Clinical and economic effects of coronary restenosis after percutaneous coronary intervention in a managed care population

PURPOSE

The epidemiology of coronary restenosis after percutaneous coronary intervention (PCI) has been documented extensively in clinical trials, but no data exist on the clinical and economic burden of restenosis in a managed care population.

DESIGN

Retrospective cohort with a nationally representative managed care claims database (IHCIS, Waltham, Mass.) representing 2.8 million members.

METHODOLOGY

Patients undergoing initial PCI between 1/1/00 and 12/31/00 (N=3,258) were identified and followed to 1 year. Clinical events, resource use, and costs between 1 month and 1 year after the initial PCI were identified. The clinical restenosis rate was estimated by multiplying the observed repeat revascularization rate by 0.85, based on previously published studies. All costs are reported from a managed care perspective in Year 2000 dollars.

PRINCIPAL FINDINGS

Overall, 14.7 percent of patients required 1 or more repeat revascularization procedures between 1 month and 1 year after initial PCI, which implies an estimated clinical restenosis rate of 12.5 percent. Mean 1-year costs were nearly 6-fold higher among patients with and without repeat revascularization (dollars 31,954 +/- dollars 31,857 vs. dollars 5,474 +/- dollars 12,006, P<.001). After adjusting for baseline imbalances, the independent incremental cost for each patient with repeat revascularization was dollars 24,955 (95 percent confidence interval, dollars 23,401-dollars 26,510). Annual follow-up costs attributable to restenosis were dollars 3,118 per initial PCI recipient (i.e., dollars 24,955 x 12.5 percent).

CONCLUSION

Clinical restenosis occurred in approximately 12.5 percent of real-world managed care PCI patients and increased health care costs by an average of dollars 3,118 per patient. These findings have important implications for the cost-effectiveness of new treatments that substantially reduce restenosis.

Quality of care of international and Canadian medical graduates in acute myocardial infarction

BACKGROUND

International medical graduates (IMGs) make up a substantial proportion of the physician workforce and play an important role in the care of patients with acute myocardial infarction (AMI). There are concerns that IMGs may provide inferior medical care compared with locally trained medical graduates, but that has not been established.

METHODS

We performed a retrospective cohort study of linked administrative databases containing health care claims of physicians' service payments, hospital discharge abstracts, and patients' vital status. We included 127,275 AMI patients admitted between April 1, 1992, and March 31, 2000, to acute care hospitals in Ontario. We then compared the risk-adjusted mortality rates and adjusted use of secondary prevention medications and cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates.

RESULTS

Of the 127,275 admitted AMI patients, 28,061 (22.0%) were treated by IMGs and 99,214 (78.0%) by Canadian medical graduates. The risk-adjusted mortality rates of IMG- and Canadian medical graduate-treated patients were not significantly different at 30 days (13.3% vs 13.4%, P = .57) and at 1 year (21.8% vs 21.9%, P = .63). Furthermore, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medications at 90 days and cardiac invasive procedures at 1 year.

CONCLUSIONS

The use of secondary prevention medications and cardiac procedures and the mortality of AMI patients were similar, regardless of the origin of medical education of the admitting physician. This information places the care provided by IMGs into perspective and supports the ability of well-selected IMGs in caring for AMI patients.

Gender disparities in the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative

OBJECTIVES

We hypothesized that significant disparities in gender exist in the management of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS).

BACKGROUND

Gender-related differences in the diagnosis and treatment of ACS have important healthcare implications. No large-scale examination of these disparities has been completed since the publication of the revised American College of Cardiology/American Heart Association guidelines for management of patients with NSTE ACS.

METHODS

Using data from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative, we examined differences of gender in treatment and outcomes among patients with NSTE ACS.

RESULTS

Women (41% of 35,875 patients) were older (median age 73 vs. 65 years) and more often had diabetes and hypertension. Women were less likely to receive acute heparin, angiotensin-converting enzyme inhibitors, and glycoprotein IIb/IIIa inhibitors and less commonly received aspirin, angiotensin-converting enzyme inhibitors, and statins at discharge. The use of cardiac catheterization and revascularization was higher in men, but among patients with significant coronary disease, percutaneous revascularization was performed in a similar proportion of women and men. Women were at higher risk for unadjusted in-hospital death (5.6% vs. 4.3%), reinfarction (4.0% vs. 3.5%), heart failure (12.1% vs. 8.8%), stroke (1.1% vs. 0.8%), and red blood cell transfusion (17.2% vs. 13.2%), but after adjustment, only transfusion was higher in women.

CONCLUSIONS

Despite presenting with higher risk characteristics and having higher in-hospital risk, women with NSTE ACS are treated less aggressively than men.

Unprotected percutaneous coronary intervention is safe and effective for treating unstable angina in the modern warrior: the second Gulf War experience at Landstuhl Regional Medical Center, Germany

BACKGROUND

Evacuation of soldiers with acute coronary syndromes to U.S. hospitals has been the treatment strategy of choice. However, percutaneous coronary intervention (PCI) complication rates have decreased to the point that it is feasible to bring this therapy forward.

METHODS

Patients presenting with acute coronary syndromes during Operation Iraqi Freedom (March 2003 to June 2003] were evacuated to Landstuhl Regional Medical Center, Germany. Patients with a high clinical risk but a low interventional risk were selected for unprotected PCI.

RESULTS

PCI was successfully accomplished for 93% of patients (13 of 14 patients). One patient had a 1-month history of progressive angina and a chronic total lesion that could not be crossed. There were no major complications.

CONCLUSION

Patients with acute coronary syndromes who are risk-stratified can be safely treated with PCI at overseas military hospitals lacking cardiothoracic surgical back-up assistance. This strategy minimizes the risk of transoceanic evacuation of this patient population.

Drug therapy during percutaneous coronary interventions in stable and unstable coronary artery disease: the Italian Drug Evaluation in Angioplasty (IDEA) study

BACKGROUND

Although periprocedural drug therapy has been shown to improve the outcome of percutaneous coronary intervention (PCI), information regarding its use in daily clinical practice is limited.

METHODS

We conducted a national survey on periprocedural drug therapy across the spectrum of PCI practice in Italy. Seventy-nine centers (41% of the Italian interventional cath labs) with a fair distribution across the country volunteered to enroll consecutive patients undergoing PCI for any indication from September 15 to 29, 2003.

RESULTS

Of the 1517 patients enrolled, 745 (49 %) had stable coronary disease and 772 (51%) acute coronary syndromes (ACS): 457 without and 315 with ST-segment elevation. Stenting was used in 89% of cases. N-acetylcysteine was used in 23% of the patients with preexisting renal dysfunction. Thienopyridine (63% clopidogrel) pretreatment was given in 49 % of the cases and, at logistic regression analysis, was independently associated with prior myocardial infarction (p < 0.001), prior PCI (p = 0.007), stable coronary disease (p = 0.005), and treatment in northern Italy (p < 0.05). Platelet glycoprotein (GP) IIb/IIIa receptor blockers (50% abciximab 50% tirofiban) were used in 22% of the stable patients and 40 % of those with ACS, a proportion increasing to 62 % when PCI was undertaken as an emergency procedure. Off-label use of these drugs was frequent (direct cath lab use of tirofiban in 55% of the cases; bailout use: 16% with abciximab and 26% with tirofiban). At logistic regression analysis, independent predictors of GP IIb/IIIa receptor blocker use were emergency procedure (odds ratio 3.6, 95 % confidence interval 2.6 to 5.0, p < 0.0001) and treatment for an ACS (odds ratio 1.6, 95% confidence interval 1.3 to 2.1, p = 0.0002). An emergency procedure was the only independent predictor for the use of abciximab instead of tirofiban (odds ratio 4.1, 95% confidence interval 2.6 to 6.5, p < 0.0001). Triple periprocedural antiplatelet therapy, including aspirin, a thienopyridine and a GP IIb/IIIa receptor blocker was administered in only 21% of cases. At discharge, all stented patients received aspirin and a thienopyridine. Despite complete procedural success in > 90% of cases, 50% of the patients were discharged on symptomatic anti-ischemic therapy.

CONCLUSIONS

A wide gap exists between guideline recommendations and periprocedural drug therapy in PCI, the only exception being full prescription of aspirin and a thienopyridine at discharge after stenting. In patients with ACS, thienopyridine pretreatment is often used as a surrogate for GP IIb/IIIa blockade, whose use rather is associated with emergency procedures. Off-label use of drugs is not uncommon.

Left main coronary artery disease: is CABG still the gold standard?

Severe stenosis of the left main coronary artery (LMCA) is a coronary artery-disease manifestation of critical prognostic importance. As a consequence of the survival advantage conferred by coronary artery bypass grafting (CABG) over medical therapy, lesions in the LMCA have been considered a standard indication for CABG for nearly 3 decades. Initial attempts to treat LMCA disease percutaneously by balloon angioplasty resulted in poor clinical outcomes, leading many to regard significant LMCA disease as a contraindication for percutaneous coronary intervention (PCI). However, the development and refinement of coronary stenting over the last 15 years, followed by the recent introduction of drug-eluting stents, has fueled renewed interest in percutaneous treatment of LMCA disease. Outcomes of recent studies using sirolimus- and/or paclitaxel-eluting stents for treatment of LMCA disease have yielded rates of in-hospital and 1-year mortality that compare favorably with those of surgery. This article will review the natural history of LMCA disease, the outcomes of CABG for LMCA disease, and the history and recent developments regarding PCI for LMCA disease.

Effect of continuous quality improvement analysis on the delivery of primary percutaneous revascularization for acute myocardial infarction: A community hospital experience

As time to reperfusion correlates with outcomes, a door-to-balloon time of 90 +/- 30 min for primary percutaneous coronary revascularization (PCI) for the treatment of acute myocardial infarction has been recently established as a guideline by the ACC/AHA. The purpose of this study is to assess the effects of a continuous quality assurance program designed to expedite primary angioplasty at a community hospital. A database of all primary PCI procedures was created in 1998. Two groups of consecutive patients treated with primary PCI were studied. Group 1 represented patients in the time period between 1 June 1998 to 1 November 1998 and group 2 represented patients in the period between 1 January 2000 and 16 June 2000. Continuous quality assurance analysis was performed. Modifications to the primary angioplasty program were initiated in the latter group. Time intervals to certain treatment landmarks were compared between the groups. Significant decreases in the time intervals from emergency room registration to initial electrocardiogram (8.4 +/- 8.2 vs. 3.7 +/- 19.5 min; P < 0.001), presentation to the catheterization laboratory to arterial access (13.5 +/- 12.9 vs. 11.6 +/- 5.8 min; P < 0.001), and emergency room registration to initial angioplasty balloon inflation (132.0 +/- 69.2 vs. 112 +/- 72.0 min; P < 0.001) were achieved. For the subgroup of patients presenting with diagnostic ST elevation myocardial infarction, a large decrease in the door-to-balloon time interval between group 1 and group 2 was demonstrated (114.15 +/- 9.67 vs. 87.92 +/- 10.93 min; P = NS), resulting in compliance with ACC/AHA guidelines. Continuous quality improvement analysis can expedite care for patients treated by primary PCI in the community hospital setting.

Percutaneous intervention for renovascular disease: rationale and patient selection

PURPOSE OF REVIEW

The anatomic diagnosis of renovascular disease is increasing in frequency due to the advent of sophisticated non-invasive imaging modalities such as MRA (Magnetic Resonance Angiography) and renal angiography at the time of cardiac catheterization. Despite this fact, the investigation and appropriate management of renovascular disease has remained a controversial topic. This review addresses the clinical syndromes associated with renal artery stenosis (RAS) and the published data guiding appropriate patient selection for revascularization.

RECENT FINDINGS

There is a growing literature in support of renal revascularization as an aid in improving anti-hypertensive control, preserving renal function, and easing the management of congestive heart failure. Meanwhile, technological advances have allowed intervention in an expanding pool of eligible patients. One such technology is the atheroembolic protection device, which may soon allow renal salvage in patients with significant baseline renal impairment that were previously denied intervention for fear of worsening renal function.

SUMMARY

The data reviewed herein helps to identify patients that will benefit from renal revascularization. Large-scale, randomized data further defining the role of renal revascularization and optimal patient selection is still needed.

Management strategies for cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock remains the most serious complication of acute MI, with an incidence of 6 to 8% and a 30-day mortality rate that remains close to 50%. While cardiogenic shock is due primarily to left ventricular failure, other causes such as acute mitral regurgitation and ventricular septal rupture must always be considered as emergency surgery may be life saving. The purpose of this review is to summarize recent advances in the care of these critically ill patients including the consideration of etiology and pathophysiology as well as the influence of age and adjunctive therapies.

RECENT FINDINGS

Early revascularization is now an American College of Cardiology/American Heart Association guideline class 1 indication for percutaneous coronary intervention (PCI) particularly for younger patients in cardiogenic shock. Recent studies suggest there may also be a benefit in elderly patients with cardiogenic shock.

SUMMARY

Prompt triage of all patients in cardiogenic shock for early angiography, intra-aortic balloon pump counterpulsation, and early revascularization with PCI or bypass surgery is now the preferred management strategy.

Primary angioplasty without on-site surgical back-up: the first experience with mobile catheterization facility

BACKGROUND AND OBJECTIVES

The aim of the present study is to assess the safety and efficacy of performing primary angioplasty in a center without on-site surgical back-up, and compare the data with the literature.

METHODS

Seventy-eight consecutive primary angioplasty procedures, performed in our center from January 2001 to February 2003, were followed prospectively. Clinical and demographic characteristics of the patients, procedural success, early and late outcomes of the patients were taken into account. The safety of angioplasty was assessed by the analysis of in-hospital complications (death, urgent need for repeat revascularization, AMI with or without ST-elevation and stroke). The angioplasty procedures were considered effective when the post-procedural residual stenosis did not exceed 50% with the distal Thrombolysis in Myocardial Infarction (TIMI) grade III flow.

RESULTS

The device success rate was 92.3%. Angiographic success rate was 88.8%. In hospital mortality rate was 4.1%. These patients were admitted with cardiogenic shock; 1 died during the procedure and the other 2 died during hospital follow-up. One patient died suddenly and another developed acute MI during the 6-month follow-up period. No patients developed stroke or were referred for urgent surgery. Four patients (5.5%) underwent repeat angioplasty during follow-up.

CONCLUSIONS

Primary angioplasty can be safely performed in centers without on-site surgery. The efficacy and safety requirements of angioplasty, performed in a center without on-site surgical back-up using a mobile catheterization facility were similar to the data obtained from the literature.