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The UK government is considering establishing a national primary angioplasty service for patients with acute myocardial infarction. David Smith and Kevin Channer debate whether moving away from first line thrombolysis is appropriate or practical

The UK government is considering establishing a national primary angioplasty service for patients with acute myocardial infarction. David Smith and Kevin Channer debate whether moving away from first line thrombolysis is appropriate or practical

BackgroundAntiplatelet and anticoagulant therapy are commonly used before, during and after peripheral arterial endovascular intervention. This survey aimed to establish antiplatelet and anticoagulant choice for peripheral arterial endovascular intervention in contemporary clinical practice. MethodsPilot-tested questionnaire distributed via collaborative research networks. ResultsOne hundred and sixty-two complete responses were collected from responders in 22 countries, predominantly the UK (48%) and the rest of the European Union (44%). Antiplatelet monotherapy was the most common choice pre-procedurally (62%). In the UK, there was no difference between dual and single antiplatelet therapy use post procedure (50% vs. 37% p=0.107). However, a significant majority of EU respondents used dual therapy (68% vs. 20% p<0.001). There was variation in choice of antiplatelet therapy by the device used and the anatomical location of the intervention artery. The majority (82%) of respondents believed there was insufficient evidence to guide antithrombotic therapy after peripheral endovascular intervention and most (92%) would support a randomised trial. ConclusionsThere is widespread variation in the use of antiplatelet therapy, especially post peripheral arterial endovascular intervention. Clinicians would support the development of a randomised trial comparing dual antiplatelet therapy with monotherapy.

OBJECTIVES: To assess clinical and coronary angiographic characteristics, previous medical history, and clinical course, by age group, in older adults after myocardial infarction who underwent primary percutaneous coronary intervention (pPCI). METHODS: Single-center, cohort study that enrolled all patients with ST-segment elevation myocardial infarction who underwent pPCI at a specialized cardiology reference center in the South of Brazil. Older adults were defined as age ≥60 years, as set out in Brazilian legislation. Patients in the following age groups were compared: 60 to 64 years, 65 to 69 years, 70 to 74 years, 75 to 79 years, and ≥80 years. Patients' clinical course was assessed at initial hospital admissions and after 2 years of clinical follow-up. Data were analyzed using SPSS 19, and significance was established at p <0.05. RESULTS: From December 2015 to December 2018, a total of 636 patients were enrolled consecutively. Angiographic success rates were around 90% in all age groups. There were no differences in medications used, except for glycoprotein IIb/IIIa inhibitors, which were more frequently used in patients of lower age groups. Older patients had more in-hospital acute renal failure and higher in-hospital mortality. Predictors of mortality were age over 75, chronic renal failure, need for ventilatory support, severe arrhythmia, and sepsis. CONCLUSIONS: pPCI in older adult patients is a safe procedure with a high success rate.

"The paper examines price discounting by health maintenance organizations and preferred provider organizations in markets for hospital services. Our empirical analysis focuses on transaction prices for angioplasty, which is a relatively common procedure, with well defined 'product' characteristics. After controlling for patient and procedure heterogeneity and market power we find that on average prices for PPOs are 8% lower than fee-for-service plans, followed by point-of-service HMOs who capture a 24% discount. Our results are in general agreement with earlier work that shows that managed care discounts are 'real', after accounting for process of care"--National Bureau of Economic Research web site

The purpose of this paper is to provide information about mortality rate in patients undergoing primary angioplasty for STEMI. Cardiovascular diseases lead to one third of the deaths worldwide, surpassing the mortality rate produced by neoplasia, acute respiratory failure and diabetes mellitus all together. In the world, approximately 17 million die annually because of cardiovascular disease and every 5 seconds one is suffering from a myocardial infarction. In 2010, in our country was implemented a national program (RO-STEMI) to offer rapid interventional treatment for patients with STEMI, aligned to ESC Guidelines. At the beginning only small parts of the patients were transferred to the hospital in charge for STEMI, so, we chose to study patients from the second year of the program and from last year. We made a retrospective study, including patients with STEMI that reached our hospital for primary angioplasty in the first 12h after the debut of the symptoms, aiming to make a parallel between the in-hospital mortality rates at maximum one month after the primary PCI. In order to be included, the patients must present ST elevation and another 1 out of 3 criteria (clinical, echocardiographic and biological changes suggestive for myocardial infarction). The main target was to evaluate the evolution of early mortality rates post primary PCI after the changes in the ESC Guidelines and the progresses in the medical field. A secondary target was to correlate mortality rates with the presence of comorbidities or risk factors.

AbstractSuperficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery for internal carotid artery (ICA) occlusive disease necessarily requires sufficient external carotid artery (ECA) blood flow. Surgical bypass is therefore precluded if there is common carotid artery (CCA) occlusion. Here we present two such cases: one patient had a CCA occlusion and the other had an ICA occlusion and ECA stenosis. Both had failed medical management, and were therefore treated with angioplasty and stenting of the ECA, followed by STA-MCA bypass. We describe the clinical and radiologic outcomes of these cases, and remark on the potential pitfalls associated with this novel approach.