The results of the Randomized Study with the Sirolimus Eluting Velocity Balloon Expandable Stent (RAVEL) were thought by many in Stockholm to launch a new era in cardiology. A total of 238 patients with stable or unstable angina due to single-vessel disease and a mean age of 63 years were randomized to receive either a bare-metal Bx Velocity stent or a similar stent coated with the immunosuppressive antibiotic sirolimus. Sirolimus is released from the stent over ≈45 days. Both groups were treated for 2 months with either clopidogrel or ticlopidine. The results after 210 days of follow-up were reported by M.C. Morice (Massy, France). The sirolimus group had a restenosis rate of zero compared with 26% in the conventional stent group (P<0.0001), and event-free survival was 96% in the sirolimus group compared with 73% in the coventional stent group. There were no late occlusions or thromboses in the sirolimus group, edge restenosis was absent, and vessel diameter was unchanged from the time of the procedure, compared with a 0.80 mm loss in the coventional stent group (P<0.0001).
Out-of-Hospital Defibrillation in Amsterdam and Piacenza
European countries have been slow to allow defibrillation by nonmedical personnel for out-of-hospital cardiac arrest, partly for legal reasons. A.P. Van Alem and colleagues (Amsterdam, Netherlands) assessed the value of training police officers and firefighters in their city to use an automatic external defibrillator (AED) if they arrive at the scene before the medical service. A total of 900 police officers received 3 hours of training (which is reviewed at intervals), and 50 AEDs were issued.
At any one time, half of Amsterdam’s population of one million is served by police carrying an AED. The allocation of areas is reversed every 4 months, so the comparison in this study was between basic life support and basic life support plus AED before the ambulance arrives. Preliminary results from 357 incidents indicate that when police have an AED, the first shock is administered a mean of 150 seconds earlier. Unfortunately, this time-gain does not translate into long-term benefit: survival has been almost identical, and very low, in the 2 groups. The explanation is probably that median time to first shock is too long (≈10 minutes).
Results from Piacenza, Italy, are more encouraging. There, G.Q. Villani and colleagues assessed the value of lay volunteers for the same purpose. Thirty-nine AEDs were deployed (12 in high-risk locations and 27 in police cars or lay-staffed ambulances), and ≈1000 volunteers were taught how to operate them. In just over half the cases of suspected sudden cardiac arrest, the volunteers arrived before the emergency medical services, and their mean time to intervention was 5.37 versus 7.48 minutes—much faster than in Amsterdam for both groups. In this study, defibrillation by “first responders” did achieve better results: the survival rate after ventricular fibrillation/tachycardia was 44% versus 21% (P<0.05) for those treated by first responders compared with the medical service. Interestingly, only 6.4% of the cardiac arrests were in the street; 86.7% were at home. On April 14, Italian law was changed to facilitate defibrillation without medical support.