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Nezafati P, Ajani A, Dinh D, Brennan A, Clark D, Reid CM, Hiew C, Freeman M, Stub D, Chandrasekhar J, Sharma A, Oqueli E. Percutaneous coronary intervention outcomes based on American College of Cardiology/American Heart Association coronary lesion classification over 14 years - Melbourne interventional group (MIG) registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00540-2. [PMID: 38876940 DOI: 10.1016/j.carrev.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/25/2024] [Accepted: 06/10/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND The American College of Cardiology / American Heart Association (ACC/AHA) introduced a coronary lesion classification in 1988 to stratify coronary lesions for probability of procedural success and complications after coronary angioplasty. Our aim is to assess the validity of the ACC/AHA lesion classification in predicting outcomes of percutaneous coronary intervention (PCI) in a contemporary cohort of patients. METHODS Consecutive PCI procedures performed between 2005 and 2018, were divided into three periods. At each period, the ACC/AHA lesion classification (A, B1, B2, C) was analysed with respect to procedural characteristics, in-hospital and 30-day outcomes, as well as long-term mortality by linkage to the National Death Index (NDI). RESULTS In total, 21,437 lesions were included with 7399 lesions (2005-2009), 6917 lesions (2010-2014) and 7121 lesions (2015-2018). There was a progressive increase in the number of complex lesions treated over time with ACC/AHA type C (15 %, 21 % and 26 %, p < 0.01). The rate of PCI procedural success decreased with increase in the complexity of lesions treated across all three periods (p < 0.01). Further, in-hospital and 30-day major adverse cardiovascular events (MACE), major adverse cardiac and cerebrovascular events (MACCE) increased across all three time periods (all p < 0.05). CONCLUSIONS Our study validates the ACC/AHA lesion classification as a meaningful tool for prediction of PCI outcomes. Despite advances in PCI techniques and technology, complex lesion PCI defined by this classification continues to be associated with adverse outcomes.
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Affiliation(s)
- Pouya Nezafati
- Department of Cardiology, Grampians Health Ballarat, Ballarat, VIC, Australia; Department of Cardiothoracic Surgery, Townsville University Hospital, Queensland Health, Townsville, QLD, Australia
| | - Andrew Ajani
- School of Public Health and Preventive Medicine (SPHPM), Monash University, Melbourne, VIC, Australia; Department of Cardiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine (SPHPM), Monash University, Melbourne, VIC, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine (SPHPM), Monash University, Melbourne, VIC, Australia
| | - David Clark
- University of Melbourne, Melbourne, VIC, Australia; Department of Cardiology, Austin Health, Heidelberg, VIC, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine (SPHPM), Monash University, Melbourne, VIC, Australia; School of Population Health Curtin University, Perth, WA, Australia
| | - Chin Hiew
- Department of Cardiology, Barwon Health Service, Geelong, VIC, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Box Hill, VIC, Australia; Eastern Health Clinical School, Monash University, Clayton, VIC, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine (SPHPM), Monash University, Melbourne, VIC, Australia; Department of Cardiology, Alfred Health, Prahran, VIC, Australia
| | - Jaya Chandrasekhar
- Department of Cardiology, Eastern Health, Box Hill, VIC, Australia; Department of Cardiology, Alfred Health, Prahran, VIC, Australia
| | - Anand Sharma
- Department of Cardiology, Grampians Health Ballarat, Ballarat, VIC, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health Ballarat, Ballarat, VIC, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia.
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O'Brien JM, Dinh D, Roberts L, Teh A, Brennan A, Duffy SJ, Clark D, Ajani A, Oqueli E, Sebastian M, Reid C, Econ CH, Freeman M, Chandrasekhar J. Associations Between Metabolic Syndrome and Long-Term Mortality in Patients who underwent Percutaneous Coronary Intervention: An Australian Cohort Analysis. Am J Cardiol 2024; 219:25-34. [PMID: 38447892 DOI: 10.1016/j.amjcard.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 02/06/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
Metabolic syndrome (MetS) provides significant risk for coronary disease, however long-term prognosis after percutaneous coronary intervention (PCI) has been understudied. We assessed the prevalence and outcomes of patients with MetS from an Australian PCI cohort. We retrospectively examined data from the Melbourne Interventional Group multicenter PCI registry using a modified definition for MetS including ≥3 of the following: hypertension, diabetes mellitus, dyslipidemia, and body mass index ≥30 kg/m2. Thirty-day outcomes and long-term mortality were compared with patients without MetS. Cox regression methods were used to assess the multivariable effect of MetS on long-term mortality. Of 41,146 patients, 12,228 (34%) had MetS. Patients with MetS experienced greater 30-day myocardial infarction (2.2% vs 1.8%, p = 0.013), whereas patients without MetS had a trend for greater 30-day mortality (3.0% vs 3.4%, p = 0.051) and greater in-hospital major bleeding (1.7% vs 2.4%, p <0.001). After a median follow-up of 5.62 years (Q1 2.03, Q3 8.89), patients with MetS experienced greater mortality (24% vs 19%, p <0.001). After adjustment, MetS was not an independent predictor of long-term mortality (hazard ratio 0.95 confidence interval 0.86 to 1.05, p = 0.35). In sensitivity analyses, MetS-Diabetic patients had the highest, and MetS-NonDiabetic obese patients had the lowest long-term mortality. One in 3 patients who underwent all-comer PCI presented with MetS and experienced greater long-term mortality compared with others. However, this association was lost after adjustment for baseline confounders, highlighting that MetS is a marker of risk after PCI. Our findings support the obesity paradox and confirm robust associations between diabetes mellitus and long-term mortality.
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Affiliation(s)
- Joseph M O'Brien
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Andrew Teh
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine
| | - Stephen J Duffy
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine
| | - David Clark
- Department of Cardiology, Austin Health, Heidelberg, Victoria Australia; Department of Cardiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Service, Ballarat, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, University Hospital Geelong, Geelong, Victoria Australia
| | - Christopher Reid
- Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Cert Health Econ
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine; Royal Melbourne Hospital, Curtin University, Perth, Western Australia, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Jaya Chandrasekhar
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia.
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Dawson LP, Rashid M, Dinh DT, Brennan A, Bloom JE, Biswas S, Lefkovits J, Shaw JA, Chan W, Clark DJ, Oqueli E, Hiew C, Freeman M, Taylor AJ, Reid CM, Ajani AE, Kaye DM, Mamas MA, Stub D. No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score. Circ Cardiovasc Interv 2024; 17:e013738. [PMID: 38487882 DOI: 10.1161/circinterventions.123.013738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/31/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI. METHODS We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort). RESULTS A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively. CONCLUSIONS The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.
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Affiliation(s)
- Luke P Dawson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.)
- Department of Cardiovascular Sciences, National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, United Kingdom (M.R., A.E.A.)
- University Hospitals of Leicester National Health Service (NHS) Trust, United Kingdom (M.R., A.E.A.)
| | - Diem T Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - Sinjini Biswas
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia (J.L.)
| | - James A Shaw
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - William Chan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Medicine, Melbourne University, Victoria, Australia (W.C.)
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (D.J.C.)
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health Ballarat, Victoria, Australia (E.O.)
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia (E.O.)
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Victoria, Australia (C.H.)
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia (M.F.)
| | - Andrew J Taylor
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, Western Australia, Australia (C.M.R.)
| | - Andrew E Ajani
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.)
- Department of Cardiovascular Sciences, National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, United Kingdom (M.R., A.E.A.)
- University Hospitals of Leicester National Health Service (NHS) Trust, United Kingdom (M.R., A.E.A.)
| | - David M Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Stroke on Trent, United Kingdom (M.R., A.E.A., M.A.M.)
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (L.P.D., D.T.D., A.B., S.B., J.L., W.C., C.M.R., A.E.A., D.S.)
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., A.J.T., D.M.K., D.S.)
- The Baker Institute, Melbourne, Victoria, Australia (L.P.D., J.E.B., J.A.S., D.M.K., D.S.)
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Ho CLB, Si S, Brennan A, Briffa T, Stub D, Ajani A, Reid CM. Multimorbidity impacts cardiovascular disease risk following percutaneous coronary intervention: latent class analysis of the Melbourne Interventional Group (MIG) registry. BMC Cardiovasc Disord 2024; 24:66. [PMID: 38262972 PMCID: PMC10804750 DOI: 10.1186/s12872-023-03636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/27/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Multimorbidity is strongly associated with disability or functional decline, poor quality of life and high consumption of health care services. This study aimed (1) To identify patterns of multimorbidity among patients undergoing first recorded percutaneous coronary intervention (PCI); (2) To explore the association between the identified patterns of multimorbidity on length of hospital stay, 30-day and 12- month risk of major adverse cardiac and cerebrovascular events (MACCE) after PCI. METHODS A retrospective cohort study of the Melbourne Interventional Group (MIG) registry. This study included 14,025 participants who underwent their first PCI from 2005 to 2015 in Victoria, Australia. Based on a probabilistic modelling approach, Latent class analysis was adopted to classify clusters of people who shared similar combinations and magnitude of the comorbidity of interest. Logistic regression models were used to estimate odd ratios and 95% confidence interval (CI) for the 30-day and 12-month MACCE. RESULTS More than two-thirds of patients had multimorbidity, with the most prevalent conditions being hypertension (59%) and dyslipidaemia (60%). Four distinctive multimorbidity clusters were identified each with significant associations for higher risk of 30-day and 12-month MACCE. The cluster B had the highest risk of 30-day MACCE event that was characterised by a high prevalence of reduced estimated glomerular filtration rate (92%), hypertension (73%) and reduced ejection fraction (EF) (57%). The cluster C, characterised by a high prevalence of hypertension (94%), dyslipidaemia (88%), reduced eGFR (87%), diabetes (73%) and reduced EF (65%) had the highest risk of 12-month MACCE and highest length of hospital stay. CONCLUSION Hypertension and dyslipidaemia are prevalent in at least four in ten patients undergoing coronary angioplasty. This study showed that clusters of patients with multimorbidity had significantly different risk of 30-day and 12-month MACCE after PCI. This suggests the necessity for treatment approaches that are more personalised and customised to enhance patient outcomes and the quality of care delivered to patients in various comorbidity clusters. These results should be validated in a prospective cohort and to evaluate the potential impacts of these clusters on the prevention of MACCE after PCI.
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Affiliation(s)
- Chau Le Bao Ho
- NHMRC Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Bentley, WA, 6102, Australia
| | - Si Si
- Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela Brennan
- NHMRC Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Bentley, WA, 6102, Australia
- Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tom Briffa
- School of Population and Global Health, the University of Western Australia, Perth, Australia
| | - Dion Stub
- Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Ajani
- Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- NHMRC Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Bentley, WA, 6102, Australia.
- Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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Warren J, Dinh D, Brennan A, Tan C, Dagan M, Stehli J, Clark DJ, Ajani AE, Reid CM, Sebastian M, Oqueli E, Freeman M, Stub D, Duffy SJ. Impact of Preprocedural Diastolic Blood Pressure on Outcomes in Patients Undergoing Percutaneous Coronary Intervention. Hypertension 2023; 80:2447-2454. [PMID: 37655489 DOI: 10.1161/hypertensionaha.123.20963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Recent US guidelines recommend lower blood pressure (BP) targets in hypertension, but aggressive lowering of diastolic BP (DBP) can occur at the expense of myocardial perfusion, particularly in the presence of coronary artery disease. We sought to establish the long-term impact of low DBP on mortality among patients undergoing percutaneous coronary intervention with well-controlled systolic BP. METHODS We analyzed data from 12 965 patients undergoing percutaneous coronary intervention between 2009 and 2018 from the Melbourne Interventional Group registry who had a preprocedural systolic BP of ≤140 mm Hg. Patients with ST-elevation myocardial infarction, cardiogenic shock, and out-of-hospital arrest were excluded. Patients were stratified into 5 groups according to preprocedural DBP: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 mm Hg. The primary outcome was long-term, all-cause mortality. Mortality data were derived from the Australian National Death Index. RESULTS Patients with DBP<50 mm Hg were older with higher rates of diabetes, renal impairment, prior myocardial infarction, left ventricular dysfunction, peripheral and cerebrovascular disease (all P<0.001). Patients with DBP<50 mm Hg had higher 30-day (2.5% versus 0.7% for the other 4 quintiles; P<0.0001) and long-term mortality (median, 3.6 years; follow-up, 29% versus 11%; P<0.0001). Cox-regression analysis revealed that DBP<50 mm Hg was an independent predictor of long-term mortality (hazard ratio [HR], 1.55 [95% CI, 1.20-2.00]; P=0.001). CONCLUSIONS In patients with well-controlled systolic BP undergoing percutaneous coronary intervention, low DBP (<50 mm Hg) is an independent predictor of long-term mortality.
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Affiliation(s)
- Josephine Warren
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Christianne Tan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
| | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
- University Hospital, Zurich, Switzerland (J.S.)
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Australia (D.J.C.)
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia (A.E.A.)
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, Geelong, Australia (M.S.)
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health Ballarat, Australia (E.O.)
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia (E.O.)
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia (M.F.)
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
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Rajakariar K, Andrianopoulos N, Gayed D, Liang D, Backhouse B, Ajani AE, Duffy SJ, Brennan A, Roberts L, Reid CM, Oqueli E, Clark D, Freeman M. Outcomes of thrombus aspiration during primary percutaneous coronary intervention for ST-elevation myocardial infarction. Intern Med J 2023; 53:1376-1382. [PMID: 35670161 DOI: 10.1111/imj.15828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). AIM To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI. METHODS We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality. RESULTS We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73). CONCLUSION The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.
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Affiliation(s)
- Kevin Rajakariar
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel Gayed
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Danlu Liang
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Brendan Backhouse
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
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Hamilton GW, Dinh D, Yeoh J, Brennan AL, Fulcher J, Koshy AN, Yudi MB, Reid CM, Hare DL, Freeman M, Stub D, Chan W, Duffy SJ, Ajani A, Raman J, Farouque O, Clark DJ. Characteristics of Radial Artery Coronary Bypass Graft Failure and Outcomes Following Subsequent Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:457-467. [PMID: 36858666 DOI: 10.1016/j.jcin.2022.11.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND When patients with prior coronary artery bypass grafting (CABG) undergo percutaneous coronary intervention (PCI), targeting the native vessel is preferred. Studies informing such recommendations are based predominantly on saphenous vein graft (SVG) PCI. There are few data regarding arterial graft intervention, particularly to a radial artery (RA) graft. OBJECTIVES The aim of this study was to report the characteristics of arterial graft stenoses and evaluate the feasibility of RA PCI. METHODS This study included 2,780 consecutive patients with prior CABG undergoing PCI between 2005 and 2018 who were prospectively enrolled in the MIG (Melbourne Interventional Group) registry. Data were stratified by PCI target vessel. RA graft PCI was compared with both native vessel (native PCI) and SVG PCI. Internal mammary graft PCI data were reported. The primary outcome was 3-year mortality. RESULTS Overall, 1,928 patients (69.4%) underwent native PCI, 716 (25.6%) SVG PCI, 86 (3.1%) RA PCI, and 50 (1.8%) internal mammary graft PCI. Compared with SVG PCI, the RA PCI cohort presented earlier after CABG, less frequently had acute coronary syndrome, and more commonly had ostial or distal anastomosis intervention (P < 0.005 for all). Compared with patients who underwent native PCI, those who underwent RA PCI were more likely to have diabetes and peripheral vascular disease (P < 0.001 for both) and to present with non-ST-segment elevation myocardial infarction (P = 0.010). The RA PCI group had no perforations or in-hospital myocardial infarctions, though no significant difference was found in periprocedural outcomes compared with either native or SVG PCI. No differences were found between RA PCI and either native or SVG PCI in 30-day outcomes or 3-year mortality. CONCLUSIONS Presenting and lesion characteristics differed between patients undergoing arterial compared with SVG PCI, implying a varied pathogenesis of graft stenosis. RA PCI appears feasible, safe, and where anatomically suitable, may be a viable alternative to native PCI.
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Affiliation(s)
- Garry W Hamilton
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia. https://twitter.com/GarryHamilton6
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Jordan Fulcher
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia; School of Population Health, Curtin University, Perth, Australia
| | - David L Hare
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - William Chan
- Department of Medicine, University of Melbourne, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Jaishankar Raman
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia.
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8
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Fernando H, Nehme Z, Dinh D, Andrew E, Brennan A, Shi W, Bloom J, Duffy SJ, Shaw J, Peter K, Nadurata V, Chan W, Layland J, Freeman M, Van Gaal W, Bernard S, Lefkovits J, Liew D, Stephenson M, Smith K, Stub D. Impact of prehospital opioid dose on angiographic and clinical outcomes in acute coronary syndromes. J Accid Emerg Med 2023; 40:101-107. [PMID: 35473753 DOI: 10.1136/emermed-2021-211519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/08/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND An adverse interaction whereby opioids impair and delay the gastrointestinal absorption of oral P2Y12 inhibitors has been established, however the clinical significance of this in acute coronary syndrome (ACS) is uncertain. We sought to characterise the relationship between prehospital opioid dose and clinical outcomes in patients with ACS. METHODS Patients given opioid treatment by emergency medical services (EMS) with ACS who underwent percutaneous coronary intervention (PCI) between 1 January 2014 and 31 December 2018 were included in this retrospective cohort analysis using data linkage between the Ambulance Victoria, Victorian Cardiac Outcomes Registry and Melbourne Interventional Group databases. Patients with cardiogenic shock, out-of-hospital cardiac arrest and fibrinolysis were excluded. The primary end point was the risk-adjusted odds of 30-day major adverse cardiac events (MACE) between patients who received opioids and those that did not. RESULTS 10 531 patients were included in the primary analysis. There was no significant difference in 30-day MACE between patients receiving opioids and those who did not after adjusting for key patient and clinical factors. Among patients with ST-elevation myocardial infarction (STEMI), there were significantly more patients with thrombolysis in myocardial infarction (TIMI) 0 or 1 flow pre-PCI in a subset of patients with high opioid dose versus no opioids (56% vs 25%, p<0.001). This remained significant after adjusting for known confounders with a higher predicted probability of TIMI 0/1 flow in the high versus no opioid groups (33% vs 11%, p<0.001). CONCLUSIONS Opioid use was not associated with 30-day MACE. There were higher rates of TIMI 0/1 flow pre-PCI in patients with STEMI prescribed opioids. Future prospective research is required to verify these findings and investigate alternative analgesia for ischaemic chest pain.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Bendigo Health, Bendigo, Victoria, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - William Shi
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Bloom
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen James Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health, Bendigo, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine-Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Jamie Layland
- Department of Cardiology, Peninsula Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Danny Liew
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Stephenson
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia .,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia
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9
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Eccleston DS, Chowdhury E, Rafter T, Sage P, Whelan A, Reid C, Liew D, Duong M, Schwarz N, Worthley SG. Long-Term Outcomes of Contemporary Percutaneous Coronary Intervention with the Xience Drug-Eluting Stent: Results from a Multicentre Australian Registry. J Clin Med 2022; 12:jcm12010280. [PMID: 36615080 PMCID: PMC9821001 DOI: 10.3390/jcm12010280] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction: Several large registries have evaluated outcomes after percutaneous coronary intervention (PCI) in the USA, however there are no contemporary data regarding long-term outcomes after PCI, particularly comparing new generation drug-eluting stents (DES) with other stents in Australia. Additionally, approval of new-generation drug-eluting stents (DES) is almost exclusively based on non-inferiority trials comparing outcomes with early generation DES, and there are limited data comparing safety and efficacy outcomes of new-generation DES with bare metal stents (BMS). This study reports in-hospital and long-term outcomes after PCI with the Xience DES from a large national registry, the GenesisCare Outcomes Registry (GCOR). Methods: The first 1500 patients consecutively enrolled from January 2015 to January 2019 and treated exclusively with either Xience DES or BMS and eligible for 1-year follow-up were included. Baseline patient and procedural data, major adverse cardiovascular events (MACE) in-hospital, at 30 days and 1-year, and medications were reported and analysed with respect to Xience DES (n = 1000) or BMS (n = 500) use. Results: In this cohort the mean age was 68.4 ± 10.7 years, 76.9% were male, 24.6% had diabetes mellitus and 45.9% presented with acute coronary syndromes. Of the overall cohort of 4765 patients from this period including all DES types, and patients who received multiple DES or a combination of DES and BMS, DES were exclusively used in 3621 (76.0%) patients, and BMS were exclusively used in 596 (12.5%). In comparison to international cohorts, adverse clinical event rates were low at 30 days in terms of mortality (0.20%), target lesion revascularisation (TLR, 0.27%) and MACE (0.47%), and at 12 months for mortality (1.26%) TLR (1.16%) and MACE (1.78%). Conclusions: Clinical practice and long-term outcomes of PCI with the Xience DES in Australia are consistent with international series. Recent trends indicate DES use has increased in parallel with good outcomes despite an increasingly complex patient and lesion cohort.
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Affiliation(s)
- David S. Eccleston
- Melbourne Private Hospital, Melbourne, VIC 3052, Australia
- Correspondence:
| | - Enayet Chowdhury
- GenesisCare Cardiology, GenesisCare, Leabrook, Adelaide, SA 5068, Australia
| | - Tony Rafter
- Wesley Hospital, Auchenflower, Brisbane, QLD 4066, Australia
| | - Peter Sage
- St Andrews Medical Clinic, Adelaide, SA 5000, Australia
| | - Alan Whelan
- Wexford Medical Centre, Murdoch, Perth, WA 6150, Australia
| | - Christopher Reid
- Faculty of Health Sciences, Curtin University, Perth, WA 6845, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - MyNgan Duong
- GenesisCare Cardiology, GenesisCare, Leabrook, Adelaide, SA 5068, Australia
| | - Nisha Schwarz
- GenesisCare Cardiology, GenesisCare, Leabrook, Adelaide, SA 5068, Australia
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10
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Hamilton GW, Yeoh J, Dinh D, Reid CM, Yudi MB, Freeman M, Brennan A, Stub D, Oqueli E, Sebastian M, Duffy SJ, Horrigan M, Farouque O, Ajani A, Clark DJ. Trends and Real-World Safety of Patients Undergoing Percutaneous Coronary Intervention for Symptomatic Stable Ischaemic Heart Disease in Australia. Heart Lung Circ 2022; 31:1619-1629. [PMID: 36856290 DOI: 10.1016/j.hlc.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) in stable ischaemic heart disease (SIHD) has not been shown to improve prognosis but can alleviate symptoms and improve quality of life. Appropriately selected patients with symptoms refractory to medical therapy therefore stand to benefit, provided safety is proven. METHODS Consecutive patients undergoing PCI for SIHD between 2005-2018 in a prospective registry were included. Yearly comparisons evaluated trends, and a sub-analysis was performed comparing proximal left anterior descending artery (prox-LAD) to other-than-proximal LAD (non-pLAD) PCI. Outcomes included peri-procedural characteristics, in-hospital and 30-day event rates including MACE, and 5-year National Death Index (NDI) linked mortality. RESULTS There were 9,421 procedures included. Over time, patients were increasingly co-morbid and had higher rates of AHA/ACC class B2/C lesions, ostial stenoses, bifurcation lesions, and chronic total occlusions (all p-for-trend ≤0.001). Over 14 years, major bleeding reduced (1.05% in 2005/06 vs 0.29% in 2017/18, p-for-trend <0.001), while other in-hospital and 30-day event rates were stably low. There were only seven (0.07%) in hospital deaths and 5-year mortality was 10.3%. No differences were found in outcomes between patients who underwent prox-LAD compared to non-pLAD PCI. Major independent predictors of NDI linked all-cause mortality included an eGFR <30 mL/min/1.73 m2 (HR 4.06, 95% CI 3.26-5.06), chronic obstructive pulmonary disease (COPD) (HR 2.25, 95% CI 1.89-2.67) and LVEF <30% (HR 2.13, 95% CI 1.57-2.89). CONCLUSIONS Although patient and procedural complexity increased over time, a high degree of procedural success and safety was maintained, including in those undergoing prox-LAD PCI. These real-world data can enhance shared decision making discussions regarding whether PCI should be pursued in patients with symptomatic SIHD refractory to medical therapy.
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Affiliation(s)
- Garry W Hamilton
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Vic, Australia
| | - Martin Sebastian
- Department of Cardiology, University Hospital Geelong, Vic, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia.
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11
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Batchelor RJ, Dinh D, Noaman S, Brennan A, Clark D, Ajani A, Freeman M, Stub D, Reid CM, Oqueli E, Yip T, Shaw J, Walton A, Duffy SJ, Chan W. Adverse 30-Day Clinical Outcomes and Long-Term Mortality Among Patients With Preprocedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Heart Lung Circ 2022; 31:638-646. [PMID: 35125322 DOI: 10.1016/j.hlc.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined. METHODS We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index. RESULTS 13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3±1.5 years. CONCLUSIONS Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.
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Affiliation(s)
- Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Diem Dinh
- Monash University, Melbourne, Vic, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | | | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Christopher M Reid
- Monash University, Melbourne, Vic, Australia; Curtin University, Perth, WA, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Vic, Australia
| | - Thomas Yip
- Deakin University, Geelong, Vic, Australia; Department of Cardiology, Barwon Health, Geelong, Vic, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.
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12
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Zare S, Meidani Z, Ouhadian M, Akbari H, Zand F, Fakharian E, Sharifian R. Identification of data elements for blood gas analysis dataset: a base for developing registries and artificial intelligence-based systems. BMC Health Serv Res 2022; 22:317. [PMID: 35260155 PMCID: PMC8902269 DOI: 10.1186/s12913-022-07706-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/01/2022] [Indexed: 11/23/2022] Open
Abstract
Background One of the challenging decision-making tasks in healthcare centers is the interpretation of blood gas tests. One of the most effective assisting approaches for the interpretation of blood gas analysis (BGA) can be artificial intelligence (AI)-based decision support systems. A primary step to develop intelligent systems is to determine information requirements and automated data input for the secondary analyses. Datasets can help the automated data input from dispersed information systems. Therefore, the current study aimed to identify the data elements required for supporting BGA as a dataset. Materials and methods This cross-sectional descriptive study was conducted in Nemazee Hospital, Shiraz, Iran. A combination of literature review, experts’ consensus, and the Delphi technique was used to develop the dataset. A review of the literature was performed on electronic databases to find the dataset for BGA. An expert panel was formed to discuss on, add, or remove the data elements extracted through searching the literature. Delphi technique was used to reach consensus and validate the draft dataset. Results The data elements of the BGA dataset were categorized into ten categories, namely personal information, admission details, present illnesses, past medical history, social status, physical examination, paraclinical investigation, blood gas parameter, sequential organ failure assessment (SOFA) score, and sampling technique errors. Overall, 313 data elements, including 172 mandatory and 141 optional data elements were confirmed by the experts for being included in the dataset. Conclusions We proposed a dataset as a base for registries and AI-based systems to assist BGA. It helps the storage of accurate and comprehensive data, as well as integrating them with other information systems. As a result, high-quality care is provided and clinical decision-making is improved.
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Affiliation(s)
- Sahar Zare
- Health Information Management Research Center (HIMRC), Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Meidani
- Health Information Management Research Center (HIMRC), Kashan University of Medical Sciences, Kashan, Iran.,Department of Health Information Management & Technology, School of Allied Health Professions, Kashan University of Medical Sciences, Kashan, Iran
| | - Maryam Ouhadian
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hosein Akbari
- Department of Epidemiology and Biostatistics, School of Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Anesthesia and Critical Care Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Esmaeil Fakharian
- Department of Neurosurgery, Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Roxana Sharifian
- Health Human Resources Research Center, Department of Health Information Management and Technology, Shiraz University of Medical Sciences, Shiraz, Iran
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13
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Koshy AN, Dinh DT, Fulcher J, Brennan AL, Murphy AC, Duffy SJ, Reid CM, Ajani AE, Freeman M, Hiew C, Oqueli E, Farouque O, Yudi MB, Clark DJ. Long-term mortality in asymptomatic patients with stable ischemic heart disease undergoing percutaneous coronary intervention. Am Heart J 2022; 244:77-85. [PMID: 34780716 DOI: 10.1016/j.ahj.2021.10.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/27/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Patients with stable ischemic heart disease (SIHD) may present with a variety of symptoms including typical angina, angina equivalents such as dyspnea or no symptoms. We sought to determine whether symptom status affects periprocedural safety and long-term mortality in patients undergoing PCI. METHODS Prospectively enrolled consecutive patients undergoing PCI for SIHD at six hospitals in Australia between 2005 to 2018 as part of the Melbourne Interventional Group registry. Symptom status was recorded at the time of PCI and patients undergoing staged PCI were excluded. RESULTS Overall, 11,730 patients with SIHD were followed up for a median period of 5 years (maximum 14.0 years, interquartile range 2.2-9.0 years) with 1,317 (11.2%) being asymptomatic. Asymptomatic patients were older, and more likely to be male, have triple-vessel disease, with multiple comorbidities including renal failure, diabetes and heart failure (all P < .01). These patients had significantly higher rates of periprocedural complications and major adverse cardiovascular events at 30-days. Long-term mortality was significantly higher in asymptomatic patients (27.2% vs 18.0%, P < .001). On cox regression for long-term mortality, after adjustment for more important clinical variables, asymptomatic status was an independent predictor (Hazard ratio (HR) 1.39 95% CI 1.16-1.66, P < .001). CONCLUSIONS In a real-world cohort of patients undergoing revascularization for SIHD, absence of symptoms was associated with higher rates of periprocedural complications and, after adjustment for more important clinical variables, was an independent predictor of long-term mortality. As the primary goal of revascularization in SIHD remains angina relief, the appropriateness of PCI in the absence of symptoms warrants justification.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Diem T Dinh
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Jordan Fulcher
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Stephen J Duffy
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- The University of Melbourne, Parkville, Victoria; Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
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14
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Dawson LP, Dinh DT, Stub D, Ahern S, Bloom JE, Duffy SJ, Lefkovits J, Brennan A, Reid CM, Oqueli E. Health-related quality of life following percutaneous coronary intervention during the COVID-19 pandemic. Qual Life Res 2022; 31:2375-2385. [PMID: 34978043 PMCID: PMC8720546 DOI: 10.1007/s11136-021-03056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 12/02/2022]
Abstract
Purpose During the COVID-19 pandemic, widespread public health measures were implemented to control community transmission. The association between these measures and health-related quality of life (HRQOL) among patients following percutaneous coronary intervention has not been studied. Methods We included consecutive patients undergoing percutaneous coronary intervention (PCI) in the state-wide Victorian Cardiac Outcomes Registry between 1/3/2020 and 30/9/2020 (COVID-19 period; n = 5024), with a historical control group from the identical period one year prior (control period; n = 5041). HRQOL assessment was performed via telephone follow-up 30 days following PCI using the 3-level EQ-5D questionnaire and Australian-specific index values. Results Baseline characteristics were similar between groups, but during the COVID-19 period indication for PCI was more common for acute coronary syndromes. No patients undergoing PCI were infected with COVID-19 at the time of their procedure. EQ-5D visual analogue score (VAS), index score, and individual components were higher at 30 days following PCI during the COVID-19 period (all P < 0.01). In multivariable analysis, the COVID-19 period was independently associated with higher VAS and index scores. No differences were observed between regions or stage of restrictions in categorical analysis. Similarly, in subgroup analysis, no significant interactions were observed. Conclusion Measures of HRQOL following PCI were higher during the COVID-19 pandemic compared to the previous year. These data suggest that challenging community circumstances may not always be associated with poor patient quality of life. Supplementary Information The online version contains supplementary material available at 10.1007/s11136-021-03056-0.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Susannah Ahern
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Jeffrey Lefkovits
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, WA, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, 1 Drummond St North, Ballarat, VIC, 3350, Australia. .,School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia.
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15
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Reperfusion times and outcomes in patients with ST-elevation myocardial infarction presenting without pre-hospital notification. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 41:136-141. [DOI: 10.1016/j.carrev.2022.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 12/31/2022]
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16
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Fernando H, Duffy SJ, Low A, Dinh D, Adrianopoulos N, Sharma A, Peter K, Stub D, Leong K, Ajani A, Clark D, Freeman M, Sebastian M, Brennan A, Selkrig L, Reid CM, Kaye D, Oqueli E. Totally Occluded Culprit Coronary Artery in Patients with Non-ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2021; 156:52-57. [PMID: 34362552 DOI: 10.1016/j.amjcard.2021.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/17/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022]
Abstract
The short- and long-term implications of identifying totally occluded culprit coronary arteries (TOCCA) in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) have not been well studied. This study compares clinical characteristics, short- and long-term outcomes of patients with NSTEMI identified with TOCCA to that of patients with non-TOCCA undergoing percutaneous coronary intervention (PCI). We analyzed data from patients with NSTEMI undergoing single-vessel PCI within the Melbourne Interventional Group multi-center registry between 2005 and 2017. Those with TOCCA were compared to those with non-TOCCA. The primary endpoint was 30-day major adverse cardiac events (MACE). Secondary endpoints included 12-month MACE and long-term mortality. A total of 6,829 patients with NSTEMI had single-vessel PCI of which 954 (14%) had TOCCA. Most TOCCA were non-left anterior descending (right coronary artery 39% versus circumflex 33% versus left anterior descending 26%; p <0.001). Cardiogenic shock and left ventricular dysfunction were higher in the TOCCA group, but non-TOCCA patients had more baseline comorbidities. Thirty-day MACE was higher in the TOCCA group (6.7% versus 3.8%; p <0.001). Long-term mortality with an average follow-up of 4.9 years was higher in the non-TOCCA group (12% versus 18%, p <0.01). Multivariable Cox-proportional hazards regression identified TOCCA as an independent predictor of 30-day MACE (HR = 1.93; 95%CI: 1.4-2.6), but not long-term mortality, which was predicted by baseline comorbidities. In conclusion, while patients with NSTEMI with TOCCA undergoing PCI represent a more unstable subgroup early on, long-term outcomes appear more dependent on baseline comorbidities.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ashlea Low
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nick Adrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anand Sharma
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Kai'En Leong
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology Austin Health, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Laura Selkrig
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Christopher M Reid
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - David Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
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17
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Noaman S, Dinh D, Reid CM, Brennan AL, Clark D, Shaw J, Freeman M, Sebastian M, Oqueli E, Ajani A, Walton A, Bloom J, Biswas S, Stub D, Duffy SJ, Chan W. Comparison of Outcomes of Coronary Artery Disease Treated by Percutaneous Coronary Intervention in 3 Different Age Groups (<45, 46-65, and >65 Years). Am J Cardiol 2021; 152:19-26. [PMID: 34147208 DOI: 10.1016/j.amjcard.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/15/2022]
Abstract
There is paucity of data examining long-term outcomes of premature coronary artery disease (CAD). We aimed to investigate the short- and long-term clinical outcomes of patients with premature CAD treated by percutaneous coronary intervention (PCI) compared to older cohorts. We analyzed data from 27,869 patients who underwent PCI from 2005-2017 enrolled in a multicenter PCI registry. Patients were divided into three age groups: young group (≤ 45 years), middle-age group (46-65 years) and older group (>65 years). There were higher rates of current smokers in the young (n = 1,711) compared to the middle-age (n = 12,830) and older groups (n = 13,328) (54.2% vs 34.6% vs 11%) and the young presented more frequently with acute coronary syndrome (ACS) (78% vs 66% vs 62%), all p <0.05. There were also greater rates of cardiogenic shock (CS), out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) in the young, all p <0.05. The young cohort with STEMI had higher rates of in-hospital, 30-day death, and long-term mortality (3.8% vs 0.2%, 4.3% vs 0.2% and 8.6% vs 3.1%, all p <0.05, respectively) compared to the non-STEMI subgroup. There was a stepwise increase in long-term mortality from the young, to middle-age, to the older group (6.1% vs 9.9% vs 26.8%, p <0.001). Younger age was an independent predictor of lower long-term mortality (HR 0.66, 95% CI 0.52-0.84, p = 0.001). In conclusion, younger patients presenting with STEMI had worse prognosis compared to those presenting with non-STEMI. Despite higher risk presentations among young patients, their overall prognosis was favorable compared to older age groups.
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Affiliation(s)
- Samer Noaman
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia; BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Victoria, Australia; BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Geelong University Hospital, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Sinjini Biswas
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia; BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia; Monash University, Victoria, Australia.
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18
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Dawson LP, Burchill L, O'Brien J, Dinh D, Duffy SJ, Stub D, Brennan A, Clark D, Oqueli E, Hiew C, Freeman M, Reid CM, Ajani AE. Differences in outcome of percutaneous coronary intervention between Indigenous and non-Indigenous people in Victoria, Australia: a multicentre, prospective, observational, cohort study. LANCET GLOBAL HEALTH 2021; 9:e1296-e1304. [PMID: 34274040 DOI: 10.1016/s2214-109x(21)00224-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/02/2021] [Accepted: 05/05/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Data on the patient characteristics and health outcomes of Indigenous Australians having revascularisation for treatment of coronary artery disease are scarce. The aim of this study was to assess differences in patient characteristics, presentations, and outcomes among Indigenous and non-Indigenous Australians having percutaneous coronary intervention (PCI) in urban and larger regional centres in Victoria, Australia. METHODS In this multicentre, prospective, observational cohort study, data were prospectively collected from six government-funded tertiary hospitals in the state of Victoria, Australia. The Melbourne Interventional Group PCI registry was used to identify patients having PCI at Victorian metropolitan and large regional hospitals between Jan 1, 2005, and Dec 31, 2018. The primary outcome was long-term mortality. Secondary outcomes were 30 day mortality and 30 day major adverse cardiovascular events (MACE), defined as a composite endpoint of death, myocardial infarction, and target-vessel revascularisation. Regression analyses, adjusted for clinically relevant covariates and geographical and socioeconomic indices, were used to establish the influence of Indigenous status on these study outcomes. FINDINGS 41 146 patient procedures were entered into the registry, of whom 179 (0·4%) were recorded as identifying as Indigenous Australian, 39 855 (96·9%) were not Indigenous Australian, and 1112 (2·7%) had incomplete data regarding ethnicity and were excluded. Compared with their non-Indigenous counterparts, Indigenous patients were younger, more often women, and more likely to have comorbidities. Indigenous Australians were also more likely to live in a regional community and areas of socioeconomic disadvantage. Procedural success and complication rates were similar for Indigenous and non-Indigenous patients having PCI. At 30 day follow-up, Indigenous Australians were more likely to be taking optimal medical therapy, although overall follow-up rates were lower and prevalence of persistent smoking was higher. Multivariable analysis showed that Indigenous status was independently associated with increased risk of long-term mortality (hazard ratio 2·49, 95% CI 1·79-3·48; p<0·0001), 30 day mortality (odds ratio 2·78, 95% CI 1·09-7·12; p=0·033), and 30-day MACE (odds ratio 1·87, 95% CI 1·03-3·39; p=0·039). INTERPRETATION Indigenous Australians having PCI in urban and larger regional centres are at increased risk of mortality and adverse cardiac events. Clinically effective and culturally safe care pathways are urgently needed to improve health outcomes among Indigenous Australians who are having PCI. FUNDING National Health and Medical Research Council, National Heart Foundation.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Luke Burchill
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Medicine, Melbourne University, Melbourne, VIC, Australia
| | - Jessica O'Brien
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, VIC, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital, Geelong, VIC, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, WA, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Medicine, Melbourne University, Melbourne, VIC, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia.
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19
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Parfrey S, Teh AW, Roberts L, Brennan A, Clark D, Duffy SJ, Ajani AE, Reid CM, Freeman M. The role of CHA2DS2-VASc score in evaluating patients with atrial fibrillation undergoing percutaneous coronary intervention. Coron Artery Dis 2021; 32:288-294. [PMID: 33394696 DOI: 10.1097/mca.0000000000000987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the review was to assess whether CHA2DS2-VASc score is predictive of mortality in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI). BACKGROUND The CHA2DS2-VASc score is validated in predicting stroke risk in atrial fibrillation. The optimum management strategy for these patients undergoing PCI is still debated. METHODS The CHA2DS2-VASc score was calculated in consecutive patients with atrial fibrillation undergoing PCI in a large Australian registry between 2007 and 2013. Patients were divided into low (1-2), intermediate (3-4) and high (≥5) groups. Clinical and procedural data, 30-day, 1-year and long-term outcomes were compared between the groups. RESULTS A total of 564 patients were included in our analysis. Patients with high CHA2DS2-VASc scores had higher mortality rates at 1-year (2, 8, 15; P = 0.002) and long-term (6, 20, 37; P < 0.001). High-risk patients were more likely to have renal impairment and multivessel disease. Increasing CHA2DS2-VASc score was associated with increased risk of stroke (0, 2, 6; P = 0.03). However, only 41.9% received anticoagulation, with no difference across the risk groups. When compared to low-risk, intermediate [HR 3.57; 95% confidence interval (CI), 1.28-9.92; P = 0.015] and high (hazard ratio 7.82; 95% CI, 2.88-21.24; P < 0.001) CHA2DS2-VASc scores were significant predictors of long-term mortality. CONCLUSIONS Higher CHA2DS2-VASc scores in patients with atrial fibrillation undergoing PCI are associated with significantly worse outcomes. Despite being high-risk, the patients in this cohort are likely undertreated with anticoagulation. Close clinical follow-up with greater utilization of anticoagulation and optimal medical therapy has the potential to improve long-term outcomes.
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Affiliation(s)
| | - Andrew W Teh
- Department of Cardiology, Box Hill Hospital
- Department of Cardiology, Austin Hospital
| | | | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
| | - David Clark
- Department of Cardiology, Austin Hospital
- University of Melbourne
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- Department of Cardiovascular Medicine, Alfred Hospital
| | - Andrew E Ajani
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- University of Melbourne
- Department of Cardiology, Royal Melbourne Hospital
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- John Curtain Distinguished Professor Director, Centre for Clinical Research and Education Director, WAHTN Clinical Trials and Data Management Centre, Curtain University, Perth, Western Australia, Australia
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20
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Biswas S, Dinh D, Andrianopoulos N, Lefkovits J, Ajani A, Duffy SJ, Chan W, Walton A, Brennan A, Clark DJ, Hiew C, Oqueli E, Reid CM, Stub D, Eccleston D. Comparison of Long-Term Outcomes After Percutaneous Coronary Intervention in Patients With Insulin-Treated Versus Non-Insulin Treated Diabetes Mellitus. Am J Cardiol 2021; 148:36-43. [PMID: 33667454 DOI: 10.1016/j.amjcard.2021.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
There are conflicting data on whether patients with insulin-treated diabetes mellitus (ITDM) have poorer outcomes compared with non-insulin treated diabetic (non-ITDM) patients following percutaneous coronary intervention (PCI). We therefore compared clinical outcomes following PCI in ITDM versus non-ITDM patients. We prospectively collected data on 4,579 patients with diabetes underwent PCI between 2005 and 2014 in a large multicenter registry and dichotomized them as having ITDM (n = 1,111) or non-ITDM (n = 3,468). The non-ITDM group was further divided into diet control only (diet-DM; n = 786) and those taking oral hypoglycemic agents (OHG-DM; n = 2,639), and clinical outcomes were compared with ITDM patients. Median follow-up for long-term mortality was 4.2 years (IQR 2.0 to 6.6 years). ITDM patients were more likely to be female, obese, and have severe renal impairment (all p <0.001). Procedural characteristics were similar other than a greater use of drug-eluting stents in ITDM patients. On multivariable analysis, ITDM was an independent predictor of 12-month major adverse cardiovascular and cerebrovascular events (MACCE; OR 1.26, 95% CI 1.02 to1.55, p = 0.03). Dividing the non-ITDM group further by treatment, a progressively higher rate of 12-month MACCE across the 3 groups was observed (13.5% vs 17.9% vs 21.8%; p <0.001). Long-term mortality was similar in the diet-DM and OHG-DM groups, but significantly higher in the ITDM group on Kaplan-Meier analysis (log-rank p <0.001). In conclusion, there is a clear gradient of adverse outcomes with escalation of therapy from diet control to OHGs to insulin.
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21
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Fernando H, Milne C, Nehme Z, Ball J, Bernard S, Stephenson M, Myles PS, Bray JE, Lefkovits J, Liew D, Peter K, Brennan A, Dinh D, Andrew E, Taylor AJ, Smith K, Stub D. An open-label, non-inferiority randomized controlled trial of lidocAine Versus Opioids In MyocarDial Infarction study (AVOID-2 study) methods paper. Contemp Clin Trials 2021; 105:106411. [PMID: 33894363 DOI: 10.1016/j.cct.2021.106411] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 02/07/2023]
Abstract
Background There is increasing evidence that opioids interfere with the oral bioavailability of P2Y12 inhibitors leading to delayed onset of antiplatelet effects. Several strategies have been proposed to mitigate this interaction including utilizing alternative analgesic agents in the management of ischemic chest pain. Methods The lidocAine Versus Opioids In MyocarDial Infarction (AVOID-2) study is a phase II, pre-hospital, open-label, non-inferiority, randomized controlled trial conducted by Ambulance Victoria and Monash University in metropolitan Melbourne, Victoria, Australia. The purpose of the study is to compare the analgesic effect (reduction in pain by arrival to hospital) and safety (e.g. adverse drug reactions) (co-primary endpoints) of intravenous lidocaine versus intravenous fentanyl in 300 adult patients attended by ambulance with suspected ST-elevation myocardial infarction (STEMI). Secondary endpoints and a cardiac magnetic resonance imaging (MRI) sub-study will also compare infarct size between these two groups. Conclusions The evaluation of alternative analgesic agents in the management of acute coronary syndromes is urgently needed to manage the opioid-P2Y12 inhibitor interaction. The results of this trial will have significant implications on the emergency management of acute coronary syndromes internationally.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Catherine Milne
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Ziad Nehme
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Jocasta Ball
- Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Stephen Bernard
- Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Michael Stephenson
- Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Paul S Myles
- Monash University, Melbourne, Australia; Department of Anesthesiology and Perioperative Medicine, The Alfred and Monash University, Australia
| | | | - Jeffrey Lefkovits
- Monash University, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | | | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia
| | | | - Diem Dinh
- Monash University, Melbourne, Australia
| | - Emily Andrew
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Andrew J Taylor
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Karen Smith
- Monash University, Melbourne, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia; Department of Cardiology, Western Health, Melbourne, Australia.
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22
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Fernando H, Dinh D, Duffy SJ, Brennan A, Sharma A, Clark D, Ajani A, Freeman M, Peter K, Stub D, Hiew C, Reid CM, Oqueli E. Rescue PCI in the management of STEMI: Contemporary results from the Melbourne Interventional Group registry. IJC HEART & VASCULATURE 2021; 33:100745. [PMID: 33786363 PMCID: PMC7988313 DOI: 10.1016/j.ijcha.2021.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/12/2021] [Accepted: 02/19/2021] [Indexed: 12/01/2022]
Abstract
Background Fibrinolysis is an important reperfusion strategy in the management of ST-elevation myocardial infarction (STEMI) when timely access to primary percutaneous coronary intervention (PPCI) is unavailable. Rescue PCI is generally thought to have worse outcomes than PPCI in STEMI. We aimed to determine short- and long-term outcomes of patients with rescue PCI versus PPCI for treatment of STEMI. Methods and results Patients admitted with STEMI (excluding out-of-hospital cardiac arrest) within the Melbourne Interventional Group (MIG) registry between 2005 and 2018 treated with either rescue PCI or PPCI were included in this retrospective cohort analysis. Comparison of 30-day major adverse cardiac events (MACE) and long-term mortality between the two groups was performed. There were 558 patients (7.1%) with rescue PCI and 7271 with PPCI. 30-day all-cause mortality (rescue PCI 6% vs. PPCI 5%, p = 0.47) and MACE (rescue PCI 10.3% vs. PPCI 8.9%, p = 0.26) rates were similar between the two groups. Rates of in-hospital major bleeding (rescue PCI 6% vs. PPCI 3.4%, p = 0.002) and 30-day stroke (rescue PCI 2.2% vs. PPCI 0.8%, p < 0.001) were higher following rescue PCI. The odds ratio for haemorrhagic stroke in the rescue PCI group was 10.3. Long-term mortality was not significantly different between the groups (rescue PCI 20% vs. PPCI 19%, p = 0.33). Conclusions With contemporary interventional techniques and medical therapy, rescue PCI remains a valuable strategy for treating patients with failed fibrinolysis where PPCI is unavailable and it has been suggested in extenuating circumstances where alternative revascularisation strategies are considered.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anand Sharma
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - David Clark
- Department of Cardiology Austin Health, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Chin Hiew
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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23
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Dagan M, Dinh DT, Stehli J, Tan C, Brennan A, Warren J, Ajani AE, Freeman M, Murphy A, Reid CM, Hiew C, Oqueli E, Clark DJ, Duffy SJ. Sex Disparity In Secondary Prevention Pharmacotherapy And Clinical Outcomes Following Acute Coronary Syndrome. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:420-428. [PMID: 33537698 DOI: 10.1093/ehjqcco/qcab007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/30/2020] [Accepted: 01/29/2021] [Indexed: 12/11/2022]
Abstract
Abstract
Aims
We sought to investigate if sex disparity exists for secondary prevention pharmacotherapy following acute coronary syndrome (ACS) and impact on long-term clinical outcomes.
Methods and results
We analysed data on medical management 30-day post-percutaneous coronary intervention (PCI) for ACS in 20 976 patients within the multicentre Melbourne Interventional Group registry (2005–2017). Optimal medical therapy (OMT) was defined as five guideline-recommended medications, near-optimal medical therapy (NMT) as four medications, sub-optimal medical therapy (SMT) as ≤3 medications. Overall, 65% of patients received OMT, 27% NMT and 8% SMT. Mean age was 64 ± 12 years; 24% (4931) were female. Women were older (68 ± 12 vs. 62 ± 12 years) and had more comorbidities. Women were less likely to receive OMT (61% vs. 66%) and more likely to receive SMT (10% vs. 8%) compared to men, P < 0.001. On long-term follow-up (median 5 years, interquartile range 2–8 years), women had higher unadjusted mortality (20% vs. 13%, P < 0.001). However, after adjusting for medical therapy and baseline risk, women had lower long-term mortality [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.79–0.98; P = 0.02]. NMT (HR 1.17, 95% CI 1.05–1.31; P = 0.004) and SMT (HR 1.79, 95% CI 1.55–2.07; P < 0.001) were found to be independent predictors of long-term mortality.
Conclusion
Women are less likely to be prescribed optimal secondary prevention medications following PCI for ACS. Lower adjusted long-term mortality amongst women suggests that as well as baseline differences between gender, optimization of secondary prevention medical therapy amongst women can lead to improved outcomes. This highlights the need to focus on minimizing the gap in secondary prevention pharmacotherapy between sexes following ACS.
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Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Diem T Dinh
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Christianne Tan
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | | | - Andrew E Ajani
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | | | - Christopher M Reid
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Chin Hiew
- Department of Cardiology, Geelong Hospital, Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Victoria, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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24
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Papapostolou S, Dinh DT, Noaman S, Biswas S, Duffy SJ, Stub D, Shaw JA, Walton A, Sharma A, Brennan A, Clark D, Freeman M, Yip T, Ajani A, Reid CM, Oqueli E, Chan W. Effect of Age on Clinical Outcomes in Elderly Patients (>80 Years) Undergoing Percutaneous Coronary Intervention: Insights From a Multi-Centre Australian PCI Registry. Heart Lung Circ 2021; 30:1002-1013. [PMID: 33478864 DOI: 10.1016/j.hlc.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/20/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI). BACKGROUND Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes. METHODS We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients <80 year old (78% male, mean age 62±10 years; non-elderly cohort) were compared to 3,282 patients ≥80 year old (61% male, mean age 84±3 years; elderly cohort). RESULTS The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p<0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction <45% and chronic kidney disease (p<0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p<0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 (HR 3.8, 95% CI: 3.4-4.3), cardiogenic shock (HR 3.0, 95% CI: 2.6-3.4), ejection fraction <30% (HR 2.5, 95% CI: 2.1-2.9); and age ≥80 years (HR 2.8, 95% CI: 2.6-3.1) were independent predictors of long-term all-cause mortality (all p<0.0001). CONCLUSION The elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients.
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Affiliation(s)
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | | | | | | | - Dion Stub
- Alfred Health, Melbourne, Vic, Australia
| | | | | | - Anand Sharma
- Ballarat Base Hospital, Ballarat Central, Vic, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | | | | | | | - Andrew Ajani
- Royal Melbourne Hospital, Melbourne, Vic, Australia; The University of Melbourne, Melbourne, Vic, Australia
| | | | - Ernesto Oqueli
- Ballarat Base Hospital, Ballarat Central, Vic, Australia
| | - William Chan
- Alfred Health, Melbourne, Vic, Australia; The University of Melbourne, Melbourne, Vic, Australia.
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25
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Noaman S, O'Brien J, Andrianopoulos N, Brennan AL, Dinh D, Reid C, Sharma A, Chan W, Clark D, Stub D, Biswas S, Freeman M, Ajani A, Yip T, Duffy SJ, Oqueli E. Clinical outcomes following ST-elevation myocardial infarction secondary to stent thrombosis treated by percutaneous coronary intervention. Catheter Cardiovasc Interv 2020; 96:E406-E415. [PMID: 32087042 DOI: 10.1002/ccd.28802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/22/2020] [Accepted: 02/11/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) secondary to stent thrombosis (ST) compared to those presenting with STEMI secondary to a de novo culprit lesion and treated by percutaneous coronary intervention (PCI). BACKGROUND ST is an infrequent but serious complication of PCI with substantial associated morbidity and mortality, however with limited data. METHODS We studied consecutive patients who underwent PCI for STEMI from 2005 to 2013 enrolled prospectively in the Melbourne Interventional Group registry. Patients were divided into two groups: the ST group comprised patients where the STEMI was due to ST and the de novo group formed the remainder of the STEMI cohort and all patients were treated by PCI. The primary endpoint was 30-day all-cause mortality. RESULTS Compared to the de novo group (n = 3,835), the ST group (n = 128; 3.2% of STEMI) had higher rates of diabetes, hypertension and dyslipidemia, established cardiovascular diseases, myocardial infarction, and peripheral vascular disease, all p < .01. Within the ST group, very-late ST was the most common form of ST, followed by late and early ST (64, 19, and 17%, respectively). There was no significant difference in the primary outcome between the ST group and the de novo group (4.7 vs. 7.1%, p = .29). On multivariate analysis, ST was not an independent predictor of 30-day mortality (odds ratio: 0.62, 95% confidence interval: 0.07-1.09, p = .068). CONCLUSION The short-term prognosis of patients with STEMI secondary to ST who were treated by PCI was comparable to that of patients with STEMI due to de novo lesions.
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Affiliation(s)
- Samer Noaman
- University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Jessica O'Brien
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Anand Sharma
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - William Chan
- University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sinjini Biswas
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Thomas Yip
- Department of Cardiology, Geelong University Hospital, Geelong, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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26
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Peck KY, Andrianopoulos N, Dinh D, Roberts L, Duffy SJ, Sebastian M, Clark D, Brennan A, Oqueli E, Ajani AE, Reid CM, Freeman M, Teh AW. Role of beta blockers following percutaneous coronary intervention for acute coronary syndrome. Heart 2020; 107:728-733. [PMID: 32887736 DOI: 10.1136/heartjnl-2020-316605] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 11/03/2022] Open
Abstract
AIMS There is a paucity of evidence supporting routine beta blocker (BB) use in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). The aim of this study was to evaluate BB use post PCI and its association with mortality. Furthermore, the study aimed to evaluate the association between BB and mortality in the subgroups of patients with left ventricular ejection fraction (LVEF) <35%, LVEF 35%-50% and LVEF >50%. METHODS Using a large PCI registry, data from patients with ACS between January 2005 and June 2017 who were alive at 30 days were analysed. Those patients taking BB at 30 days were compared with those who were not taking BB. The primary outcome was all-cause mortality. The mean follow-up was 5.3±3.5 years. RESULTS Of the 17 562 patients, 83.3% were on BB. Mortality was lower in the BB group (13.1% vs 19.5%, p=0.0001). Multivariable Cox proportional hazards model showed that BB use was associated with lower overall mortality (adjusted HR 0.87, 95% CI 0.78 to 0.97, p=0.014). In the subgroup analysis, BB use was associated with reduced mortality in LVEF <35% (adjusted HR 0.63, 95% CI 0.44 to 0.91, p=0.013), LVEF 35%-50% (adjusted HR 0.80, 95% CI 0.68 to 0.95, p=0.01), but not LVEF >50% (adjusted HR 1.03, 95% CI 0.87 to 1.21, p=0.74). CONCLUSION BB use remains high and is associated with reduced mortality. This reduction in mortality is primarily seen in those with reduced ejection fraction, but not in those with preserved ejection fraction.
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Affiliation(s)
- Kah Yong Peck
- Department of Cardiology, Eastern Health, Box Hill Hospital, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Box Hill Hospital, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiovascular Medicine, Alfred Health, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, University Hospital, Geelong, Victoria, Australia
| | - David Clark
- Department of Cardiology, The University of Melbourne, Austin Hospital Clinical School, Melbourne, Victoria, Australia
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Deakin University, Ballarat, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Eastern Health, Box Hill Hospital, Melbourne, Victoria, Australia .,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The University of Melbourne, Austin Hospital Clinical School, Melbourne, Victoria, Australia
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27
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Yeoh J, Andrianopoulos N, Reid CM, Yudi MB, Hamilton G, Freeman M, Noaman S, Oqueli E, Picardo S, Brennan A, Chan W, Stub D, Duffy S, Farouque O, Ajani A, Clark DJ. Long-term outcomes following percutaneous coronary intervention to an unprotected left main coronary artery in cardiogenic shock. Int J Cardiol 2020; 308:20-25. [PMID: 32192748 DOI: 10.1016/j.ijcard.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/27/2020] [Accepted: 03/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In cardiogenic shock with severe left main coronary artery stenosis (LM), limited information exists on short and longer-term outcomes. We sought to determine the outcomes of unprotected LM PCI in cardiogenic shock. METHODS Excluding patients with previous CABG, consecutive patients undergoing PCI in cardiogenic shock from the Melbourne Intervention Group registry between 2005 and 2013 were analysed. Those post LM PCI were compared to those post non-LM PCI. Patient and procedural data were collected with 30-day and 12-month follow-up. Australian National Death Index linkage was performed for long-term mortality analysis. RESULTS After excluding previous CABG, 18,069 procedures were performed during 1st January 2005 to 30th November 2013, 601 procedures in the setting of cardiogenic shock. Of these, 45 were performed to an isolated LM and 556 to a non-LM. Those with LM PCI were older and more likely to have a baseline left ventricular ejection fraction (LVEF) of <45%. The in-hospital, 30-day, 12-month and long-term mortality to 9 years in cardiogenic shock after LM PCI was 64.4%, 66.7%, 73.3% and 80.0% compared to 36.5%, 36.9%, 40.5% and 46.0%, after non-LM PCI (p < 0.001). On multivariate analysis, LM PCI was a significant independent predictor of long-term mortality (HR1.59, 95%CI 1.00-2.53, p = 0.048). Landmark analysis of survivors to discharge found the long-term mortality of LM PCI approaches 60% compared to 27% for those with non-LM PCI (p = 0.003). CONCLUSION Long-term outcomes after PCI to LM in cardiogenic shock are poor, with much of the excess in mortality occurring early. However, reasonable long-term survival was found beyond the initial high-risk period.
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Affiliation(s)
- Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Garry Hamilton
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Melaine Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Samer Noaman
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Australia
| | - Sandra Picardo
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia
| | - William Chan
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Dion Stub
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Stephen Duffy
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Australia.
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28
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Dawson LP, Cole JA, Lancefield TF, Ajani AE, Andrianopoulos N, Thrift AG, Clark DJ, Brennan AL, Freeman M, O'Brien J, Sebastian M, Chan W, Shaw JA, Dinh D, Reid CM, Duffy SJ. Incidence and risk factors for stroke following percutaneous coronary intervention. Int J Stroke 2020; 15:909-922. [PMID: 32248767 DOI: 10.1177/1747493020912607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stroke rates and risk factors may change as percutaneous coronary intervention practice evolves and no data are available comparing stroke incidence after percutaneous coronary intervention to the general population. AIMS This study aimed to identify the incidence and risk factors for inpatient and subsequent stroke following percutaneous coronary intervention with comparison to age-matched controls. METHODS Data were prospectively collected from 22,618 patients undergoing percutaneous coronary intervention in the Melbourne Interventional Group registry (2005-2015). The cohort was compared to the North-East Melbourne Stroke Incidence Study population-based cohort (1997-1999) and predefined variables assessed for association with inpatient or outpatient stroke. RESULTS Inpatient stroke occurred in 0.33% (65.3% ischemic, 28.0% haemorrhagic, and 6.7% cause unknown), while outpatient stroke occurred in 0.55%. Inpatient and outpatient stroke were associated with higher rates of in-hospital major adverse cardiovascular outcomes (p < 0.0001) and mortality (p < 0.0001), as well as 12-month mortality (p < 0.0001). Factors independently associated with inpatient stroke were renal impairment, ST-elevation myocardial infarction, previous stroke, left ventricular ejection fraction 30-45%, and female sex, while those associated with outpatient stroke were previous stroke, chronic lung disease, previous myocardial infarction, rheumatoid arthritis, female sex, and older age. Compared to the age-standardized population-based cohort, stroke rates in the 12 months following discharge were higher for percutaneous coronary intervention patients <65 years old, but lower for percutaneous coronary intervention patients ≥65 years old. CONCLUSIONS Risk of inpatient stroke following percutaneous coronary intervention appears to be largely associated with clinical status at presentation, while outpatient stroke relates more to age and chronic disease. Compared to the general population, outpatient stroke rates following percutaneous coronary intervention are higher for younger, but not older, patients.
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Affiliation(s)
- Luke P Dawson
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Justin A Cole
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | | | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Jessica O'Brien
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | - Martin Sebastian
- Department of Cardiology, University Hospital Geelong, Geelong, Australia
| | - William Chan
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - James A Shaw
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Australia
| | - Stephen J Duffy
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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29
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Ariyaratne TV, Ademi Z, Ofori-Asenso R, Huq MM, Duffy SJ, Yan BP, Ajani AE, Clark DJ, Billah B, Brennan AL, New G, Andrianopoulos N, Reid CM. The cost-effectiveness of guideline-driven use of drug-eluting stents: propensity-score matched analysis of a seven-year multicentre experience. Curr Med Res Opin 2020; 36:419-426. [PMID: 31870180 DOI: 10.1080/03007995.2019.1708288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with '0', 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000-$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71-91%, '0' indications, 49-67%, 1 indication, 56-82%, 2 indications, 70-90%, and ≥3 indications, 97-99%.Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with '0' indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.
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Affiliation(s)
- Thathya V Ariyaratne
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Richard Ofori-Asenso
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Molla M Huq
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Stephen J Duffy
- Cardiovascular Medicine, Heart Centre, Alfred Hospital, Melbourne, Australia
| | - Bryan P Yan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Andrew E Ajani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong
- Royal Melbourne Hospital, Parkville, Australia
| | - David J Clark
- The Department of Cardiology, Austin Hospital, Heidelberg, Australia
| | - Baki Billah
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gishel New
- Department of Cardiology, Box Hill Hospital, Box Hill, Australia
| | - Nick Andrianopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Public Health, Curtin University, Perth, Australia
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Noaman S, Andrianopoulos N, Brennan AL, Dinh D, Reid C, Stub D, Biswas S, Clark D, Shaw J, Ajani A, Freeman M, Yip T, Oqueli E, Walton A, Duffy SJ, Chan W. Outcomes of cardiogenic shock complicating acute coronary syndromes. Catheter Cardiovasc Interv 2020; 96:E257-E267. [PMID: 32017332 DOI: 10.1002/ccd.28759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/24/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS). BACKGROUND CS remains the leading cause of mortality in patients presenting with ACS despite advances in care. METHODS We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS. RESULTS Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p < .01. Patients in the CS group had higher rates of in-hospital (40.4 vs. 1.2%) and 30-day (41 vs. 1.7%) mortality compared to the non-CS group. Long-term mortality over a median follow-up of 4.2 years was higher in the CS group (50.6 vs. 13.8%), p < .001. Trends of in-hospital and 30-day mortality rates of CS complicating ACS were relatively stable from 2005 to 2013. Predictors of long-term NDI-linked mortality within the CS group include severe left ventricular systolic dysfunction (HR 3.0), glomerular filtration rate (GFR) <30 (HR 2.56), GFR 30-59 (HR 1.94), OHCA (HR 1.46), diabetes (HR 1.44), and age (HR 1.02), all p < .05. CONCLUSIONS Rates of CS-related mortality complicating ACS have remained very high and steady over nearly a decade despite progress in STEMI systems of care, PCI techniques, and medical therapy.
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Affiliation(s)
- Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Christopher Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Sinjini Biswas
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Thomas Yip
- Department of Cardiology, Geelong University Hospital, Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.,Clinical Research Domain, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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Yudi MB, Farouque O, Andrianopoulos N, Ajani AE, Brennan A, Murphy AC, Lefkovits J, Reid CM, Oqueli E, Sebastian M, Duffy SJ, Clark DJ. Prognostic significance of suboptimal secondary prevention pharmacotherapy after acute coronary syndromes. Intern Med J 2020; 51:366-374. [PMID: 31943665 DOI: 10.1111/imj.14750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/02/2020] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Optimal secondary prevention pharmacotherapy is the cornerstone of post-acute coronary syndrome (ACS) management. The prognostic impact of not receiving five guideline-recommended therapies is poorly described. AIM To ascertain the prognostic significance of suboptimal pharmacotherapy in ACS survivors. METHODS Consecutive patients with ACS from the Melbourne Interventional Group registry who were alive at 30 days following their index percutaneous coronary intervention were included. Patients were divided into three categories based on the number of secondary prevention medications prescribed. The optimal medical therapy (OMT), near-optimal medical therapy (NMT), suboptimal medical therapy (SMT) groups were prescribed 5, 4 and ≤ 3 medications, respectively. Primary endpoint was long-term mortality. Cox-proportional hazard modelling was undertaken to assess independent predictors of survival. RESULTS Of the 9375 patients included, 5678 (60.6%) received OMT, 2903 (31.0%) received NMT and 794 (8.5%) received SMT. Patients receiving SMT were older, more likely to be female and had higher burden of comorbidities (renal impairment, congestive heart failure, diabetes, peripheral vascular disease; P < 0.01 for all). SMT was associated with higher long-term mortality at 3.9 ± 2.2 years when compared to NMT and OMT (16.8% vs 10.5% vs 8.2%, P < 0.001). Compared to OMT, SMT was an independent predictor of long-term mortality (hazard ratio, HR 1.62, 95% confidence interval, CI 1.30-2.02, P < 0.01) while NMT was associated with a clinically significant 14% mortality hazard (HR 1.14, 95% CI 0.97-1.34, P = 0.11). CONCLUSIONS There is a graded long-term hazard associated with not receiving OMT after an ACS. Improvements in secondary prevention pharmacotherapy models of care are warranted to further decrease the long-term mortality.
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Affiliation(s)
- Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Re-examining the effect of door-to-balloon delay on STEMI outcomes in the context of unmeasured confounders: a retrospective cohort study. Sci Rep 2019; 9:19978. [PMID: 31882674 PMCID: PMC6934575 DOI: 10.1038/s41598-019-56353-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 12/10/2019] [Indexed: 11/08/2022] Open
Abstract
Literature studying the door-to-balloon time-outcome relation in coronary intervention is limited by the potential of residual biases from unobserved confounders. This study re-examines the time-outcome relation with further consideration of the unobserved factors and reports the population average effect. Adults with ST-elevation myocardial infarction admitted to one of the six registry participating hospitals in Australia were included in this study. The exposure variable was patient-level door-to-balloon time. Primary outcomes assessed included in-hospital and 30 days mortality. 4343 patients fulfilled the study criteria. 38.0% (1651) experienced a door-to-balloon delay of >90 minutes. The absolute risk differences for in-hospital and 30-day deaths between the two exposure subgroups with balanced covariates were 2.81 (95% CI 1.04, 4.58) and 3.37 (95% CI 1.49, 5.26) per 100 population. When unmeasured factors were taken into consideration, the risk difference were 20.7 (95% CI −2.6, 44.0) and 22.6 (95% CI −1.7, 47.0) per 100 population. Despite further adjustment of the observed and unobserved factors, this study suggests a directionally consistent linkage between longer door-to-balloon delay and higher risk of adverse outcomes at the population level. Greater uncertainties were observed when unmeasured factors were taken into consideration.
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Gellatly RM, Connell C, Tan C, Andrianopoulos N, Ajani AE, Clark DJ, Nanayakkara S, Sebastian M, Brennan A, Freeman M, O'Brien J, Selkrig LA, Reid CM, Duffy SJ. Trends of Use and Outcomes Associated With Glycoprotein-IIb/IIIa Inhibitors in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. Ann Pharmacother 2019; 54:414-422. [PMID: 31766865 DOI: 10.1177/1060028019889550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Glycoprotein IIb/IIIa inhibitors (GPIs) are a treatment option in the management of acute coronary syndromes (ACSs). Evidence supporting the use of GPIs predates trials establishing the benefits of P2Y12 inhibitors, routine early invasive therapy, and thrombectomy devices in patients with ACS. Objective: The aim of this study was to determine trends in GPI use and their associated outcomes in contemporary practice. Methods: We assessed GPI use in patients with ACS undergoing percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry (2005-2013). The primary endpoint was the 30-day incidence of major adverse cardiovascular events (MACE). The safety endpoint was in-hospital major bleeding. Results: GPIs were used in 40.5% of 12 357 patients with ACS undergoing PCI. GPI use decreased over the study period (P for trend <0.0001). Patients were more likely to receive GPIs if they were younger, presented with a ST-elevation myocardial infarction (STEMI), had more complex (B2/C-type) lesions, and when thrombectomy devices were used (all P < 0.0001). MACE were higher in patients receiving GPI (4.9% vs 4.1%, P = 0.03). Propensity score matching revealed no difference in 30-day mortality and 30-day MACE (odds ratio [OR] = 1.00; 95% CI = 0.99-1.004 and OR = 1.01; 95% CI = 0.99-1.02, respectively). GPI use was associated with more bleeding complications (3.6% vs 1.8%, P < 0.0001). Conclusion and Relevance: GPI use in ACS patients undergoing PCI has declined, and use appears to be dictated by ACS type and lesion complexity, as opposed to high-risk comorbidities. GPI use was associated with a doubling in bleeding complications.
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Affiliation(s)
| | - Cia Connell
- Alfred Hospital, Melbourne, Victoria, Australia
| | | | | | - Andrew E Ajani
- Monash University, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Parkville, Victoria, Australia.,The University of Melbourne, Victoria, Australia
| | | | | | | | | | | | | | | | | | - Stephen J Duffy
- Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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Biswas S, Andrianopoulos N, Dinh D, Duffy SJ, Lefkovits J, Brennan A, Noaman S, Ajani A, Clark DJ, Freeman M, Oqueli E, Hiew C, Reid CM, Stub D, Chan W. Association of Body Mass Index and Extreme Obesity With Long-Term Outcomes Following Percutaneous Coronary Intervention. J Am Heart Assoc 2019; 8:e012860. [PMID: 31648578 PMCID: PMC6898845 DOI: 10.1161/jaha.119.012860] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Previous studies have reported a protective effect of obesity compared with normal body mass index (BMI) in patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether this effect extends to the extremely obese. In this large multicenter registry‐based study, we sought to examine the relationship between BMI and long‐term clinical outcomes following PCI, and in particular to evaluate the association between extreme obesity and long‐term survival after PCI. Methods and Results This cohort study included 25 413 patients who underwent PCI between January 1, 2005 and June 30, 2017, who were prospectively enrolled in the Melbourne Interventional Group registry. Patients were stratified by World Health Organization–defined BMI categories. The primary end point was National Death Index–linked mortality. The median length of follow‐up was 4.4 years (interquartile range 2.0‐7.6 years). Of the study cohort, 24.8% had normal BMI (18.5‐24.9 kg/m2), and 3.3% were extremely obese (BMI ≥40 kg/m2). Patients with greater degrees of obesity were younger and included a higher proportion of diabetics (P<0.001). After adjustment for age and comorbidities, a J‐shaped association was observed between different BMI categories and adjusted hazard ratio (HR) for long‐term mortality (normal BMI, HR 1.00 [ref]; overweight, HR 0.85, 95% CI 0.78‐0.93, P<0.001; mild obesity, HR 0.85, 95% CI 0.76‐0.94, P=0.002; moderate obesity, HR 0.95, 95% CI 0.80‐1.12, P=0.54; extreme obesity HR 1.33, 95% CI 1.07‐1.65, P=0.01). Conclusions An obesity paradox is still apparent in contemporary practice, with elevated BMI up to 35 kg/m2 associated with reduced long‐term mortality after PCI. However, this protective effect appears not to extend to patients with extreme obesity.
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Affiliation(s)
- Sinjini Biswas
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of CardiologyThe Alfred HospitalMelbourneAustralia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Diem Dinh
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Stephen J. Duffy
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of CardiologyThe Alfred HospitalMelbourneAustralia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneAustralia
| | - Angela Brennan
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Samer Noaman
- Department of CardiologyThe Alfred HospitalMelbourneAustralia
- Department of MedicineUniversity of MelbourneMelbourneAustralia
| | - Andrew Ajani
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneAustralia
- Department of MedicineUniversity of MelbourneMelbourneAustralia
| | | | | | - Ernesto Oqueli
- Department of CardiologyBallarat Health ServicesBallaratAustralia
- School of MedicineDeakin UniversityBallaratAustralia
| | - Chin Hiew
- Department of CardiologyUniversity Hospital GeelongGeelongAustralia
| | - Christopher M. Reid
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
- School of Public HealthCurtin UniversityPerthAustralia
| | - Dion Stub
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
- Department of CardiologyThe Alfred HospitalMelbourneAustralia
- Baker IDI Heart and Diabetes InstituteMelbourneAustralia
| | - William Chan
- Department of CardiologyThe Alfred HospitalMelbourneAustralia
- Department of MedicineUniversity of MelbourneMelbourneAustralia
- Baker IDI Heart and Diabetes InstituteMelbourneAustralia
- Department of MedicineMonash UniversityMelbourneAustralia
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35
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Murphy AC, Yudi MB, Farouque O, Dinh D, Duffy SJ, Brennan A, Reid CM, Andrianopoulos N, Koshy AN, Martin L, Dagan M, Freeman M, Blusztein D, Ajani AE, Clark DJ. Impact of Gender and Door-to-Balloon Times on Long-Term Mortality in Patients Presenting With ST-Elevation Myocardial Infarction. Am J Cardiol 2019; 124:833-841. [PMID: 31327488 DOI: 10.1016/j.amjcard.2019.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/21/2022]
Abstract
Guidelines mandate emergent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of gender. We sought to compare the door-to-balloon times and the impact of timely reperfusion on clinical outcomes in women compared with men presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI). We analyzed data from 6,179 consecutive patients presenting with STEMI undergoing PPCI from the Melbourne Interventional Group registry (2005 to 2017). The primary outcome was long-term mortality. Of the 6,179 patients included 1,258 (20.3%) were female. Female patients were older (69 ± 13 vs 62 ± 12 years; p < 0.001), had more co-morbidities and had longer median symptom-to-balloon times (204 [interquartile range {IQR} 154 to 294] vs 181 [IQR 139 to 258] minutes; p < 0.001) and longer median door-to-balloon times (81 [IQR 55 to 102] vs 75 [IQR 51 to 102)] minutes; p < 0.001), while receiving less drug-eluting stents (39% vs 43%; p = 0.01) and having less radial access for PPCI (15% vs 21%; p < 0.001). Furthermore, female patients received less guideline-directed medical therapy than men with less prescription of aspirin (93.4% vs 95.4%; p = 0.02), statins (96.5% vs 97.6%; p < 0.05), and beta blockers (84.3% vs 89.4%; p < 0.001). Unadjusted in-hospital and 30-day mortality rates were higher in women (8.8% vs 6.2%, 9.8% vs 6.9%; p < 0.001). However, on Cox-proportional hazards modeling, gender was not an independent predictor of long-term mortality (hazards ratio 0.99, 95% confidence interval 0.83 to 1.18; p = 0.92) at a mean follow-up of 4.8 ± 3.5 years. In conclusion, in this large multicenter registry of patients with STEMI, women had longer ischemic times, higher risk profiles, and differing interventional approaches compared with men. Addressing these gender inequalities with early identification of symptoms, adherence to guideline-directed medical therapy, as well as higher rates of radial access and use of drug-eluting stents has the potential to further improve outcomes in women with STEMI.
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Affiliation(s)
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Diem Dinh
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Angela Brennan
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Christopher M Reid
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Nick Andrianopoulos
- Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Lorelle Martin
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Victoria, Australia
| | - David Blusztein
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew E Ajani
- University of Melbourne, Melbourne, Australia; Center of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia.
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Improved Survival After the Ross Procedure Compared With Mechanical Aortic Valve Replacement. J Am Coll Cardiol 2019; 71:1337-1344. [PMID: 29566818 DOI: 10.1016/j.jacc.2018.01.048] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND It is unclear whether the Ross procedure offers superior survival compared with mechanical aortic valve replacement (AVR). OBJECTIVES This study evaluated experience and compared long-term survival between the Ross procedure and mechanical AVR. METHODS Between 1992 and 2016, a total of 392 Ross procedures were performed. These were compared with 1,928 isolated mechanical AVRs performed during the same time period as identified using the University of Melbourne and Australia and New Zealand Society of Cardiac and Thoracic Surgeons' Cardiac Surgery Databases. Only patients between 18 and 65 years of age were included. Propensity-score matching was performed for risk adjustment. RESULTS Ross procedure patients were younger, and had fewer cardiovascular risk factors. The Ross procedure was associated with longer cardiopulmonary bypass and aortic cross-clamp times. Thirty-day mortality was similar (Ross, 0.3%; mechanical, 0.8%; p = 0.5). Ross procedure patients experienced superior unadjusted long-term survival at 20 years (Ross, 95%; mechanical, 68%; p < 0.001). Multivariable analysis showed the Ross procedure to be associated with a reduced risk of late mortality (hazard ratio: 0.34; 95% confidence internal: 0.17 to 0.67; p < 0.001). Among 275 propensity-score matched pairs, Ross procedure patients had superior survival at 20 years (Ross, 94%; mechanical, 84%; p = 0.018). CONCLUSIONS In this Australian, propensity-score matched study, the Ross procedure was associated with better long-term survival compared with mechanical AVR. In younger patients, with a long life expectancy, the Ross procedure should be considered in centers with sufficient expertise.
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Papapostolou S, Andrianopoulos N, Duffy SJ, Brennan AL, Ajani AE, Clark DJ, Reid CM, Freeman M, Sebastian M, Selkrig L, Yudi MB, Noaman SQ, Chan W. Long-term clinical outcomes of transient and persistent no-reflow following percutaneous coronary intervention (PCI): a multicentre Australian registry. EUROINTERVENTION 2019; 14:185-193. [PMID: 28966156 DOI: 10.4244/eij-d-17-00269] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the study was to evaluate long-term outcomes of transient versus persistent no-reflow. METHODS AND RESULTS A total of 17,547 patients with normal flow post percutaneous coronary intervention (PCI) were compared to 590 patients (3.2%) with transient no-reflow and 144 patients (0.8%) with persistent no-reflow. Long-term all-cause mortality was obtained by linkage with the National Death Index (NDI). No-reflow patients were more likely to have presented with ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OHCA) or cardiogenic shock (all p<0.01). Long-term NDI-linked all-cause mortality was highest in patients with persistent no-reflow (31%) followed by transient no-reflow (22%) and normal flow (14%) over a median follow-up of 5.2, 5.5 and 4.5 years, respectively (all p<0.0001). Kaplan-Meier survival estimates demonstrated a graded increase in all-cause mortality from normal flow, to transient to persistent no-reflow (p<0.01), with the highest mortality occurring early (<30 days) in the persistent no-reflow group (p<0.0001). Multivariate Cox proportional hazards modelling identified glomerular filtration rate <30 mL/min, ejection fraction <30%, persistent no-reflow and transient no-reflow as independent predictors of increased hazard for all-cause mortality (all p<0.05). CONCLUSIONS Transient and persistent no-reflow were associated with a stepwise reduction in long-term survival. The presence of even transient no-reflow appears to be an important predictor of adverse long-term outcome.
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Affiliation(s)
- Stavroula Papapostolou
- Department of Cardiovascular Medicine, Alfred Health, The Alfred Hospital, Melbourne, VIC, Australia
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Mulder DS, Spicer J. Registry-Based Medical Research: Data Dredging or Value Building to Quality of Care? Ann Thorac Surg 2019; 108:274-282. [DOI: 10.1016/j.athoracsur.2018.12.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 10/31/2018] [Accepted: 12/29/2018] [Indexed: 12/16/2022]
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Biswas S, Brennan A, Duffy SJ, Andrianopoulos N, Chan W, Walton A, Noaman S, Shaw JA, Ajani A, Clark DJ, Freeman M, Hiew C, Oqueli E, Lefkovits J, Reid CM, Stub D. The Impact of Out-of-Hours Presentation on Clinical Outcomes in ST-Elevation Myocardial Infarction. Heart Lung Circ 2019; 29:814-823. [PMID: 31262617 DOI: 10.1016/j.hlc.2019.05.184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 03/26/2019] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Systems of care have been established to ensure patients with ST-elevation myocardial infarction (STEMI) get timely access to primary percutaneous coronary intervention (PPCI). In this study, we evaluated whether patients undergoing PPCI both in-hours and out-of-hours experience similar care and clinical outcomes. METHODS Of 9,865 patients who underwent PCI for STEMI from 2005 to 2016 and were enrolled in the multi-centre Melbourne Interventional Group registry, patients who had initially presented to a non-PCI capable hospital, received thrombolysis or presented >12hourspost-symptom onset were excluded. Our final study cohort of 4,590 patients were dichotomised by whether PPCI was performed in-hours or out-of-hours, and compared. The primary outcome was 30-day mortality. RESULTS The in-hours group included 1,865 patients (40.6%) while 2,725 patients (59.4%) had out-of-hours PPCI. Patients presenting out-of-hours had longer median door-to-balloon time (DTBT; 83 [IQR 61-109] vs. 60 [IQR 41-88] mins, p<0.01) and were more likely to receive a drug-eluting stent (p=0.001). Procedural characteristics were otherwise similar although rates of radial access were low overall (18.4%). No differences in in-hospital, 30-day or 12-month mortality were observed between the groups (p=NS). On Cox proportional hazards modelling, out-of-hours presentation was not an independent predictor of 30-day mortality (HR 0.94, 95% CI 0.71-1.22). A landmark analysis of data from 2012 did not change the primary outcome. CONCLUSION Despite a slightly longer DTBT, patients undergoing PPCI out-of-hours experienced similar care and clinical outcomes to the in-hours group. Given the majority of patients with STEMI present out-of-hours, these data have implications for STEMI systems of care.
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Affiliation(s)
- Sinjini Biswas
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Samer Noaman
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - James A Shaw
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Andrew Ajani
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Vic, Australia; School of Medicine, Deakin University, Ballarat, Vic, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia.
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Warren J, Nanayakkara S, Andrianopoulos N, Brennan A, Dinh D, Yudi M, Clark D, Ajani AE, Reid CM, Selkrig L, Shaw J, Hiew C, Freeman M, Kaye D, Kingwell BA, Dart AM, Duffy SJ, Reid C, Andrianopoulos N, Brennan A, Dinh D, Reid C, Ajani A, Duffy S, Clark D, Freeman M, Hiew C, Andrianopoulos N, Oqueli E, Brennan A, Duffy S, Shaw J, Walton A, Dart A, Broughton A, Federman J, Keighley C, Hengel C, Peter K, Stub D, Chan W, Warren J, O’Brien J, Selkrig L, Huntington R, Clark D, Farouque O, Horrigan M, Johns J, Oliver L, Brennan J, Chan R, Proimos G, Dortimer T, Chan B, Nadurata V, Huq R, Fernando D, Al-Fiadh A, Yudi M, Sugumar H, Ramchand J, Han H, Picardo S, Brown L, Oqueli E, Hengel C, Sharma A, Zhu B, Ryan N, Harrison T, New G, Roberts L, Freeman M, Rowe M, Proimos G, Cheong Y, Goods C, Fernando D, Teh A, Parfrey S, Ramzy J, Koshy A, Venkataraman P, Flannery D, Hiew C, Sebastian M, Yip T, Mok M, Jaworski C, Hutchinson A, Cimenkaya C, Ngu P, Khialani B, Salehi H, Turner M, Dyson J, McDonald B, Van Den Nouwelant D, Halliburton K, Reid C, Andrianopoulos N, Brennan A, Dinh D, Yan B, Ajani A, Warren R, Eccleston D, Lefkovits J, Iyer R, Gurvitch R, Wilson W, Brooks M, Biswas S, Yeoh J. Impact of Pre-Procedural Blood Pressure on Long-Term Outcomes Following Percutaneous Coronary Intervention. J Am Coll Cardiol 2019; 73:2846-2855. [DOI: 10.1016/j.jacc.2019.03.493] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/28/2022]
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Trends and predictors of recurrent acute coronary syndrome hospitalizations and unplanned revascularization after index acute myocardial infarction treated with percutaneous coronary intervention. Am Heart J 2019; 212:134-143. [PMID: 31004916 DOI: 10.1016/j.ahj.2019.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/15/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Repeat hospitalizations for recurrent acute coronary syndrome (ACS) or unplanned revascularization after acute myocardial infarction (MI) are common, costly and potentially preventable. We aim to describe 10-year trends and identify independent risk factors of these repeat hospitalizations. METHODS We analyzed data from 9615 patients from the Melbourne Interventional Group registry (2005-2014) who underwent percutaneous coronary intervention (PCI) for their index MI and survived to discharge. Patients with ≥1 hospitalization for recurrent ACS events and/or unplanned revascularization in the year after discharge were included in the recurrent coronary hospitalization group. We assessed yearly trends of recurrent coronary events and identified independent predictors using multivariate analysis. RESULTS Recurrent coronary hospitalization occurred in 1175 (12.2%) patients. There was a significant decrease in the rate of recurrent ACS hospitalization (15.3%-7.6%, P for trend <.001) and unplanned revascularization (4.2%-2.1%, P for trend = .01), but not in all-cause re-hospitalizations (P for trend = .28). On multivariate analysis, female gender, diabetes mellitus, previous coronary bypass surgery, previous PCI, reduced ejection fraction, heart failure, multi-vessel coronary disease and obstructive sleep apnea were independent predictors of recurrent coronary hospitalizations (all P < .05). CONCLUSIONS Recurrent hospitalization for ACS or unplanned revascularization has decreased significantly over the past decade. Risk factors for such events are numerous and largely non-modifiable, however they identify a cohort of patients in whom non-culprit vessel PCI in multi-vessel disease, optimization of left ventricular dysfunction and diabetes management may improve outcomes.
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Murphy A, Hamilton G, Andrianopoulos N, Yudi MB, Farouque O, Duffy SJ, Lefkovits J, Brennan A, Reid CM, Ajani AE, Clark DJ. One-Year Outcomes of Patients With Established Coronary Artery Disease Presenting With Acute Coronary Syndromes. Am J Cardiol 2019; 123:1387-1392. [PMID: 30797559 DOI: 10.1016/j.amjcard.2019.01.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/23/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
The risk of major adverse cardiovascular events (MACE) remains high in patients with established coronary artery disease (CAD). The aim of this study was to assess the prognostic significance of established CAD in patients who present with acute coronary syndromes (ACS) using a large established multicenter registry. Consecutive patients from the Melbourne Interventional Group registry who presented with ACS and underwent percutaneous coronary intervention from 2005 to 2015 were included. Patients with a history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery were included in the established CAD cohort. The primary end points were 12-month mortality and 12-month MACE. Of the 12,878 ACS patients included in our study, 3,542 (28%) patients had established CAD. Over the 10-year study period, the proportion of patients presenting with established CAD decreased (30.7% to 25.2%; p-for-overall-trend <0.001). Non-ST elevation myocardial infarction was the most prominent presentation in the established CAD cohort (45.1%) whereas ST-elevation myocardial infarction was the most prominent in the de novo CAD cohort (51%; p< 0.001). The patients in the established CAD cohort were older, had more co-morbidities and were more likely to present with high-risk features such as atrial fibrillation, left main disease, multivessel CAD and left ventricular dysfunction (all p < 0.001). Regarding revascularization in ST-elevation myocardial infarction presentations, symptom-to-door time was shorter, whereas door-to-balloon-time was longer in those with established CAD (p < 0.001). On multivariate analysis, established CAD was an independent risk factor for 12-month MACE (odds ratio 1.40, 95% confidence intervals 1.23 to 1.58, p < 0.001), but not for 12-month mortality (odds ratio 1.08, 95% confidence intervals 0.77 to 1.52, p = 0.66). In conclusion, patients with a history of myocardial infarction or previous revascularization have a higher rate of MACE at 12 months. Despite this they do not appear to suffer from higher mortality.
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Predictors and Outcomes of Cardiac Surgery-Associated Delirium. A Single Centre Retrospective Cohort Study. Heart Lung Circ 2019; 28:455-463. [DOI: 10.1016/j.hlc.2018.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/01/2018] [Accepted: 01/20/2018] [Indexed: 01/25/2023]
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Ramzy J, Andrianopoulos N, Roberts L, Duffy SJ, Clark D, Teh AW, Ajani AE, Reid CM, Brennan A, Freeman M. Outcomes in patients with peripheral vascular disease following percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 94:588-597. [DOI: 10.1002/ccd.28145] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/14/2019] [Accepted: 01/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- John Ramzy
- Department of CardiologyThe Royal Melbourne Hospital Melbourne Victoria Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventative MedicineMonash University Melbourne Victoria Australia
| | - Louise Roberts
- Department of CardiologyBox Hill Hospital Melbourne Victoria Australia
- Eastern Health Clinical SchoolMonash University Melbourne Victoria Australia
| | - Stephen J. Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventative MedicineMonash University Melbourne Victoria Australia
- Department of Cardiovascular MedicineAlfred Hospital Melbourne Victoria Australia
| | - David Clark
- Department of CardiologyAustin Hospital Melbourne Victoria Australia
| | - Andrew W. Teh
- Department of CardiologyBox Hill Hospital Melbourne Victoria Australia
- Eastern Health Clinical SchoolMonash University Melbourne Victoria Australia
| | - Andrew E. Ajani
- Department of CardiologyThe Royal Melbourne Hospital Melbourne Victoria Australia
| | - Christopher M. Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventative MedicineMonash University Melbourne Victoria Australia
- School of Public HealthCurtin University Perth Western Australia Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Department of Epidemiology and Preventative MedicineMonash University Melbourne Victoria Australia
| | - Melanie Freeman
- Department of CardiologyBox Hill Hospital Melbourne Victoria Australia
- Eastern Health Clinical SchoolMonash University Melbourne Victoria Australia
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Biswas S, Andrianopoulos N, Duffy SJ, Lefkovits J, Brennan A, Walton A, Chan W, Noaman S, Shaw JA, Ajani A, Clark DJ, Freeman M, Hiew C, Oqueli E, Reid CM, Stub D. Impact of Socioeconomic Status on Clinical Outcomes in Patients With ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e004979. [DOI: 10.1161/circoutcomes.118.004979] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sinjini Biswas
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - Nick Andrianopoulos
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
| | - Stephen J. Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia (J.L., A.A.)
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
| | - Antony Walton
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - William Chan
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia (W.C., D.S.)
| | - Samer Noaman
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - James A. Shaw
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
| | - Andrew Ajani
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia (J.L., A.A.)
| | - David J. Clark
- Department of Cardiology, Austin Health, Melbourne, Australia (D.J.C.)
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia (M.F.)
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Australia (C.H.)
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Australia (E.O.)
| | - Christopher M. Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- School of Public Health, Curtin University, Perth, Australia (C.M.R.)
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia (S.B., N.A., S.J.D., J.L., A.B., A.A., C.M.R., D.S.)
- Department of Cardiovascular Medicine, The Alfred Hospital, Melbourne, Australia (S.B., S.J.D., A.W., W.C., S.N., J.A.S., D.S.)
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia (W.C., D.S.)
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Ariyaratne TV, Ademi Z, Huq M, Rosenfeldt F, Duffy SJ, Parkinson B, Yap CH, Smith J, Billah B, Yan BP, Brennan AL, Tran L, Reid CM. The Real-World Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Stenting in High-Risk Patients: Propensity Score-Matched Analysis of a Single-Centre Experience. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:661-674. [PMID: 29998450 DOI: 10.1007/s40258-018-0407-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND There are limited economic evaluations comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multi-vessel coronary artery disease (MVCAD) in contemporary, routine clinical practice. OBJECTIVE The aim was to perform a cost-effectiveness analysis comparing CABG and PCI in patients with MVCAD, from the perspective of the Australian public hospital payer, using observational data sources. METHODS Clinical data from the Melbourne Interventional Group (MIG) and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) registries were analysed for 1022 CABG (treatment) and 978 PCI (comparator) procedures performed between June 2009 and December 2013. Clinical records were linked to same-hospital admissions and national death index (NDI) data. The incremental cost-effectiveness ratios (ICERs) per major adverse cardiac and cerebrovascular event (MACCE) avoided were evaluated. The propensity score bin bootstrap (PSBB) approach was used to validate base-case results. RESULTS At mean follow-up of 2.7 years, CABG compared with PCI was associated with increased costs and greater all-cause mortality, but a significantly lower rate of MACCE. An ICER of $55,255 (Australian dollars)/MACCE avoided was observed for the overall cohort. The ICER varied across comparisons against bare metal stents (ICER $25,815/MACCE avoided), all drug-eluting stents (DES) ($56,861), second-generation DES ($42,925), and third-generation of DES ($88,535). Moderate-to-low ICERs were apparent for high-risk subgroups, including those with chronic kidney disease ($62,299), diabetes ($42,819), history of myocardial infarction ($30,431), left main coronary artery disease ($38,864), and heart failure ($36,966). CONCLUSIONS At early follow-up, high-risk subgroups had lower ICERs than the overall cohort when CABG was compared with PCI. A personalised, multidisciplinary approach to treatment of patients may enhance cost containment, as well as improving clinical outcomes following revascularisation strategies.
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Affiliation(s)
- Thathya V Ariyaratne
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia.
| | - Zanfina Ademi
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Molla Huq
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Franklin Rosenfeldt
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Bonny Parkinson
- Macquarie University Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Cheng-Hon Yap
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Cardiothoracic Unit, Geelong Hospital, Geelong, VIC, Australia
| | - Julian Smith
- Department of Surgery, School of Clinical Sciences, Monash Health, Monash University, Melbourne, VIC, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Bryan P Yan
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Lavinia Tran
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine (DEPM), Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, 6th Floor, 99 Commercial Rd, Melbourne, VIC, 3004, Australia
- School of Public Health, Curtin University, Perth, WA, Australia
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O'Brien J, Reid CM, Andrianopoulos N, Ajani AE, Clark DJ, Krum H, Loane P, Freeman M, Sebastian M, Brennan AL, Shaw J, Dart AM, Duffy SJ. Heart Rate as a Predictor of Outcome Following Percutaneous Coronary Intervention. Am J Cardiol 2018; 122:1113-1120. [PMID: 30107905 DOI: 10.1016/j.amjcard.2018.06.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 06/15/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
Data from previous studies of patients with heart failure and coronary artery disease suggest that those with higher resting heart rates (HRs) have worse cardiovascular outcomes. We sought to evaluate whether HR immediately before percutaneous coronary intervention (PCI) is an independent predictor for 30-day outcome. We analyzed the outcome of 3,720 patients who had HR recorded before PCI from the Melbourne Interventional Group registry. HR and outcomes were analyzed by quintiles, and secondarily by dichotomizing into <70 or ≥70 beats/min. Patients with cardiogenic shock, intra-aortic balloon pump or inotropic support, and out-of-hospital arrest were excluded. The mean ± SD HR was 70.9 ± 14.7 beats/min. HR by quintile was 55 ± 5, 64 ± 2, 70 ± 1, 77 ± 3, and 93 ± 13 beats/min, respectively. Patients with higher HR were more likely to be women, current smokers, have higher systolic and diastolic blood pressure, atrial fibrillation, recent heart failure, lower ejection fraction, and ST-elevation myocardial infarction as the indication for the PCI (all p ≤0.002). However, rates of treated hypertension, multivessel disease, previous myocardial infarction, PCI, and coronary bypass surgery were lower (all p ≤0.004). Increased HR was associated with higher 30-day mortality (p for trend = 0.04), target vessel revascularization (p for trend = 0.003), and 30-day major adverse cardiac events (MACE) (p for trend = 0.004). In a multivariable analysis, HR was an independent predictor of 30-day MACE (OR 1.21 per quintile; 95% confidence interval (CI): 1.06 to 1.39, p = 0.004). When dichotomized into <70 or ≥70 beats/min, HR independently predicted both 30-day MACE (OR 1.59, 95% CI 1.08 to 2.36, p = 0.02) and 30-day mortality (OR 2.80, 95% CI 1.10 to 7.08, p = 0.03). In conclusion, HR immediately before PCI is an independent predictor of adverse 30-day cardiovascular outcomes.
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Yudi MB, Farouque O, Andrianopoulos N, Ajani AE, Brennan A, Lefkovits J, Reid CM, Chan W, Duffy SJ, Clark DJ. Pretreatment with dual antiplatelet therapy in patients with ST-elevation myocardial infarction. Catheter Cardiovasc Interv 2018; 92:E98-E105. [PMID: 28963757 DOI: 10.1002/ccd.27325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 08/14/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND The optimal time to administer P2Y12 inhibitors in patients with ST-elevation myocardial infarction (STEMI) remains to be defined. We sought to assess whether a pretreatment strategy was associated with improved coronary reperfusion and clinical outcomes. METHODS Consecutive patients from the Melbourne Interventional Group registry (2005-2014) who presented with STEMI and underwent primary PCI were included. Those who received any P2Y12 inhibitor prior to arrival in the cardiac catheterisation laboratory were included in the pretreatment group. The primary endpoints were the proportion of patients with initial TIMI flow grade <3 and in-hospital bleeding. The secondary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). RESULTS Of the 2,807 patients included, 892(31.8%) received pretreatment. Clopidogrel was the most common P2Y12 inhibitor used (79.6%). Pretreatment was associated with less thromboaspiration and GPIIb/IIIa inhibitor use (both P < 0.01). Pretreatment was not associated with lower rates of TIMI flow <3 on initial angiogram (78.0% vs. 80.7%, P = 0.18) nor with increased in-hospital bleeding (3.6% vs. 3.9%, P = 0.67). Pretreatment was associated with lower 12-month mortality (4.7% vs. 7.0%, P = 0.02) but similar MACE rate (13.0% vs. 14.1%, P = 0.43). Multivariate analysis revealed pretreatment was not an independent predictor of 12-month mortality (OR 0.79; 95% CI 0.5-1.3, P = 0.32). CONCLUSION Pretreatment with a P2Y12 inhibitor in patients with STEMI was not routine practice in our Australian cohort and was not associated with improved coronary reperfusion or clinical outcomes. Larger studies are required to definitively ascertain the risk/benefit ratio of dual antiplatelet therapy pretreatment in STEMI.
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Affiliation(s)
- Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Andrew E Ajani
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Western Australia
| | - William Chan
- Department of Cardiovascular Medicine, Alfred Health, Melbourne, Australia
| | - Stephen J Duffy
- Department of Cardiovascular Medicine, Alfred Health, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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O'Brien J, Saxena A, Reid CM, Tran L, Baker RA, Newcomb A, Smith J, Huq MM, Duffy SJ. Thirty-day outcomes in Indigenous Australians following coronary artery bypass grafting. Intern Med J 2018; 48:780-785. [DOI: 10.1111/imj.13790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/06/2018] [Accepted: 02/28/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Jessica O'Brien
- Department of Cardiovascular Medicine; The Alfred Hospital; Melbourne Victoria Australia
| | - Akshat Saxena
- Discipline of Cardiothoracic Surgery; University of Sydney; Sydney New South Wales Australia
| | - Christopher M. Reid
- Centre for Cardiovascular Research and Education (CCRE) in Therapeutics; Monash University; Melbourne Victoria Australia
- School of Public Health; Curtin University; Perth Western Australia Australia
| | - Lavinia Tran
- Centre for Cardiovascular Research and Education (CCRE) in Therapeutics; Monash University; Melbourne Victoria Australia
| | - Robert A. Baker
- Cardiac and Thoracic Surgical Unit; Flinders Medical Centre and Flinders University; Adelaide South Australia Australia
| | - Andrew Newcomb
- Cardiothoracic Surgery, St Vincent's Clinical School Department of Surgery; University of Melbourne; Melbourne Victoria Australia
| | - Julian Smith
- Departments of Surgery, Monash University and of Cardiothoracic Surgery; Monash Medical Centre; Melbourne Victoria Australia
| | - Molla M. Huq
- Centre for Cardiovascular Research and Education (CCRE) in Therapeutics; Monash University; Melbourne Victoria Australia
| | - Stephen J. Duffy
- Department of Cardiovascular Medicine; The Alfred Hospital; Melbourne Victoria Australia
- Centre for Cardiovascular Research and Education (CCRE) in Therapeutics; Monash University; Melbourne Victoria Australia
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Stub D, Lefkovits J, Brennan AL, Dinh D, Brien R, Duffy SJ, Cox N, Nadurata V, Clark DJ, Andrianopoulos N, Harper R, McNeil J, Reid CM. The Establishment of the Victorian Cardiac Outcomes Registry (VCOR): Monitoring and Optimising Outcomes for Cardiac Patients in Victoria. Heart Lung Circ 2018; 27:451-463. [DOI: 10.1016/j.hlc.2017.07.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 05/11/2017] [Accepted: 07/26/2017] [Indexed: 11/25/2022]
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