Clinical and economic outcomes of embolic complications and strategies for distal embolic protection during percutaneous coronary intervention in saphenous vein grafts

BACKGROUND

Although distal embolic protection (DEP) is increasingly utilized in saphenous vein graft percutaneous coronary intervention (SVG PCI), the clinical and economic outcomes of different DEP strategies are unknown.

METHODS

We compared 3 DEP strategies (no DEP, routine DEP, selective DEP in high-risk cases) in 126 consecutive cases of SVG PCI performed without DEP in a single catheterization laboratory over a 4-year period. No SVG PCI was excluded. High risk was defined using 2 multivariate predictors of embolic complication previously validated by NCDR (graft age greater than or equal to 8 years and or friable appearance with thrombus). Costs were determined by a ratio of cost-to-charges methodology and average cost of the two FDA-approved DEP devices ($1,350) with similar efficacy.

RESULTS

Without DEP, the incidence of embolic complications was 17% (22/126), resulting in major adverse coronary events (MACE) in 3.2% (4/126) of all cases: 2 deaths, 1 myocardial infarction, and 1 emergency coronary artery bypass. Embolic complications significantly increased both procedure costs by $2,725 (p < .001) and total hospital costs approximately $2,800 (p < 0.05). Risk adjustment for selective DEP use correctly predicted 86% (19/22) of embolic complications, including all MACE, at an incremental cost of $684 per patient for selective DEP versus $1,150 per patient for routine DEP. Selective DEP would cost $43,127 per death prevented versus $72,461 using routine DEP during the index hospitalization.

CONCLUSIONS

Embolic complications increase cost in excess of the cost of a DEP device. This risk adjustment model correctly predicted the majority of cases of embolic complication and all MACE, suggesting that selective DEP use may help reduce utilization of DEP by an almost 50% cost reduction compared to routine use.

Ad Hoc percutaneous coronary interventions in patients with stable coronary artery disease—A study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR®)

OBJECTIVE

To utilize the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) to monitor the performance and safety of ad hoc PCIs.

BACKGROUND

The performance of ad hoc PCI remains controversial. Patients' preference, cost, and vascular access issues favor an ad hoc strategy. Adequate time for thoughtful decision-making, scheduling complexity, informed consent, and physician reimbursement favor PCI on a subsequent day.

METHODS

We analyzed results in 68,528 patients with stable angina entered in the ACC-NCDR from 2001-2003. Ad hoc PCI was evaluated in many clinical and nonclinical subgroups. A multivariable analysis was performed to determine whether ad hoc PCI had an independent relationship with complications or procedure success.

RESULTS

Overall, 60.6% of patients underwent ad hoc PCI. There was no difference in ad hoc PCI mortality, renal failure, or vascular complications from staged PCI. A lower percentage of patients at high vs. low risk and with vs. without renal failure underwent ad hoc PCIs (58.6% vs.63.0% and 50.7% vs. 60.9% respectively). There was wide variation in the performance of ad hoc PCIs according to payer (70.2-60.3%), hospital PCI volume (67-50.2%), hospital owner (89.7-59.6%), and geographic area (75.5-47.4%). Ad hoc PCI per se was not independently related to PCI success or complications.

CONCLUSIONS

PCI success was related to patient/lesion related factors and not to the performance of ad hoc PCIs per se. Although ad hoc PCI can be performed in more patients than at present, this strategy will never be possible in all patients at all times.

Are Drug-Eluting Stents the Preferred Treatment for Multivessel Coronary Artery Disease?

Drug-eluting stents (DES) constitute a major breakthrough in restenosis prevention after initial percutaneous coronary intervention (PCI). Target lesion and vessel revascularization rates of <10% at six months follow-up represent a significant medical advance. Many cardiologists consider it reasonable to assume that PCI using DES ought to be considered equivalent, if not superior, to bypass surgery. The argument made is that in previous randomized clinical trials comparing PCI to coronary artery bypass grafting, restenosis was the determining factor favoring surgery, an event that clinical experience suggests is no longer as frequent. In the absence of a definitive clinical trial to support this view, how should the prudent, cutting edge cardiologist evaluate the data and manage their patients?

Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines

BACKGROUND

An American College of Cardiology/American Heart Association (ACC/AHA) Task Force periodically revises and publishes guidelines with evidence-based recommendations for appropriate use of percutaneous coronary intervention (PCI). Some studies have suggested that closer adherence to guidelines can reduce variations in care, can improve quality, and may ultimately result in better outcomes, but this finding is incompletely understood. Guidelines themselves must change to be responsive to continuously evolving clinical practice. Our goal here was to investigate whether any relationship existed between the most recent ACC/AHA recommended indications for PCI and short term in-hospital outcomes.

METHODS AND RESULTS

We analyzed the ACC National Cardiovascular Data Registry for the period of January 1, 2001, through March 31, 2004. We excluded PCI procedures performed for acute myocardial infarction (ST-segment elevation myocardial infarction); all others were grouped by their indications according to the standard ACC/AHA scheme: Class I, evidence and/or agreement that PCI is useful and effective; Class IIa, conflicting evidence and/or divergent opinions, weight is in favor; Class IIb, usefulness/efficacy is less well established; and Class III, evidence and/or agreement that PCI is not useful or effective and may be harmful. Clinical success was defined as angiographic success (<20% residual stenosis) at all lesions attempted without the adverse events of myocardial infarction, same-admission bypass surgery, or death. There were 412 617 PCI procedures included in the analysis. Frequency of indications was as follows: Class I, 64%; Class IIa, 21%; Class IIb, 7%; and Class III, 8%. Clinical success declined across the indications classes (92.8%, 91.7%, 89%, and 85.5%, respectively; P<0.001), whereas adverse events increased.

CONCLUSIONS

In this large survey of contemporary PCI practice, most procedures were performed for Class I indications. A significant relationship between evidence-based indications recommended by the ACC/AHA Task Force and in-hospital outcomes was noted.

Mortality after emergent percutaneous coronary intervention in cardiogenic shock secondary to acute myocardial infarction and usefulness of a mortality prediction model

Although percutaneous coronary intervention (PCI) in the setting of cardiogenic shock has a high in-hospital mortality rate, it has been shown to decrease the mortality rate in certain subgroups. The identity and relative importance of variables that are predictive of in-hospital mortality rate after PCI for cardiogenic shock are uncertain. Accordingly, we examined data of >300,000 patients in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) that were collected from 1998 to 2002 and evaluated the outcomes in 483 consecutive patients who underwent emergency PCI for cardiogenic shock. Patients' mean age was 65 +/- 13 years, with men predominating (61%). All underwent emergency/salvage PCI in the setting of cardiogenic shock after acute myocardial infarction. Mean left ventricular ejection fraction was 30 +/- 16%. Stents were placed in 64% of patients, and thrombolytic agents were administered in 26%. Although PCI was angiographically successful in 79% of patients, the in-hospital mortality rate was 59.4%. Length of stay after PCI was 7.2 +/- 8 days. Logistic regression using all available variables identified 6 multivariate predictors of death: age (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.68 to 3.28, p <0.001) for each 10-year increment, female gender (OR 1.55, 95% CI 1.00 to 2.41, p <0.001), baseline renal insufficiency (creatinine >2.0 mg/dl; OR 4.69, 95% CI 1.96 to 11.23, p <0.001), total occlusion in the left anterior descending artery (OR 1.99, 95% confidence interval 1.28 to 3.09, p <0.01), no stent used (OR 2.55, 95% CI 1.63 to 3.96, p <0.01), and no glycoprotein IIb/IIIa inhibitor used during PCI (OR 1.96, 95% CI 1.30 to 2.98, p <0.01). In a second analysis using only variables known to the clinician at the time of initial presentation, gender, age, renal insufficiency, and total occlusion of the left anterior descending coronary artery were significant. In conclusion, analysis of patients from the ACC-NCDR who underwent emergency PCI for acute myocardial infarction in the presence of cardiogenic shock shows an in-hospital mortality rate of approximately 60% when PCI is attempted.

Hormone Therapy and Selective Estrogen Receptor Modulators for Prevention of Coronary Heart Disease in Postmenopausal Women

Coronary heart disease is the leading cause of morbidity and mortality in women older than the age of 50 in the United States today. Traditional cardiovascular risk factors (hyperlipidemia, glucose intolerance, and hypertension) are more clearly associated with significant cardiovascular risk after menopause. The increased incidence of cardiovascular events in postmenopausal women and the evidence that cardiovascular disease on average manifests a decade later in women compared with men suggests that estrogen deficiency may predispose women to a higher cardiovascular risk. Numerous biologic mechanisms have been proposed that relate use of hormone therapy (HT) to improved lipid profiles, insulin sensitivity, and vascular reactivity. Early observational trials in the last 2 decades showed a significant decrease in cardiovascular events. Recently published randomized clinical trial results, however, have led to uncertainty about the earlier established cardiovascular benefits of HT. To complicate issues further, alternative estrogenlike compounds, selective estrogen receptor modulators, are being introduced that appear to convey similar cardiovascular benefit and notably less cancer risk than HT. The newly released randomized trials on hormone and nonhormonal agents are reviewed.

Changes in coronary endothelial function predict progression of allograft vasculopathy after heart transplantation

OBJECTIVE

Coronary endothelial dysfunction may be an early marker for cardiac allograft vasculopathy (CAV) in orthotopic heart transplant recipients. We used serial studies to evaluate changes in coronary endothelial function in patients with and without clinically evident CAV.

BACKGROUND

In serial studies with intravascular ultrasound (IVUS) and Doppler flow wire measurements, we previously demonstrated that annual decrements in coronary endothelial function are associated with progressive intimal thickening.

METHODS

We studied 45 patients annually, beginning at transplantation until pre-specified end-points (angiographic CAV or cardiac death) were reached. At each study, we measured coronary endothelial function using intracoronary infusions of adenosine, acetylcholine, and nitroglycerin. We simultaneously recorded IVUS images and Doppler velocities.

RESULTS

Of the 45 patients studied, 9 reached end-points during the study (6 had CAV and 3 died). The mean annual change in area response to acetylcholine was -4.5% +/- 3.0% in patients who reached end-points and -0.9% +/- 1.5% in those who did not (p = 0.04). The mean annual decrement in flow response to acetylcholine was greater in patients who reached end-points (-31% +/- 11% vs -5% +/- 5%, p = 0.08). Responses to adenosine and nitroglycerin did not differ.

CONCLUSIONS

When serial responses were evaluated, patients with end-points had more rapid decreases in endothelial function. The rate of disease progression may be more important than the absolute degree of intimal thickening in early CAV. These data implicate endothelial dysfunction in the development of clinically significant vasculopathy and suggest that serial studies of endothelial function may provide important prognostic information about the development of CAV after heart transplantation.

Drug-eluting stent task force: Final report and recommendations of the working committees on cost-effectiveness/economics, access to care, and medicolegal issues

Coronary artery disease remains a major health problem worldwide. Since introduction of percutaneous transluminal coronary angioplasty and stents, much progress has been made. Percutaneous coronary intervention, however, has been limited by restenosis (repeat obstruction of arteries that have been previously treated. Introduction of drug-eluting stents (DESs) in April 2003 was a major breakthrough in preventing restenosis. In March 2003, The Society for Cardiovascular Angiography and Interventions (SCAI) published a position statement on the clinical implications of DESs, recommending an evidence-based adoption strategy. Subsequently, in May 2003, SCAI formed a multidisciplinary Drug Eluting Stent (DES) Task Force to address the significant nonclinical ramifications posed by DESs: medicolegal, financial, and access to care. The Task Force included representatives from physician societies, industry, academia, the reimbursement community, and health policy organizations. The resultant report presents analyses, options, and recommendations regarding those nonclinical issues based on the collective experience and knowledge of the Task Force members. The Task Force trusts that this report will be of value to the diverse constituencies involved with introduction of this important new technology.

Occupational hazards of interventional cardiologists: Prevalence of orthopedic health problems in contemporary practice

Invasive cardiologists generally consider radiation to be the chief occupational hazard. Heavy leaded aprons worn to reduce this risk may be associated with orthopedic complications. This study was designed to characterize the prevalence of these occupational health problems. The Interventional Committee of the Society for Cardiac Angiography and Interventions (SCAI) sent to its Internet-registered members a Web-based survey. Inquiries included age, years of invasive practice, and diagnostic/interventional cases/year. Questions (yes/no) focused on orthopedic (spine, hips, knees, and ankles) and radiation-associated problems (cataracts and cancers). The survey was sent to over 1,600 members with 424 responses. Responders were on average busy and experienced, performing catheterization > 10 years in 62% of cases and > 20 years in 24% others. Average annual diagnostic-only case load was > 200/year in 72%, > 300/year in 43%, and > 500/year in 18% of responders. Reported annual interventional caseload was > 100/year in 83%, > 200/year in 37%, and > 300/year in 15% of operators. Orthopedic problems included spine problems in 42% of responders (of these, 70% were lumbosacral and 30% cervical). Hip, knee, or ankle problems were noted in 28% of operators. Spine problems were related to the annual procedural caseload and the number of years in practice. Over one-third reported spine problems had caused them to miss work. The results of the radiation queries were inconclusive. These results document that interventional cardiologists commonly suffer orthopedic disease, frequently leading to lost work days.

SCAI statement on ad hoc versus the separate performance of diagnostic cardiac catheterization and coronary intervention

Coronary intervention may be combined with diagnostic cardiac catheterization or performed separately. In the early years of angioplasty, performing these procedures separately was standard practice. Gradually, ad hoc intervention (performing diagnostic angiography and coronary intervention within the same session) has become more common, largely because of its convenience for patients and efficiency for physicians. However, the safety and potential cost savings of this approach remain uncertain. Criteria for the appropriate use of ad hoc intervention have not been established. Ad hoc intervention is reasonable for many, but not appropriate for all patients and should not be considered standard therapy. This document updates an earlier review of this topic and provides suggestions for the use of ad hoc intervention as a routine strategy.

Updated risk adjustment mortality model using the complete 1.1 dataset from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR)

OBJECTIVES

To revise and update a risk adjustment model for in-hospital mortality following percutaneous coronary intervention (PCI) procedures using all data from the 1.1 version of the American College of Cardiology National Cardiovascular Data Registry (ACC-NCR).

BACKGROUND

A model based on data received at the ACC-NCDR from 1998-2000 was previously reported. The revision of this mortality model reflects all of the data submitted using 1.1 data specifications and collected through the second quarter of 2001. The model was applied to selected high-risk subgroups from a sample of data collected during the year 2001 from version 2.0 of the NCDR.

METHODS

Data on 173,743 PCI procedures collected at the ACC-NCDR between January 1, 1998 and March 31, 2001 were analyzed. A mortality model was generated as well as separate models for presentation with and without acute myocardial infarction within 24 hours. The model was used to generate predicted mortalities that were compared to observed mortalities in more current high-risk patient subgroups in the NCDR.

RESULTS

The same factors that were previously found to be associated with increased risk of PCI mortality were re-verified in the current analysis. Inclusion of the complete 1.1 dataset produced some changes in the regression weights and the constant value. Excellent discrimination was achieved in the revised model (C-Index = 0.89). The model was applied to high-risk patient groups from data collected on 76,249 during the calendar year 2001 using the 2.0 NCDR data elements and definitions. These analyses showed a high level of agreement between observed mortality of each subgroup and the predicted mortality rates generated from the revised 1.1 PCI mortality model.

CONCLUSIONS

Risk adjustment models for in-hospital mortality following PCI for all patients and for those with and without recent MI were regenerated using all data collected from the 1.1 data specifications of the ACC-NCDR and validated on high-risk groups from data collected during 2001 under data version 2.0 of the NCDR. These models reflect the most up-to-date analysis of mortality prediction from this large, multi-center national database.

Improved in-hospital outcomes in acute coronary syndromes (unstable angina/non-ST segment elevation myocardial infarction) despite similar TIMI risk scores

BACKGROUND

The Thrombolysis In Myocardial Infarction (TIMI) Risk Score has been shown to predict prognosis in acute coronary syndromes (ACS) comprised of unstable angina (UA) and non-ST segment elevation myocardial infarction (STEMI). We sought to evaluate the impact of newer antiplatelet and antithrombotic therapies for ACS, such as glycoprotein IIb/IIIa inhibitors (GPI) and low molecular weight heparin (LMWH), on in-hospital outcomes over time in patients (pts) with similar TIMI risk scores.

METHODS

The baseline demographics and clinical outcomes of pts with ACS (UA and non-STEMI) in 1998 (Group 1998) and 2000 (Group 2000) at a single large university medical center were compared using a prospectively collected database. In-hospital major adverse cardiac events (MACE) included death, MI, or recurrent angina that resulted in urgent revascularization. Risk was estimated by utilizing the TIMI Risk Score, which uses 7 predictor variables: age > 65 years, at least 3 risk factors for coronary artery disease, prior coronary stenosis of 50%, ST segment deviation on EKG, severe angina, prior aspirin use, and elevated cardiac biomarkers.

RESULTS

Comparing Group 1998 (n = 563) and Group 2000 (n = 604), there was no difference between the mean TIMI Risk Score (2.90 1.52 vs. 2.91 1.52; p = 0.97), demonstrating a similar risk profile. Nevertheless, significant improvement in in-hospital MACE (9.1% vs. 2.8%; p < 0.001) was noted. The improvement in MACE was due to differences in rates of recurrent angina, without significant differences in death and myocardial infarction. This occurred temporally in association with a significant increase in GPI (1.0% vs. 8.3%; p < 0.01) and LMWH (0.0% vs. 15.6%; p < 0.001) use within 24 hours of presentation, and the increased utilization of intracoronary stenting (46.6% vs. 64.6%; p = 0.005), findings which were confirmed with multivariate analysis.

CONCLUSION

Despite similar TIMI Risk Scores, the in-hospital outcomes of pts with ACS have improved over time. This temporal change is associated with the greater use of newer antiplatelet and antithrombotic therapies and increased utilization of intracoronary stenting.