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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.

This study examines how a medically contested procedure for people living with multiple sclerosis was framed by the news media and challenged by user-generated Facebook content. While expected narrative patterns ensued (advocates being positive and the scientific community being cautious), embedded were collective action oppositional frames that forced shifts in scientific and policy decisions that defied standard evidentiary support in Canada. Medical experts and researchers need to engage in more effective science communication about the nature of the research process and engage affected health communities more in the research agenda, particularly for conditions characterized by considerable unmet need.

Introduction: The acute coronary
occlusion associated with a high valuation of
morbimortalidad in the acute infarction of the myocardium
with elevation of the ST segment (STEMI), represents a
challenge for the interventionist, due the unknown amount
of thrombus load and its characteristics beyond the
occlusion (microvascular obstruction (MVO), distal
stenosis), which leads to complicate the primary
angioplasty (PTCA) and to the no refl ow phenomenon (NFP),
which has an overall incidence reported from 20 to 40%.
Objectives: To evaluate the effi cacy of the distal
coronary angiography with microcatheter, that leads to an
individualized therapeutic strategy, with the purpose of
prevent the NFP in the accute coronary occlusion in STEMI
treated with PTCA. Material and methods: 70 patients were
included with STEMI. We performed coronary angiography with
microcatheter distal to the obstruction, and the
therapeutic strategy was chosen in accordance with fi
ndings: stenosis, thrombus amount or MVO. After the PTCA
were performed, we evaluated the NFP incidence. Results:
Report of 70 patients, the majority men (80%), class Killip
Kimbal I (95 %), with disease of the right coronary artery
in 57%, and anterior descending coronary artery in 37%.
Distal thrombus was present in 47% of the studied patients.
An obstruction length of more than 30 mm was observed in
21% of the cases, also we observed dissection of the
arteries in a 21%, MVO was presented in 41%, and distal
stenosis in 25%. Used therapeutic strategies: It was
applied medicated stent in 81% of the patients, long
balloon in 93%, and thrombolytic therapy in 30%. We
observed a NFP incidence of 18.6 %. Conclusions: The
diagnostic and therapeutic approach for STEMI that this
study recommends, diminishes the NFP in comparison with
reported. An obstruction > 30 mm is an independent
factor for NFP, therefore in these cases we recommend use
the described diagnostic approach and long
balloon.

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