Exogenous adenosine triphosphate disodium administration during primary percutaneous coronary intervention reduces no-reflow and preserves left ventricular function in patients with acute anterior myocardial infarction: a study using myocardial contrast echocardiography

BACKGROUND

It is unknown whether adenosine triphosphate disodium (ATP) administration during primary percutaneous coronary intervention (PCI) is useful in anterior acute myocardial infarction (AMI).

METHODS

The study was a prospective, non-randomized, open-label trial. Primary PCI was successfully performed in 204 consecutive patients with first anterior AMI. ATP at a mean dose of 117 microg/kg/min for 45 min on an average was infused intravenously during PCI in 100 patients (Group 1). In the other 104 patients, normal saline was administered (Group 2). ST-segment resolution (STR) was estimated 90 min after recanalization. The no-reflow ratio was measured 2 weeks later, using intravenous myocardial contrast echocardiography. Left ventricular ejection fraction (LVEF), LV regional wall motion (LVRWM), and LV end-diastolic volume index (LVEDVI) were measured 6 months later.

RESULTS

Baseline patient characteristics of the two groups were similar, including TIMI risk scores. Significant STR (> or =50% resolution compared to baseline) (66% versus 50%; Group 1 versus Group 2, p=0.02), no-reflow ratio (24% versus 34%, indicated by mean values, p=0.02), LVEF (61% versus 55%, p=0.0007), LVRWM (-1.56 versus -2.05, using the SD/chord, p=0.0001), and LVEDVI (60 ml/m(2) versus 71 ml/m(2), p=0.0007) were significantly better in Group 1, and the no-reflow ratio, LVEF, LVRWM and LVEDVI were significantly better in ATP-administered patients, regardless of antecedent angina or advanced age. ATP Administration was consistently identified as a significant determinant for STR, no-reflow ratio, LVEF, LVRWM, and LVEDVI.

CONCLUSIONS

Intravenous ATP administration during reperfusion is an independent determinant of STR and the no-reflow ratio, and LVEF, LVRWM, and LVEDVI at 6 months after primary PCI.

Canadian quality indicators for percutaneous coronary interventions

BACKGROUND

Quantifying adherence to quality indicators can serve as a direct measure of quality of care and provide the foundation for quality improvement. However, quality indicators for percutaneous coronary intervention (PCI) have not been developed in Canada.

OBJECTIVE

To develop a set of quality and outcome indicators for PCI that can be used across Canada.

METHODS

A 12-member national expert panel was selected to represent practice in different regions of Canada. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, and follow-up discussions to obtain consensus.

RESULTS

A total of 26 indicators including six structure indicators, nine process indicators, and 11 outcomes indicators were identified by the national expert panel to be representative of high quality of care for PCI. Pharmacological indicators included prescription of acetylsalicylic acid, clopidogrel and statin therapy as adjunctive therapy for PCI. Nonpharmacological process indicators included minimal procedure volumes, door-to-balloon time in primary PCI, prevention of contrast-induced nephropathy and selected patient education counselling instructions. Outcome indicators included death, myocardial infarction, target vessel revascularization and vascular access complications after PCI.

CONCLUSIONS

A new set of PCI quality indicators for use in the Canadian health care system was developed. The widespread adoption and implementation of PCI quality indicators in clinical practice will facilitate the identification of practice gaps to enable quality improvement efforts and to optimize the outcomes of patients undergoing PCI throughout Canada.

Emergency percutaneous coronary interventions for acute myocardial infarction with ST-segment elevation in a regional hospital: a quality control study

BACKGROUND

An invasive approach of acute myocardial infarction with ST-segment elevation (STEMI) with primary percutaneous coronary intervention (PCI) is currently considered as the most efficient revascularisation strategy and is performed around-the-clock in tertiary hospitals. The present study is aimed at investigating the short term outcome of primary PCI eligible patients after STEMI in a regional institution (CHCV, Sion) in comparison to a University Hospital (CHUV, Lausanne).

METHODS

From January the 1st to December the 31st 2002, all consecutive STEMI patients of both centres who had an emergency coronary arteriography were included in the analysis. Clinical and angiographic data were retrospectively collected. The primary end point was the combined incidence of in-hospital death, reinfarction, and target vessel revascularisation (TVR) at 7 days.

RESULTS

The analysis included 58 patients in the CHVC (60+/-13 years, 16% of whom were female) and 160 patients in the CHUV (63+/-12 years, 25% were female). Both populations were identical according to the severity of coronary artery disease and distribution of risk factors, except for smokers (55% in CHCV, 39% CHUV, p=0.04). Most of the patients were treated by PCI in both centres (80% CHCV versus 86% CHUV, p=NS). A low proportion in both groups underwent urgent surgical treatment (3.5% CHCV versus 5.5% CHUV, p=NS). At 7 days, adverse events free survival was not statistically different.

CONCLUSION

These results were expected because the CHCV fulfils the international guidelines criteria for performance of emergency angioplasty. Our study demonstrates that around-the-clock primary PCI for acute STEMI can safely be done in a regional hospital (CHCV Sion) providing there is strict adherence to all aspects of international guidelines.

Randomized, controlled trial of coronary artery bypass surgery versus percutaneous coronary intervention in patients with multivessel coronary artery disease: six-year follow-up from the Stent or Surgery Trial (SoS)

BACKGROUND

The Stent or Surgery Trial is a randomized, controlled trial comparing percutaneous coronary intervention with coronary artery bypass grafting (CABG) for patients with multivessel disease. Initial results at a median follow-up of 2 years showed a survival advantage for patients randomized to CABG. This article reports survival outcome at a median follow-up of 6 years.

METHODS AND RESULTS

A total of 988 (n=488 percutaneous coronary intervention, n=500 CABG) patients were randomized at 53 centers during the period from 1996 to 1999. Investigators established survival status from hospital or community medical records or national databases or by direct contact with patients and their relatives. All-cause mortality was compared with hazard ratios and confidence intervals calculated from Cox proportional hazards models. Prespecified subgroup analyses for diabetes mellitus, angina grade, and angiographic severity of coronary disease at baseline were performed with tests for interaction. At a median follow-up of 6 years, 53 patients (10.9%) died in the percutaneous coronary intervention group compared with 34 (6.8%) in the CABG group (hazard ratio 1.66, 95% confidence interval 1.08 to 2.55, P=0.022). Little evidence was found that the treatment effect on mortality differed between subgroups according to baseline angina grade (interaction test P=0.52), the severity of coronary disease (P=0.92), or diabetic status (P=0.15).

CONCLUSIONS

At a median follow-up of 6 years, a continuing survival advantage was observed for patients managed with CABG, which is not consistent with results from other stent-versus-CABG studies.

Elective and primary angioplasty at hospitals without on-site surgery versus with on-site surgery: results from a national registry

INTRODUCTION

Current European clinical guidelines do not restrict interventional cardiology at centers without on-site surgical backup, but disagreement still exists whether hospitals with cardiac catheterization laboratories, but without on-site cardiac surgery, should develop percutaneous coronary intervention (PCI) programs. Technical improvements in equipment and pharmacologic adjunctive therapy have increased the safety margins of diagnostic and therapeutic cardiac catheterization and more than half of the patients treated by PCI in Portugal are treated at hospitals without on-site cardiac surgery.

OBJECTIVES

We set out to compare clinical outcomes of elective and primary PCI for ST-segment elevation myocardial infarction at centers without on-site cardiac surgery with those at centers with on-site cardiac surgery.

METHODS

Based on the Portuguese Registry of Interventional Cardiology, we retrospectively reviewed a total of 13,235 PCI procedures performed from January 2002 to June 2006 and compared the results for 7,112 patients treated at hospitals without on-site cardiac surgery with 6,123 patients treated at hospitals with on-site cardiac surgery.

RESULTS

Demographic data were similar, with a mean age of 64 (55-72) vs. 63 (54-71) years, 75% vs. 76% male and 25.0% vs. 24.2% with diabetes respectively at centers without and with on-site surgical backup. Hospital mortality at centers without and with on-site surgical backup respectively was: chronic angina: 0.3% vs. 0.3% (NS); acute coronary syndromes: 1.5% vs. 1.0% (NS); acute myocardial infarction with ST elevation and without cardiogenic shock: 4.0% vs. 5.0% (NS); cardiogenic shock: 50.9% vs. 53.4% (NS).

CONCLUSIONS

Similar clinical outcomes for interventional cardiology were achieved at hospitals without on-site cardiac surgery and those with on-site cardiac surgery. In the era of coronary stents, adjunctive therapy and experienced operators, elective and primary PCI can safely be performed without on-site surgical backup.

Repeat thrombolysis or conservative therapy vs. rescue percutaneous coronary intervention for failed thrombolysis: systematic review and meta-analysis

BACKGROUND

Despite proven advantages of primary percutaneous coronary intervention (PCI), thrombolysis remains the first line treatment for ST-elevation myocardial infarction (STEMI) worldwide. Management of patients with failed thrombolysis is still debated, and data from existing randomized controlled trials are conflicting.

AIM

To compare the risk/benefit profile of repeat thrombolysis (RT) vs. rescue PCI in patients with failed thrombolysis.

METHODS

Search of BioMedCentral, CENTRAL, mRCT and PubMed for randomized controlled trials comparing rescue PCI vs. conservative therapy and/or RT vs. conservative therapy. Outcomes of interest assessed by adjusted indirect meta-analysis: major adverse events (MAE, defined as the composite of overall mortality and re-infarction), stroke, congestive heart failure (CHF), major bleeds (MB), and minor bleeds. Overall mortality and re-infarction have been also analysed individually.

RESULTS

Eight trials were included (1318 patients). Follow-up ranged from 'in-hospital' to 6 months. No significant difference was found for the risk of MAE [OR 0.93(0.26-3.35), P = 0.4], overall mortality [OR 1.01(0.52-1.95), P = 0.15], stroke [OR 5.03(0.64-39.1), P = 0.58] and CHF [OR 0.74(0.28-1.96), P = 0.6]. Compared with conservative therapy, rescue PCI was associated with a 70% reduction in the risk of re-infarction [OR 0.32(0.14-0.74), P = 0.008], number needed to treat 17. No difference in terms of MB was found [OR 0.5(0.1-2.5), P = 0.09], while a greater risk of minor bleeds was observed with rescue PCI [OR 2.48(1.08-5.7), P = 0.04], number needed to harm 50.

CONCLUSION

Although the observed benefit is modest, these data support the use of PCI after failed thrombolysis.

Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary intervention

OBJECTIVE

To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance.

DESIGN

Analysis of prospectively collected data.

SETTING

Tertiary centre NHS hospital in the north east of England.

PARTICIPANTS

Five cardiologists carrying out percutaneous coronary interventions between January 2003 and December 2006.

MAIN OUTCOME MEASURES

In-hospital major adverse cardiovascular and cerebrovascular events (in-hospital death, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accident) analysed against the logistic north west quality improvement programme predicted risk, for each operator. Results are displayed as funnel plots summarising overall performance for each operator and cumulative funnel plots for an individual operator's performance on a case series basis.

RESULTS

The funnel plots for 5198 patients undergoing percutaneous coronary interventions showed an average observed rate for major adverse cardiovascular and cerebrovascular events of 1.96% overall. This was below the predicted risk of 2.06% by the logistic north west quality improvement programme risk score. Rates of in-hospital major adverse cardiovascular and cerebrovascular events for all operators were within the 3sigma upper control limit of 2.75% and 2sigma upper warning limit of 2.49%.

CONCLUSION

The overall in-hospital major adverse cardiovascular and cerebrovascular events rates were under the predicted event rate. In-hospital rates after percutaneous coronary intervention procedure can be monitored successfully using funnel and cumulative funnel plots with 3sigma control limits to display and publish each operator's outcomes. The upper warning limit (2sigma control limit) could be used for internal monitoring. The main advantage of these charts is their transparency, as they show observed and predicted events separately. By this approach individual operators can monitor their own performance, using the predicted risk for their patients but in a way that is compatible with benchmarking to colleagues, encapsulated by the funnel plot. This methodology is applicable regardless of variations in individual operator case volume and case mix.

[The Danish Heart Registry--a clinical database]

INTRODUCTION

The Danish Heart Registry (DHR) keeps track of all coronary angiographies (CATH), percutaneous coronary interventions (PCI), coronary artery bypass grafting (CABG), and adult heart valve surgery performed in Denmark. DHR is a clinical database established in order to follow the activity and quality of the procedures mentioned.

MATERIALS AND METHODS

Information concerning each procedure, age, gender, and co-morbidity of the patient was collected. Each patient was followed with respect to survival for 30 days by linkage to the central personal registry in Denmark. Mortality was estimated by the Kaplan-Meier method and comparisons of 30-day mortality between centres were carried out in Cox proportional hazard models.

RESULTS

The mortality within 30 days after PCI was 3.2% and closely related to the indication for PCI: ST-elevation myocardial infarction (STEMI) 6.8%; non-STEMI & unstable angina pectoris 1.9% and stable angina pectoris 0.5%. The 30-day mortality after PCI on the indication STEMI did not differ between the five centres, P=0.30. Mortality within 30 days after isolated CABG was 2.6% and was closely related to the EuroSCORE. The 30-day mortality after isolated CABG did not differ between the five centres, P=0.12.

CONCLUSION

The 30-day mortality was closely related to the indication for PCI and the EuroSCORE for patients undergoing CABG. There were no significant differences in 30-day mortality between centres after either primary PCI or isolated CABG.

On the waiting list for possible coronary revascularisation. Symptoms relief during the first year and association between quality of life and the very long-term mortality risk

AIM

To describe: a/ the improvement in quality of life (QoL) among patients on the waiting list for coronary revascularisation and b/ the association between QoL and very long-term mortality.

PATIENTS

All patients on the waiting list for possible coronary revascularisation in western Sweden during one week in September 1990.

METHODS

QoL was assessed at the start of the survey and one year later among patients who both were and were not revascularised. Survival data were gathered for the subsequent 14 years.

RESULTS

From the start, 883 patients were evaluated in the survey. Among patients who were revascularised, an improvement was seen in all the aspects of QoL that were studied during the first year as compared with patients who were not revascularised, in whom only minor changes in QoL were seen during the first year. After one year, there were seven aspects of QoL which were significantly associated with the risk of death during the subsequent 14 years, when adjusting for age, sex, previous history and extent of coronary artery disease. They were: tiredness (OR=1.4), weakness (OR=1.5), lack of energy (OR=1.5), inability to react (OR=1.7), use of sedatives (OR=3.2), dyspnea when dressing (OR=2.1) and chest pain when dressing (OR=1.9).

CONCLUSION

Among patients on the waiting list for possible coronary revascularisation, there was a marked improvement in QoL among those who were revascularised. In a variety of aspects of QoL, an association with the very long-term risk of death was observed.

A citywide protocol for primary PCI in ST-segment elevation myocardial infarction

BACKGROUND

If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain.

METHODS

We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians.

RESULTS

Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001).

CONCLUSIONS

Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

Contact-to-balloon time and door-to-balloon time after initiation of a formalized data feedback in patients with acute ST-elevation myocardial infarction

For many patients with ST-segment elevation myocardial infarctions (STEMIs), the time from presentation to percutaneous coronary intervention exceeds established goals. This study was conducted to examine the effects of formalized data assessment and systematic feedback on treatment times. All patients with STEMIs treated with percutaneous coronary intervention in a semi-rural 3-hospital network from January 1, 2006, to December 31, 2006, were prospectively analyzed (n = 114). Patients presenting during the first 3-month period (January 1, 2006, to March 31, 2006) were included as the reference group (n = 33). Time points from initial contact with the medical system to revascularization were assessed, analyzed, and presented in an interactive session to hospital and emergency services staff members. Data from patients with STEMIs presenting during the next 3 quarters were presented in the same manner (n = 28, 25, and 28). The median contact-to-balloon time was 113 minutes in the reference quarter, decreasing to 83, 66, and 74 minutes in the intervention groups (p <0.0001), whereas the median door-to-balloon time decreased from 54 minutes in the reference group to 35, 31, and 26 minutes in the intervention groups (p <0.0001). The proportion of patients with contact-to-balloon times <90 minutes increased from 21% to 79% (p <0.0001). There were significant reductions in the durations of initial treatment on location and in the emergency room and in puncture-to-balloon-time in the catheterization laboratory, and more patients were transported directly to the catheterization laboratory, bypassing the emergency room (from 23% in the reference quarter to 76% in the last intervention quarter, p <0.0001). In conclusion, formalized data feedback leads to marked reduction in revascularization times in patients with STEMIs.

[In favour of performing coronary balloon dilatation in 'smaller' hospitals]

Until now, the permission to set up a centre for percutaneous coronary intervention (PCI) has been governed by Dutch law to ensure the availability and quality of PCI procedures. Recently, the Minister of Health proposed abolishing this law for PCI procedures. The Dutch Society of Cardiology has issued stringent guidelines for PCI centres. Even small hospitals should be able to start a PCI programme by following these stringent guidelines.