Establishing Thresholds for Minimal Clinically Important Differences for the Peripheral Artery Disease Questionnaire

BACKGROUND

Understanding minimum clinically important differences (MCID) in patient-reported outcomes is essential in interpreting the magnitude of changes in these measures. No MCID from patients' perspectives has ever been published for peripheral artery disease-specific health status assessment tools. The Peripheral Artery Questionnaire (PAQ) is a commonly used, validated peripheral artery disease-specific health status instrument for which we sought to prospectively establish its MCID from patients' perspectives.

METHODS AND RESULTS

Patients presenting to vascular clinics with new or worsened claudication in the US cohort of the PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry who completed baseline and follow-up PAQ assessments along with the Global Assessment of Functioning scale were included. Mean change in PAQ summary scores from 3- to 6-month follow-up was calculated according to Global Assessment of Functioning category. MCID was defined as the mean difference in scores between those with small improvement or deterioration and those with no change. Multivariable linear regression was used to provide an MCID estimate after adjusting for patients' 3-month PAQ score. Of the 483 patients who completed the Global Assessment of Functioning score at 6 months and who had available 3- and 6-month PAQ assessments, the mean age was 69 years, 42% were female, and 71% were White. The MCIDs for PAQ summary scale improvement and worsening were 8.7 (2.9-14.5) and -11.0 (-18.6 to -3.3), respectively. After multivariable adjustment, these were 8.9 (3.0-14.8) and -11.2 (-18.2 to -4.2), respectively. There was no significant interaction between treatment (invasive versus noninvasive) and Global Assessment of Functioning response (P=0.75).

CONCLUSIONS

In patients with new or worsened claudication, a 10-point change in PAQ summary score represents an MCID. This estimate needs external validation and may inform the interpretation of PAQ scores when used as outcomes in clinical trials or in routine clinical care. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01419080.

Times up to demonstrate a difference is current DES platforms

Current generation durable polymer DES have sustained efficacy and safety out to 5 years. The Orsiro DES has both a bioresorbable polymer and ultra thin struts and has the potential to improve the safety of DES. In this all comers trial, 3 year outcomes with Orsiro DES were similar to the durable polymer zotarolimus eluting stent.

Readmission following urgent transcatheter aortic valve implantation versus urgent balloon aortic valvuloplasty in patients with decompensated heart failure or cardiogenic shock

BACKGROUND

Urgent transcatheter aortic valve implantation (TAVI) is a feasible option for aortic stenosis (AS) patients with decompensated heart failure (HF) and cardiogenic shock (CS) as compared to the more traditional urgent balloon aortic valvuloplasty (BAV).

OBJECTIVES

We conducted a retrospective analysis to compare risk and cause of readmission in these two high-risk groups.

METHODS

Nationwide Readmission Database (NRD) 2011-2014 was retrospectively analyzed to identify patients with AS having either urgent TAVI or urgent BAV using appropriate ICD-9 codes. Propensity scores were used to match patients with urgent TAVI as compared to patients with urgent BAV. Statistical analysis was performed using the Stata 15.1 software.

RESULTS

We identified a weighted sample of 6,670 patients with urgent BAV and 6,964 patients with urgent TAVI. The all-cause 30- and 90-day readmission was lower in the urgent TAVI group compared to urgent BAV (15.4 vs. 22.5%, (aHR): 0.92 [0.90-0.95] p < .001). 30-day readmission due to CV cause and HF was also lower in the urgent TAVI group (aHR, 0.93: p < .001 and aHR, 0.98: p = .040, respectively). The 30-day gastrointestinal (GI) bleed readmission rate was three times higher in urgent TAVI group (aHR, 3.00:95% CI (1.23-7.33), p = .016), but was not statistically significant at 90-days. Cardiac causes of readmission were the predominant cause of readmission in both groups, but more pronounced in urgent BAV group (60.3 vs. 40.5%, p < .001).

CONCLUSION

Urgent TAVI appears beneficial in patients with AS and decompensated HF or CS driven by roughly 10 and 25% reductions in overall readmissions at 30 and 90 days, and marked reductions in reintervention, although offset partially by higher risk of readmission due to GI bleeding at 30 days.

Characteristics and Outcomes of Patients With History of CABG Undergoing Cardiac Catheterization Via the Radial Versus Femoral Approach

OBJECTIVES

The aims of this study were to examine rates of radial artery access in post-coronary artery bypass grafting (CABG) patients undergoing diagnostic catherization and/or percutaneous coronary intervention (PCI), whether operators with higher procedural volumes and higher percentage radial use were more likely to perform diagnostic catherization and/or PCI via the radial approach in post-CABG patients, and clinical and procedural outcomes in post-CABG patients who undergo diagnostic catherization and/or PCI via the radial or femoral approach.

BACKGROUND

There are limited data comparing outcomes of patients with prior CABG undergoing transradial or transfemoral diagnostic catheterization and/or PCI.

METHODS

Using the National Cardiovascular Data Registry CathPCI Registry, all diagnostic catheterizations and PCIs performed in patients with prior CABG from July 1, 2009, to March 31, 2018 (n = 1,279,058, 1,173 sites) were evaluated. Temporal trends in transradial access were examined, and mortality, bleeding, vascular complications, and procedural metrics were compared between transradial and transfemoral access.

RESULTS

The rate of transradial access increased from 1.4% to 18.7% over the study period. Transradial access was associated with decreased mortality (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.75 to 0.91), decreased bleeding (OR: 0.57; 95% CI: 0.51 to 0.63), decreased vascular complications (OR: 0.38; 95% CI: 0.30 to 0.47), increased PCI procedural success (OR: 1.11; 95% CI: 1.06 to 1.16; p < 0.0001), and significantly decreased contrast volume across all procedure types. Transradial access was associated with shorter fluoroscopy time for PCI-only procedures but longer fluoroscopy time for diagnostic procedures plus ad hoc PCI and diagnostic procedures only. Operators with a higher rate of transradial access in non-CABG patients were more likely to perform transradial access in patients with prior CABG.

CONCLUSIONS

The rate of transradial artery access in patients with prior CABG undergoing diagnostic catheterization and/or PCI has increased over the past decade in the United States, and it was more often performed by operators using a transradial approach in non-CABG patients. Compared with transfemoral access, transradial access was associated with improved clinical outcomes in patients with prior CABG.

Outcomes with drug-coated balloons vs. drug-eluting stents in small-vessel coronary artery disease

BACKGROUND

The use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial.

METHODS

We performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725).

RESULTS

Over a median follow-up duration of 6 months, DCB was associated with smaller late lumen loss (LLL) compared with DES (mean difference -0.12 mm) (95% confidence intervals (CI) [-0.21, -0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49-1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16-1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51-3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40-2.82], p = 0.91). DCBs were associated with lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23-1.00], p = 0.05, I2 = 0%).

CONCLUSION

PCI of SVD with DCBs is associated with smaller LLL, lower risk of MI, and similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data are still needed.

Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage closure: an updated meta-analysis and systematic review

Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echocardiography (TEE) to guide implantation of percutaneous left atrial appendage closure (LAAC) devices in patients with atrial fibrillation (AF) and a high bleeding risk. We reviewed the efficacy and safety of ICE compared to TEE in LAAC in this updated meta-analysis. Medline, CINAHL, EMBASE and Scopus were systematically searched for studies comparing ICE and TEE in percutaneous LAAC. Our primary outcomes of interest were procedural success and study reported periprocedural complications. Secondary outcomes included various procedural characteristics. Risk ratios (RR), standardized mean differences (SMD) and their corresponding 95% confidence intervals (CI) were calculated. The analysis was performed using a random-effect model. Nine observational studies met our inclusion criteria with a total of 2620 patients (ICE: 679 and TEE: 1941). Mean CHA2DS2-Vasc (4.4 ± 0.3 for ICE vs 4.5 ± 0.3 for TEE, P = 0.60) and HAS-BLED (3.2 ± 0.4 vs 3.1 ± 0.6, P = 0.78) scores were comparable between the two groups. There was no significant difference in procedure success rate (RR: 1.01, 95% CI: 0.99-1.02, P= 0.31) and periprocedural complications (RR: 0.85, 95% CI: 0.59-1.23, P = 0.39). No significant difference was observed in procedure duration, fluoroscopy time and contrast volume used while a trend towards decreased hospital length of stay was seen with the use of ICE. Thus, our updated meta-analysis shows ICE is as effective and safe as TEE for implantation of LAAC devices.

Institutional Red Blood Cell Transfusion Rates Are Correlated Following Endovascular and Surgical Cardiovascular Procedures: Evidence That Local Culture Influences Transfusion Decisions

Background

The relationship between local hospital culture and transfusion rates following endovascular and surgical cardiovascular procedures has not been well studied.

Methods and Results

Patients undergoing coronary revascularization, aortic valve replacement, lower extremity peripheral vascular intervention, or carotid artery revascularization from up to 852 US hospitals in the Nationwide Readmissions Database were identified. Crude and risk‐standardized red blood cell transfusion rates were determined for each procedure. Pearson correlation coefficients were calculated between respective procedural transfusion rates. Median odds ratios were estimated to reflect between‐hospital variability in red blood cell transfusion rates following the same procedure for a given patient. There was wide variation in red blood cell transfusion rates across different procedures, from 2% following carotid endarterectomy to 29% following surgical aortic valve replacement. For surgical and endovascular modalities, transfusion rates at the same hospital were highly correlated for aortic valve replacement (r=0.67; P<0.001), moderately correlated for coronary revascularization (r=0.56; P<0.001) and peripheral vascular intervention (r=0.51; P<0.001), and weakly correlated for carotid artery revascularization (r=0.19, P<0.001). Median odds ratios were all >2, highest for coronary artery bypass graft surgery and surgical aortic valve replacement, indicating substantial site variation in transfusion rates.

Conclusions

After adjustment for patient‐related factors, wide variation in red blood cell transfusion rates remained across surgical and endovascular procedures employed for the same cardiovascular condition. Transfusion rates following these procedures are highly correlated at individual hospitals and vary widely across hospitals. In aggregate, these findings suggest that local institutional culture significantly influences the decision to transfuse following invasive cardiovascular procedures and highlight the need for randomized data to inform such decisions.

Systematic review and meta-analysis of short-term outcomes with drug-coated balloons vs. stenting in acute myocardial infarction

The role of drug-coated balloons (DCBs) in patients with acute myocardial infarction (AMI) remains controversial. We performed a meta-analysis of all published studies comparing the outcomes of DCBs vs. stenting in AMI patients. Four studies with 497 patients (534 lesions) were included (three randomized controlled trials and one observational study). During a mean follow-up of 9 months (range 6-12 months), DCBs were associated with similar risk of major adverse cardiovascular events (5% vs. 4.4%; OR 1.24, 95% CI: [0.34, 4.51], p = 0.74, I² = 35%), all-cause mortality (0.02% vs. 0.04%; OR 077, 95% CI: [0.15, 3.91], p = 0.75, I² = 25%), cardiac death (0.01% vs. 0.02%; OR 0.64, 95% CI: [0.16, 2.64], p = 0.54), myocardial infarction (0% vs. 1.4%; OR 0.18, 95% CI: [0.01, 3.56], p = 0.26), and target lesion revascularization (3.7% vs. 2%; OR 1.74, 95% CI: [0.42, 7.13], p = 0.44, I² = 17%) compared with stenting. During a mean follow-up of 7 months (range 6-9 months), DCBs had similar late lumen loss compared with stenting (mean difference 0.04 mm, 95% CI [- 0.21-0.28], p = 0.77, I² = 92%). In patients with AMI, there was no statistical difference in the incidence of clinical and angiographic outcomes between AMI patients treated with DCB and DES. Larger studies with longer-term follow-up are needed to assess the clinical utility of DCBs in this setting.

Seasonal variation in U.S. hospitalizations for chronic limb-threatening ischemia

BACKGROUND

Seasonal variation in coronary artery disease is well described, with a peak in the winter and a trough in the summer. However, little is known about seasonal trends in hospital admission for critical limb-threatening ischemia (CLTI) and associated outcomes.

METHODS

Patients admitted with CLTI from January 1, 2012 through August 31, 2015 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample based upon administrative claims diagnosis codes. The primary outcome was seasonal hospitalization incidence, and secondary outcomes included mortality rates and rates of in-hospital major and minor amputations among nondiabetics and diabetics.

RESULTS

Of 1,276,745 hospitalizations for CLTI during the study period, 28.3% occurred in the spring, the peak admission season, and 19.1% occurred in the fall, the nadir. In-hospital mortality was highest during the winter (adjusted odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.03-1.14), and followed the highest seasonal rates of influenza in the fall; however, other important comorbidities did not differ significantly by season. For the overall cohort, there was no significant seasonal variation in rates of major or minor amputation, although seasonal rates were different according to diabetic status. Patients without diabetes had the highest odds of amputation in the spring (OR 1.07; 95% CI: 1.02-1.12), although this trend was not identified among patients with diabetes.

CONCLUSIONS

There is significant seasonal variability in CLTI admissions and mortality but minimal variability in amputation rates. Understanding the seasonal variation in CLTI may help to identify individuals at greatest risk for hospitalization and death through patient and provider education efforts.

Temporal Trends and Outcomes of Mechanical Complications in Patients With Acute Myocardial Infarction

OBJECTIVES

The aim of this study was to examine the temporal trends and outcomes of mechanical complications after myocardial infarction in the contemporary era.

BACKGROUND

Data regarding temporal trends and outcomes of mechanical complications after ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) are limited in the contemporary era.

METHODS

The National Inpatient Sample database (2003 to September 2015) was queried to identify all STEMI and NSTEMI hospitalizations. Temporal trends and outcomes of mechanical complications after STEMI and NSTEMI, including papillary muscle rupture, ventricular septal defect, and free wall rupture, were described.

RESULTS

The analysis included 3,951,861 STEMI and 5,114,270 NSTEMI hospitalizations. Mechanical complications occurred in 10,726 of STEMI hospitalizations (0.27%) and 3,041 of NSTEMI hospitalizations (0.06%), with no changes in trends (p = 0.13 and p = 0.83, respectively). The rates of in-hospital mortality in patients with mechanical complications were 42.4% after STEMI and 18.0% after NSTEMI, with no significant trend changes (p = 0.62 and p = 0.12, respectively). After multivariate adjustment, patients who had mechanical complications after myocardial infarction had higher in-hospital mortality, cardiogenic shock, acute kidney injury, hemodialysis, and respiratory complications compared with those without mechanical complications. Predictors of lower mortality in patients with mechanical complications who developed cardiogenic shock included surgical repair in the STEMI and NSTEMI cohorts and percutaneous coronary intervention in the STEMI cohort.

CONCLUSIONS

Contemporary data from a large national database show that the rates of mechanical complications are low in patients presenting with STEMI and NSTEMI. Post-myocardial infarction mechanical complications continue to be associated with high mortality rates, which did not improve during the study period.

Special Article - Acute myocardial injury in patients hospitalized with COVID-19 infection: A review

The Coronavirus Disease 2019 (COVID-19) is now a global pandemic with millions affected and millions more at risk for contracting the infection. The COVID-19 virus, SARS-CoV-2, affects multiple organ systems, especially the lungs and heart. Elevation of cardiac biomarkers, particularly high-sensitivity troponin and/or creatine kinase MB, is common in patients with COVID-19 infection. In our review of clinical analyses, we found that in 26 studies including 11,685 patients, the weighted pooled prevalence of acute myocardial injury was 20% (ranged from 5% to 38% depending on the criteria used). The plausible mechanisms of myocardial injury include, 1) hyperinflammation and cytokine storm mediated through pathologic T-cells and monocytes leading to myocarditis, 2) respiratory failure and hypoxemia resulting in damage to cardiac myocytes, 3) down regulation of ACE2 expression and subsequent protective signaling pathways in cardiac myocytes, 4) hypercoagulability and development of coronary microvascular thrombosis, 5) diffuse endothelial injury and 'endotheliitis' in several organs including the heart, and, 6) inflammation and/or stress causing coronary plaque rupture or supply-demand mismatch leading to myocardial ischemia/infarction. Cardiac biomarkers can be used to aid in diagnosis as well as risk stratification. In patients with elevated hs-troponin, clinical context is important and myocarditis as well as stress induced cardiomyopathy should be considered in the differential, along with type I and type II myocardial infarction. Irrespective of etiology, patients with acute myocardial injury should be prioritized for treatment. Clinical decisions including interventions should be individualized and carefully tailored after thorough review of risks/benefits. Given the complex interplay of SARS-CoV-2 with the cardiovascular system, further investigation into potential mechanisms is needed to guide effective therapies. Randomized trials are urgently needed to investigate treatment modalities to reduce the incidence and mortality associated with COVID-19 related acute myocardial injury.

A Case of Acute Thrombotic Myocardial Infarction in Polyarteritis Nodosa

This is a case of a 33-year-old male with acute myocardial infarction from complete thrombotic occlusion of the distal left anterior descending and 1st obtuse marginal artery secondary to polyarteritis nodosa. This case highlights the treatment course and need for continued awareness of vasculitis as a cause for myocardial infarction.

Effect of Genotype-Guided Oral P2Y12 Inhibitor Selection vs Conventional Clopidogrel Therapy on Ischemic Outcomes After Percutaneous Coronary Intervention: The TAILOR-PCI Randomized Clinical Trial

IMPORTANCE

After percutaneous coronary intervention (PCI), patients with CYP2C19*2 or *3 loss-of-function (LOF) variants treated with clopidogrel have increased risk of ischemic events. Whether genotype-guided selection of oral P2Y12 inhibitor therapy improves ischemic outcomes is unknown.

OBJECTIVE

To determine the effect of a genotype-guided oral P2Y12 inhibitor strategy on ischemic outcomes in CYP2C19 LOF carriers after PCI.

DESIGN, SETTING, AND PARTICIPANTS

Open-label randomized clinical trial of 5302 patients undergoing PCI for acute coronary syndromes (ACS) or stable coronary artery disease (CAD). Patients were enrolled at 40 centers in the US, Canada, South Korea, and Mexico from May 2013 through October 2018; final date of follow-up was October 2019.

INTERVENTIONS

Patients randomized to the genotype-guided group (n = 2652) underwent point-of-care genotyping. CYP2C19 LOF carriers were prescribed ticagrelor and noncarriers clopidogrel. Patients randomized to the conventional group (n = 2650) were prescribed clopidogrel and underwent genotyping after 12 months.

MAIN OUTCOMES AND MEASURES

The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia at 12 months. A secondary end point was major or minor bleeding at 12 months. The primary analysis was in patients with CYP2C19 LOF variants, and secondary analysis included all randomized patients. The trial had 85% power to detect a minimum hazard ratio of 0.50.

RESULTS

Among 5302 patients randomized (median age, 62 years; 25% women), 82% had ACS and 18% had stable CAD; 94% completed the trial. Of 1849 with CYP2C19 LOF variants, 764 of 903 (85%) assigned to genotype-guided therapy received ticagrelor, and 932 of 946 (99%) assigned to conventional therapy received clopidogrel. The primary end point occurred in 35 of 903 CYP2C19 LOF carriers (4.0%) in the genotype-guided therapy group and 54 of 946 (5.9%) in the conventional therapy group at 12 months (hazard ratio [HR], 0.66 [95% CI, 0.43-1.02]; P = .06). None of the 11 prespecified secondary end points showed significant differences, including major or minor bleeding in CYP2C19 LOF carriers in the genotype-guided group (1.9%) vs the conventional therapy group (1.6%) at 12 months (HR, 1.22 [95% CI, 0.60-2.51]; P = .58). Among all randomized patients, the primary end point occurred in 113 of 2641 (4.4%) in the genotype-guided group and 135 of 2635 (5.3%) in the conventional group (HR, 0.84 [95% CI, 0.65-1.07]; P = .16).

CONCLUSIONS AND RELEVANCE

Among CYP2C19 LOF carriers with ACS and stable CAD undergoing PCI, genotype-guided selection of an oral P2Y12 inhibitor, compared with conventional clopidogrel therapy without point-of-care genotyping, resulted in no statistically significant difference in a composite end point of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia based on the prespecified analysis plan and the treatment effect that the study was powered to detect at 12 months.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01742117.

Impact of Artificial Intelligence on Interventional Cardiology: From Decision-Making Aid to Advanced Interventional Procedure Assistance

Access to big data analyzed by supercomputers using advanced mathematical algorithms (i.e., deep machine learning) has allowed for enhancement of cognitive output (i.e., visual imaging interpretation) to previously unseen levels and promises to fundamentally change the practice of medicine. This field, known as "artificial intelligence" (AI), is making significant progress in areas such as automated clinical decision making, medical imaging analysis, and interventional procedures, and has the potential to dramatically influence the practice of interventional cardiology. The unique nature of interventional cardiology makes it an ideal target for the development of AI-based technologies designed to improve real-time clinical decision making, streamline workflow in the catheterization laboratory, and standardize catheter-based procedures through advanced robotics. This review provides an introduction to AI by highlighting its scope, potential applications, and limitations in interventional cardiology.

Cardiac implantable electronic device placement following alcohol septal ablation for hypertrophic cardiomyopathy in the United States

BACKGROUND

Cardiac implantable electronic devices (CIED) are sometimes required after alcohol septal ablation (ASA) for hypertrophic cardiomyopathy (HCM). The primary objectives of this study were to characterize the incidence, timing, and predictors of CIED placement after ASA for HCM.

METHODS

Patients were identified from the 2010-2015 Nationwide Readmissions Databases. Incidence, timing and independent predictors of CIED placement, as well as 30-day readmission rates were examined.

RESULTS

There were 1296 patients (national estimate = 2864) with HCM who underwent ASA. CIED were implanted in 322 (25% overall; 14% permanent pacemaker, 11% implantable cardioverter defibrillator) during the index hospitalization. Of these, 21%, 23%, 21%, and 18% occurred on postprocedure day 0, 1, 2, and 3, respectively. Only 17 (1.3%) patients underwent CIED implantation between discharge and 30-day follow up. Independent predictors of index hospitalization CIED implantation included older age, diabetes, heart failure, nonelective index hospital admission and hospitalization at a privately owned hospital. Nonelective 30-day readmission rates among those who did and did not undergo CIED placement during their index hospitalization, were 6.8% and 7.9%, respectively (p = .53); median time to readmission was also similar between groups.

CONCLUSIONS

One in four HCM patients undergoing ASA underwent CIED implantation during their index hospitalization; nearly 2/3rd during the first 48 h postprocedure. Private hospital ownership independently predicted CIED placement. More data are needed to better understand the unexpectedly high rates of CIED placement, earlier than anticipated timing of implantation and differential rates by hospital ownership.

Multivessel Versus Culprit-Only Revascularization in STEMI and Multivessel Coronary Artery Disease: Meta-Analysis of Randomized Trials

OBJECTIVES

The goal of this systematic review and meta-analysis was to provide a comprehensive evaluation of contemporary randomized trials addressing the efficacy and safety of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction and multivessel coronary artery disease.

BACKGROUND

Multivessel coronary artery disease is present in about one-half of patients with ST-segment elevation myocardial infarction. Randomized controlled trials comparing multivessel and culprit vessel-only PCI produced conflicting results regarding the benefits of a multivessel PCI strategy.

METHODS

A comprehensive search for published randomized controlled trials comparing multivessel PCI with culprit vessel-only PCI was conducted on ClinicalTrials.gov, PubMed, Web of Science, EBSCO Services, the Cochrane Central Register of Controlled Trials, Google Scholar, and scientific conference sessions from inception to September 15, 2019. A meta-analysis was performed using a random-effects model to calculate the risk ratio (RR) and 95% confidence interval (CI). Primary efficacy outcomes were all-cause mortality and reinfarction.

RESULTS

Ten randomized controlled trials were included, representing 7,030 patients: 3,426 underwent multivessel PCI and 3,604 received culprit vessel-only PCI. Compared with culprit vessel-only PCI, multivessel PCI was associated with no significant difference in all-cause mortality (RR: 0.85; 95% CI: 0.68 to 1.05) and lower risk for reinfarction (RR: 0.69; 95% CI: 0.50 to 0.95), cardiovascular mortality (RR: 0.71; 95% CI: 0.50 to 1.00), and repeat revascularization (RR: 0.34; 95% CI: 0.25 to 0.44). Major bleeding (RR: 0.92; 95% CI: 0.50 to 1.67), stroke (RR: 1.15; 95% CI: 0.65 to 2.01), and contrast-induced nephropathy (RR: 1.25; 95% CI: 0.80 to 1.95) were not significantly different between the 2 groups.

CONCLUSIONS

Multivessel PCI was associated with a lower risk for reinfarction, without any difference in all-cause mortality, compared with culprit vessel-only PCI in patients with ST-segment elevation myocardial infarction.