a global reduction in left ventricular function with stress echocardiogram and none had significant disease on angiography. One patient with LBBB and an equivocal stress echocardiogram had no significant disease at angiography. No patient with a normal stress echocardiogram had significant stenoses at angiography. Discordance between positive stress echocardiograms and conventional angiography may reflect microvascular disease. Conclusion: Stress echocardiography is a satisfactory and safe test with a high sensitivity and high NPV. doi:10.1016/j.hlc.2009.05.232 231 STUDENT CARDIOVASCULAR EXAMINATION SKILLS: ASSESSMENT AND DEVELOPMENT OF A NOVEL WEB-BASED RESOURCE L.J. Chiang, C. Aspinall, T.P. Harland, H.C. Lowe Concord Repatriation General Hospital, University of Sydney, NSW, Australia Background: It has been suggested that cardiovascular examination (CE) skills are declining. Alternative teaching methods using multimedia may encourage more effective learning to complement traditional methods. We hypothesised that 2nd and 3rd year medical students would have specific perceived and actual deficiencies in the CE, and by designing a novel web-based resource targeting these deficiencies, CE skills could be improved.
S103
Methods: Students completed a questionnaire assessing their confidence in CE, a written competency test in CE, and an audio competency test in cardiac auscultation. We then developed an interactive web-based resource teaching CE techniques, with specific emphasis on students’ deficiencies, as identified by these competency tests. Students were then re-tested, and their confidence and competency re-assessed. Results: Sixty-two students were examined, and reported low confidence and exhibited low levels of competency in assessing the jugular venous pressure (JVP) and cardiac auscultation. Sixteen students were followed up. Students’ confidence in the areas of deficiency increased significantly (p < 0.05) after using the web-based resource. However, the overall written and cardiac auscultation competency tests showed only a non-significant (p = 0.07) trend towards improvement. Conclusions: (1) Medical students have important perceived and actual deficiencies in CE, mainly in assessing the JVP and cardiac auscultation. (2) Design and implementation of an interactive web-based resource is possible. (3) Use of this web-based resource has resulted in improved student confidence and a trend toward improved competency, indicating potential for such a resource to be used to support traditional bedside teaching among medical students. doi:10.1016/j.hlc.2009.05.233 232 SURVIVAL AND NEUROLOGIC RECOVERY IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION RESUSCITATED FROM CARDIAC ARREST D O h-Ici, C. Zakhem
Senanayake, K.
Harrison, Y.L.
Lim, B.
Centre for Cardiovascular Therapeutics, Western Hospital, Melbourne, Australia Objectives: The outcome of resuscitated patients after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction is poor. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation acute myocardial infarction (STEMI). In comatose survivors of OHCA, mild therapeutic hypothermia (MTH) improves neurological recovery. We investigated the feasibility and safety of combining primary PCI and MTH in comatose survivors of ventricular fibrillation with STEMI after return of spontaneous circulation (ROSC). Methods: Sixty consecutive patients undergoing primary PCI and MTH from July 1, 2004 to July 31, 2008 were compared to 30 consecutive patients who underwent primary PCI but no MTH between January 1, 2002 and June 20, 2004. There were no significant differences between the MTH and no MTH groups in general characteristics, time to ROSC and angiographic features. Mortality and neurologic recovery at discharge and at 30 days were assessed by individual chart review.
ABSTRACTS
Heart, Lung and Circulation 2009;18S:S1–S286
S104
Heart, Lung and Circulation 2009;18S:S1–S286
Abstracts
ABSTRACTS
Results: Hospital survival with full neurologic recovery was significantly better in the MTH group (62% vs 18%; p = 0.001). Conclusion: Primary PCI and MTH are feasible and may be combined safely in comatose survivors of ventricular fibrillation with signs of STEMI. This strategy may improve survival with good neurological recovery. doi:10.1016/j.hlc.2009.05.234 233 NEED FOR TRANSVENOUS TEMPORARY PACING IS ASSOCIATED WITH HIGH 12-MONTH MORTALITY—RESULTS FROM A 3-YEAR RETROSPECTIVE CLINICAL AUDIT Helena M.H. Choi, William Y.S. Wang, Harry C. Lowe Concord Repatriation General Hospital, Hospital Rd, Concord, NSW 2139 & The University of Sydney, Australia Background: Transvenous temporary pacemakers (TP) are commonly used for high-risk or symptomatic bradyarrhythmias. TP insertion is relatively straightforward and TPs have been used successfully for over 40 years. However, with changes in patient demographics, medical therapy and coronary intervention in recent years, the clinical outcomes of patients requiring TP is unclear. Objective: A retrospective 3-year analysis of TP was performed to clarify current practice, and associated morbidities and mortalities in a tertiary hospital in Sydney. Methods: Data were collected on patient characteristics, clinical indications, insertion procedures, complications, permanent pacemaker use, in-patient morbidities and mortalities, and 12-months out-of-hospital mortality. Results: All procedures in Concord Hospital between January 2005 and December 2007 were included. Eightytwo patients (49% females) required a total of 119 TP insertions. The median age was 80. TP was associated with acute coronary syndromes in 15 patients (18%). Most common indications were complete AV block with (29%) or without (15%) ventricular escape, junctional rhythm from any cause (17%) and sinus node disease (15%). Over half of the patients (51%) were on negative chronotropic medications including beta-blockers (38%) and digoxin (12%). Overall complication rate was 8%, including one case of right ventricular perforation. Sixty-one patients (74%) proceeded to a permanent pacemaker in the same presentation. The hospital in-patient mortality rate was 12% with 4 patients dying due to a direct cardiac cause. Moreover, the 12-month mortality rate was also high at 21%. Conclusions: Although TP insertion is relatively safe, patients requiring TP insertion have high in-hospital and 12-month mortality rates. doi:10.1016/j.hlc.2009.05.235
234 THE ABSENCE OF STRESS IN PATIENTS WITH “STRESS CARDIOMYOPATHY” C.W. Wong 1 , A. Khan 1,2 , J.L. Looi 1 , I. Zeng 3 , A.J. Kerr 1 1 Department of Cardiology Middlemore Hospital, Auckland, New Zealand 2 Department of Cardiology, North Shore Hospital, Auckland, New Zealand 3 CCREP, Middlemore Hospital, Auckland, New Zealand
Background: Apical Ballooning Syndrome (ABS) otherwise known as “Stress Cardiomyopathy” is classically preceded by exposure to a severe emotional or physical stressor. Presentation mimics that of myocardial infarction. A number of patients presented with ABS who had no clear preceding stressor. Aim: To investigate the frequency of preceding stressors in ABS presentation and compare the clinical characteristics of those with and without stress. Methods: Cohort study of 60 consecutive Auckland region patients who fulfilled the 2004 Mayo Clinic proposed diagnostic criteria for ABS between March 2004 and February 2009. Because of the subjectivity of “stress” we subdivided patients into three groups: A, major stressor [n = 20]; B, minor stressor [n = 17]; and C, no identifiable stressor [n = 23]. Results: The Cohorts are predominantly European (75%) and female (95%) with mean age of 65 years. Triggering factors were physical stress in 17 patients and emotional stress in 20 patients. There were no statistically significant differences between the three groups separately, or between the two groups with any stress (61.6%) and that with no identifiable stress (38.3%), with regards to patient demographics, left ventricular ejection fraction or outcome. Serum potassium was significantly lower in the group with preceding stress (3.69 vs 4.13, p = 0.02). Conclusion: Only one-third of patients had a severe physical or emotional stressor identified by clinicians at the time of their admission. The absence of a preceding stressor should not deter clinicians from suspecting ABS particularly in women presenting with suspected MI. doi:10.1016/j.hlc.2009.05.236 235 THE IMPACT OF RENAL DYSFUNCTION ON MORTALITY IN PATIENTS WITH INFECTIVE ENDOCARDITIS D. Isacson, R. Sy, A. Yong, T. Chung, L. Kritharides Department of Cardiology, Concord Repatriation General Hospital, Sydney, Australia Background: Renal dysfunction is commonly seen in patients with infective endocarditis (IE). We aimed to assess the impact of renal dysfunction on mortality in patients with this condition. Methods: We retrospectively reviewed the case records of 254 consecutive patients admitted with IE to two ter-