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Aims: Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile., Methods and Results: In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events., Conclusions: When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina., (© 2021. The Author(s).)

Aim: This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility., Methods: All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy., Results: The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites., Conclusion: In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.

Background and Purpose: In acute ST segment elevation myocardial infarction (STEMI), rapid restoration of epicardial coronary blood flow and myocardial perfusion limits infarct size and improves survival. Primary percutaneous coronary intervention (PCI) is superior to systemic fibrinolysis when instantly performed by experienced operators. The "Herzinfarktverbund Essen" (HIVE) is an urban STEMI network supporting direct patient transfer for primary PCI to four PCI centers covering a city area of 600,000 inhabitants. Integrated health care is an optional part of the HIVE allowing for reimbursement of medical innovations such as the evaluation of infarct size and the presence and extent of microvascular obstruction by contrast-enhanced cardiac magnetic resonance (CMR). The aim of this study was to assess the prognostic impact of contrast-enhanced CMR in the patient cohort of a regional STEMI network., Patients and Methods: Within the 1st year (09/2004 to 08/2005) of the HIVE registry, 489 patients with acute myocardial infarction were treated in the four primary PCI centers. In one of the centers, including 143 patients, early CMR imaging using a standardized MR protocol for infarct quantification was performed whenever possible. Patients with hemodynamic instability, emergency coronary artery bypass grafting, resuscitation or death prior to CMR, claustrophobia, and other general contraindications to MRI had to be excluded, leaving 67 patients (54 male; mean age 61 +/- 12 years) for final evaluation. CMR was performed 4.5 +/- 2.5 days after admission on a 1.5-T MR scanner (Sonata, Siemens Medical Solutions, Erlangen, Germany) including steady-state free precession (SSFP) cine imaging for left ventricular function and single-shot inversion-recovery SSFP imaging for delayed enhancement (DE) and no-reflow (NR) evaluation following injection of 0.2 mmol/kg body weight gadodiamide (Omniscan, GE Healthcare Buchler, Munich, Germany). NR and DE volumes were calculated from single-shot short-axis stacks taken within the 1st minute following gadodiamide infusion by manual planimetry and summation of disks. 1-year follow-up data (telephone interview) for major adverse cardiac events (MACE: cardiac death, myocardial infarction, and rehospitalization for congestive heart failure, angina pectoris, or revascularization) were available for all patients., Results: DE as a measure of infarct size was 9% +/- 7% (range 0-33%) of left ventricular mass (LVM), and mean volume of microvascular obstruction was 2% +/- 3% (range 0-17%). Microvascular obstruction was present in 61% of patients. 16 MACE (one cardiac death, one myocardial infarction, and 14 rehospitalizations for congestive heart failure or unstable angina pectoris with PCI in six cases) occurred within the follow-up period of 430 +/- 63 days. Patients with MACE had larger infarcts (14% +/- 10% vs. 8% +/- 6% DE), lower left ventricular ejection fraction (LVEF 44% +/- 17% vs. 48% +/- 14%) and larger NR (3% +/- 5% vs. 2% +/- 3%). Using a stepwise logistic regression model, only NR > 0.5% of LVM was independently related to outcome (odds ratio = 3.9, confidence interval 1.1-13.9)., Conclusion: NR as a correlate of microvascular obstruction remains independently related to prognosis in patients with acute myocardial infarction treated by PCI.

If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient’s admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis. [ABSTRACT FROM AUTHOR]