INTRODUCTIONTicagrelor is a novel antiplatelet drug developed to reduce atherothrombosis. The PLATO trial compared ticagrelor and aspirin to clopidogrel and aspirin in patients with acute coronary syndromes (ACS). Ticagrelor was found to be superior in the primary composite endpoint of cardiovascular death, myocardial infarction or stroke, without increasing major bleeding events. The current study estimates the lifetime cost-effectiveness of ticagrelor relative to generic clopidogrel from a Singapore public healthcare perspective.

METHODSThis study used a two-part cost-effectiveness model. The first part was a 12-month decision tree (using PLATO trial data) to estimate the rates of major cardiovascular events, healthcare costs and health-related quality of life. The second part was a Markov model estimating lifetime quality-adjusted survival and costs conditional on events during the initial 12 months. Daily drug costs applied were SGD 1.05 (generic clopidogrel) and SGD 6.00 (ticagrelor). Cost per quality-adjusted life years (QALY) was estimated from a Singapore public healthcare perspective using life tables and short-term costs from Singapore, and long-term costs from South Korea. Deterministic and probabilistic sensitivity analyses were performed.

RESULTSTicagrelor was associated with a lifetime QALY gain of 0.13, primarily driven by lower mortality. The resulting incremental cost per QALY gained was SGD 10,136.00. Probabilistic sensitivity analysis indicated that ticagrelor had a > 99% probability of being cost-effective, given the lower recommended WHO willingness-to-pay threshold of one GDP/capita per QALY.

CONCLUSIONBased on PLATO trial data, one-year treatment with ticagrelor versus generic clopidogrel in patients with ACS, relative to WHO reference standards, is cost-effective from a Singapore public healthcare perspective.

Acute Coronary Syndrome ; drug therapy ; economics ; Adenosine ; analogs & derivatives ; economics ; therapeutic use ; Aspirin ; administration & dosage ; Clinical Trials as Topic ; Cost-Benefit Analysis ; Decision Trees ; Drug Costs ; Humans ; Markov Chains ; Platelet Aggregation Inhibitors ; administration & dosage ; economics ; Purinergic P2Y Receptor Antagonists ; administration & dosage ; economics ; Quality-Adjusted Life Years ; Republic of Korea ; Singapore ; Ticlopidine ; administration & dosage ; analogs & derivatives

As the nonspecific clinical presentation of hypereosinophilic syndrome (HES) may mimic many multisystemic diseases, it often presents as a diagnostic challenge. Herein, we report the case of a 60-year-old man who presented with progressive heart failure symptoms and eosinophilia. Despite extensive diagnostic evaluation, no underlying cause was found. Transthoracic echocardiography revealed a large left ventricular thrombus, which is suggestive of hypereosinophilic cardiac involvement. The patient was started on steroids and responded clinically and haematologically.
Blood Cell Count ; Contrast Media ; chemistry ; Echocardiography ; Eosinophils ; cytology ; Flow Cytometry ; Heart Atria ; pathology ; Heart Diseases ; complications ; diagnostic imaging ; Heart Failure ; complications ; Heart Ventricles ; pathology ; Humans ; Hypereosinophilic Syndrome ; complications ; diagnostic imaging ; Male ; Middle Aged ; Motion ; Steroids ; therapeutic use ; Thrombosis ; complications ; diagnostic imaging ; Treatment Outcome

The main areas of emphasis in the Advanced Cardiac Life Support (ACLS) guidelines are: early recognition of cardiac arrest and call for help; good-quality chest compressions; early defibrillation when applicable; early administration of drugs; appropriate airway management ensuring normoventilation; and delivery of appropriate post-resuscitation care to enhance survival. Of note, it is important to monitor the quality of the various care procedures. The resuscitation team needs to reduce unnecessary interruptions to chest compressions in order to maintain adequate coronary perfusion pressure during the ACLS drill. In addition, the team needs to continually look out for reversible causes of the cardiac arrest.

INTRODUCTION: Prognostic thresholds for 30-day major adverse cardiac events (MACE) have been studied for high-sensitivity troponin T (hsTnT) in patients with suspected acute coronary syndrome (ACS), but there is limited data on the prognostic performance of hsTnT for one-year MACE. METHODS: We prospectively measured hsTnT (in ng/mL up to two decimal places) at 0, 2 and 7 hours for patients presenting with symptoms suggestive of ACS to our emergency department from March 2010 to April 2013. We assessed the prognostic performance of hsTnT cut-offs for 30-day and one-year MACE, and the utility of delta-hsTnT in predicting MACE. RESULTS: Among 2,444 patients studied, 273 (11.2%) developed MACE (including index MACE) by 30 days and 359 (14.7%) patients developed MACE at one year. The suggested hsTnT cut-off for 30-day MACE was ≥ 10 ng/L at 0 hour (positive predictive value [PPV] 33.5%, negative predictive value [NPV] 94.5%) and 7 hours (PPV 37.3%, NPV 94.5%), and ≥ 20 ng/L at 2 hours (PPV 36.9%, NPV 96.9%). For one-year MACE, the suggested cut-off was also ≥ 10 ng/L at all readings. Plasma hsTnT ≥ 30 ng/L at any reading gave PPV > 54% and NPV > 93% for 30-day MACE. Absolute 0-2 hour and 2-7 hour delta-hsTnT ≥ 10 ng/L gave PPV > 50% for 30-day and one-year MACE. CONCLUSION Patients with 0-, 2- or 7-hour hsTnT ≥ 30 ng/L and 0-2 hour delta-hsTnT ≥ 10 ng/L had PPV > 50% for 30-day and one-year MACE, and should be investigated thoroughly.

INTRODUCTIONEarly use of mechanical cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) may improve survival outcomes. Current evidence for such devices uses outcomes from an intention-to-treat (ITT) perspective. We aimed to determine whether early use of mechanical CPR using a LUCAS 2 device results in better outcomes.

METHODSA prospective, randomised, multicentre study was conducted over one year with LUCAS 2 devices in 14 ambulances and manual CPR in 32 ambulances to manage OHCA. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were survival at 24 hours, discharge from hospital and 30 days.

RESULTSOf the 1,274 patients recruited, 1,191 were eligible for analysis. 889 had manual CPR and 302 had LUCAS CPR. From an ITT perspective, outcomes for manual and LUCAS CPR were: ROSC 29.2% and 31.1% (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82-1.45; p = 0.537); 24-hour survival 11.2% and 13.2% (OR 1.20, 95% CI 0.81-1.78; p = 0.352); survival to discharge 3.6% and 4.3% (OR 1.20, 95% CI 0.62-2.33; p = 0.579); and 30-day survival 3.0% and 4.0% (OR 1.32, 95% CI 0.66-2.64; p = 0.430), respectively. By as-treated analysis, outcomes for manual, early LUCAS and late LUCAS CPR were: ROSC 28.0%, 36.9% and 24.5%; 24-hour survival 10.6%, 15.5% and 8.2%; survival to discharge 2.9%, 5.8% and 2.0%; and 30-day survival 2.4%, 5.8% and 0.0%, respectively. Adjusted OR for survival with early LUCAS vs. manual CPR was 1.47 after adjustment for other variables (p = 0.026).

CONCLUSIONThis study showed a survival benefit with LUCAS CPR as compared to manual CPR only, when the device was applied early on-site.

INTRODUCTIONPeak currents are the final arbiter of defibrillation in patients with ventricular fibrillation (VF). However, biphasic defibrillators continue to use energy in joules for electrical conversion in hopes that their impedance compensation properties will address transthoracic impedance (TTI), which must be overcome when a fixed amount of energy is delivered. However, optimal peak currents for conversion of VF remain unclear. We aimed to determine the role of peak current and optimal peak levels for conversion in collapsed VF patients.

METHODSAdult, non-pregnant patients presenting with non-traumatic VF were included in the study. All defibrillations that occurred were included. Impedance values during defibrillation were used to calculate peak current values. The endpoint was return of spontaneous circulation (ROSC).

RESULTSOf the 197 patients analysed, 105 had ROSC. Characteristics of patients with and without ROSC were comparable. Short duration of collapse < 10 minutes correlated positively with ROSC. Generally, patients with average or high TTI converted at lower peak currents. 25% of patients with high TTI converted at 13.3 ± 2.3 A, 22.7% with average TTI at 18.2 ± 2.5 A and 18.6% with low TTI at 27.0 ± 4.7 A (p = 0.729). Highest peak current conversions were at < 15 A and 15-20 A. Of the 44 patients who achieved first-shock ROSC, 33 (75.0%) received < 20 A peak current vs. > 20 A for the remaining 11 (25%) patients (p = 0.002).

CONCLUSIONFor best effect, priming biphasic defibrillators to deliver specific peak currents should be considered.