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    <recommendedItem id="20100101_19_224"
                     title="Prehospital ECG Speeds STEMI Care (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/MyocardialInfarction/tb/18052?impressionId=1265774373540"
                     
      Transmitting ECG results from the field to the emergency department dramatically improved door-to-balloon time for patients with ST-elevation myocardial infarction (STEMI), researchers found.&lt;br&gt;
&lt;br&gt;The strategy cut a half hour from the process, from 90.5 minutes to 60.2 minutes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), well within the recommended 90-minute window, according to Shukri David, MD, of Providence Hospital and Medical Center in Southfield, Mich., and colleagues.&lt;br&gt;
&lt;br&gt;Nearly all patients who had a prehospital ECG (97.4%) had a door-to-balloon time of less than 90 minutes, compared with only 61.5% of those who had an ECG upon arrival at the hospital (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), the researchers reported in the January issue of &lt;em&gt;Catheterization and Cardiovascular Interventions&lt;/em&gt;.&lt;br&gt;

&lt;br&gt;&quot;It&apos;s very important that patients who are suffering a myocardial infarction get to a cath lab so that we can establish blood flow to the injured myocardium,&quot; David said in an interview. &quot;That will save lives.&quot;&lt;/p&gt;

&lt;p&gt;Guidelines from both the American College of Cardiology and the American Heart Association have called for patients with STEMI to have blocked vessels opened within 90 minutes of arriving at the hospital, citing ECG conducted by emergency medical services personnel as one way to meet this goal.&lt;/p&gt;
&lt;p&gt;Previous studies, including a pilot study by David&apos;s group, have supported this approach.&lt;/p&gt;
&lt;p&gt;To validate the use of prehospital ECG, David and his colleagues conducted a prospective, observational study at three hospitals in Michigan over a 55-month period.&lt;/p&gt;
&lt;p&gt;When possible, EMS personnel obtained a 12-lead ECG during the initial assessment of patients with chest pain. The findings were transmitted to the emergency department via cellular link.&lt;/p&gt;
&lt;p&gt;Once STEMI was confirmed, the physician in the emergency department activated the cardiac catheterization team as the patient was en route to the hospital. This allowed the patient to head directly to the cath lab.&lt;/p&gt;
&lt;p&gt;Patients with STEMI who did not have prehospital ECGs but were treated at the same hospitals served as the controls.&lt;/p&gt;
&lt;p&gt;Although both groups of patients were generally similar, blacks were much less likely to get a prehospital ECG than whites  --  15.7% versus 31% (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001)  --  primarily because ambulances in Detroit only received ECG capabilities at the end of the study, according to the researchers.&lt;/p&gt;
&lt;p&gt;Prehospital ECG reduced door-to-balloon time, but did not have a significant effect on either length of hospital stay or inhospital mortality. David and his colleagues said they likely didn&apos;t observe a mortality benefit because of the relatively low number of total deaths (2% in controls versus 0% in the intervention group).&lt;/p&gt;
&lt;p&gt;In the control group, the time of presentation with STEMI affected the door-to-balloon time. Patients treated during working hours had a shorter time to reperfusion than those treated during off-hours (75 versus 98 minutes, &lt;em&gt;P&lt;/em&gt;=0.04).&lt;/p&gt;
&lt;p&gt;However, with the use of prehospital ECG, there was a significant reduction in door-to-balloon time regardless of the time of presentation.&lt;/p&gt;
&lt;p&gt;&quot;The use of the prehospital ECG is a way of overcoming the obstacle of delay in cardiac catheterization laboratory activation during off-hours,&quot; the researchers wrote.&lt;/p&gt;

&lt;p&gt;&quot;We were able to take the disadvantage out of having a patient show up on off-hours, or weekends, or holidays,&quot; David said.&lt;/p&gt;

&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors did not report any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_1531"
                     title="HRS: Long-Term Follow-up Confirms ICD Survival Benefit"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/HRS/tb/14238?impressionId=1265774373540"
                     
       BOSTON, May 15  -- After eight years of follow up, the survival benefit from implantable cardioverter defibrillators (ICDs) was durable and robust, except for patients who developed worsening heart failure, researchers here reported.
              &lt;p&gt;&lt;p&gt;&quot;The cumulative probability of all-cause mortality was 45% among patients treated with an ICD as compared with 61% among patients without an ICD (&lt;em&gt;P&lt;/em&gt; &amp;lt;0.001),&quot; said Ilan Goldenberg M.D., of the University of Rochester Medical Center in Rochester, N.Y. 
              &lt;p&gt;Dr. Goldenberg reported the findings from a follow-up study of the landmark MADIT-II (Multicenter Automatic Defibrillator Trial II) trial at a late-breaking clinical trials plenary at the Heart Rhythm Society meeting. 
              &lt;p&gt;The only exceptions to the benefit from the ICD group of patients &quot;were patients who developed heart failure,&quot; he said. 
              &lt;p&gt;The MADIT-II trial recruited 1,232 patients who had a myocardial infarction in the previous 30 days and a LVEF of 30% or less -- 742 patients were randomized to ICD therapy, while controls received medical therapy.
              &lt;p&gt;During the trial, about 20% of the ICD patients were hospitalized with new or worsening heart failure, which was higher than the 15% rate of heart failure hospitalization in the control group. But the difference was not statistically significant. 
              &lt;p&gt;It was this group of patients, plus patients who developed worsening heart failure during the eight-year follow-up, who did not benefit from ICD therapy, Dr. Goldenburg said.
              &lt;p&gt;Patients who developed heart failure had a 13% reduction in relative risk of death (&lt;em&gt;P&lt;/em&gt;=0.34), versus a 47% reduction in relative risk of death for patients who did not develop heart failure (&lt;em&gt;P&lt;/em&gt;=0.002).
              &lt;p&gt;When the MADIT-II results were reported in March 2002, they were considered practice-changing. They indicated that implanting an ICD in patients with evidence of left ventricular dysfunction after a heart attack could improve survival by 31% compared with optimal medical therapy.
              &lt;p&gt;At four years post-MADIT-II, there was a 41% relative reduction in risk of death in the ICD arm, and at eight years the relative reduction in risk of death was 37%.
              &lt;p&gt;After 24 months, implanting an ICD in 17 patients would save one life, but after eight years, treating just six patients would save one life, Dr. Goldenberg said. 
              &lt;p&gt; 
              &lt;p&gt;Device-pacing programming also had an effect on long-term outcome. A subset of patients who received ICD dual-chamber devices that were set to a pacing rate of DDD-60 or DDD-70 during the trial experienced an increase in mortality during the &quot;late phase of the extended follow-up,&quot; Dr. Goldenberg said. 
              &lt;p&gt; 
              &lt;p&gt;By comparison, patients who had single chamber devices set to a backup pacing rate at VVI-40 to 50, had a 30% reduction in relative risk of death  (&lt;em&gt;P&lt;/em&gt;=0.009).
              &lt;p&gt; 
              &lt;p&gt;Bruce L. Wilkoff, M.D., director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic Foundation, told &lt;em&gt;MedPage Today&lt;/em&gt; that he reported a similar finding in the DAVID trial.
              &lt;p&gt; 
              &lt;p&gt;&quot;Personally, the MADIT-II findings vindicate me,&quot; he said. &quot;If you program DDD-R, you eliminate the benefit of ICD. You swap out the reduction in sudden cardiac death and give [patients] heart failure.&quot;
               &lt;p&gt;
              &lt;p&gt;&quot;These results confirm a long-term benefit, and now we can tell our patients that we have extended their lives,&quot; Dr. Goldenberg said.
              &lt;p&gt;Richard Page, M.D., head of the division of cardiology at the University of Washington, said he found the long-term results &quot;reassuring as a clinician because now we know that MADIT-II wasn&apos;t just some flash-in-the-pan.&quot;
              &lt;p&gt; 
              &lt;p&gt;Dr. Wilkoff agreed and predicted that the long-term MADIT-II data &quot;will be very impactful [sic].&quot;
              &lt;p&gt; 
              &lt;p&gt;His reasoning was that the findings confirm that ICD is &quot;a long-term strategy&quot; that should put to rest the argument that &quot;if you didn&apos;t get a shock in the first year or the second year, implanting the device was a            mistake. That&apos;s nonsense.&quot;
               
              &lt;p&gt; 
              &lt;p&gt;Dr. Page, who wasn&apos;t involved in the trial, said the finding on heart failure &quot;makes sense because it is the patients who don&apos;t progress to heart failure who are more likely to have an arrhythmic event. So it kind of makes sense that these are the patients who had the greatest benefit because they were protected so well [by the ICD].&quot;
              &lt;p&gt; 
              &lt;p&gt;Dr. Goldenberg and colleagues assessed long-term efficacy by acquiring post-trial mortality data from National Death Registries. For U.S. patients they used registry data through December 2006 and for European patients they had registry data through March 2009. 
              &lt;p&gt; 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt; The MADIT-II trial was supported by Boston Scientific. 
              &lt;p&gt; 
              &lt;p&gt;Dr. Goldenberg reported no financial conflicts.
              &lt;p&gt; 
              &lt;p&gt;Dr. Page said he received consulting fees from Astellas Pharma, Pfizer, and sanofi aventis.
              &lt;p&gt; 
              &lt;p&gt;Dr. Wilkoff has disclosed that he has received grant/research support from Medtronic, St. Jude Medical, Boston Scientific, Spectranetics, and Biotronik. He is a consultant for Medtronic, St. Jude Medical, Boston Scientific, Spectranetics, Cook, and LifeWatch.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
    </recommendedItem>
    <recommendedItem id="20090101_2_120"
                     title="Paramedic Triage Reduces Time to Balloon with No Extra Risk"
                     score="-0.007"
                     href="