The Zwolle risk score was designed to stratify in-hospital mortality risk of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (pPCI) and for ...decision-making in the unit where patients are admitted. We assessed the accuracy of Zwolle risk score for in-hospital mortality estimation compared with the GRACE score in all patients (n = 4446) admitted for STEMI in 3 university hospitals. Only one fourth of the patients were classified as high-risk by the Zwolle risk score vs 60% by the GRACE score. In-hospital mortality was 10.6%. A statistically significant increase in in-hospital mortality, adjusted by age, gender, and revascularization, was observed with both scores. The assessment of the optimal cut-off points verified the accuracy of Zwolle score ≥4 as optimal threshold for high-risk categorization. In contrast, GRACE score ≥140 had very low specificity as well as percentage of patients correctly classified; GRACE score ≥175 was fairly better. The reclassification index of the Zwolle score after applying the GRACE score was 35.5%. Selection of high-risk STEMI patients treated with pPCI based on the Zwolle risk score has higher specificity than the GRACE score and might be useful in clinical practice.
Despite emerging evidence suggesting that selected patients presenting with ST-segment elevation myocardial infarction (STEMI) treated successfully with primary percutaneous coronary intervention ...(PPCI) may be considered for early discharge, STEMI patients are typically hospitalised longer to monitor for serious complications.
We assessed the feasibility of identifying low-risk STEMI patients in our institution for early discharge using the Zwolle risk score (ZRS). We evaluated consecutive STEMI patients who underwent successful PPCI within the period 1 January 2016 to 31 December 2017. Low-risk was defined as ZRS≤3. Demographic, angiographic characteristics, length of stay (LOS), and 30-day major adverse cardiovascular events (MACE) defined as cardiac death, stroke, congestive cardiac failure, and non-fatal myocardial infarction, were recorded.
There were 183 STEMI patients in our study cohort (mean age 62.0±12.2 years, 77.0% male). The median ZRS was 2 (interquartile range 1–4) with 132 (72.1%) patients classified as low-risk. The overall 30-day MACE and mortality rates were 10.4% and 3.3% respectively. None of the 35 (26.5%) low-risk patients who were discharged within 72 hours experienced MACE at 30 days. Low-risk STEMI patients had significantly shorter median LOS (86.3 vs. 93.2 hours, p=0.002), lower 30-day MACE (4.5% vs. 25.5%, p<0.0001) and mortality (0% vs. 11.8%, p<0.0001) compared to high-risk group (ZRS>3). Receiver operating characteristic (ROC) curve analyses for ZRS in predicting 30-day MACE and mortality yielded C-statistics of 0.79 (95%CI 0.68-0.90, p<0.0001) and 0.98 (95%CI 0.95–1.00, p<0.0001) respectively.
Low-risk STEMI patients stratified by Zwolle risk score, who were treated successfully with PPCI, experienced low 30-day MACE and mortality rates, indicating that early discharge may be safe in these patients. Larger studies are warranted to evaluate the safety of ZRS-guided early discharge of STEMI patients, as well as the economic and psychological impacts.
Death, judgement, heaven, and hell are the themes of a late medieval hymn manuscript associated with the Brethren of the Common Life at Zwolle. These same themes constitute the basis of penitential ...meditation in these circles. This book offers a new view on the spirituality of the Modern Devotion and its close connection with music.
Background The Zwolle Risk Score was designed to identify the risk of complications in patients with ST-segment‒elevation myocardial infarction (STEMI) following percutaneous coronary intervention ...(PCI). Its utility following PCI in STEMI treated with thrombolysis is unknown. The objective was to evaluate the safety of using the Zwolle Risk Score to triage patients with STEMI following PCI, including patients receiving thrombolysis. Methods and Results Patients aged ≥18 years with STEMI and primary PCI or PCI after thrombolysis were included. A triage protocol was developed, with high-risk patients those with Zwolle Risk Score ≥4 triaged to the cardiac intensive care unit. A prospective evaluation of the triaging protocol was performed on 452 patients, mean age 65±12 years, 73% men. Median Zwolle Risk Score was 3 (interquartile range, 2‒5), with 257 low-risk (57%), and 195 high-risk (43%) patients. Adherence to the protocol was 91%. In-hospital mortality was 0.4% in low-risk and 13% in high-risk patients (
<0.001). Seventy-two patients (16%) received thrombolysis. Median time post-thrombolysis to PCI was 281 minutes (interquartile range, 219‒376). In-hospital mortality was 0% versus 9% (
=0.083) for low- and high-risk patients, respectively. High-risk patients had higher rates of cardiogenic shock (34% versus 1%,
<0.001), pulmonary edema (60% versus 9%,
<0.001), arrhythmia (25% versus 2%,
<0.001), blood transfusion (10% versus 2%,
<0.001), and stroke (4% versus 0.4%,
=0.011). Median hospital costs decreased by $1419 per low-risk patient after protocol implementation. Conclusions For patients with STEMI following primary PCI or PCI following thrombolysis, a Zwolle-based triaging system is safe and may decrease cardiac intensive care unit usage costs.
The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation ...(Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI).
A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications.
Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.
•A predicted prognosis for patients with STEMI is considered to be a necessary instrument for stratifying risk for these patients•The FASTEST risk score was validated and can be used in patients with ...STEMI•The FASTEST appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 h of admission•FASTEST added prognostic value over GRACE and ZWOLLE score in STEMI patients.
The optimal length of stay for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) is still undetermined. The ...Zwolle risk score (ZRS) is a simple tool designed to identify patients who can be safely discharged within 72 hours. The purpose of this study was to assess the applicability and performance of the ZRS in our population.
We studied 276 consecutive patients (mean age 62±14 years, 75% male, 20% Killip class >1) admitted over a two-year period for STEMI and treated with PPCI. ZRS, length of stay, 30-day mortality and readmission were obtained for all patients. Low risk was defined as ZRS ≤3.
The median ZRS was 3 (interquartile range IQR 1–4), with 171 patients (62%) being classified as low risk. Thirty-day mortality was 4.7% (13 patients). Compared to other patients, low-risk patients had shorter length of stay (median 5.0 IQR 4–7 vs. 7.0 5–13 days, p<0.001), and lower 30-day mortality (0 vs. 12.4%, p<0.001), yielding a negative predictive value of 100% (95% CI 97.0–100%) for the proposed cutoff. The ZRS showed excellent discriminative power (C-statistic: 0.937, 95% CI 0.906–0.968, p<0.001), and good calibration against the original cohort.
The ZRS appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 hours of admission. Using the ZRS in our population could result in a more rational use of in-patient resources.
A duração ótima de internamento após enfarte agudo do miocárdio com supradesnivelamento do segmento ST (EAMCST) não complicado, submetido a intervenção coronária percutânea primária (ICPP), permanece por determinar. O Score de Zwolle (SZ) é um instrumento simples, desenhado para identificar os doentes candidatos a alta precoce (<72h) segura. Este estudo pretendeu avaliar a aplicabilidade do SZ na nossa população.
Analisámos 276 doentes consecutivos (idade média 62±14 anos, 75% homens, 20% em classe de Killip>1) com EAMCST submetidos a ICPP durante um período de dois anos. Foram obtidos os SZ, duração de internamento, mortalidade e readmissão aos 30 dias. Foi definido baixo risco como SZ ≤3.
A mediana do SZ foi de 3 distância interquartil (IQR) 1-4 e 171 doentes (62%) foram classificados como de baixo risco. A mortalidade aos 30 dias foi de 4,7% (13 doentes). Em comparação com os restantes, os doentes de baixo risco tiveram menor duração de internamento mediana 5,0 (IQR 4-7) versus 7,0 (IQR 5-13) dias, p<0,001 e menor mortalidade (0 versus 12,4%, p<0,001), resultando num valor preditivo negativo de 100% (IC95% 97,0-100%) para o cut-off proposto. O ZS mostrou excelente poder descriminativo (estatística-C: 0,937, IC95% 0,906-0,968, p<0,001) e boa calibração quando comparado com o coorte original.
O SZ parece capaz de identificar com precisão os doentes com EAMCST de baixo risco que podem ter alta segura 72h após a admissão. O uso do SZ na nossa população poderá resultar numa utilização mais racional dos recursos hospitalares.
Societal infrastructures are the lifeblood of societies, and the sustainability of infrastructures is very important. Societal infrastructures can experience conflicting spatial claims with other ...societal infrastructures, disturbing the sustainable situation. The objective of this paper is to design large infrastructures, with a focus on the Drinking Water Infrastructure (DWI), in a more sustainable way by using the resilience concept. To study this, a case study was done in the Netherlands, where an overlap is present between the DWI and the protection zones, and a new railroad and water safety measures in the river IJssel. The case showed that conflicting infrastructures are inflexible and unable to adapt to change due to several reasons in the governance and in the infrastructure system itself. The case was useful for identifying eight design principles to prevent conflicting claims between large infrastructures.
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