A 2 part presentation. Part 1 reviews a paper on the long-term clinical outcomes of STEMI patients undergoing remote ischaemic perconditioning prior to primary percutaneous coronary intervention. The 2nd part looks at how this technique can be used in Paramedic practice.
Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Mont...Khaled Ali Ghanayem
Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury The COBI Randomized Clinical Trial - Journal club.
JAMA. 2021;325(20):2056-2066. doi:10.1001/jama.2021.5561
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
Dyslipidemia and CVS by Mohit Soni and Chandan KumarOlgaGoryacheva4
My students Mohit Soni and Chandan Kumar had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2
journal club is one of the important academic activity during MD/MS courses. Present PPT is a journal club presented on an article that compare two antihypertensives and the presentation also includes critical analysis of the article.
Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Mont...Khaled Ali Ghanayem
Effect of Continuous Infusion of Hypertonic Saline vs Standard Care on 6-Month Neurological Outcomes in Patients With Traumatic Brain Injury The COBI Randomized Clinical Trial - Journal club.
JAMA. 2021;325(20):2056-2066. doi:10.1001/jama.2021.5561
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
Fundación EPIC _ Left atrial appendage closure. Clinical evidence; where we a...Fundacion EPIC
Presentación de la ponencia "Cierre Percutáneo de Orejuela Izquierda. Evidencia clínica: dónde estamos?" realizada por Raul Moreno en los Diálogos EPIC_Cierre Percutáneo de la Orejuela Izquierda el 15 de Marzo de 2018 en Madrid (España)
Left atrial appendage closure. Clinical evidence; where we are? by Raul Moreno at Diálogos EPIC_Percutaneous left atrial appendage closure, March 15th 2018 in Madrid (Spain)
Dyslipidemia and CVS by Mohit Soni and Chandan KumarOlgaGoryacheva4
My students Mohit Soni and Chandan Kumar had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2
journal club is one of the important academic activity during MD/MS courses. Present PPT is a journal club presented on an article that compare two antihypertensives and the presentation also includes critical analysis of the article.
Introduction: Recent times have witnessed almost half, or sometimes more cardiac surgical procedures are performed in patients above 75 years of age. Traditionally, the EuroSCORE II and STS risk scoring systems have been widely used across the globe. Extensive reviews have shown that EuroSCORE II probably overestimates the perioperative risk at lower score levels while the STS score tends to underestimate the risk.
Frailty is a broad term that encircles aspects of nutrition, lack of agility, inactivity, lack of strength and wasting; and is seen in 25-50% of elderly patients. It has been defined as a geriatric syndrome reflecting a state of reduced physiological reserve and increased vulnerability to poor resolution of homeostasis after a stressor event. Conversely, pre-frailty, which is potentially reversible, is associated with higher risk of older adults developing cardiovascular disease.
Frailty assessment includes a variety of physical and cognitive tests, functional assessments and evaluating nutritional status. Literature has highlighted what is referred to as the ‘obesity paradox’, meaning obese patients with heart failure fair better than leaner patients, possibly because they have more metabolic reserve and also because weight loss in itself is a risk factor for frailty.
Patient Selection: To comprehensively assess a patient, factors that describe the biological status of the patient should be incorporated. There are various methods of assessment and modified Fried criteria or comprehensive assessment of frailty are a couple of systems commonly used.
Conclusion: Systematic reviews have shown that frail patients have higher chance of mortality, major adverse cardiac and cerebrovascular events and functional decline after cardiac surgery. A holistic assessment not only categorises patients into the apt risk category and hence match goals and treatments; but also, will pick up patients with pre-frailty who will benefit from multidisciplinary intervention and be better prepared for the intervention.
Important Trials of the Day & Basics of Biostatistics | IACTS SCORE 2020IACTSWeb
This presentation emphasizes on the importance of biostatistics in the interpretation, analysis and design of studies and trials in the daily life of an academic surgeon. It also sheds light on some important clinical trials of the present milieu that are playing a vital role in the course that cardiothoracic surgery is taking.
Courtesy of Dr. Prasanna Simha Mohan Rao, MS, MCh, DNB, PGDHHM. He presently serves as Professor and Unit Chief of Cardiothoracic and Vascular Surgery at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru.
This presentation accompanies a video that is part of the lecture series of IACTS SCORE 2020 held at the SSSIHMS Whitefield, Bengaluru between 7th and 8th March, 2020.
DANISH is a major breakthrough trial published in NEJM on 29/09/2016 regarding Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure. All content of this slide is Copy right of NEJM.
Survival after cardiac arrest is poor but some therapies can make a difference. This presentation discusses the evidence for therpauetic hypothermia, normoxia, management of blood pressure and early cardiac catherterisation. It also makes the case that these might be elements of a bundle of care.
Presentation by Dr Jason Wu - resident in Critical Care at TWH, for the critical care journal club report findings of a paper by Kaukonen KM, et al. N Engl J Med. 2015 & update from the recent SMACC conference in Chicago #FOAMed #SMACC (http://www.ncbi.nlm.nih.gov/m/pubmed/25776936/)
Terapi Endovaskuler, Standar Baru Manajemen Stroke Iskemik Akut? Ersifa Fatimah
Konon, plenary pertama International Stroke Conference (ISC) 2015 yang digelar di Nashville, Tennessee bulan Februari lalu merupakan sesi ISC terseru selama beberapa tahun terakhir. Sebagaimana diberitakan dalam Medscape (Hughes, 2015), para presenter terpaksa memberi jeda beberapa saat untuk menyambut applause dari audiens. Suatu kejadian langka dalam partemuan saintifik. Adalah MR CLEAN, ESCAPE, EXTEND-IA, dan SWIFT PRIME yang menjadi topik hangat lantaran keempat studi ini dirilis dengan hasil yang positif dramatis hingga diprediksi bakal menjadikan terapi endovascular sebagai standar baru dalam manajemen stroke iskemik akut. Sehebat apakah 4 studi yang “menyejarah” dalam tatalaksana stroke iskemik akut ini? Bagaimana bila studi-studi ini diadopsi dan diaplikasikan dalam praktik sehari-hari di sentra kita?
Note: Esai ini ditulis saat SWIFT PRIME fulltext belum published (akhir Maret-awal April 2015). Update & beberapa revisi dibuat menjelang presentasi tanggal 18 Mei 2015.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Remote Ischaemic Conditioning: A Paper Review & Uses in Paramedic Practice
1.
2. Describe the procedure of Remote Ischaemic
Conditioning
Review the paper
Discuss how this could relate to future
paramedic practice
Answer any questions
4. What is Remote
Ischaemic
Conditioning?
Remote ischemic conditioning (RIC) is a therapeutic strategy for protecting organs or
tissue against the detrimental effects of acute ischemia-reperfusion injury (IRI). (Lim
and Hausenloy, 2012)
It was first discovered by Murry et al. in 1986 who described a phenomenon in which
the application of one or more brief cycles of non-lethal ischemia and reperfusion to an
organ or tissue protects a remote organ or tissue from a sustained episode of lethal
ischaemia-reperfusion injury. (Lim and Hausenloy, 2012)
So, in simpler terms…
‘It is a method of protecting organs or tissues from damage and
reperfusion complications occurring after blood flow and
oxygenation is restored to the area. It also increases recovery of
damaged tissue and thus reduces long-term health complications.’
Overview
5. What is Remote
Ischaemic
Conditioning?
Nobody really knows yet.
The precise mechanism is still unclear
(Le Page and Prunier, 2015)
It is believed that the cells exposed to
the small periods of ischaemia either
produce a protective substance which
enters the circulatory system, or the
ischaemic cells open nervous
pathways to the brain, which in turn
relays nervous impulses to the other
areas of ischaemia and causes them
to release a chemical.
How does it work?
Sivaraman et al. 2015
6. What is Remote
Ischaemic
Conditioning?
In the majority of
studies utilising
remote ischaemic
per-conditioning
this method is the
procedure used.
Procedure
Place cuff on
patients arm
Inflate to
200mmHg
Leave
inflated for 5
minutes
Deflate cuff
and allow
reperfusion of
arm for 5
minutes
Repeat
process 3
more times
7. What is Remote
Ischaemic
Conditioning?
Uses
PRE-ISCHAEMIC CONDITIONING
Used prior to an ischaemic event, such as cardiac surgery.
PER-ISCHAEMIC CONDITIONING
Used during an ischaemic event, such as on a STEMI patient prior to pPCI.
POST-ISCHAEMIC CONDITIONING
Following an ischaemic event for a period of time, most commonly used after pPCI.
Remote Ischaemic Conditioning can be sub-divided into 3 different methods, each can be used
in different situations:
9. The Article
The Authors and History
Published in the European
Heart Journal in 2014.
AUTHORS
• Led by Astrid Sloth – a research fellow at Aarhus University Hospital,
Denmark
• The authors have amassed a total of 426+ publications between
them all (www.pubfacts.net), on many subjects ranging from RIC to
neonatal pig resuscitation.
FUNDING
• The research was funded by the Danish Council for Strategic
Research and Foundation Leducq.
• The design, conduction, analysis, interpretation and reporting of the
trial was independent of both funding sources.
DECLARATION OF INTERESTS
• 4 of the authors are shareholders in ‘CellAegis’ – a company that
makes an automatic RIC machine.
• No other conflicts of interest were reported.
10. • The aims of this trial were based on a follow up from the results of a parent trial by
Botker et al. which was published in The Lancet in 2010:
‘Remote Ischaemic Conditioning Before Hospital Admission, As A ComplimentTo
Angioplasty, And Effect On Myocardial Salvage In Patients With Acute Myocardial
Infarction: A RandomisedTrial’
• This trial concluded patients who had remote ischaemic conditioning performed
prior to primary percutaneous coronary intervention had an increase in myocardial
salvage post procedure compared to those that did not.
This secondary trial was designed to investigate the long-
term clinical outcome of patients receiving remote ischaemic
conditioning as an adjunct to primary percutaneous coronary
intervention.
12. • >18 years
AGE
• <12h prior to admission
SYMPTOM DURATION
• >0.1mV in two or more contiguous ECG leads
ST-SEGMENT ELEVATION
13. • Not confirmed on arrival at hospital
DIAGNOSIS
• History of previous Myocardial Infarction
• History of previous Coronary Artery Bypass Graft (CABG)
HISTORY
• Chest pain onset >12h prior to admission
SYMPTOM ONSET
14. Methodology
TRIAL PERIOD:
February 2007 – November 2008
TOTAL PATIENTS ENROLLED:
333
RIC+pPCI (intervention group):
166
(40 did not meet trial criteria)
Final amount: 126
pPCI ONLY (control group):
167
(42 did not meet trial criteria)
Final amount: 125
OUTCOMES MEASURED
DAY 1-30
Salvage Index / LV function
YEAR 5
MACCE (majoradverse cardiac or cerebral event)
Trial Flowchart
15. • Patients meeting the inclusion criteria received
Remote Ischaemic Conditioning initiated in the
ambulance during transport to pPCI.
• 82 patients were excluded from the trial on arrival at
hospital as they did not meet the described trial
criteria.
16. Methodology
This study used 4
cycles of
inflation/deflation
with both periods
lasting 5 minutes.
Technique Used
INFLATE 5 MINS
DEFLATE 5 MINS
INFLATE 5 MINS
DEFLATE 5 MINS
INFLATE 5 MINS
DEFLATE 5 MINS
INFLATE 5 MINS
Place cuff on
patients arm
Inflate to
200mmHg
Leave
inflated for 5
minutes
Deflate cuff
and allow
reperfusion
of arm for 5
minutes
Repeat
process 3
more times
17. PRIMARY ENDPOINTS SECONDARY ENDPOINTS
MACCE
‘MAJOR ADVERSE CARDIAC
AND CEREBROVASCULAR
EVENTS’
Defined as a composite of:
• All-cause mortality*
• Myocardial infarction
• Readmission for heart failure
• Ischaemic stroke/TIA
Comprised of the individual components of
the primary endpoint.
• All-cause mortality*
• Myocardial infarction
• Readmission for heart failure
• Ischaemic stroke/TIA
* ‘ALL-CAUSE MORTALITY’ WAS DEFINED AS ANY DEATH OCCURING WITHIN THE FOLLOW-UP PERIOD, THIS WAS SUB-DIVIDED INTO ‘CARDIAC’ AND
‘NON-CARDIAC DEATHS’. CARDIAC DEATHS WERE DEFINED AS DEATHS WITH AN EVIDENT CARDIAC CAUSE OR DEATH FROM AN UNKNOWN CAUSE.
18.
19. pPCI WITH RIC
(126 PATIENTS)
13.5%
(n17)
pPCI WITHOUT RIC
(126 PATIENTS)
25.6%
(n32)
PRIMARY ENDPOINT
(MACCE OCURRING IN THE 3 YEAR FOLLOW UP PERIOD)
20.
21. SECONDARY ENDPOINTS
ALL CAUSE
MORTALITY
pPCI WITH RIC
pPCI
WITHOUT RIC
CARDIAC
MORTALITY
pPCI WITH RIC
pPCI
WITHOUT RIC
NON-CARDIAC
MORTALITY
pPCI WITH RIC
pPCI
WITHOUT RIC
n5(4.9%) vs n15(12.0%) n2(1.6%) vs n5(4.0%) n3(2.4%) vs n10(8.0%)
ALL CAUSE MORTALITY reduced in patients who had RIC prior to pPCI
• Reduced CARDIAC MORTALITY (2 vs 5)
• Reduced NON-CARDIAC MORTALITY (3 vs 10)
22. SECONDARY ENDPOINTS
MYOCARDIAL
INFARCTION
pPCI WITH RIC
pPCI
WITHOUT RIC
N-STEMI
pPCI WITH RIC
pPCI
WITHOUT RIC
STEMI
pPCI WITH RIC
pPCI
WITHOUT RIC
n8(6.4%) vs n11(8.8%) n2(1.6%) vs n4(3.2%) n6(4.8%) vs n7(5.6%)
• 8 patients had a second Myocardial Infarction within the 3 year follow up period if they
had RIC prior to pPCI, compared to 11 that did not have RIC.
• The incidence of STEMI was higher in the non-RIC group however there was no
significant difference in N-STEMI between both groups.
23. SECONDARY ENDPOINTS
READMISSION FOR
HEART FAILURE
pPCI WITH RIC
pPCI
WITHOUT RIC
DECOMPENSATED
CHRONIC/ACUTE
HEART FAILURE
pPCI WITH RIC
pPCI
WITHOUT RIC
DEVICE
IMPLANTATION
(ICD/BIV-…
pPCI WITH RIC
pPCI
WITHOUT RIC
n4(3.2%) vs n7(5.6%) n3(2.4%) vs n3(2.4%) n1(0.8%) vs n4(3.2%)
• 7 patients who did not receive RIC were readmitted to hospital due to heart failure,
compared to 4 who were.
• There was no difference in the incidence of Acute Heart Failure in both groups of
patients.
• Only 1 patient who received RIC required pacemaker/internal defibrillator implantation,
whereas 4 who did not receive RIC did.
24. SECONDARY ENDPOINTS
ISCHAEMIC
STROKE/TIA
pPCI WITH RIC
pPCI
WITHOUT RIC
STROKE
pPCI WITH RIC
pPCI
WITHOUT RIC
TIA
pPCI WITH RIC
pPCI
WITHOUT RIC
n3(2.4%) vs n4(3.2%) n2(1.6%) vs n4(3.2%) n1(0.8%) vs n0(0.0%)
• 3 patients had an ischaemic stroke orTIA in the ‘received RIC’ group, compared to 4
patients who did not have RIC.
• All 4 of these patients had a stroke.
• 1 patient from the ‘received RIC’ group had aTIA, with none from the without RIC group
having aTIA.
25. • A P-value of <0.05 was considered statistically significant
in this study.
• The primary endpoints investigated met this (P-value
0.018), however only the ‘All-Cause Mortality’ secondary
endpoint was classed as being statistically significant.
26. ‘Remote ischaemic conditioning
before primary percutaneous
coronary intervention seemed to
improve long-term clinical
outcomes in patients with ST-
elevation myocardial infarction.’
27. ‘However, our results need to be
confirmed in a larger multicentre
trial before remote ischaemic
conditioning can be implemented
in guidelines as an adjunct to
primary percutaneous coronary
intervention.’
28. The number of patients involved is small
• This meant a number of secondary endpoints were not
classed as statistically significant
Exclusion Criteria
• Almost 25% of the patients from the original trial were
excluded from the results due to not meeting criteria
The process is open to bias
• Paramedics performing RIC would of known they were
doing the procedure, it could not be blinded.
29. STUDY AUTHORS OUTCOME
Cardioprotective Role Of Remote
Ischemic Periconditioning In
Primary Percutaneous Coronary
Intervention: Enhancement By
Opioid Action.
Rentoukas et al.
Reduced Troponin levels in STEMI patients
treated with RIC & Morphine compared to
control group.
Remote Ischemic Post-
conditioning OfThe Lower Limb
During Primary Percutaneous
Coronary Intervention Safely
Reduces Enzymatic Infarct Size In
Anterior Myocardial Infarction: A
Randomized ControlledTrial.
Crimi et al.
Reduced myocardial oedema and increased
ST segment resolution in the group of
patients who received RIC.
Remote Ischaemic Conditioning
Reduces Myocardial Infarct Size
And Myocardial Oedema In
Patients With ST-segment
Elevation Myocardial Infarction
White et al.
Reduced infarct size, myocardial oedema and
Troponin levels.
Increased myocardial salvage.
31. • Cardiovascular disease is the leading cause of death in the UK, in 2013-2014 a total of 80,724
patients were admitted to hospital suffering from a Myocardial Infarction (Myocardial
Ischaemia National Audit Project [MINAP], 2014).
• The development and implementation of novel adjuvant strategies to attenuate myocardial
ischaemia-reperfusion injury and reduce infarct size remains a major, unmet clinical need.
(Przyklenk, 2015)
• For patients with ischaemic heart disease, remote ischaemic conditioning may offer an
innovative, non-invasive and virtually cost-free therapy for protecting the myocardium
against the detrimental effects of acute ischaemia-reperfusion injury, preserving cardiac
function and improving clinical outcomes. (Sivaraman, Pickard and Hausenloy, 2015)
• ‘Ischaemic conditioning’ has the therapeutic potential to protect the heart against acute
ischaemia/reperfusion injury (IRI) and improve clinical outcomes in patients with ischaemic
heart disease, the leading cause of death and disability worldwide. (Bulluck and Hausenloy,
2015)
32. STEMI
• Reduced mortality
• Improved long-term
health outcomes
• Can be used alongside
current practice
ISCHAEMIC
STROKE
• Increased tissue
survival (Hougaard et
al. 2013)
POST
ROSC
• Reduced markers of
cell damage when
applied immediately
after ROSC (Albrecht
et al. 2015)
33. NON INVASIVE, EFFECTIVE AND SAFE
Remote Ischaemic Conditioning is non-invasive, effective, and free of both cost and side-effects. (Vercueil, 2015)
NOT AFFECTED BY PHARMACOLOGY
RIC as an adjunct to pPCI seems to improve the Myocardial Salvage Index of patients with STEMI regardless of medications. (Sloth et al, 2015)
ENHANCED WHEN USED WITH MORPHINE
The cardioprotective effect of RIC is enhanced with Morphine use and reduced reperfusion injury in patients undergoing pPCI. (Rentoukas et al. 2010)
CHEAP
For patients with ischaemic heart disease, remote ischaemic conditioning may offer an innovative, non-invasive and virtually cost-free therapy for protecting the myocardium against
the detrimental effects of acute ischaemia-reperfusion injury, preserving cardiac function and improving clinical outcomes. (Sivaraman, Pickard and Hausenloy, 2015)
USES EQUIPMENT ALREADY AVAILABLE ON AMBULANCES
NEEDS LITTLE TRAINING
CAN BE USED ALONGSIDE CURRENT TREATMENT AND PATHWAYS
FOR
35. 80,724
20,311
14,908
• Patients suffering
Myocardial Infarction in
2013-2014 (MINAP,
2014)
• Admitted via
Ambulance directly or
via transfer with STEMI
for pPCI (MINAP, 2014)
• 26.6% removed due to
not meeting criteria
THEORETICALLY IFTHE RESULTS OFTHIS STUDYWERE APPLIEDTO 2013-2014…
BY APPLYINGTHE 13.5& vs 25.6% 5YEAR SURVIVAL RATES…
38. • In ischaemic stroke patients tissue survival analysis suggests that prehospital RIC may have immediate
neuroprotective effects. (Hougaard et al, 2013)
ISCHAEMIC STROKES
• In patients with ST-elevation myocardial infarction, RIC before percutaneous coronary intervention reduced
the incidence of contrast inducedAcute Kidney Injury. (Yamanaka et al, 2015)
POST pPCI KIDNEY INJURY PREVENTION
• RIC provided perioperative myocardial protection and improved the prognosis of patients undergoingCABG
surgery. (Thielmann et al, 2013)
POST CARDIAC SURGERY
• SAH represents a clinical condition suitable for a proof-of-concept trial for the application of preconditioning
(Koch & Gonzalez, 2013)
SUBARACHNOID HAEMORRHAGE
• RIC applied immediately after ROSC reduces serum concentrations of markers for cell damage and improves
end-systolic pressure volume relationship 4 h after ROSC. (Albrecht et al, 2015)
POST ROSC
• RIC significantly decreased the standard biomarkers of acute brain injury in patients with severeTBI. (Joseph
et al, 2015)
TRAUMATIC BRAIN INJURY
• The beneficial effects of RIC in organ protection during the Shock/Resuscitation phase of care suggest a role
for the application of RIC in the early post-trauma period. (Leung et al, 2015)
SHOCK
39. STUDY DETAILS
Effect of RIC on Clinical Outcomes in
STEMI Patients Undergoing pPCI
(CONDI2)
The aim of the study is to investigate whether RIC can
improve clinical outcomes (cardiovascular death and
heart failure) at one year in patients presenting with
ST-elevation Myocardial Infarction and undergoing
pPCI.
Effect Of Remote Ischaemic
PreconditioningOn Clinical Outcomes
In Patients Undergoing Coronary
Artery Bypass Graft Surgery (ERICCA)
To determine the effect of RIC on Major Adverse
Cardiac and Cerebral Events (MACCE) 12 months after
cardiac surgery. MACCE include cardiovascular (CV)
death, myocardial infarction, revascularisation, and
stroke.
40. The increasing insight into the mechanisms behind the cardioprotective effects of RIC has
uncovered several targets for pharmacological intervention that potentially may partly
reproduce the effects of mechanical conditioning. (Schmidt, Redington and Botker, 2014)
41. • The results of this study and others are encouraging - they have been shown to improve the
outcomes of patients and the procedure is adaptable to many different situations.
• An increasing number of treatments and pathways are being made available to pre-
hospital clinicians treating these patients, this is something that can be used in
combination with these and is not affected by them.
• It is a very low risk non-invasive procedure.
• In times of money and resource limitations this does not require any additional investment
or equipment and very little training.
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Conditioning Before Hospital Admission, As A Complement To Angioplasty, And Effect On Myocardial Salvage In Patients With Acute Myocardial Infarction: A Randomised Trial. The Lancet, 375(9716), pp.727-734 [Online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/20189026
(Accessed 18 June 2015)
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