• Ambulance clinician assessment and management of transient loss of consciousness: a retrospective clinical audit

      Shaw, Joanna; Ulrich, Alex; Fothergill, Rachael; Whitbread, Mark (2016-01)
      Abstract published with permission. Introduction: Transient loss of consciousness (T-LOC) is thought to be underestimated and under-managed in the pre-hospital setting. This clinical audit aims to assess the compliance of ambulance clinicians against the National Institute of Clinical Excellence guidance on the management of patients with T-LOC. Method: Ninety-four patients’ clinical records and electrocardiograms (ECGs) were reviewed to determine appropriateness of assessment and patient management. Results: In this limited sample, findings show standard assessments and history documented for all patients were equally well recorded for T-LOC patients, but those specific to T-LOC were not. The number of ECGs conducted and interpreted correctly was an additional area of concern. Conclusions: Further assessments and history specific to T-LOC are required in the pre-hospital setting to ensure any potentially serious causes are recognised and these patients are taken to hospital.
    • Comparison of outcomes for primary percutaneous coronary intervention during out of working hours versus in working hours: an observational cohort study of 11,461 patients

      Iqbal, M. Bilal; Ilsley, Charles D.; Mikhail, Ghada; Khamis, Ramzi; Archbold, Andrew; Crake, Tom; Firoozi, Sam; Kalra, Sundeep S.; Knight, Charles; Lim, Pitt; et al. (2014-09)
    • Contemporary trends in cardiogenic shock: Incidence, intra-aortic balloon pump utilisation and outcomes from the London Heart Attack Group

      Rathod, Krishnaraj S.; Koganti, Sudheer; Iqbal, M. Bilal; Jain, Ajay K.; Kalra, Sundeep S.; Astroulakis, Zoe; Lim, Pitt; Rakhit, Roby D.; Dalby, Miles C.; Lockie, Tim; et al. (2018-02)
    • Coronary artery bypass graft patients treated with primary percutaneous coronary intervention have high long-term adverse event rates (10 920 STEMI patients from the London Heart Attack Group)

      Akhtar, M.M.; Jones, Daniel A.; Rathod, Krishnaraj S.; Modi, B.; Lim, Pitt; Virdi, Gurkamal K.; Bromage, Dan; Jain, A.J.; Singh Kalra, S.; Crake, Tom; et al. (2013-05)
      Background Limited information exists regarding procedural success and clinical outcomes of ST-segment elevation myocardial infarction (STEMI) in patients with previous CABG undergoing primary PCI. We sought to compare outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PCI) with or without previous coronary artery bypass grafts (CABG). Methods This was an observational cohort study of 10,920 patients with STEMI who were treated with PPCI between 2004 and 2011 at eight tertiary cardiac centres across London, UK. Patient’s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a mean follow-up of 3.0 years. Results 347 (3.2%) patients had previous CABG. Patients with previous CABG were older and had more associated comorbidities than patients who have never had CABG. In patients with previous CABG, the infarct related artery (IRA) was split evenly between a bypass graft and a native vessel. Procedural success (defined as TIMI 3 flow at the end of procedure) was less likely in patients with previous CABG than in patients who had never undergone CABG (80.7 vs 88.2% respectively, p<0.001). Patients with previous CABG had higher all-cause mortality (30.1% vs 16.7%, p<=0.0001) during the follow-up period (figure 1). After multivariate adjustment this difference persisted (HR: 1.3, 95% CI 1.11 to 1.63, p=0.02). When stratifying prior CABG patients by the type of IRA (figure 2); long term MACE were significant more likely in patients who had bypass graft PCI than in patients that had native vessel PCI, 35.7% versus 20.4% (p=0.03). Conclusions Previous CABG patients with STEMI treated with primary PCI have higher long-term adverse events. The long-term outcome is also worse if the IRA is a bypass graft rather than a native coronary artery. https://heart.bmj.com/content/heartjnl/99/suppl_2/A30.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/heartjnl-2013-304019.41
    • Culprit vessel versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction and multivessel disease: real-world analysis of 3984 patients in London

      Iqbal, M. Bilal; Ilsley, Charles; Kabir, Tito; Smith, Robert; Lane, Rebecca; Mason, Mark; Clifford, Piers; Crake, Tom; Firoozi, Sam; Kalra, Sundeep S.; et al. (2014-11)
    • Does triage of patients diagnosed by paramedics with ventricular tachycardia directly to arrhythmia centres improve patient care?

      Cooklin, Michael; Sporton, S.; Lovell, M.; Kanagaratnam, P.; Lowe, M.; Markides, V.; Mason, Mark; Whitbread, Mark (2014-10)
    • Exploratory analysis on the need for an ECMO eCPR service in South East London

      Auzinger, G.; Best, T.; Gelandt, E.; Hurst, T.; Kakar, V.; Loveridge, R.; Morgan, L.; Nevett, Joanne; Park, C.; Patel, S.; et al. (2016-11)
    • High incidence of acute coronary occlusion in patients without protocol positive ST segment elevation referred to an open access primary angioplasty programme

      Apps, Andrew; Malhotra, Aseem; Tarkin, Jason; Smith, Robert; Kabir, Tito; Lane, Rebecca; Mason, Mark; Ali, Omar; Rogers, Paula; Banya, Winston; et al. (2013-07)
      BACKGROUND: Primary percutaneous coronary intervention (PPCI) programmes vary in admission criteria from open referral to acceptance of electrocardiogram (ECG) protocol positive patients only. Rigid criteria may result in some patients with acutely occluded coronary arteries not receiving timely reperfusion therapy. OBJECTIVE: To compare the prevalence of acute coronary occlusion and, in these cases, single time point biomarker estimates of myocardial infarct size between patients presenting with protocol positive ECG changes and those presenting with less diagnostic changes in the primary angioplasty cohort of an open access PPCI programme. METHODS: We retrospectively performed a single centre cross sectional analysis of consecutive patients receiving PPCI between January and August 2008. Cases were categorised according to presenting ECG-group A: protocol positive (ST segment elevation/left bundle branch block/posterior ST elevation myocardial infarction), group B: ST segment depression or T-wave inversion, or group C: minor ECG changes. Clinical characteristics, coronary flow grades and 12 h postprocedure troponin-I levels were reviewed. RESULTS: During the study period there were 513 activations of the PPCI service, of which 390 underwent immediate angiography and 308 underwent PPCI. Of those undergoing PPCI, 221 (72%) were in group A, 41 (13%) in group B and 46 (15%) in group C. Prevalence of coronary occlusion was 75% in group A compared with 73% in group B and 63% in group C. Median 12 h postintervention troponin-I (25th-75th percentile) for those with coronary occlusion was significantly higher in group A patients; 28.9 μg/l (13.2-58.5) versus 18.1 μg/l (6.7-32.4) for group B (p=0.03); and 15.5 μg/l (3.8-22.0) for group C (p<0.001), suggesting greater infarct size in group A. CONCLUSIONS: A number of patients referred to an open access PPCI programme have protocol negative ECGs but myocardial infarction and acute coronary artery occlusion amenable to angioplasty. https://pmj.bmj.com/content/postgradmedj/89/1053/376.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/postgradmedj-2012-130818
    • Impact of inter-hospital transfer for primary percutaneous coronary intervention on survival (10 108 STEMI patients from the London Heart Attack Group)

      Jones, Daniel A.; Bromage, Dan; Rathod, Krishnaraj S.; Lim, Pitt; Virdi, Gurkamal K.; Jain, A.J.; Singh Kalra, S.; Crake, Tom; Meier, Pascal; Astroulakis, Zoe; et al. (2013-05)
      Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI). We evaluated whether direct transfer to a cardiac centre performing primary percutaneous coronary intervention (PPCI) leads to improved survival compared with transfer via a non-PPCI performing hospital in STEMI patients in a regional network. Methods This was an observational cohort study of 10 108 patients with STEMI treated with PPCI between 2004 and 2011 at eight tertiary cardiac centres across London, UK. Patient ’s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (IQR range 1.2 – 4.6 years). Results 6492 patients (64.2%) were transferred directly to a PCI performing centre (direct) and 3616, (35.8%) were transferred via a non-PCI performing centre (indirect). There were higher rates of previous MI and previous CABG in the indirect group, with higher rates of poor LV function in the direct group (table 1). Median time to reperfusion (symptom to balloon) in transferred patients was 58 min longer compared to patients admitted directly (p<0.001). However, symptom to first hospital door times were similar. Transferred patients had significantly lower rates of infarct-related artery (IRA) TIMI 0 flow (54.5% vs 62.9%, p<0.0001) and higher rates of IRA TIMI 3 flow (17% vs 10.7%, p>0.0001) at presentation compared to those transferred directly. Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without transfer (12.3% direct vs 14.3% indirect, p=0.060). Age-adjusted Cox analysis revealed inter-hospital transfer for PPCI was associated with all cause mortality (HR 0.89 (95% CI 0.79 to 0.99)), however this was not maintained after multivariate adjustment (HR 0.84 (95% CI 0.62 to 1.14)). Conclusions In this large registry survival appear comparable in patients with STEMI admitted directly versus transferred for primary PCI. This is despite longer symptom to balloon times. This unexpected finding may reflect the earlier initiation of medical therapy (eg, anti-platelets and GpIIb/IIIa receptor inhibitors) and earlier pharmacological reperfusion, reflected by lower IRA TIMI 0 rates at angiography in the patients transferred from a non-PCI hospital. https://heart.bmj.com/content/heartjnl/99/suppl_2/A22.2.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/heartjnl-2013-304019.30
    • Increases in survival from out-of-hospital cardiac arrest: a five year study

      Fothergill, Rachael; Watson, Lynne R.; Chamberlain, Douglas; Virdi, Gurkamal K.; Moore, Fionna; Whitbread, Mark (2013-08)
    • Inter-hospital transfer for primary angioplasty: delays are often due to diagnostic uncertainty rather than systems failure and universal time metrics may not be appropriate

      Tarkin, Jason; Malhotra, Aseem; Apps, Andrew; Smith, Robert; Di Mario, Carlo; Rogers, Paula; Lane, Rebecca; Kabir, Tito; Mason, Mark; Ilsley, Charles; et al. (2015-09)
    • Intra-aortic balloon pump counterpulsation in the post-resuscitation period is associated with improved functional outcomes in patients surviving an out-of-hospital cardiac arrest: insights from a dedicated heart attack centre

      Iqbal, M. Bilal; Al-Hussaini, Abtehale; Rosser, Gareth; Rajakulasingham, Ramyah; Patel, Jayna; Elliott, Katharine; Mohan, Poornima; Phylactou, Maria; Green, Rebecca; Whitbread, Mark; et al. (2016-12)
    • Level of consciousness on admission to a Heart Attack Centre is a predictor of survival from out-of-hospital cardiac arrest

      Deakin, Charles D.; Fothergill, Rachael; Moore, Fionna; Watson, Lynne R.; Whitbread, Mark (2014-07)
    • Manual thrombectomy with platelet glycoprotein IIb/IIIa blockade is associated with lower mortality in patients treated with primary PCI (9266 patients from the London Heart Attack Group)

      Virdi, Gurkamal K.; Whitbread, Mark; Modi, B.N.; Jones, Daniel A.; Rathod, Krishnaraj S.; Lim, Pitt; Jain, A.J.; Akhtar, M.M.; Singh Kalra, S.; Crake, Tom; et al. (2013-05)
    • Manual thrombus aspiration is not associated with reduced mortality in patients treated with primary percutaneous coronary intervention: an observational study of 10,929 patients with St-segment elevation myocardial infarction from the London heart attack group.

      Jones, Daniel A.; Rathod, Krishnaraj S.; Gallagher, Sean; Jain, Ajay K.; Kalra, Sundeep Singh; Lim, Pitt; Crake, Tom; Ozkor, Mick; Rakhit, Roby; Knight, Charles; et al. (2015-04)
    • Mechanical thrombectomy use is associated with decreased mortality in patients treated with primary percutaneous coronary intervention (9935 patients from the London Heart Attack Group)

      Modi, B.N.; Jones, Daniel A.; Rathod, Krishnaraj S.; Akhtar, M.M.; Jain, Ajay K.; Singh Kalra, S.; Crake, Tom; Meier, Pascal; Astroulakis, Zoe; Dollery, C.; et al. (2013-05)
      Introduction During Primary Percutaneous Coronary Intervention (PPCI) post ST-Segment Myocardial Infarction (STEMI), distal embolisation of thrombus may lead to failure to re-establish normal flow in the infarct-related artery. Manual thrombus aspiration has been shown to improve coronary perfusion as assessed by time to ST-segment resolution and myocardial blush grade. Evidence supporting the benefit of thrombus aspiration on clinical outcomes, however, is limited and inconsistent. We aimed to assess the impact of manual thrombectomy on mortality in patients presenting with STEMI across all PPCI centres in London over a 5 year period from 2007 until 2012. Methods This was an observational cohort study of 9935 consecutive patients with STEMI treated with PPCI between 2007 and 2012 at eight tertiary cardiac centres across London, UK. Patient's details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 2.0 years (IQR range 1.1 –3.1 years). Results Of the 9935 consecutive STEMI patients presenting for PPCI, 2859 had mechanical thrombectomy. Patients who had manual thrombectomy were significantly younger (average age 60.6 vs 62.9) and were less likely to have had a previous myocardial infarction (11.9% of thrombectomy patients vs 14.7% of nonthrombectomy patients). Patients receiving manual thromectomy were found to be significantly more likely to have had PPCI via a radial approach (33.1% in thrombectomy patients vs 19.9% in nonthromectomy patients). Procedural success (defined as TIMI 3 flow at the end of procedure) was found to be significantly more likely in patients receiving manual thrombectomy (89.5% vs 86.7%) (table 1). Patients with thrombectomy use had similar unadjusted all-cause mortality rates to those without thrombectomy use (12.7% vs 16.5%, p=NS) during the 5-year follow-up period (figure 1). After multivariable adjustment thrombectomy use was associated with significantly decreased mortality rates (HR: 0.82, 95% CI 0.68 to 0.9, p=0.04). Conclusion Mechanical thrombectomy use appears to be associated with improved outcome, in the form of decreased mortality, in this large observational trial. https://heart.bmj.com/content/heartjnl/99/suppl_2/A32.2.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/heartjnl-2013-304019.46
    • Methodology and consent issues in emergency medicine: the ARREST trial in out-of-hospital cardiac arrest

      Perkins, Alexander; Patterson, Tiffany; Evans, Richard; Clayton, Tim; Fothergill, Rachael; Whitbread, Mark; Redwood, Simon R. (2019-10-22)
    • Out-of-hospital cardiac arrest - optimal management

      Frohlich, Georg M.; Lyon, Richard; Sasson, Comilla; Crake, Tom; Whitbread, Mark; Indermuehle, Andreas; Timmis, Adam; Meier, Pascal (2013-11)