Search

Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational–retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82–89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25–87), with 73 patients (70%) reaching the invasive procedure

The service strategy (same-day transfer between the spoke hospital and the hub center with catheterization laboratory facility to perform invasive procedures) has been shown to improve the management of patients with non-ST-elevation acute coronary syndrome admitted to spoke hospitals. However, few data exist about the safety of this strategy and, in particular, the safety of retransferring patients to spoke centers immediately after successful percutaneous coronary intervention.We used data from a prospective registry to retrospectively describe the application, performance and outcome of the service strategy in the daily clinical practice in our province, organized in 5 spoke hospitals and a hub center in Reggio Emilia, Italy.From January 2013 to December 2017, 1183 consecutive patients were admitted to the cath-lab in the hub center from spoke hospitals with a diagnosis of non-ST-elevation acute coronary syndrome. Mean age was 68 ± 12 years, with a mean GRACE risk score of 137 ± 3. Overall, 1063 patients (90%) were managed with a service strategy. The mean time between hospital admission and access to the cath-lab for coronary artery angiography ± percutaneous coronary intervention was 46.6 h (27.5-71.2). No major adverse events (all-cause mortality, arrhythmias, or acute myocardial infarction) were observed during the back transfer from the invasive center to the referring non-invasive center. At 30 days, acute myocardial infarction was observed in 1.3% of patients and all-cause mortality was 0.5%. At 1-year follow-up, acute myocardial infarction was reported in 10% of patients and all-cause mortality was 2.8%.A wide adoption of the service strategy in our provincial network in patients with non-ST-elevation acute coronary syndrome admitted to spoke centers allowed an early access to the cath-lab as recommended by international guidelines. The safety of the service strategy is confirmed in our experience, with no major adverse events occurring during the back transfer.

To evaluate the impact of symptom-onset-to-balloon delay on ST-segment resolution (STR) in patients with acute myocardial infarction transferred from community hospitals for angioplasty after pharmacological treatment. The study design was prospective, single centre registry.Between October 2000 and December 2003, 330 consecutive patients agedor =75 years with high-risk myocardial infarction were considered; 193 patients underwent primary percutaneous coronary intervention (PCI) (group P), whereas 137 patients were given pharmacological therapy and were immediately transferred to the hospital with PCI facilities (group F).Compared with group P, group F showed a longer time to treatment (253 +/- 136 vs. 195 +/- 141 min; P0.0001) and a higher percentage of Thrombolysis In Myocardial Infarction flow grade 2-3 at pre-PCI angiography (107 [78.1%] vs. 48 [24.8%]; P0.0001). The rate of STRor =70% was similar in groups P and F (121 [62.7%] vs. 94 [68.6%]; P = 0.41). Even after accounting for baseline variables, STR70% was not significantly related to the transfer strategy (adjusted hazard ratio 0.94, 95% confidence interval 0.94-1.77; P = 0.8). Patients with incomplete STR showed a higher six-month mortality compared with patients with complete STR (10 [8.85%] vs. 6 [2.76%]; P = 0.027).The STR index predicts survival in patients with ST-elevation myocardial infarction treated with angioplasty either directly or after pharmacological treatment and hospital transfer. Pharmacological facilitation seems to be able to counterbalance the negative consequences of the transfer-related time delay on myocardial reperfusion as evaluated by the STR index.

OBJECTIVE: Growing interest in the use of drug-eluting stents (DESs) in coronary angioplasty has prompted the Healthcare Agency of the Emilia Romagna Region to draw up recommendations for their appropriate clinical use in high-risk patients. Since the adoption of any new technology necessitates economic appraisal, we analysed the resource consumption of the various types of angioplasty procedures and the impact on the budget of a cardiology department. METHODS: A retrospective economic appraisal was carried out on the coronary angioplasty procedures performed in 2004 in the Department of Interventional Cardiology of Reggio Emilia. On the basis of the principles of activity-based costing, detailed hospital costs were estimated for each procedure and compared with the relevant diagnosis-related group (DRG) reimbursement. RESULTS: In 2004, the Reggio Emilia hospital performed 806 angioplasty procedures for a total expenditure of euro 5,176,268. These were 93 plain old balloon angioplasty procedures (euro 487,329), 401 procedures with bare-metal stents (euro 2,380,071), 249 procedures with DESs (euro 1,827,386) and 63 mixed procedures (euro 481,480). Reimbursements amounted to euro 5,816,748 (11% from plain old balloon angioplasty, 50% from bare-metal stent, 31% from DES and 8% from mixed procedures) with a positive margin of about euro 680,480 between costs incurred and reimbursements obtained, even if the reimbursement for DES and mixed procedures was not covering all the incurred costs. CONCLUSIONS: Analysis of the case-mix of procedures revealed that an overall positive margin between costs and DRG reimbursements was achieved. It therefore emerges that adherence to the indications of the Healthcare Agency of the Emilia Romagna Region for the appropriate clinical use of DESs is economically sustainable from the hospital enterprise point of view, although the DRG reimbursements are not able to differentiate among resource consumptions owing to the adoption of innovative technologies.

A situs inversus with dextrocardia (DC) is a rare condition in adults. Usually, patients have structurally normal hearts and normal life expectancy. The incidence of coronary artery disease in this setting is similar to that in the general population. Coronary revascularization may present potential difficulties related to the unusual anatomy. Although the radial artery is a safe and effective site of access for coronary interventions, some anatomical variations may make this procedure more complicated. We describe two cases of patients with situs viscerum inversus and acute myocardial infarction who underwent successful transradial percutaneous coronary intervention (PCI). We will show that coronary angioplasty with stent application via the radial approach in patients with DC is feasible and effective also in emergency and urgent care.

We report the case of a young woman referred to our hospital for anterior ST-elevation myocardial infarction to be treated with primary coronary angioplasty. Angiography showed total dissection of the left anterior descending coronary artery, which was successfully treated with primary coronary angioplasty and multiple coronary stent implantation. Spontaneous coronary artery dissection is an unusual cause of acute coronary syndrome, which occurs more frequently in women with many pregnancies (our patient had eight sons before hospital admission for acute myocardial infarction). Although technically challenging, primary coronary angioplasty is a good strategy for treating coronary artery dissection.

Eight patients with office blood pressure >140/90 mmHg, despite being treated with at least three antihypertensive drugs, underwent catheter-based renal denervation. Secondary hypertension was excluded in all patients. Every patient underwent follow-up at 30 days, and then every 3 months. At 6 and 12 months the median value of systolic clinic blood pressure decreased from 161 mmHg (25th-75th percentiles: 158-191 mmHg) at baseline to 144 mmHg (25th-75th percentiles: 136-153 mmHg) at follow up (P=0.012), and the median value of diastolic clinic blood pressure decreased from 102 mmHg (25th-75th percentiles: 94-122 mmHg) at baseline to 90 mmHg (25th-75th percentiles: 78-99 mmHg) at follow-up (P=0.012). The number of medications decreased from 5 (range, 2-8) at baseline to 3.3 (range, 0-6) at follow up. There was a significant decrease of left ventricular mass index from a median of 160 g/m2 (25th-75th percentiles: 147-151 g/m2) at baseline to 126 g/m2 (25th-75th percentiles 107-151 g/m2) at follow-up (P=0.043) was detected. The renal function, and metabolic and neurohumoral parameters, did not change significantly. No complications were observed.