Clinical outcomes of fibrinolytic therapy for prehospital treatment of acute myocardial infarction

Fibrinolytic Therapy (FT) is an important form of treatment for cases of Acute Myocardial Infarction (AMI), especially in those places where Primary Percutaneous Coronary Intervention (PPCI) is not available, which is the main form of treatment and can be used even in the prehospital care. Aimed to describe the clinical outcomes of the use of FT in prehospital care for treating patients with AMI. This research covered a total of 53 patients and was carried out from march to october 2017, referring to the care provided from january 2015 to december 2016 in two stages, in which the first occurred with the Mobile Emergency Service (SAMU) and Walk-in Emergency Care Units (UPA), and the second in the referenced hospital services as gateways to those units. Data were collected from secondary sources. The clinical outcomes of FT considered in the form of absolute and relative frequencies and measures of central tendency were considered. The main signs and symptoms at admission were chest pain (84.62%), sweating (36.54%), dyspnea (26.92%), hypertension (19.23%), nausea (17.31%), malaise (17.31%) and emesis (13.46%). The main characteristic of chest discomfort was chest pain (70.45%). The FT drug administered in all patients was tenecteplase. The median time from symptom-to-door was 180 minutes, while symptom-reperfusion was 300 minutes and door-to-needle 160 minutes. Regarding the outcome, 74.47% had clinical improvement, 19.15% died, 4.25% had refractory AMI and 2.13% had reinfarction. The main characteristic of clinical improvement was the reversal of chest pain (68.57%), characterized as myocardial reperfusion criteria. The present study presented the main outcomes of FT use with improvement of those patients who were treated with it, and shorter times related to chest discomfort and the administration of FT were responsible for increasing the outcomes of clinical improvement and decreasing the outcome of death.

Reperfusion strategy and in-hospital outcomes for ST elevation myocardial infarction in secondary and tertiary hospitals in predominantly rural central China: a multicentre, prospective and observational study

ObjectivesTo assess differences in reperfusion treatment and outcomes between secondary and tertiary hospitals in predominantly rural central China.DesignMulticentre, prospective and observational study.SettingSixty-six (50 secondary and 16 tertiary) hospitals in Henan province, central China.ParticipantsPatients with ST elevation myocardial infarction (STEMI) within 30 days of symptom onset during 2016–2018.Primary outcome measuresIn-hospital mortality, and in-hospital death or treatment withdrawal.ResultsAmong 5063 patients of STEMI, 2553 were treated at secondary hospitals. Reperfusion (82.0% vs 73.0%, p<0.001) including fibrinolytic therapy (70.3% vs 4.4%, p<0.001) were more preformed, whereas primary percutaneous coronary intervention (11.7% vs 68.6%, p<0.001) were less frequent at secondary hospitals. In secondary hospitals, 53% received fibrinolytic therapy 3 hours after onset, and 5.8% underwent coronary angiography 2–24 hours after fibrinolysis. Secondary hospitals had a shorter onset-to-first-medical-contact time (176 min vs 270 min, p<0.001). Adjusted in-hospital mortality (adjusted OR 1.23, 95% CI 0.89 to 1.70, p=0.210) and in-hospital death or treatment withdrawal (adjusted OR 1.18, 95% CI 0.82 to 1.70, p=0.361) were similar between secondary and tertiary hospitals.ConclusionsWith fibrinolytic therapy as the main reperfusion strategy, the reperfusion rate was higher in secondary hospitals, whereas in-hospital outcomes were similar compared with tertiary hospitals. Public awareness, capacity of primary and secondary care institutes to treat STEMI, and establishment of deeper cooperation among different-level healthcare institutes need to further improve.Trial registration numberNCT02641262.

Fifteen-minute consultation: A structured approach to children with parapneumonic effusion and empyema thoracis

Parapneumonic effusion is defined as the accumulation of pleural fluid associated with lung infection/pneumonia. Parapneumonic effusions can be uncomplicated or complicated. They are caused by the spread of infection and inflammation to the pleural space, and can develop into empyema thoracis—frank pus in the pleural space. Chest radiograph and thoracic ultrasound are the key imaging modalities for the diagnosis of parapneumonic effusion. Management aims are reducing inflammation and bacteria in the pleural cavity, and enabling full lung expansion. Broad-spectrum intravenous antibiotics, with the addition of chest tube drainage and fibrinolytic therapy for larger collections, are the mainstays of management. This article provides a clear, evidence-based and structured approach to the assessment and management of parapneumonic effusion/empyema thoracis in children and young people.

Challenges in Image-Guided Drainage of Infected Pleural Collections: A Review

Infected pleural fluid collections (IPFCs) commonly occur as a part of bacterial, fungal, or tubercular pneumonia or due to involvement of pleura through hematogenous route. Management requires early initiation of therapeutic drugs, as well as complete drainage of the fluid, to relieve patients’ symptoms and prevent pleural fibrosis. Image-guided drainage plays an important role in achieving these goals and improving outcomes. Intrapleural fibrinolytic therapy (IPFT) is also a vital component of the management. The concepts of image-guided drainage procedures, IPFT, and nonexpanding lung are discussed in this review.

Abstract P183: Effects Of L-arginine Supplementation On Cognitive Impairment In Hypertensive Frail Elderly Adults

Background: L-Arginine is an amino acid which is involved in nitric oxide production regulating vascular tone and cardiovascular homeostasis. Hypertension is one of the most common comorbidities worldwide, and leads to endothelial dysfunction contributing to atherosclerosis, inflammation, and oxidative stress. Frailty is a syndrome of decreased physiological reserves with increased susceptibility to stressors leading to higher mortality, hospitalization, disability, and functional and cognitive impairment. Cognitive impairment is a very common feature in hypertensive frail older adults. Hence, it is very important to treat cognitive impairment to delay and/or prevent adverse events. Our study, thus, investigated the effects of 4-weeks supplementation of L-Arginine on global cognitive function. Methods: We studied 101 frail older patients from April 2020 to April 2021. All subjects were recruited from ASL (local health company of Italian Ministry of Health) Avellino, Italy. All patients fulfilled all of the following inclusion criteria: a previous diagnosis of hypertension, a confirmed frail status, age >65 years. The exclusion criteria were: age <65 years, absence of frailty status, absence of hypertension, left ventricular ejection fraction <25%, with previous myocardial infarction or previous PPCI or/and coronary by-pass grafting, or previous fibrinolytic therapy. The study was approved by the local Ethics Committee and a written consent was signed. Results: We are reporting here the results in 52 patients who hitherto successfully completed the study. The cognitive screening was available at baseline (before treatment) and during a follow-up of 4 weeks. The non-treated group (n=27) had a Montreal Cognitive Assessment (MoCA) score 22.9±0.9 at basal and 23.4±1.0 at follow-up (p=0.06). The treated group (oral L-Arginine, 1.66 g, twice a day; n=25) displayed a MoCA score 23.1±0.7 at basal and 24.2±0.6 at follow-up (p<0.001); the difference between the follow-up groups was significant as well (p<0.001). Conclusions: Our data show a significant improvement in the MoCA score in the group treated with L-Arginine. More extensive studies are needed to verify the efficacy of L-Arginine in this population.

Expanding the discussion on fibrinolytic contraindications

The European Resuscitation Council Guidelines recommend the administration of fibrinolytic therapy when acute pulmonary embolism is a known or suspected cause of cardiac arrest. However, contraindications that limit the use of fibrinolytics are sometimes challenged by clinicians, including head trauma in the previous three weeks. We report on the successful use of rescue fibrinolytic therapy on a patient with acute head trauma who had a cardiac arrest in the emergency department as a result of a pulmonary embolism (PE). To the best of our knowledge, this is the first case of successful fibrinolytic therapy for a patient with acute head trauma in the literature.

The use of fibrinolytic therapy for parapneumonic effusion in pregnancy: a case report and a review

The use of intrapleural fibrinolytics for complicated parapneumonic effusion has been shown to be an effective and safe alternative to surgery. However, there is limited evidence about its use during pregnancy. We present a case and a review of the literature of pregnant women who had successful treatment of their complicated parapneumonic effusion with intrapleural fibrinolytics. To our knowledge this is the first review of cases of pregnant women with parapneumonic effusion managed with intrapleural fibrinolytic.