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Pack QR, Priya A, Lagu T, Pekow PS, Schilling JP, Hiser WL, Lindenauer PK. Association Between Inpatient Echocardiography Use and Outcomes in Adult Patients With Acute Myocardial Infarction. JAMA Intern Med 2019; 179:1176-1185. [PMID: 31206134 PMCID: PMC6580445 DOI: 10.1001/jamainternmed.2019.1051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes. OBJECTIVE To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019. EXPOSURES Rates of transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate. RESULTS Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results. CONCLUSIONS AND RELEVANCE In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.
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Affiliation(s)
- Quinn R Pack
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield.,Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Aruna Priya
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Penelope S Pekow
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,School of Public Health and Health Sciences, University of Massachusetts, Amherst
| | - Joshua P Schilling
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - William L Hiser
- Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield.,Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield.,Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
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Mukherjee JT, Beshansky JR, Ruthazer R, Alkofide H, Ray M, Kent D, Manning WJ, Huggins GS, Selker HP. In-hospital measurement of left ventricular ejection fraction and one-year outcomes in acute coronary syndromes: results from the IMMEDIATE Trial. Cardiovasc Ultrasound 2016; 14:29. [PMID: 27488569 PMCID: PMC4973066 DOI: 10.1186/s12947-016-0068-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/22/2016] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND In patients with acute coronary syndrome (ACS), reduced left ventricular ejection fraction (LVEF) is a known marker for increased mortality. However, the relationship between LVEF measured during index ACS hospitalization and mortality and heart failure (HF) within 1 year are less well-defined. METHODS We performed a retrospective analysis of 445 participants in the IMMEDIATE Trial who had LVEF measured by left ventriculography or echocardiogram during hospitalization. RESULTS Adjusting for age and coronary artery disease (CAD) history, lower LVEF was significantly associated with 1-year mortality or hospitalization for HF. For every 5 % LVEF reduction, the hazard ratio [HR] was 1.26 (95 % CI 1.15, 1.38, P < 0.001). Participants with LVEF < 40 % had higher hazard of 1-year mortality or HF hospitalization than those with LVEF > 40 (HR 3.59; 95 % CI 2.05, 6.27, P < 0.001). The HRs for the association of LVEF with the study outcomes were similar whether measured by left ventriculography or by echocardiography, (respectively, HR 1.32; 95 % CI 1.15, 1.51 and 1.21; 95 % CI 1.106, 1.35, interaction P = 0.32) and whether done within 24 h or not within 24 h (respectively, HR 1.28; 95 % CI 1.10, 1.50 and 1.23; 95 % CI 1.10, 1.38, interaction P = 0.67). CONCLUSIONS Among patients with ACS, lower in-hospital LVEF is associated with increased 1-year mortality or hospitalization for HF, regardless of the method or timing of the LVEF assessment. This has prognostic implications for clinical practice and suggests the possibility of using various methods of LVEF determination in clinical research.
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Affiliation(s)
- Jayanta T Mukherjee
- Clinical and Translational Science Graduate Program, Sackler School of Biomedical Sciences, Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.,Department of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA, USA.,Riverside Methodist Hospital, Ohio Health Heart and Vascular Physicians, Columbus, OH, USA
| | - Joni R Beshansky
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #63, Boston, MA, 02111, USA.,Regis College, Weston, MA, USA
| | - Robin Ruthazer
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #63, Boston, MA, 02111, USA.,Department of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA, USA
| | - Hadeel Alkofide
- Clinical and Translational Science Graduate Program, Sackler School of Biomedical Sciences, Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.,College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Madhab Ray
- Clinical and Translational Science Graduate Program, Sackler School of Biomedical Sciences, Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - David Kent
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #63, Boston, MA, 02111, USA
| | - Warren J Manning
- Department of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA, USA
| | - Gordon S Huggins
- MCRI Center for Translational Genomics, Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA, USA
| | - Harry P Selker
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #63, Boston, MA, 02111, USA. .,Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.
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3
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Lee HH, Lee WH, Chiu CA, Chu CY, Hsu PC, Su HM, Lin TH, Voon WC, Lai WT, Sheu SH. The Current Status of Performing Left Ventriculography in Taiwan. ACTA CARDIOLOGICA SINICA 2016; 32:49-54. [PMID: 27122930 DOI: 10.6515/acs20150520b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Left ventriculography (LVG) is a gold standard examination of left ventricular function, although it also involves a small but significant risk of complications. However, it was recently reported to be overused in the USA in comparison to an alternative imaging modality. In this study, our aim was to analyze the real-world use of LVG in Taiwan. METHODS This cohort study analyzed the data in the Taiwan National Health Insurance Bureau database for patients undergoing coronary angiography from 1996-2008. The most recent imaging modalities were used to evaluate left ventricular function including echocardiography and single-photon emission computed tomography (SPECT) within 30-day. The primary outcome was the concomitant use of LVG during coronary angiography. RESULTS Of 8653 patients who underwent coronary angiography, LVG was performed on 4634 (53.6%) of those study participants. The frequency of LVG use was lower in the groups indicating left ventricular function evaluation, including acute myocardial infarction, heart failure and shock (49.5 vs. 57.1%, p < 0.001). In the population that had undergone a recent left ventricular assessment, the use of LVG was lower (52.2% vs. 54.7%, p = 0.03). Multivariate analysis found that 30-day imaging tests are not a predictor for use of LVG. CONCLUSIONS In Taiwan, about one half of those patients whose data we reviewed actually received coronary angiography and LVG at the same time. Ultimately, we found that there was no overuse of LVG in those patients with recent alternative imaging modality performed. KEY WORDS Angiography; Coronary; Ventriculography.
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Affiliation(s)
- Hung-Hao Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Wen-Hsien Lee
- Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital
| | - Cheng-An Chiu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ho-Ming Su
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chol Voon
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hsiung Sheu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Papolos A, Narula J, Bavishi C, Chaudhry FA, Sengupta PP. U.S. Hospital Use of Echocardiography. J Am Coll Cardiol 2016; 67:502-11. [DOI: 10.1016/j.jacc.2015.10.090] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/15/2022]
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Ng VG, Lansky AJ, Meller S, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie B, Shah R, Mehran R, Stone GW. The prognostic importance of left ventricular function in patients with ST-segment elevation myocardial infarction: the HORIZONS-AMI trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 3:67-77. [PMID: 24562805 DOI: 10.1177/2048872613507149] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM Left ventricular (LV) dysfunction during and after hospitalization for ST-segment elevation myocardial infarction (STEMI) is associated with increased mortality. Whether baseline LV dysfunction impacts STEMI outcomes is not well studied. Furthermore, whether bivalirudin and paclitaxel-eluting stents (PES) are beneficial in patients with LV dysfunction is unknown. We studied the impact of left ventricular ejection fraction (LVEF) on outcomes of patients with STEMI in the HORIZONS-AMI trial. METHODS LVEF was determined in 2648 (73.5%) of 3602 enrolled STEMI patients, who were divided into three groups according to LV function: (1) severely impaired (LVEF <40%); (2) moderately impaired (LVEF 40-50%); and (3) normal (LVEF ≥50%). RESULTS Compared to patients with normal LV function, those with severely impaired LVEF had higher 1-year rates of net adverse clinical events (27.1 vs. 14.2%, p<0.0001), major adverse cardiovascular events (20.7 vs. 9.5%, p<0.0001), cardiac death (10.6 vs. 1.2%, p<0.0001), and non-coronary artery bypass graft major bleeding (12.5 vs. 6.6%, p=0.001), differences which persisted after adjustment for baseline characteristics. Among patients with LVEF <40%, treatment with bivalirudin compared to heparin+GPIIb/IIIa inhibitors resulted in reduced 1-year mortality (5.8 vs. 18.3%, p=0.007). Patients with LVEF <40% receiving PES rather than bare metal stents had lower rates of 1-year ischaemia-driven target lesion revascularization (2.9 vs. 12.6%, p=0.02) and reinfarction (4.5 vs. 14.7%, p=0.03). CONCLUSIONS Among patients with STEMI undergoing primary percutaneous coronary intervention, adverse events are markedly increased in those with LVEF <40% during the index revascularization procedure. Nevertheless, these high-risk patients experience substantial clinical benefits from bivalirudin and PES.
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Affiliation(s)
- Vivian G Ng
- Yale University School of Medicine, New Haven, CT, USA
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Miller AL, Dib C, Li L, Chen AY, Amsterdam E, Funk M, Saucedo JF, Wang TY. Left Ventricular Ejection Fraction Assessment Among Patients With Acute Myocardial Infarction and Its Association With Hospital Quality of Care and Evidence-Based Therapy Use. Circ Cardiovasc Qual Outcomes 2012; 5:662-71. [DOI: 10.1161/circoutcomes.112.965012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The left ventricular ejection fraction (LVEF) has prognostic and therapeutic utility after acute myocardial infarction (AMI). Although LVEF assessment is a key performance measure among AMI patients, contemporary rates of in-hospital assessment and its association with therapy use have not been well characterized.
Methods and Results—
We examined rates of in-hospital LVEF assessment among 77 982 non–ST-elevation myocardial infarction patients and 50 863 ST-elevation myocardial infarction patients in Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines between January 2007 and September 2009, after excluding patients who died in-hospital or who were transferred to another acute care facility, discharged to end-of-life care, or had missing LVEF assessment status. LVEF assessment increased significantly over time, with higher rates among ST-elevation myocardial infarction than non–ST-elevation myocardial infarction patients (95.1% versus 91.6%;
P
<0.001). Excluding patients with prior heart failure did not alter these observations. Significant interhospital variability in LVEF assessment rates was observed. Compared with patients with in-hospital LVEF assessment, patients who did not have LVEF assessed were older and more likely to have clinical comorbidities. In multivariable modeling, lower overall hospital quality of AMI care was also associated with lower likelihood of LVEF assessment (odds ratio for failure to assess LVEF, 1.09; 95% confidence interval, 1.05–1.13 per 10% decrease in defect-free care). Patients with in-hospital LVEF assessment were more likely to be discharged on evidence-based secondary prevention medication therapies compared with paients without LVEF assessment.
Conclusions—
The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.
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Affiliation(s)
- Amy Leigh Miller
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Chadi Dib
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Li Li
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Anita Y. Chen
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Ezra Amsterdam
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Marjorie Funk
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Jorge F. Saucedo
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
| | - Tracy Y. Wang
- From the Brigham and Women’s Hospital, Cardiovascular Electrophysiology, Boston, MA (A.L.M.); University of Oklahoma Health Sciences Center, Division of Cardiovascular Diseases, Oklahoma City (C.D., J.F.S.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (L.L., A.Y.C., T.Y.W.); University of California–Davis, Division of Cardiovascular Medicine, Sacramento, CA (E.A.); and Yale University, School of Nursing, New Haven, CT (M.F.)
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Witteles RM, Knowles JW, Perez M, Morris WM, Spettell CM, Brennan TA, Heidenreich PA. Use and overuse of left ventriculography. Am Heart J 2012; 163:617-23.e1. [PMID: 22520528 DOI: 10.1016/j.ahj.2011.12.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 12/22/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Left ventriculography provided the first imaging of left ventricular function and was historically performed as part of coronary angiography despite a small but significant risk of complications. Because modern noninvasive imaging techniques are more accurate and carry smaller risks, the routine use of left ventriculography is of questionable utility. We sought to analyze the frequency that left ventriculography was performed during coronary angiography in patients with and without a recent alternative assessment of left ventricular function. METHODS We performed a retrospective analysis of insurance claims data from the Aetna health care benefits database including all adults who underwent coronary angiography in 2007. The primary outcome was the concomitant use of left ventriculography during coronary angiography. RESULTS Of 96,235 patients who underwent coronary angiography, left ventriculography was performed in 78,705 (81.8%). Use of left ventriculography was high in all subgroups, with greatest use in younger patients, those with a diagnosis of coronary disease, and those in the Southern United States. In the population who had undergone a very recent ejection fraction assessment by another modality (within 30 days) and who had had no intervening diagnosis of new heart failure, myocardial infarction, hypotension, or shock (37,149 patients), left ventriculography was performed in 32,798 patients (88%)-a rate higher than in the overall cohort. CONCLUSIONS Left ventriculography was performed in most coronary angiography cases and often when an alternative imaging modality had been recently completed. New clinical practice guidelines should be considered to decrease the overuse of this invasive test.
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Jedrzkiewicz S, Goodman SG, Yan RT, Grondin FR, Gallo R, Welsh RC, Lai K, Huynh T, Yan AT. Evaluation of left ventricular ejection fraction in non-ST-segment elevation acute coronary syndromes and its relationship to treatment. Am Heart J 2010; 159:605-11. [PMID: 20362719 DOI: 10.1016/j.ahj.2010.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 01/29/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND In-hospital assessment of left ventricular ejection fraction (LVEF) in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is emphasized in current practice guidelines. There are limited data regarding the evaluation of LVEF and clinical characteristics and in-hospital management in the "real world." METHODS Registries including the Canadian Acute Coronary Syndrome (ACS) I and II, Global Registry of Acute Coronary Events (main GRACE/expanded GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 13,703 NSTE-ACS patients across Canada between 1999 and 2008. Patients were stratified by in-hospital LVEF measurement, and LVEF was categorized as normal, mildly, or moderately to severely impaired. We compared clinical characteristics, cardiac procedures, and clinical outcomes across these groups. Multivariable logistic regression identified factors independently associated with the assessment of LVEF. RESULTS Overall, 8,116 patients (59.2%) had LVEF measurement, and of the 7,667 patients with available LVEF data, 4,470 (58.3%) had normal, 1,916 (25%) mildly impaired, and 1,281 (16.7%) moderately to severely impaired LVEF. Patients with LVEF assessment more frequently (all P < .001) underwent cardiac catheterization, percutaneous coronary intervention or coronary bypass surgery, and had higher (both P < .001) rates of myocardial (re) infarction and heart failure. In-hospital reinfarction, higher Killip class, abnormal biomarker, hospital stay >10 days, and on-site cardiac catheterization facility were independently associated with LVEF assessment. Despite increasing LVEF assessment over time (P for trend < .001), 31.2% of patients in the most recent registry (2008) had no in-hospital LVEF assessment. CONCLUSIONS In-hospital LVEF assessment is not performed in many NSTE-ACS patients. The LVEF assessment, associated with increased use of evidence-based therapies and invasive cardiac procedures, was obtained more frequently in patients with myocardial (re) infarction, heart failure on presentation, and prolonged hospital stay.
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Affiliation(s)
- Sean Jedrzkiewicz
- Terrence Donnelly Heart Center, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Joffe SW, Chalian A, Tighe DA, Aurigemma GP, Yarzebski J, Gore JM, Lessard D, Goldberg RJ. Trends in the use of echocardiography and left ventriculography to assess left ventricular ejection fraction in patients hospitalized with acute myocardial infarction. Am Heart J 2009; 158:185-92. [PMID: 19619693 DOI: 10.1016/j.ahj.2009.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 05/25/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although current guidelines strongly recommend the measurement of ejection fraction (EF) in all patients hospitalized with acute myocardial infarction (AMI), there are limited data available describing trends in the use of diagnostic modalities to assess EF in these patients. The purpose of this study was to evaluate trends in the use of ventriculography and echocardiography to measure EF in a community sample of patients hospitalized with AMI. METHODS The medical records of 5,380 residents of the Worcester (MA) metropolitan area hospitalized with AMI at 11 greater Worcester medical centers between 1997 and 2005 were reviewed. RESULTS Between 1997 and 2005, the proportion of patients hospitalized with AMI undergoing measurement of EF by both ventriculography and echocardiography increased from 11% to 18%, whereas the percentage of patients who did not receive an evaluation of EF by either modality decreased from 37% to 27%. The percentage of patients undergoing measurement of EF by ventriculography alone increased from 14% to 20%, whereas the percentage of patients undergoing measurement of EF by echocardiography alone remained stable at 37%. In 1997, echocardiography was performed before ventriculography in approximately two thirds of hospitalized patients, whereas in 2005, ventriculography was performed before echocardiography in approximately two thirds of patients with AMI. CONCLUSIONS The use of left ventriculography and the concurrent use of both ventriculography and echocardiography to assess EF in patients with AMI are increasing. Although the proportion of patients who do not have their EF assessed has declined during recent years, many still do not receive a determination of their EF.
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