Relation of Age to Survival in Patients with Obstructive Sleep Apnea who Develop an Acute Coronary Event (from the National Inpatient Sample)

This study was undertaken to investigate whether obstructive sleep apnea (OSA) produces a survival advantage in acute coronary syndrome (ACS), and to evaluate the mechanism of any benefit, including the impact of age and other risk factors. The National Inpatient Sample was queried for all patients who were admitted for ACS during the years 2013 to 2014. The primary outcomes were all-cause in-hospital mortality and cardiogenic shock (CS). Multivariable logistic regression was used for analysis. A total of 1,080,340 patients with ACS were included, 63,255 patients had OSA. The majority of patients were males (60.3%) and of Caucasian race (75%). The mean age was 67 years (SEM: 0.1). Despite a higher burden of risk factors and older age, OSA patients had a lower risk for mortality and cardiogenic shock adjusted OR 0.68 (95%CI 0.61-0.75), p <0.001 and 0.81 (95%CI: 0.74 to 0.89), p <0.001 respectively. Age was an important effect modifier. Survival advantage and lower risk for CS arises at the age above 55 and become more apparent with increasing age. In conclusion, despite a higher CV risk profile, and older age, OSA produces a survival benefit in ACS. Age is a significant modifier of risk in OSA patients with ACS. Ischemic preconditioning might explain these results.

The Embryologic Origin of Vieussens' Ring

Vieussens' ring is an embryologic remnant that acquires clinical significance as an intercoronary collateral vessel in advanced coronary artery disease. Its origin as a peritruncal structure early in embryologic development, and its association with congenital pulmonary artery fistula, provides a crucial insight into the early stages of the coronary circulation. This review describes the embryologic basis of Vieussens' ring in relation to the formation of the coronary arteries, which explains its location, appearance, and clinical importance.

Views of Appropriate Use Criteria for catheterization and percutaneous coronary revascularization by practicing interventional cardiologists: Results of a survey of American College of Cardiology Interventional Section members

OBJECTIVES

The American College of Cardiology (ACC) Interventional Section Council leadership sought to examine the views of interventional cardiologists regarding the practical implementation and the value of the Appropriate Use Criteria (AUC) in their clinical practice.

BACKGROUND

The ACC AUC for revascularization were originally intended to assess trends in revascularization patterns by hospitals and physicians to ensure that both under- and over-utilization were minimized. As a quality assurance tool, the AUC were designed to allow physicians to obtain insight into their practice patterns and improve their practice. Recent trends toward tying payment to performance have raised concerns that these criteria will be incorrectly applied to individual patient reimbursement, which is not what they were designed to do. Consequently, the AUC have become controversial, not for their value in quality assessment, but for the manner in which agencies have used the AUC as a tool to potentially deny payment for certain patients.

METHODS

Utilizing an online survey, members of the ACC Interventional Section were queried regarding the use of AUC, how they use them, and how they feel utilization impacts the care of patients.

RESULTS

We found substantial variability in how the AUC were utilized and concern regarding the value of AUC. Among our findings was that respondents were split (51% vs 49%) regarding the value of AUC to patients and/or their laboratory.

CONCLUSIONS

In this article, we discuss the implications of these findings and consider options on how AUC might be made a better-accepted and more impactful tool for clinicians and patients.

A Comprehensive Evidence-Based Decision Algorithm for Assisting Clinicians and Patients With Stable Ischemic Heart Disease in Selecting Revascularization Strategy in Multivessel Disease

We propose an evidenced-based algorithm for the selection of revascularization strategy (coronary artery bypass surgery, percutaneous coronary intervention, or optimal medical therapy) to be applied in multivessel, non-acute coronary syndrome presentations. This algorithm provides a highly effective tool that is comprehensible to both physicians and patients.

Occupational health hazards in the interventional laboratory: Time for a safer environment

Over the past 30 years, the advent of fluoroscopically guided interventional procedures has resulted in dramatic increments in both X-ray exposure and physical demands that predispose interventionists to distinct occupational health hazards. The hazards of accumulated radiation exposure have been known for years, but until recently the other potential risks have been ill-defined and under-appreciated. The physical stresses inherent in this career choice appear to be associated with a predilection to orthopedic injuries, attributable in great part to the cumulative adverse effects of bearing the weight and design of personal protective apparel worn to reduce radiation risk and to the poor ergonomic design of interventional suites. These occupational health concerns pertain to cardiologists, radiologists and surgeons working with fluoroscopy, pain management specialists performing nonvascular fluoroscopic procedures, and the many support personnel working in these environments. This position paper is the work of representatives of the major societies of physicians who work in the interventional laboratory environment, and has been formally endorsed by all. In this paper, the available data delineating the prevalence of these occupational health risks is reviewed and ongoing epidemiological studies designed to further elucidate these risks are summarized. The main purpose is to publicly state speaking with a single voice that the interventional laboratory poses workplace hazards that must be acknowledged, better understood and mitigated to the greatest extent possible, and to advocate vigorously on behalf of efforts to reduce these hazards. Interventional physicians and their professional societies, working together with industry, should strive toward the ultimate zero radiation exposure work environment that would eliminate the need for personal protective apparel and prevent its orthopedic and ergonomic consequences. © 2008 Wiley-Liss, Inc.

Damped and Ventricularized Coronary Pressure Waveforms

Although the terms ventricularization and damping are commonly used in the cath lab and are widely recognized as indicating possible flow limitation due to catheter position, their hemodynamic origins and mechanism have not been well studied. Often, they are thought to be synonymous terms. Both patterns are due to distortion of the normal harmonic frequencies of wave conduction. Pressure damping is seen when the outer diameter of the catheter is larger than the ostial diameter or when the tip of the catheter is pressed against the vessel wall. It is characterized by an abrupt decline of mean coronary pressure with narrow pulse pressure and delayed upstroke and downstroke. Conversely, ventricularization is seen when the catheter tip is advanced into an ostial stenosis, partially obstructing flow, and is characterized by a steep decline of pressure in diastole with large pulse pressure, absence of the dicrotic notch, and appearance of presystolic positive deflection. A ventricularized pressure waveform can be considered a hybrid between coronary arterial pressure and coronary wedge pressure.