Treatment of Late Thrombosis of Drug-eluting Stent Using a Thrombus Extraction Catheter We report on the case of a 69-year-old patient with late thrombosis of a drug-eluting stent, admitted to hospital with anterior AMI, who was successfully treated using a thrombus extraction catheter (Pronto TM V3). DESCRIPTORS: Stents. Coronary thrombosis. Thrombectomy. RESUMO Relatamos o caso de um paciente de 69 anos com trombose tardia de stent farmacológico, admitido com infarto agudo do miocárdio anterior, tratado com sucesso com o uso de cateter de aspiração de trombos (Pronto TM V3).
Background The behemoth telemedicine program, Latin America Telemedicine Infarct Network (LATIN) has exponentially grown in 4 countries in Central and South America. It has provided AMI coverage to >100 million patients and it has contributed to transforming AMI care in the continent by its “halo” effect. We continue our meticulous search in evaluating the impact of LATIN and in doing so, we have confronted a sobering reality. Purpose To make continued improvements in population-based AMI management, the continued success of the initiative requires participation from healthcare policy makers, health economists, and payers. Methods LATIN was created as a hub and spoke model to hugely increase access (>100 million population coverage) to quality AMI treatment primarily with short door to balloon time (D2B) PCI. Innovative telemedicine platforms were created and networked at all 350 centers that were located in small clinics and primary health centers in poor sections of the countries (spokes) and at 24/7 PCI capable institutions (hubs). Remote cardiologists, located in 3 central locations, provided immediate EKG diagnosis (time to telemedicine diagnosis, TTD <3.5 minutes) and they provided expert guidance for the entire STEMI process, Door in Door Out (DIDO), and transport times (TT). LATIN performance metrics, under its strict control, and including process metrics at the hubs, spokes, and at the command telemedicine sites, were measured and plotted. The macroeconomic variables of insurance approvals, ambulance structure, and availability of ICU beds were determined and incorporated into performance variables of the LATIN program. Results 784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Over 4 years of operation, the proportion of reperfused STEMI patients has ranged between 41–48% - the major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation. Conclusions Sustained improvements, as a result of stringent QA processes and continuous education, have resulted in reduced D2B, TTD, DIDO, TT, and in overall mortality. However, LATIN remains constrained with a large proportion of patients that are diagnosed but not treated, largely because of payer denials. Although this metric is showing improvement from broad dissemination of LATIN benefits, further gains from LATIN will result mainly from improved reimbursements.
Revisiting blood pressure targets in patients with comorbidities / Remote patient monitoring and telemedicine 855stand which patients are well-represented and thus reasonable candidates for a SPRINT-supported treatment strategy. Methods: We defined and mapped the "data-rich, data-limited, and data-free zones" of the SPRINT trial based on subjects' baseline characteristics, and not on inclusion and exclusion criteria. For each participant (n=9361), a z-score was computed for 6 distinct continuous variables: age, SBP, fasting serum glucose, non-HDL cholesterol, serum creatinine, and BMI. Individual Summary Scores (SS) were generated based on these parameters-all weighted equally-to scale with the Euclidean distance of the participant from the theoretical "average patient" in six-dimensional space. SS were then calculated for 2007-14 National Health and Nutrition Examination Survey (NHANES) participants' ages 35 years or older, with SBP≥130mmHg, and with HgbA1c<7%. Results: Within SPRINT, a SS of 1.35 represents the 90th percentile and 1.78 represents the 97.5th percentile. We chose these values as borders between the data-rich, data-limited, and data-free zones. Analysis of NHANES participants' SS reveals 17% are in SPRINT's data-limited zone and 8% are in its data-free zone. The NHANES population mapped onto SPRINT data zones shows a landscape of applicability by race and sex (Figure1A.) A decision aid using the six variables, along with the SS, was generated to help clinicians understand how closely a patient approximates the SPRINT trial population. A 47-year-old overweight man with coronary artery disease and normal renal function is within the data-rich zone despite being excluded from SPRINT for age, whereas a 50-year-old prediabetic woman with chronic kidney disease and a BMI of 35 is fully within the SPRINT parameters, yet falls in the data-free zone. A visual aid identifies which parameters are most similar or dissimilar between the patient and the SPRINT population (Figure1B). Conclusion:The process of defining data zones based on patient characteristics holds promise as a refinement in how we judge landmark trials in the context of our patients. REMOTE PATIENT MONITORING AND TELEMEDICINE | BEDSIDE Background:We explored the role of telemedicine in reducing disparities in AMI care between developed and developing countries. LATIN is designed to study the feasibility of providing comprehensive AMI management using remote expert guidance. Methods: Regions in Brazil, Colombia and Mexico lacking AMI care, were selected, incorporating a hub and spoke strategy for expanding access. Small clinics and primary health centers in remote areas (spokes), were strategically connected to hubs with established primary PCI programs. Experts at 3 central sites in Uberlandia, Sao Paolo and Bogota, made urgent EKG diagnosis and tele consultation for the entire STEMI network triggering ambulance dispatch and implementing standardized guidelined protocols of care. ED Bypass has been initiated in busier centers in Brazil with...
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