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  1. Article ; Online: Factors influencing the adoption of telemedicine for treatment of military veterans with post-traumatic stress disorder.

    Kruse, Clemens Scott / Atkins, James M / Baker, Tiffany D / Gonzales, Estefania N / Paul, Jennifer L / Brooks, Matthew

    Journal of rehabilitation medicine

    2018  Volume 50, Issue 5, Page(s) 385–392

    Abstract: Background: Military veterans returning from a combat zone often face mental health challenges as a result of traumatic experiences. The veteran in the United States has been underdiagnosed and underserved. Since its advancement in the 1990s, ... ...

    Abstract Background: Military veterans returning from a combat zone often face mental health challenges as a result of traumatic experiences. The veteran in the United States has been underdiagnosed and underserved. Since its advancement in the 1990s, telemedicine has become a more prevalent means of delivering services for post-traumatic stress disorder among veterans in the United States, but its adoption is not ubiquitous.
    Objective: To clarify the association of telemedicine and the treatment of veterans with post-traumatic stress disorder through identification of facilitators and barriers to the adoption of the modality.
    Methods: Reviewers analysed articles from CINAHL and PubMed databases, using relative key words, selecting the 28 most germane to the study objective.
    Results: The most common adoption facilitators were: improving access to rural populations of veterans (22%), effective treatment outcomes (16%), and decreased costs related to care (13%). The most prevalent barriers were: veterans lacking access to necessary modalities (25%), availability of physicians competent in post-traumatic stress disorder treatment (20%), and complications with technology (20%). Five themes surfaced for facilitators: accessibility, effectiveness, cost reduction, positive patient perception, and supportive community; and 5 themes for barriers: access to technology, technical complications, physician availability, negative patient perception, and uninformed patients.
    Conclusion: This literature review identifies cost and outcomes-effectiveness. The association of telemedicine with the treatment of veterans with post-traumatic stress disorder is feasible, beneficial and effective.
    MeSH term(s) Adult ; Female ; Humans ; Military Personnel/psychology ; Stress Disorders, Post-Traumatic/therapy ; Telemedicine/methods ; Treatment Outcome ; United States ; Veterans/psychology
    Language English
    Publishing date 2018-05-08
    Publishing country Sweden
    Document type Journal Article ; Review
    ZDB-ID 2039427-5
    ISSN 1651-2081 ; 1651-2235 ; 0891-060X ; 1650-1977
    ISSN (online) 1651-2081 ; 1651-2235
    ISSN 0891-060X ; 1650-1977
    DOI 10.2340/16501977-2302
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  2. Book: Advances in cardiopulmonary resuscitation

    Atkins, James M

    (Medical grand rounds)

    1993  

    Author's details James M. Atkins
    Series title Medical grand rounds
    MeSH term(s) Cardiopulmonary Resuscitation
    Language English
    Size 21 p.
    Publisher University of Texas Southwestern Medical Center
    Publishing place Dallas
    Document type Book
    Database Catalogue of the US National Library of Medicine (NLM)

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  3. Article ; Online: Electrocardiographic patterns of proximal left anterior descending artery occlusion in ST-elevation myocardial infarction may be modified by 3-vessel coronary artery disease.

    Neeland, Ian J / Sulistio, Melanie S / Stoller, Douglas A / de Lemos, James A / Atkins, James M / McGuire, Darren K

    Journal of electrocardiology

    2012  Volume 45, Issue 3, Page(s) 272–276

    Abstract: Background: The electrocardiographic (ECG) pattern of ST-segment deviation in myocardial infarction is integral to the proper assessment of the location, extent, and functional significance of the infarct but may be modified by the underlying coronary ... ...

    Abstract Background: The electrocardiographic (ECG) pattern of ST-segment deviation in myocardial infarction is integral to the proper assessment of the location, extent, and functional significance of the infarct but may be modified by the underlying coronary artery anatomy.
    Methods: We describe the ECG findings in 2 cases of proximal left anterior descending (LAD) artery occlusion in ST-elevation myocardial infarction (STEMI) associated with 3-vessel coronary artery disease.
    Results: Both patients had atypical ECG patterns of ST-segment elevation in leads V(2), I, and aVL and ST-segment depression with positive T waves suggestive of extensive subendocardial ischemia in leads II, III, aVF, and V(3) through V(6); acute proximal LAD occlusion and concomitant 3-vessel coronary artery disease were observed angiographically.
    Conclusion: Electrocardiographic changes in proximal LAD STEMI may be modified by the presence of significant atherosclerotic disease elsewhere in the coronary vasculature. Recognition of this ECG pattern may aid the clinician in the rapid identification of high-risk STEMI.
    MeSH term(s) Aged ; Coronary Occlusion/complications ; Coronary Occlusion/diagnosis ; Electrocardiography/methods ; Female ; Humans ; Male ; Myocardial Infarction/complications ; Myocardial Infarction/diagnosis
    Language English
    Publishing date 2012-01-14
    Publishing country United States
    Document type Case Reports ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 410286-1
    ISSN 1532-8430 ; 0022-0736
    ISSN (online) 1532-8430
    ISSN 0022-0736
    DOI 10.1016/j.jelectrocard.2011.12.003
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  4. Article ; Online: Emergency medical service predictive instrument-aided diagnosis and treatment of acute coronary syndromes and ST-segment elevation myocardial infarction in the IMMEDIATE trial.

    Selker, Harry P / Beshansky, Joni R / Ruthazer, Robin / Sheehan, Patricia R / Sayah, Assaad J / Atkins, James M / Aufderheide, Tom P / Pirrallo, Ronald G / D'Agostino, Ralph B / Massaro, Joseph M / Griffith, John L

    Prehospital emergency care

    2011  Volume 15, Issue 2, Page(s) 139–148

    Abstract: Background: A challenge for emergency medical service (EMS) is accurate identification of acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI) for immediate treatment and transport. The electrocardiograph-based acute ... ...

    Abstract Background: A challenge for emergency medical service (EMS) is accurate identification of acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI) for immediate treatment and transport. The electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) and the thrombolytic predictive instrument (TPI) have been shown to improve diagnosis and treatment in emergency departments (EDs), but their use by paramedics in the community has been less studied.
    Objective: To identify candidates for participation in the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial, we implemented EMS use of the ACI-TIPI and the TPI in out-of-hospital electrocardiographs and evaluated its impact on paramedic on-site identification of ACS and STEMI as a community-based approach to improving emergency cardiac care.
    Methods: Ambulances in the study municipalities were outfitted with electrocardiographs with ACI-TIPI and TPI software. Using a before-after quasi-experimental design, in Phase 1, for seven months, paramedics were provided with the ACI-TIPI/TPI continuous 0-100% predictions automatically printed on electrocardiogram (ECG) text headers to supplement their identification of ACS; in Phase 2, for 11 months, paramedics were told to identify ACS based on an ACI-TIPI cutoff probability of ACS ≥ 75% and/or TPI detection of STEMI. In Phase 3, this cutoff approach was used in seven additional municipalities. Confirmed diagnoses of ACS, acute myocardial infarction (AMI), and STEMI were made by blinded physician review for 100% of patients.
    Results: In Phase 1, paramedics identified 107 patients as having ACS; in Phase 2, 104. In Phase 1, 45.8% (49) of patients so identified had ACS confirmed, which increased to 76.0% (79) in Phase 2 (p < 0.001). Of those with ACS, 59.2% (29) had AMI in Phase 1 versus 84.8% (67) with AMI in Phase 2 (p < 0.01), and STEMI was confirmed in 40.8% (20) versus 68.4% (54), respectively (p < 0.01). In Phase 3, of 226 patients identified by paramedics as having ACS, 74.3% (168) had ACS confirmed, of whom 81.0% (136) had AMI and 65.5% (110) had STEMI. Among patients with ACS, the proportion who received percutaneous coronary intervention (PCI) was 30.6% (15) in Phase 1, increasing to 57.0% (45) in Phase 2 (p < 0.004) and 50.6% (85) in Phase 3, and the proportions of patients with STEMI receiving PCI rose from 75.0% (15) to 83.3% (45) (p < 0.4) and 82.7% (91).
    Conclusions: In a wide range of EMS systems, use of electrocardiographs with ACI-TIPI and TPI decision support using a 75% ACI-TIPI cutoff improves paramedic diagnostic performance for ACS, AMI, and STEMI and increases the proportions of patients who receive PCI.
    MeSH term(s) Acute Coronary Syndrome/diagnosis ; Acute Coronary Syndrome/drug therapy ; Acute Coronary Syndrome/therapy ; Chest Pain ; Chi-Square Distribution ; Decision Support Systems, Clinical ; Diagnosis, Computer-Assisted/instrumentation ; Diagnosis, Computer-Assisted/methods ; Electrocardiography/instrumentation ; Electrocardiography/methods ; Emergency Medical Technicians/statistics & numerical data ; Emergency Service, Hospital/statistics & numerical data ; Female ; Health Status Indicators ; Humans ; Male ; Middle Aged ; Myocardial Infarction/diagnosis ; Myocardial Infarction/drug therapy ; Myocardial Infarction/therapy ; Predictive Value of Tests ; Sensitivity and Specificity ; Software ; Time Factors
    Language English
    Publishing date 2011-03-02
    Publishing country England
    Document type Evaluation Study ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 1461751-1
    ISSN 1545-0066 ; 1090-3127
    ISSN (online) 1545-0066
    ISSN 1090-3127
    DOI 10.3109/10903127.2010.545478
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  5. Article: Sex-related differences in the presentation and outcome of out-of-hospital cardiopulmonary arrest: a multiyear, prospective, population-based study.

    Wigginton, Jane G / Pepe, Paul E / Bedolla, John P / DeTamble, Lucy A / Atkins, James M

    Critical care medicine

    2002  Volume 30, Issue 4 Suppl, Page(s) S131–6

    Abstract: Objective: To examine whether previously observed sex-related differences in coronary artery disease syndromes also apply to patients with out-of-hospital sudden cardiac arrest, a probable subset of patients with coronary artery disease who are easy to ... ...

    Abstract Objective: To examine whether previously observed sex-related differences in coronary artery disease syndromes also apply to patients with out-of-hospital sudden cardiac arrest, a probable subset of patients with coronary artery disease who are easy to recognize and are treated in a standardized fashion.
    Design: Prospective, population-based study conducted over a 6-yr period.
    Setting: A large urban municipality (population, 1.1 million) served by a single emergency medical services system with centralized medical direction and standardized protocols.
    Patients: All patients with out-of-hospital, nontraumatic, primary cardiac arrest.
    Interventions: Standardized advanced cardiac life support protocols.
    Measurements and main results: During the 6 yrs of the study, 4147 consecutive patients were studied, 42% of whom were women (p <.001). Although women were significantly older than men (mean age, 68.7 +/- 18 vs. 61.7 +/- 17 yrs; p =.001), there were no significant differences for the percentages of witnessed and unwitnessed arrests, response intervals, and the length and type of treatment provided. Although men were more likely to have ventricular fibrillation/ventricular tachycardia on presentation (41% vs. 30%), women had more asystole (8.8% vs. 7%) and (organized) pulseless electrical activity than men (24% vs. 18%; p <.001). Nevertheless, more women were resuscitated (13.5% vs. 10.7%; p =.005), particularly women with non-ventricular fibrillation/ventricular tachycardia presentation (12.6% vs. 9.6%; p <.02). These differences were more pronounced when controlling for age (95% confidence interval, 1.44 [1.25-1.74]).
    Conclusions: In cases of out-of-hospital sudden cardiac arrest, women have significantly better resuscitation rates than men, especially when controlling for age, particularly among women with non-ventricular fibrillation/ventricular tachycardia presentations. Additional studies are required to validate these observations, not only for long-term survival and external validity, but also for other potential genetic factors and potential discrepancies with other studies.
    MeSH term(s) Age Factors ; Aged ; Emergency Medical Services ; Female ; Heart Arrest/mortality ; Humans ; Male ; Middle Aged ; Prospective Studies ; Resuscitation ; Sex Factors ; Tachycardia, Ventricular/mortality ; Time Factors ; Treatment Outcome ; Ventricular Fibrillation/mortality
    Language English
    Publishing date 2002-04
    Publishing country United States
    Document type Journal Article
    ZDB-ID 197890-1
    ISSN 1530-0293 ; 0090-3493
    ISSN (online) 1530-0293
    ISSN 0090-3493
    DOI 10.1097/00003246-200204001-00002
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  6. Article ; Online: Study design for the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial: A double-blind randomized controlled trial of intravenous glucose, insulin, and potassium for acute coronary syndromes in emergency medical services.

    Selker, Harry P / Beshansky, Joni R / Griffith, John L / D'Agostino, Ralph B / Massaro, Joseph M / Udelson, James E / Rashba, Eric J / Ruthazer, Robin / Sheehan, Patricia R / Desvigne-Nickens, Patrice / Rosenberg, Yves D / Atkins, James M / Sayah, Assaad J / Aufderheide, Tom P / Rackley, Charles E / Opie, Lionel H / Lambrew, Costas T / Cobb, Leonard A / Macleod, Bruce A /
    Ingwall, Joanne S / Zalenski, Robert J / Apstein, Carl S

    American heart journal

    2012  Volume 163, Issue 3, Page(s) 315–322

    Abstract: Background: Experimental studies suggest that metabolic myocardial support by intravenous (IV) glucose, insulin, and potassium (GIK) reduces ischemia-induced arrhythmias, cardiac arrest, mortality, progression from unstable angina pectoris to acute ... ...

    Abstract Background: Experimental studies suggest that metabolic myocardial support by intravenous (IV) glucose, insulin, and potassium (GIK) reduces ischemia-induced arrhythmias, cardiac arrest, mortality, progression from unstable angina pectoris to acute myocardial infarction (AMI), and myocardial infarction size. However, trials of hospital administration of IV GIK to patients with ST-elevation myocardial infarction (STEMI) have generally not shown favorable effects possibly because of the GIK intervention taking place many hours after ischemic symptom onset. A trial of GIK used in the very first hours of ischemia has been needed, consistent with the timing of benefit seen in experimental studies.
    Objective: The IMMEDIATE Trial tested whether, if given very early, GIK could have the impact seen in experimental studies. Accordingly, distinct from prior trials, IMMEDIATE tested the impact of GIK (1) in patients with acute coronary syndromes (ACS), rather than only AMI or STEMI, and (2) administered in prehospital emergency medical service settings, rather than later, in hospitals, after emergency department evaluation.
    Design: The IMMEDIATE Trial was an emergency medical service-based randomized placebo-controlled clinical effectiveness trial conducted in 13 cities across the United States that enrolled 911 participants. Eligible were patients 30 years or older for whom a paramedic performed a 12-lead electrocardiogram to evaluate chest pain or other symptoms suggestive of ACS for whom electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument indicated a ≥75% probability of ACS, and/or the thrombolytic predictive instrument indicated the presence of a STEMI, or if local criteria for STEMI notification of receiving hospitals were met. Prehospital IV GIK or placebo was started immediately. Prespecified were the primary end point of progression of ACS to infarction and, as major secondary end points, the composite of cardiac arrest or in-hospital mortality, 30-day mortality, and the composite of cardiac arrest, 30-day mortality, or hospitalization for heart failure. Analyses were planned on an intent-to-treat basis, on a modified intent-to-treat group who were confirmed in emergency departments to have ACS, and for participants presenting with STEMI.
    Conclusion: The IMMEDIATE Trial tested whether GIK, when administered as early as possible in the course of ACS by paramedics using acute cardiac ischemia time-insensitive predictive instrument and thrombolytic predictive instrument decision support, would reduce progression to AMI, mortality, cardiac arrest, and heart failure. It also tested whether it would provide clinical and pathophysiologic information on GIK's biological mechanisms.
    MeSH term(s) Acute Coronary Syndrome/diagnosis ; Acute Coronary Syndrome/drug therapy ; Acute Coronary Syndrome/mortality ; Adult ; Cardioplegic Solutions ; Dose-Response Relationship, Drug ; Double-Blind Method ; Electrocardiography ; Emergency Medical Services/methods ; Follow-Up Studies ; Glucose/administration & dosage ; Humans ; Infusions, Intravenous ; Insulin/administration & dosage ; Myocardium/metabolism ; Potassium/administration & dosage ; Survival Rate/trends ; Time Factors ; Tomography, Emission-Computed, Single-Photon ; Treatment Outcome ; United States/epidemiology
    Chemical Substances Cardioplegic Solutions ; Insulin ; glucose-insulin-potassium cardioplegic solution ; Glucose (IY9XDZ35W2) ; Potassium (RWP5GA015D)
    Language English
    Publishing date 2012-03-18
    Publishing country United States
    Document type Comparative Study ; Journal Article ; Multicenter Study ; Randomized Controlled Trial ; Research Support, N.I.H., Extramural
    ZDB-ID 80026-0
    ISSN 1097-6744 ; 0002-8703
    ISSN (online) 1097-6744
    ISSN 0002-8703
    DOI 10.1016/j.ahj.2012.02.002
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  7. Article ; Online: One-year outcomes of out-of-hospital administration of intravenous glucose, insulin, and potassium (GIK) in patients with suspected acute coronary syndromes (from the IMMEDIATE [Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care] Trial).

    Selker, Harry P / Udelson, James E / Massaro, Joseph M / Ruthazer, Robin / D'Agostino, Ralph B / Griffith, John L / Sheehan, Patricia R / Desvigne-Nickens, Patrice / Rosenberg, Yves / Tian, Xin / Vickery, Ellen M / Atkins, James M / Aufderheide, Tom P / Sayah, Assaad J / Pirrallo, Ronald G / Levy, Michael K / Richards, Michael E / Braude, Darren A / Doyle, Delanor D /
    Frascone, Ralph J / Kosiak, Donald J / Leaming, James M / Van Gelder, Carin M / Walter, Gert-Paul / Wayne, Marvin A / Woolard, Robert H / Beshansky, Joni R

    The American journal of cardiology

    2014  Volume 113, Issue 10, Page(s) 1599–1605

    Abstract: The Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency care Trial of very early intravenous glucose-insulin-potassium (GIK) for acute coronary syndromes (ACS) in out-of-hospital emergency medical service (EMS) ...

    Abstract The Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency care Trial of very early intravenous glucose-insulin-potassium (GIK) for acute coronary syndromes (ACS) in out-of-hospital emergency medical service (EMS) settings showed 80% reduction in infarct size at 30 days, suggesting potential longer-term benefits. Here we report 1-year outcomes. Prespecified 1-year end points of this randomized, placebo-controlled, double-blind, effectiveness trial included all-cause mortality and composites including cardiac arrest, mortality, or hospitalization for heart failure (HF). Of 871 participants randomized to GIK versus placebo, death occurred within 1 year in 11.6% versus 13.5%, respectively (unadjusted hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.57 to 1.23, p = 0.36). The composite of cardiac arrest or 1-year mortality was 12.8% versus 17.0% (HR 0.71, 95% CI 0.50 to 1.02, p = 0.06). The composite of hospitalization for HF or mortality within 1 year was 17.2% versus 17.2% (HR 0.98, 95% CI 0.70 to 1.37, p = 0.92). The composite of mortality, cardiac arrest, or HF hospitalization within 1 year was 18.1% versus 20.4% (HR 0.85, 95% CI 0.62 to 1.16, p = 0.30). In patients presenting with suspected ST elevation myocardial infarction, HRs for 1-year mortality and the 3 composites were, respectively, 0.65 (95% CI 0.33 to 1.27, p = 0.21), 0.52 (95% CI 0.30 to 0.92, p = 0.03), 0.63 (95% CI 0.35 to 1.16, p = 0.14), and 0.51 (95% CI 0.30 to 0.87, p = 0.01). In patients with suspected acute coronary syndromes, serious end points generally were lower with GIK than placebo, but the differences were not statistically significant. However, in those with ST elevation myocardial infarction, the composites of cardiac arrest or 1-year mortality, and of cardiac arrest, mortality, or HF hospitalization within 1 year, were significantly reduced.
    MeSH term(s) Acute Coronary Syndrome/diagnosis ; Acute Coronary Syndrome/drug therapy ; Acute Coronary Syndrome/mortality ; Adult ; After-Hours Care/methods ; Cardioplegic Solutions ; Cause of Death/trends ; Double-Blind Method ; Electrocardiography ; Female ; Follow-Up Studies ; Glucose/administration & dosage ; Heart Arrest/mortality ; Heart Arrest/prevention & control ; Humans ; Infusions, Intravenous ; Insulin/administration & dosage ; Male ; Middle Aged ; Myocardium/metabolism ; Outpatients ; Potassium/administration & dosage ; Retrospective Studies ; Survival Rate/trends ; Time Factors ; Treatment Outcome ; United States/epidemiology
    Chemical Substances Cardioplegic Solutions ; Insulin ; glucose-insulin-potassium cardioplegic solution ; Glucose (IY9XDZ35W2) ; Potassium (RWP5GA015D)
    Language English
    Publishing date 2014-03-01
    Publishing country United States
    Document type Journal Article ; Multicenter Study ; Randomized Controlled Trial ; Research Support, N.I.H., Extramural
    ZDB-ID 80014-4
    ISSN 1879-1913 ; 0002-9149
    ISSN (online) 1879-1913
    ISSN 0002-9149
    DOI 10.1016/j.amjcard.2014.02.010
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  8. Article ; Online: ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction?

    Henry, Timothy D / Atkins, James M / Cunningham, Michael S / Francis, Gary S / Groh, William J / Hong, Robert A / Kern, Karl B / Larson, David M / Ohman, Erik Magnus / Ornato, Joseph P / Peberdy, Mary Ann / Rosenberg, Michael J / Weaver, W Douglas

    Journal of the American College of Cardiology

    2006  Volume 47, Issue 7, Page(s) 1339–1345

    Abstract: Despite substantial progress in the diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI), implementation of this knowledge into routine clinical practice has been variable. It has become increasing clear that primary ... ...

    Abstract Despite substantial progress in the diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI), implementation of this knowledge into routine clinical practice has been variable. It has become increasing clear that primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion if it can be performed in a timely manner. Recent European data suggest that transfer for direct PCI may also be preferable to fibrinolytic therapy. We believe it is time to establish a national policy for treatment of patients with STEMI to develop a coordinated system of care similar to that of the level 1 trauma system.
    MeSH term(s) Electrocardiography ; Health Policy ; Humans ; Myocardial Infarction/diagnosis ; Myocardial Infarction/physiopathology ; Myocardial Infarction/therapy ; Triage
    Language English
    Publishing date 2006-04-04
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 605507-2
    ISSN 1558-3597 ; 0735-1097
    ISSN (online) 1558-3597
    ISSN 0735-1097
    DOI 10.1016/j.jacc.2005.05.101
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  9. Article ; Online: Out-of-hospital administration of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial.

    Selker, Harry P / Beshansky, Joni R / Sheehan, Patricia R / Massaro, Joseph M / Griffith, John L / D'Agostino, Ralph B / Ruthazer, Robin / Atkins, James M / Sayah, Assaad J / Levy, Michael K / Richards, Michael E / Aufderheide, Tom P / Braude, Darren A / Pirrallo, Ronald G / Doyle, Delanor D / Frascone, Ralph J / Kosiak, Donald J / Leaming, James M / Van Gelder, Carin M /
    Walter, Gert-Paul / Wayne, Marvin A / Woolard, Robert H / Opie, Lionel H / Rackley, Charles E / Apstein, Carl S / Udelson, James E

    JAMA

    2012  Volume 307, Issue 18, Page(s) 1925–1933

    Abstract: Context: Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, ... ...

    Abstract Context: Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration.
    Objective: To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS).
    Design, setting, and participants: Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS.
    Intervention: Intravenous GIK solution (n = 411) or identical-appearing 5% glucose placebo (n = 460) administered by paramedics in the out-of-hospital setting and continued for 12 hours.
    Main outcome measures: The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation.
    Results: There was no significant difference in the rate of progression to MI among patients who received GIK (n = 200; 48.7%) vs those who received placebo (n = 242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P = .34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events occurred in 6.8% (n = 28) with GIK vs 8.9% (n = 41) with placebo (P = .26).
    Conclusions: Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality.
    Trial registration: clinicaltrials.gov Identifier: NCT00091507.
    MeSH term(s) Acute Coronary Syndrome/drug therapy ; Acute Coronary Syndrome/mortality ; Aged ; Allied Health Personnel ; Angina, Unstable/complications ; Angina, Unstable/drug therapy ; Cardioplegic Solutions/therapeutic use ; Decision Support Techniques ; Double-Blind Method ; Electrocardiography ; Emergency Medical Services ; Female ; Glucose/therapeutic use ; Heart Arrest/prevention & control ; Hospital Mortality ; Humans ; Insulin/therapeutic use ; Male ; Middle Aged ; Myocardial Infarction/etiology ; Myocardial Infarction/prevention & control ; Odds Ratio ; Potassium/therapeutic use ; Survival Analysis ; Treatment Outcome
    Chemical Substances Cardioplegic Solutions ; Insulin ; glucose-insulin-potassium cardioplegic solution ; Glucose (IY9XDZ35W2) ; Potassium (RWP5GA015D)
    Language English
    Publishing date 2012-03-27
    Publishing country United States
    Document type Clinical Trial ; Journal Article ; Multicenter Study ; Randomized Controlled Trial ; Research Support, N.I.H., Extramural
    ZDB-ID 2958-0
    ISSN 1538-3598 ; 0254-9077 ; 0002-9955 ; 0098-7484
    ISSN (online) 1538-3598
    ISSN 0254-9077 ; 0002-9955 ; 0098-7484
    DOI 10.1001/jama.2012.426
    Database MEDical Literature Analysis and Retrieval System OnLINE

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