Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group

Gender-related changes in the practice and outcomes of percutaneous coronary interventions in Northern New England from 1994 to 1999

OBJECTIVES

We sought to determine whether the changing practice of interventional cardiology has been associated with improved outcomes for women, and how these outcomes compare with those for men.

BACKGROUND

Previous work from the early 1990s suggested women are at a higher risk than men for adverse outcomes after percutaneous coronary interventions (PCIs). From 1994 to 1999 data were collected on 33,666 consecutive hospital admissions for a PCI in Northern New England. Multivariate models were used to adjust for differences in case-mix across year of procedure when comparing outcomes. Direct standardization was used to calculate adjusted rates.

RESULTS

From 1994 to 1999, the case-mix worsened for both women and men, although women had more co-morbidities than did men throughout the period. Stent use increased over time (>75% in 1999). Concomitantly, the need for emergency coronary artery bypass graft surgery (CABG) decreased significantly (p(trend) < or = 0.001; in 1999: 0.06% for women, 0.05% for men). Although the emergency CABG rates were higher for women at the beginning of the study, by the end, they were comparable (adjusted odds ratio 1.34, 95% confidence interval 0.76 to 2.38, p = 0.315). The myocardial infarction (MI) rates decreased over time for both women (by 29.7%, p(trend) = 0.378) and men (by 37.6%, p(trend) = 0.009) and did not differ by gender. The mortality rates did not decrease significantly over time and were not significantly different between the genders (mean 1.21% for women, 1.06% for men; p = 0.096).

CONCLUSIONS

Concurrent with the changing practice of PCI, and despite treating sicker patients, there have been important improvements in post-PCI CABG and MI rates for women, as well as for men. Unlike in earlier years, there are no longer significant differences in outcomes by gender.

Cause of in-hospital death in 12,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. The Northern New England Cardiovascular Disease Study Group

BACKGROUND

Some deaths after percutaneous coronary angioplasty (PTCA) occur in high-risk situations (eg, shock), whereas others are unexpected and related to procedural complications. To better describe the epidemiologic causes of death after PTCA, we undertook a systematic review of all in-hospital PTCA deaths in Northern New England from 1990 to 1993.

METHODS

The medical records of 121 patients who died during their acute hospitalization for PTCA were reviewed with a standardized data extraction tool to determine a mode of death (eg, low output failure, arrhythmia, respiratory failure) and a circumstance of death (eg, death attributable to a procedural complication, preexisting acute cardiac disease). Any death not classified as a procedural complication was reviewed by a committee and the circumstance of death assigned by a majority rule.

RESULTS

Low-output failure was the most common mode of death occurring in 80 (66.1%) of 121 patients. Other modes of death included ventricular arrhythmias (10.7%), stroke (4.1%), preexisting renal failure (4.1%), bleeding (2.5%), ventricular rupture (2.5%), respiratory failure (2.5%), pulmonary embolism (1.7%), and infection (1.7%). The circumstance of death was a procedural complication in 65 patients (53.7%) and a preexisting acute cardiac condition in 41 patients (33.9%). Women were more likely to die of a procedural complication than were men.

CONCLUSION

Procedural complications account for half of all post-PTCA deaths and are a particular problem for women. Other deaths are more directly related to patient acuity or noncardiac, comorbid conditions. Understanding why women face an increased risk of procedural complications may lead to improved outcomes for all patients.

The Northern New England Cardiovascular Disease Study Group: a regional collaborative effort for continuous quality improvement in cardiovascular disease

BACKGROUND

The Northern New England Cardiovascular Disease Study Group, a voluntary regional consortium, includes all cardiothoracic surgeons and interventional cardiologists, as well as nurses, anesthesiologists, perfusionists, administrators, and scientists associated with the six medical centers in Maine, New Hampshire, and Vermont and one Massachusetts-based medical center that support coronary artery bypass graft (CABG) surgery and percutaneous coronary interventions (PCI). Since 1987 the group has met at least three times a year to foster improvements in patient care.

PROGRESS IN THE STUDY OF CABG SURGERY

The group's activities have included continued monitoring of outcomes, training in continuous quality improvement, and a benchmarking effort that allowed institutions to learn from one another. In the postintervention period (mid-1991 through early 1992) there were 293 fewer deaths (n = 575) than the 868 expected. In 1995 a new cycle of quality improvement work aimed at identifying the causes and correlates of postoperative mortality began. Study groups for each institution were organized to examine issues related to death from low-output states.

PROGRESS IN THE STUDY OF PCIS

Major improvement in hospital outcomes have occurred in relation to the improving technology (primarily coronary stenting). Near-twofold variability in the use of stents has led to vigorous discussions about the role of new devices.

LESSONS LEARNED

Randomized clinical trials are very important to assessing the effects of specific treatments, but most of what is known about actual clinical care will come from observational studies. Demonstrating the variability in practice patterns can be a potent stimulus to try to answer the important questions.