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Handmark M, Lin A, Edsfeldt A, Sarno G, Fraser A, Rich-Edwards JW, Gonҫalves I, Pihlsgård M, Timpka S. STEMI, Revascularization, and Peak Troponin by Adverse Pregnancy Outcomes in Women With Myocardial Infarction. JACC. ADVANCES 2024; 3:101088. [PMID: 39070091 PMCID: PMC11277779 DOI: 10.1016/j.jacadv.2024.101088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/15/2024] [Accepted: 05/07/2024] [Indexed: 07/30/2024]
Abstract
Background Women with a history of adverse pregnancy outcomes have a higher risk of coronary heart disease. Emerging evidence suggests that women with a history of preeclampsia have a different pattern of overall coronary atherosclerosis and that they at the time of myocardial infarction (MI) more frequently present with ST-segment elevation MI (STEMI) compared to women with no such history. Objectives The purpose of this study was to determine whether among women with MI, those with a history of adverse pregnancy outcomes are more likely to present with STEMI or other clinical characteristics indicating a more severe myocardial injury. Methods The study sample consisted of 8,320 women aged ≤65 years with first MI in Sweden 2007 to 2022. Regression models were used to estimate the association between adverse pregnancy outcomes (hypertensive disorders of pregnancy [non-preeclamptic hypertension and preeclampsia], small for gestational age [SGA] infant, and preterm delivery) and STEMI, invasive revascularization, and high troponin, while considering known predictors of coronary heart disease. Results In total, 3,128 (38%) of women suffered STEMI. The adjusted OR of presenting with STEMI were higher in women with a history of preterm preeclampsia (OR: 1.40; 95% CI: 1.05-1.88), or an SGA infant (OR: 1.30; 95% CI: 1.13-1.50) compared to women with no such history, as well as for in-hospital revascularization. Stratified by infarct type, troponin levels did not differ by adverse pregnancy outcome history. Conclusions Among women with a first MI, a history of preterm preeclampsia or SGA infant were associated with STEMI and invasive revascularization.
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Affiliation(s)
- Moa Handmark
- Perinatal and Cardiovascular Epidemiology and Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Annie Lin
- Perinatal and Cardiovascular Epidemiology and Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Andreas Edsfeldt
- Cardiovascular Research - Translational Studies, Lund University, Malmö, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund/Malmö, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Abigail Fraser
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Janet W. Rich-Edwards
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Isabel Gonҫalves
- Cardiovascular Research - Translational Studies, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital, Lund/Malmö, Sweden
| | - Mats Pihlsgård
- Perinatal and Cardiovascular Epidemiology and Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Simon Timpka
- Perinatal and Cardiovascular Epidemiology and Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Obstetrics and Gynaecology, Skåne University Hospital, Malmö, Sweden
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Boukantar M, Chiaroni PM, Gallet R, Zamora P, Truong T, Mangiameli A, Rostain L, Tuffreau-Martin AS, Natella PA, Oubaya N, Teiger E. A Randomized Controlled Trial of Nonfasting vs Fasting Before Interventional Coronary Procedures: The TONIC Trial. JACC Cardiovasc Interv 2024; 17:1200-1210. [PMID: 38811102 DOI: 10.1016/j.jcin.2024.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/11/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Fasting before coronary procedures is currently recommended to reduce complications despite the lack of scientific evidence. OBJECTIVES The TONIC (Comparison Between Fasting and No Fasting Before Interventional Coronary Intervention on the Occurrence of Adverse Events) noninferiority trial investigated the safety and comfort of a nonfasting strategy (ad libitum food and drinks) vs traditional fasting (>6 hours for solid food and liquids) before coronary procedures. METHODS In this monocentric, prospective, single-blind randomized controlled trial, 739 patients undergoing coronary procedures were included and randomized to a fasting or a nonfasting strategy. Emergency procedures were excluded. The primary endpoint was a composite of vasovagal reaction, hypoglycemia (defined by blood sugar ≤0.7 g/L), and isolated nausea and/or vomiting. Noninferiority margin was 4%. Secondary endpoints were contrast-induced nephropathy and patients' satisfaction. RESULTS Among the 739 procedures (697 elective and 42 semiurgent), 517 angiographies, and 222 angioplasties (including complex and high-risk procedures) were performed. The primary endpoint occurred in 30 of 365 nonfasting patients (8.2%) vs 37 of 374 fasting patients (9.9%), demonstrating noninferiority (absolute between-group difference, -1.7%; 1-sided 95% CI upper limit: 1.8%). No food-related adverse event occurred, and contrast-related acute kidney injuries were similar between groups. Overall, procedure satisfaction and perceived pain were similar in both groups, but nonfasting patients reported less hunger and thirst (P < 0.01). In case of redo coronary procedures, most patients (79%) would choose a nonfasting strategy. CONCLUSIONS The TONIC randomized trial demonstrates the noninferiority of a nonfasting strategy to the usual fasting strategy for coronary procedures regarding safety, while improving patients' comfort.
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Affiliation(s)
- Madjid Boukantar
- Interventional Cardiology, Henri Mondor Hospital, Créteil, France.
| | | | - Romain Gallet
- Interventional Cardiology, Henri Mondor Hospital, Créteil, France
| | - Patrick Zamora
- Interventional Cardiology, Henri Mondor Hospital, Créteil, France
| | - Tony Truong
- Interventional Cardiology, Henri Mondor Hospital, Créteil, France
| | | | - Laura Rostain
- Interventional Cardiology, Henri Mondor Hospital, Créteil, France
| | | | | | - Nadia Oubaya
- University Paris Est Créteil, INSERM, IMRB, Créteil, France; AP-HP, Hôpitaux Henri-Mondor, Department of Public Health, Creteil, France
| | - Emmanuel Teiger
- Interventional Cardiology, Henri Mondor Hospital, Créteil, France
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Chow C, Doll J. Contemporary Risk Models for In-Hospital and 30-Day Mortality After Percutaneous Coronary Intervention. Curr Cardiol Rep 2024; 26:451-457. [PMID: 38592570 DOI: 10.1007/s11886-024-02047-0] [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] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Risk models for mortality after percutaneous coronary intervention (PCI) are underutilized in clinical practice though they may be useful during informed consent, risk mitigation planning, and risk adjustment of hospital and operator outcomes. This review analyzed contemporary risk models for in-hospital and 30-day mortality after PCI. RECENT FINDINGS We reviewed eight contemporary risk models. Age, sex, hemodynamic status, acute coronary syndrome type, heart failure, and kidney disease were consistently found to be independent risk factors for mortality. These models provided good discrimination (C-statistic 0.85-0.95) for both pre-catheterization and comprehensive risk models that included anatomic variables. There are several excellent models for PCI mortality risk prediction. Choice of the model will depend on the use case and population, though the CathPCI model should be the default for in-hospital mortality risk prediction in the United States. Future interventions should focus on the integration of risk prediction into clinical care.
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Affiliation(s)
- Christine Chow
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jacob Doll
- Department of Medicine, University of Washington, Seattle, WA, USA.
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4
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Deng W, Wang D, Wan Y, Lai S, Ding Y, Wang X. Prediction models for major adverse cardiovascular events after percutaneous coronary intervention: a systematic review. Front Cardiovasc Med 2024; 10:1287434. [PMID: 38259313 PMCID: PMC10800829 DOI: 10.3389/fcvm.2023.1287434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Background The number of models developed for predicting major adverse cardiovascular events (MACE) in patients undergoing percutaneous coronary intervention (PCI) is increasing, but the performance of these models is unknown. The purpose of this systematic review is to evaluate, describe, and compare existing models and analyze the factors that can predict outcomes. Methods We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 during the execution of this review. Databases including Embase, PubMed, The Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and SINOMED were comprehensively searched for identifying studies published from 1977 to 19 May 2023. Model development studies specifically designed for assessing the occurrence of MACE after PCI with or without external validation were included. Bias and transparency were evaluated by the Prediction Model Risk Of Bias Assessment Tool (PROBAST) and Transparent Reporting of a multivariate Individual Prognosis Or Diagnosis (TRIPOD) statement. The key findings were narratively summarized and presented in tables. Results A total of 5,234 articles were retrieved, and after thorough screening, 23 studies that met the predefined inclusion criteria were ultimately included. The models were mainly constructed using data from individuals diagnosed with ST-segment elevation myocardial infarction (STEMI). The discrimination of the models, as measured by the area under the curve (AUC) or C-index, varied between 0.638 and 0.96. The commonly used predictor variables include LVEF, age, Killip classification, diabetes, and various others. All models were determined to have a high risk of bias, and their adherence to the TRIPOD items was reported to be over 60%. Conclusion The existing models show some predictive ability, but all have a high risk of bias due to methodological shortcomings. This suggests that investigators should follow guidelines to develop high-quality models for better clinical service and dissemination. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=400835, Identifier CRD42023400835.
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Affiliation(s)
- Wenqi Deng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Dayang Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Cardiovascular Diseases, Beijing University of Chinese Medicine, Beijing, China
| | - Yandi Wan
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Sijia Lai
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yukun Ding
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xian Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Institute of Cardiovascular Diseases, Beijing University of Chinese Medicine, Beijing, China
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5
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Ridwan M, Sari IP, Salawati L, Heriansyah T, Taufik NH, Putri CJE, Nurjani N. Association between six-minute walk distance and prognosis of atherosclerotic coronary heart disease post-cardiac rehabilitation. NARRA J 2023; 3:e242. [PMID: 38450344 PMCID: PMC10914091 DOI: 10.52225/narra.v3i3.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 09/25/2023] [Indexed: 03/08/2024]
Abstract
Plaque accumulation in the coronary arteries is a major cause of coronary heart disease (CHD), a disease infamously known as a contributor for global death burden. Major adverse cardiac events (MACE) pose significant risks for CHD patients, highlighting the urgency of effective management and cardiac rehabilitation in CHD management. Studies have reported the role of the six-minute walk distance (6MWD) test in predicting outcomes for CHD patients; however, none have performed the investigation in Aceh setting. The aim of this study was to investigate the reliability of 6MWD as a prognostic factor for post-cardiac rehabilitation of patients with atherosclerotic CHD. A cross-sectional study was conducted in Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia. MACE was determined through in-person interviews, and phone calls with 30 atherosclerotic CHD patients who completed cardiac rehabilitation between August 2018 and September 2020. The association between 6MWD and prognosis, assessed by MACE incidence, was calculated. The results revealed that 6MWD was strongly associated with MACE occurrence during post-cardiac rehabilitation (p=0.029; prevalence ratio 4.5). Furthermore, CHD patients achieving 6MWD of more than 300 meters exhibited a lower incidence of MACE (10.5%) than patients with 6MWD of less than 300 meters (45.5%). In conclusion, the present study sheds light on the importance of improving functional capacity in patients with atherosclerotic CHD post-cardiac rehabilitation due to its significant association with the prognosis.
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Affiliation(s)
- Muhammad Ridwan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Cardiology and Vascular Medicine, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Indah P. Sari
- Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
| | - Liza Salawati
- Department of Family Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
| | - Teuku Heriansyah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Cardiology and Vascular Medicine, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Nasyaruddin H. Taufik
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia
- Department of Medical Rehabilitation, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia; Cardiac Rehabilitation Unit, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Cut JE. Putri
- Department of Medical Rehabilitation, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia; Cardiac Rehabilitation Unit, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
| | - Nurjani Nurjani
- Department of Medical Rehabilitation, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia; Cardiac Rehabilitation Unit, Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia
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Pehrson M, Edsfeldt A, Sarno G, Fraser A, Rich-Edwards JW, Pihlsgård M, Timpka S. Long-Term Outcome Following Coronary Artery Stenting by History of Preterm Delivery. JACC. ADVANCES 2022; 1:100142. [PMID: 38939462 PMCID: PMC11198654 DOI: 10.1016/j.jacadv.2022.100142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 06/29/2024]
Abstract
Background Women are at a greater risk of a major adverse cardiovascular event (MACE) after percutaneous coronary intervention than men. A history of preterm delivery is a female-specific risk factor for coronary artery disease, but its relevance in the treatment of coronary artery disease is unknown. Objectives The purpose of this study was to analyze the association between a history of preterm delivery and MACE after the first coronary artery stenting. Methods We included a nationwide sample of 5,766 Swedish women aged ≤65 years receiving their first coronary stent during 2006 to 2017. To adjust for periprocedural characteristics and estimate the association between a history of preterm delivery and MACE at >30 days from stenting, we used proportional hazards regression. We also investigated mortality by history of preterm delivery. Results During a median follow-up time of 3.7 years (IQR: 1.3-6.7 years), 1,200 (20.8%) women had a MACE. In total, 963 (16.7%) women had a history of preterm delivery. A history of preterm delivery was associated with a higher risk of MACE (adjusted HR: 1.19; 95% CI: 1.03-1.38) and mortality (adjusted HR ratio: 1.38; 95% CI: 1.02-1.85). Similar associations were observed when excluding women with a history of hypertensive disorders of pregnancy or diabetes. Subgroup analyses suggested that women with a history of early preterm delivery had lower risk of MACE than those who had late preterm delivery (P = 0.04). Conclusions History of preterm delivery is associated with worse prognosis following the first coronary artery stenting in women and warrants consideration as a risk factor also in the secondary prevention setting.
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Affiliation(s)
- Moa Pehrson
- Perinatal and Cardiovascular Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Andreas Edsfeldt
- Cardiovascular Research- Translational Studies, Lund University, Malmö, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund/Malmö, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Abigail Fraser
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Janet W. Rich-Edwards
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mats Pihlsgård
- Perinatal and Cardiovascular Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Simon Timpka
- Perinatal and Cardiovascular Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
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7
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Baschat AA, Blackwell SB, Chatterjee D, Cummings JJ, Emery SP, Hirose S, Hollier LM, Johnson A, Kilpatrick SJ, Luks FI, Menard MK, McCullough LB, Moldenhauer JS, Moon-Grady AJ, Mychaliska GB, Narvey M, Norton ME, Rollins MD, Skarsgard ED, Tsao K, Warner BB, Wilpers A, Ryan G. Care Levels for Fetal Therapy Centers. Obstet Gynecol 2022; 139:1027-1042. [PMID: 35675600 PMCID: PMC9202072 DOI: 10.1097/aog.0000000000004793] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/03/2022] [Indexed: 01/05/2023]
Abstract
Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal, or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal, and neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight and monitoring of clinical performance and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed to match the anticipated care complexity, with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level I fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture but that would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level II center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level III therapy center should offer the full range of fetal interventions (including open fetal surgery) and be able manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.
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Affiliation(s)
- Ahmet A. Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology &Obstetrics, Johns Hopkins University
| | - Sean B Blackwell
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | - Debnath Chatterjee
- Department of Anesthesiology, Children’s Hospital Colorado/Colorado Fetal Care Center, University of Colorado School of Medicine
| | | | - Stephen P. Emery
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine
| | - Shinjiro Hirose
- Division of Pediatric, General, Thoracic and Fetal Surgery, Department of Surgery, University of California Davis Medical Center
| | - Lisa M. Hollier
- Division of Maternal-Fetal; Medicine, Department of Obstetrics & Gynecology, Baylor College of Medicine
| | - Anthony Johnson
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Texas, Mc Govern Medical School
| | | | - Francois I Luks
- Department of Surgery, Alpert Medical School of Brown University and Hasbro Children’s Hospital
| | - M. Kathryn Menard
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill
| | | | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Anita J. Moon-Grady
- Division of Pediatric Cardiology, Department of Clinical Pediatrics, University of California, San Francisco
| | - George B. Mychaliska
- Department of Pediatric Surgery, C.S. Mott Children’s Hospital, University of Michigan
| | - Michael Narvey
- Division of Neonatology, Department of Pediatrics, University of Manitoba
| | - Mary E. Norton
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco
| | | | - Eric D. Skarsgard
- Centre for Surgical Research, Department of Surgery, BC Children’s Hospital, University of British Columbia
| | - KuoJen Tsao
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Texas, Mc Govern Medical School
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine
| | | | - Greg Ryan
- Ontario Fetal Care Centre, Mount Sinai Hospital, University of Toronto
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8
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Rigatelli G, Zuin M, Picariello C, Gianese F, Osti S, Mazza A, Vassilev D, Dinh H, Van Tan N, Nghia N, Roncon L. Gender-related differences in clinical outcomes after either single or double left main bifurcation stenting. Heart Vessels 2022; 37:1326-1336. [PMID: 35178606 DOI: 10.1007/s00380-022-02038-7] [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: 11/29/2021] [Accepted: 01/28/2022] [Indexed: 12/25/2022]
Abstract
We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10 years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8 months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.
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Affiliation(s)
- Gianluca Rigatelli
- Division of Cardiology, Department of Specialistic Medicine, Rovigo General Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy.
| | - Marco Zuin
- Department of Translational Medicine, Section of Internal and Cardiorespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Claudio Picariello
- Division of Cardiology, Department of Specialistic Medicine, Rovigo General Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
| | - Filippo Gianese
- Division of Cardiology, Department of Specialistic Medicine, Rovigo General Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
| | - Sabrina Osti
- Division of Cardiology, Department of Specialistic Medicine, Rovigo General Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
| | - Alberto Mazza
- Department of Internal Medicine, Rovigo General Hospital, Rovigo, Italy
| | - Dobrin Vassilev
- Head of Cardiology, Alexandroska University Hospital Medical School, Sofia, Bulgaria
| | - Huy Dinh
- Department of Interventional Cardiology, Tam Duc Heart Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Van Tan
- Department of Interventional Cardiology, Thong Nhat Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Nghia
- Department of Interventional Cardiology, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Loris Roncon
- Division of Cardiology, Department of Specialistic Medicine, Rovigo General Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
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9
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Labib S, Kassem HH, Kandil H. Peri-Procedural Blood Pressure Changes and Their Relationship with MACE in Patients Undergoing Percutaneous Coronary Intervention: A Cross-Sectional Study. Integr Blood Press Control 2020; 13:187-195. [PMID: 33335422 PMCID: PMC7736835 DOI: 10.2147/ibpc.s268848] [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: 08/04/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022] Open
Abstract
Background Peri-procedural blood-pressure (BP) changes were investigated and correlated to Major adverse cardiovascular events (MACE) as predictor of outcome for patients undergoing percutaneous coronary intervention (PCI); whether acute coronary syndrome (Unstable angina, or MI; STEMI or NSTEMI) or scheduled for elective PCI. Methods Resting BP in the 204 recruited patients undergoing PCI throughout 2018 was measured thrice – in the ward before transferring to the cardiac catheterization lab (cath lab), in the cath lab, and after transfer to the recovery room. Patients were categorized based on their systolic and diastolic BP peri-procedural difference as systolic (SBP): with a large difference (>20 mmHg, n=47), with a small difference (≤20 mmHg, n=157) (shock patients excluded); diastolic (DBP): with a large difference (>10 mmHg, n=65), and with a small difference (≤10 mmHg, n=139). The primary end-points were MACE including all-cause mortality, non-fatal myocardial infarction, and stroke during the hospital stay. The Mann–Whitney U and Chi-square tests were used to analyze the data accordingly (p<0.005). Results Within the category of MACE, cardiac mortality was the only adverse cardiac event encountered in the study sample. Cardiac mortality was significantly higher in both the large SBP-difference group versus the other group (10.6% vs 0.6%, p=0.003) and the large DBP-difference group versus the small-difference group (7.7% vs 0.7%, p=0.013). Conclusion Peri-procedural systolic and diastolic BP differences, greater than 20 mmHg and 10 mmHg, respectively, correlated with MACE in all patients undergoing PCI.
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Affiliation(s)
- Susan Labib
- Department of Cardiology, Cairo University, Cairo, Egypt
| | | | - Hossam Kandil
- Department of Cardiology, Cairo University, Cairo, Egypt
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10
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Cockburn J, Kemp T, Ludman P, Kinnaird T, Johnson T, Curzen N, Robinson D, Mamas M, de Belder A, Hildick-Smith D. Percutaneous coronary intervention in octogenarians: A risk scoring system to predict 30-day outcomes in the elderly. Catheter Cardiovasc Interv 2020; 98:1300-1307. [PMID: 33283484 DOI: 10.1002/ccd.29406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/26/2020] [Accepted: 11/15/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Octogenarians are a high-risk group presenting for percutaneous coronary intervention (PCI). We aimed to create a 30-day mortality risk model for octogenarians presenting with both acute coronary syndrome (ACS) and chronic stable angina (CSA), using comprehensive mandatory UK data submissions to the UK National database. BACKGROUND Octogenarians are a high-risk group presenting for percutaneous coronary intervention, and decisions on whether or not to undertake intervention in this cohort can be challenging. The increasing number of octogenarians in the general population means they represent an important high-risk subgroup of patients. METHODS The data group consisted of 425,897 PCI procedures undertaken in the UK between 2008 and 2012 during which time there was comprehensive data linkage to mortality via the Office of National Statistics. Of these procedures, 44,221 (10.4%) were in patients aged ≥80. These comprised the model group. Logistic regression was used to create a predictive score which ultimately consisted of the following weightings: age 80-89 (n = 1); age > 90 (n = 2); unstable angina/non-ST-elevation myocardial infraction (NSTEMI) (n = 1); STEMI (n = 2); creatinine >200 mmol/L (n = 1); preprocedural ventilation (n = 1); left ventricular ejection fraction <30% (n = 1); cardiogenic shock (n = 2). Multiple imputation was used to account for missing data. RESULTS The patient cohort was divided into a derivation (n = 22,072) and a validation dataset (n = 22,071). Receiver operating characteristic analyses were used to derive the area-under-the-curve to assess properties of the score. The scoring system generated an AUC 0.83, (95% CI 0.80-0.85) suggesting high sensitivity and specificity. Scores of 1-4 were associated with good survival but scores ≥5 were associated with an estimated likelihood of death within 30 days of ≥40%. CONCLUSIONS This octogenarian risk score maybe a useful tool to determine the chance of a successful outcome in elderly patients presenting for PCI.
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Affiliation(s)
- James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Tiffany Kemp
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Peter Ludman
- Queen Elizabeth Hospital NHS Trust, Birmingham, UK
| | | | | | - Nick Curzen
- University Hospital Southampton, Southampton, UK
| | - Derek Robinson
- Department of Mathematics, Sussex University, Brighton, UK
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Manchester, UK
| | - Adam de Belder
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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11
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Prognostic value of coronary computed tomography angiography in patients with prior percutaneous coronary intervention. J Cardiovasc Comput Tomogr 2020; 15:268-273. [PMID: 32981882 DOI: 10.1016/j.jcct.2020.09.007] [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: 08/25/2020] [Accepted: 09/15/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We sought to determine the prognostic value of coronary computed tomography angiography (CCTA) in patients with a history of percutaneous coronary intervention (PCI). BACKGROUND Although the prognostic value of CCTA has been well studied, its incremental value in patients with previous PCI has not been robustly investigated. METHODS Consecutive patients with previous PCI were prospectively enrolled and CCTA images were evaluated for coronary artery disease (CAD) severity. Patients were followed for major adverse cardiovascular events (MACE) which was a composite of cardiac death and non-fatal myocardial infarction. All-cause death was assessed as a secondary endpoint. RESULTS A total of 501 patients were analyzed with a mean follow-up time of 59.5 ± 32.0 months and 52 patients (10.4%) experienced MACE. Multivariable Cox regression analysis showed that CAD severity was a predictor of MACE with 0, 1, 2, and 3 vessel disease having annual rates of 1.3%, 2.2%, 2.2%, and 5.3%, respectively. All-cause death was similar in all categories of CAD. CONCLUSIONS In patients with previous PCI, CAD severity as measured with CCTA has independent and incremental prognostic value.
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12
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Rashid M, Ludman PF, Mamas MA. British Cardiovascular Intervention Society registry framework: a quality improvement initiative on behalf of the National Institute of Cardiovascular Outcomes Research (NICOR). EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 5:292-297. [PMID: 31050720 DOI: 10.1093/ehjqcco/qcz023] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 11/14/2022]
Abstract
The British Cardiovascular Intervention Society (BCIS) percutaneous coronary intervention (PCI) registry is hosted by the National Institute of Cardiovascular Outcomes Research (NICOR) at Bart's Heart Centre and collects clinical characteristics, indications, procedural details, and outcomes of all patients undergoing PCI in the UK. The data are used for audit and research to monitor and improve PCI practices and patient outcomes. Bespoke live data analysis and structured monthly reports are used to provide real-time feedback to all participating hospitals about the provision of care. Risk-adjusted analyses are used as a quality metric and benchmarking PCI practices. The consecutive patients undergoing PCI in all PCI performing hospitals in the UK from 1994 to present. One hundred and thirteen variables encompassing patient demographics, indication, procedural details, complications, and in-hospital outcomes are recorded. Prospective data are collected electronically and encrypted before transfer to central database servers. Data are validated locally and further range checks, sense checks, and assessments of internal consistency are applied during data uploads. Analyses of uploaded data including an assessment of data completeness are provided to all hospitals for validation, with repeat validation rounds prior to public reporting. Endpoints are in-hospital PCI complications, bleeding and mortality. All-cause mortality is obtained via linkage to the Office of National Statistics. No other linkages are available at present. Available for research by application to NICOR at http://www.nicor.org.uk/ using a data sharing agreement.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Peter F Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, UK
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13
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Jones DA, Rathod KS, Koganti S, Lim P, Firoozi S, Bogle R, Jain AK, MacCarthy PA, Dalby MC, Malik IS, Mathur A, DeSilva R, Rakhit R, Kalra SS, Redwood S, Ludman P, Wragg A. The association between the public reporting of individual operator outcomes with patient profiles, procedural management, and mortality after percutaneous coronary intervention: an observational study from the Pan-London PCI (BCIS) Registry using an interrupted time series analysis. Eur Heart J 2019; 40:2620-2629. [PMID: 31220238 DOI: 10.1093/eurheartj/ehz152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/17/2019] [Accepted: 03/03/2019] [Indexed: 01/10/2023] Open
Abstract
AIMS The public reporting of healthcare outcomes has a number of potential benefits; however, unintended consequences may limit its effectiveness as a quality improvement process. We aimed to assess whether the introduction of individual operator specific outcome reporting after percutaneous coronary intervention (PCI) in the UK was associated with a change in patient risk factor profiles, procedural management, or 30-day mortality outcomes in a large cohort of consecutive patients. METHODS AND RESULTS This was an observational cohort study of 123 780 consecutive PCI procedures from the Pan-London (UK) PCI registry, from January 2005 to December 2015. Outcomes were compared pre- (2005-11) and post- (2011-15) public reporting including the use of an interrupted time series analysis. Patients treated after public reporting was introduced were older and had more complex medical problems. Despite this, reported in-hospital major adverse cardiovascular and cerebrovascular events rates were significantly lower after the introduction of public reporting (2.3 vs. 2.7%, P < 0.0001). Interrupted time series analysis demonstrated evidence of a reduction in 30-day mortality rates after the introduction of public reporting, which was over and above the existing trend in mortality before the introduction of public outcome reporting (35% decrease relative risk 0.64, 95% confidence interval 0.55-0.77; P < 0.0001). CONCLUSION The introduction of public reporting has been associated with an improvement in outcomes after PCI in this data set, without evidence of risk-averse behaviour. However, the lower reported complication rates might suggest a change in operator behaviour and decision-making confirming the need for continued surveillance of the impact of public reporting on outcomes and operator behaviour.
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Affiliation(s)
- Daniel A Jones
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Krishnaraj S Rathod
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Sudheer Koganti
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Pitt Lim
- Department of Cardiology, St. George's Healthcare NHS Foundation Trust, St. George's Hospital, Blackshaw Road, Tooting, London, UK
| | - Sam Firoozi
- Department of Cardiology, St. George's Healthcare NHS Foundation Trust, St. George's Hospital, Blackshaw Road, Tooting, London, UK
| | - Richard Bogle
- Department of Cardiology, St. George's Healthcare NHS Foundation Trust, St. George's Hospital, Blackshaw Road, Tooting, London, UK
| | - Ajay K Jain
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Philip A MacCarthy
- Department of Cardiology, Kings College Hospital, King's College Hospital NHS Foundation Trust, Denmark Hill, 10 Cutcombe Road, London, UK
| | - Miles C Dalby
- Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Middlesex, UK
| | - Iqbal S Malik
- Department of Cardiology, Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - Anthony Mathur
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Ranil DeSilva
- Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Middlesex, UK
| | - Roby Rakhit
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, UK
| | - Sundeep Singh Kalra
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, UK
| | - Simon Redwood
- Department of Cardiology, St Thomas' NHS Foundation Trust, Guys & St. Thomas Hospital, Westminster Bridge Rd, London, UK
| | - Peter Ludman
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, UK
| | - Andrew Wragg
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
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14
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Acute and Long-Term Outcomes of Patients with Impaired Left Ventricular Systolic Function Undergoing Rotational Atherectomy: A Single-Center Observational Retrospective Study. Cardiol Ther 2019; 8:267-281. [PMID: 31350729 PMCID: PMC6828855 DOI: 10.1007/s40119-019-0143-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction Rotational atherectomy (RA) historically was contraindicated in patients with impaired left ventricular (LV) function due to inherent cardio-depressive effects. Contemporary RA practice is less aggressive than traditional RA and no longer withheld from patients with reduced ejection fraction (EF). The aim of this analysis is to explore the outcomes of rotational atherectomy (RA) in patients with reduced left ventricular ejection fraction (LVEF). Methods Patients undergoing RA (n = 644) were divided into three groups according to LVEF (severely reduced ≤ 35%, n = 82; moderately reduced 36–54%, n = 170; and preserved LVEF ≥ 55%, n = 392). Results Compared to patients with preserved LVEF, those with severely reduced LVEF had higher rates of angiographic failure (12.2 vs. 3.3%, p = 0.003) and in-hospital major adverse cardiac events (MACE: 9.8 vs. 2.3%, p = 0.004) driven by more peri-procedural myocardial infarction (MI: 6.1 vs. 1.5%, p = 0.049). In-hospital outcomes were similar between patients with preserved and moderately reduced LVEF. At 5-year follow-up, a stepwise increase in all-cause death was observed with lower LVEF (preserved: 15%, moderately reduced: 23%, severely reduced: 43%; p < 0.001). On the other hand, revascularization and MI rates at 5 years were not affected by LVEF. Conclusions Compared to patients with preserved LVEF, those with severely reduced LVEF have worse acute outcomes after RA, whereas a moderate reduction of LVEF poses no additional acute hazard after RA. Up to 5 years, the extent of left ventricular dysfunction was associated with a stepwise increase in mortality. Electronic supplementary material The online version of this article (10.1007/s40119-019-0143-4) contains supplementary material, which is available to authorized users.
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15
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Andrews M, Iqbal J, Wall JJ, Teare D, El-Omar M, Fath-Ordoubadi F, Gunn J. Development and Validation of a Novel Risk Score for Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:980-984. [PMID: 30773426 DOI: 10.1016/j.carrev.2018.12.020] [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: 10/10/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary percutaneous coronary intervention (PPCI) is the default treatment for patients with ST elevation myocardial infarction (STEMI) and carries a higher risk of adverse outcomes when compared with elective and urgent PCI. Conventional PCI risk scores tend to be complex and may underestimate the risk associated with PPCI due to under-representation of patients with STEMI in their datasets. This study aimed to develop a simple, practical and contemporary risk model to provide risk stratification in PPCI. METHODS Demographic, clinical and outcome data were collected for all patients who underwent PPCI between January 2009 and October 2013 at the Northern General Hospital, Sheffield. Multiple regression analysis was used to identify independent predictors of mortality and to construct a risk model. This model was then separately validated on an internal and external dataset. RESULTS The derivation cohort included 2870 patients with a 30-day mortality of 5.1% (145 patients). Only four variables were required to predict 30-day mortality: age [OR:1.047, 95% CI:1.031-1.063], call-to-balloon (CTB) time [OR:1.829, 95% CI:1.198-2.791], cardiogenic shock [OR:13.886, 95% CI:8.284-23.275] and congestive heart failure [OR:3.169, 95% CI:1.420-7.072]. Internal validation was performed in 693 patients and external validation in 660 patients undergoing PPCI. Our model showed excellent discrimination on ROC-curve analysis (C-Stat = 0.87 internal and 0.86, external), and excellent calibration on Hosmer-Lemeshow testing (p = 0.37 internal, 0.55 external). CONCLUSIONS We have developed a bedside risk model which can predict 30-day mortality after PPCI using only four variables: age, CTB time, congestive heart failure and shock.
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Affiliation(s)
- Michael Andrews
- Department of Cardiovascular Science, University of Sheffield, UK.
| | - Javaid Iqbal
- Department of Cardiovascular Science, University of Sheffield, UK; Department of Cardiology, Northern General Hospital, Sheffield, UK
| | - Joshua J Wall
- Department of Cardiovascular Science, University of Sheffield, UK
| | - Dawn Teare
- School of Health and Related Research, University of Sheffield, UK
| | - Magdi El-Omar
- Department of Cardiology, Manchester Royal Infirmary, Manchester, UK
| | | | - Julian Gunn
- Department of Cardiovascular Science, University of Sheffield, UK; Department of Cardiology, Northern General Hospital, Sheffield, UK
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16
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Sohrabi B, Separham A, Habibolahi H, Enamzadeh E, Ghamari B, Karkon Shayan F. Prediction of clinical outcomes of patients treated with percutaneous coronary intervention for ST-Elevation myocardial infarction using familial history of premature coronary artery disease. JOURNAL OF ANALYTICAL RESEARCH IN CLINICAL MEDICINE 2018. [DOI: 10.15171/jarcm.2018.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: ST-elevation myocardial infarction (STEMI) is a relatively common cause of mortality among patients. The effects of risk factors as predictors of mortality in patients has been shown in different studies. The present study was performed aiming to evaluate the association between a family history of premature coronary artery diseases (CADs) with clinical outcomes among patients treated with percutaneous coronary intervention (PCI) for STEMI. Methods: This descriptive-analytical study was conducted in Shahid Madani Hospital of Tabriz University of Medical Sciences, Tabriz, Iran, on 200 patients with STEMI with a PCI. 100 out of these 200 patients had a family history of premature CAD. Patients were followed up within 48 hours after PCI, as well as one year after admission, and the secondary outcomes including myocardial infarction (MI), heart failure, ventricular arrhythmias (VAs), pulmonary edema, and death were evaluated. Results: The mean age of the patients with positive and negative family history of premature CAD was 56.37 ± 8.20 and 61.72 ± 7.42 years, respectively. The mean age of the patients with a family history of a premature CAD was significantly lower than that of patients without a family history of a premature CAD (P = 0.001). There was no significant difference in the frequency of CAD risk factors, angiographic findings, and its complications, ST-segment resolution and frequency of secondary outcomes during 48 hours and one year after admission between the study groups (P > 0.050). Conclusion: The present study showed that a family history of premature CAD does not predict the clinical outcomes in patients treated with PCI for STEMI which should be validated across future studies.
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Affiliation(s)
- Bahram Sohrabi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Separham
- Department of Cardiology, School of medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Habibolahi
- Department of Cardiology, School of medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elgar Enamzadeh
- Department of Cardiology, School of medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behnaz Ghamari
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Karkon Shayan
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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17
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Vershinina EO, Repin AN. Predictors of long term adverse events after scheduled endovascular coronary interventions. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2018. [DOI: 10.15829/1728-8800-2018-4-46-52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- E. O. Vershinina
- SRI of Cardiology “Tomsk National Research Medical Center of RAS”
| | - A. N. Repin
- SRI of Cardiology “Tomsk National Research Medical Center of RAS”
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18
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Wall JJS, Iqbal J, Andrews M, Teare D, Ghobrial M, Hinton T, Turton S, Quffa L, El-Omar M, Fraser DG, Siotia A, Gunn J. Development and validation of a clinical risk score to predict mortality after percutaneous coronary intervention. Open Heart 2017; 4:e000576. [PMID: 28878944 PMCID: PMC5574428 DOI: 10.1136/openhrt-2016-000576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 04/27/2017] [Accepted: 05/09/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To develop and validate a contemporary clinical risk score to predict mortality after percutaneous coronary intervention (PCI). METHODS Using data collected from patients undergoing PCI at the South Yorkshire Cardiothoracic Centre, Sheffield, UK, between January 2007 and September 2013, a risk score was developed to predict mortality. Logistic regression was used to evaluate the effect of each variable upon 30-day mortality. A backwards stepwise logistic regression model was then used to build a predictive model. The results were validated both internally and externally with data from Manchester Royal Infirmary, UK. 30-Day mortality status was determined from the UK Office of National Statistics. RESULTS The development data set comprised 6522 patients from Sheffield. Five risk factors, including cardiogenic shock, procedural urgency, history of renal disease, diabetes mellitus and age, were statistically significant to predict 30-day mortality. The risk score was validated internally on a further 3290 patients from Sheffield and externally on 3230 patients from Manchester. The discrimination of the model was high in the development (C-statistic=0.82, 95% CI 0.79 to 0.85), internal (C-statistic=0.81, 95% CI 0.76 to 0.86) and external (C statistics=0.90, 95% CI 0.87 to 0.93) cohorts. There was no significant difference between observed and predicted mortality in any group. CONCLUSION This contemporary risk score reliably predicts 30-day mortality after PCI using a small number of clinical variables obtainable prior to the procedure, without knowledge of the coronary anatomy.
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Affiliation(s)
- Joshua J S Wall
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK
| | - Javaid Iqbal
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK
| | - Michael Andrews
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK
| | - Dawn Teare
- Sheffield School for Health and Related Research, Sheffield, UK
| | - Mina Ghobrial
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK.,Freeman Hospital, Newcastle Upon Tyne Hospitals Foundation Trust, Newcastle Upon Tyne, UK
| | - Thomas Hinton
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK.,Bristol Heart Institute, Bristol, UK.,University of Bristol, Bristol, UK
| | - Samuel Turton
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Leila Quffa
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK
| | | | | | | | - Julian Gunn
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield, UK.,Insigneo Institute for In Silico Medicine, Sheffield, UK
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Moon-Grady AJ, Baschat A, Cass D, Choolani M, Copel JA, Crombleholme TM, Deprest J, Emery SP, Evans MI, Luks FI, Norton ME, Ryan G, Tsao K, Welch R, Harrison M. Fetal Treatment 2017: The Evolution of Fetal Therapy Centers - A Joint Opinion from the International Fetal Medicine and Surgical Society (IFMSS) and the North American Fetal Therapy Network (NAFTNet). Fetal Diagn Ther 2017; 42:241-248. [PMID: 28531885 PMCID: PMC5739586 DOI: 10.1159/000475929] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/18/2017] [Indexed: 01/23/2023]
Abstract
More than 3 decades ago, a small group of physicians and other practitioners active in what they called "fetal treatment" authored an opinion piece outlining the current status and future challenges anticipated in the field. Many advances in maternal, neonatal, and perinatal care and diagnostic and therapeutic modalities have been made in the intervening years, yet a thoughtful reassessment of the basic tenets put forth in 1982 has not been published. The present effort will aim to provide a framework for contemporary redefinition of the field of fetal treatment, with a brief discussion of the necessary minimum expertise and systems base for the provision of different types of interventions for both the mother and fetus. Our goal will be to present an opinion that encourages the advancement of thoughtful practice, ensuring that current and future patients have realistic access to centers with a range of fetal therapies with appropriate expertise, experience, and subspecialty and institutional support while remaining focused on excellence in care, collaborative scientific discovery, and maternal autonomy and safety.
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Affiliation(s)
- Anita J Moon-Grady
- The Fetal Treatment Center, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
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20
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Ludman P, de Belder M, Redwood S, Banning A. United Kingdom: coronary and structural heart interventions from 2010 to 2015. EUROINTERVENTION 2017; 13:Z83-Z88. [DOI: 10.4244/eij-d-16-00833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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A contemporary risk model for predicting 30-day mortality following percutaneous coronary intervention in England and Wales. Int J Cardiol 2016; 210:125-32. [PMID: 26942330 PMCID: PMC4819905 DOI: 10.1016/j.ijcard.2016.02.085] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 02/08/2016] [Accepted: 02/14/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND The current risk model for percutaneous coronary intervention (PCI) in the UK is based on outcomes of patients treated in a different era of interventional cardiology. This study aimed to create a new model, based on a contemporary cohort of PCI treated patients, which would: predict 30 day mortality; provide good discrimination; and be well calibrated across a broad risk-spectrum. METHODS AND RESULTS The model was derived from a training dataset of 336,433 PCI cases carried out between 2007 and 2011 in England and Wales, with 30 day mortality provided by record linkage. Candidate variables were selected on the basis of clinical consensus and data quality. Procedures in 2012 were used to perform temporal validation of the model. The strongest predictors of 30-day mortality were: cardiogenic shock; dialysis; and the indication for PCI and the degree of urgency with which it was performed. The model had an area under the receiver operator characteristic curve of 0.85 on the training data and 0.86 on validation. Calibration plots indicated a good model fit on development which was maintained on validation. CONCLUSION We have created a contemporary model for PCI that encompasses a range of clinical risk, from stable elective PCI to emergency primary PCI and cardiogenic shock. The model is easy to apply and based on data reported in national registries. It has a high degree of discrimination and is well calibrated across the risk spectrum. The examination of key outcomes in PCI audit can be improved with this risk-adjusted model.
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Usefulness of Intra-aortic Balloon Pump Counterpulsation. Am J Cardiol 2016; 117:469-76. [PMID: 26708637 DOI: 10.1016/j.amjcard.2015.10.063] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/30/2015] [Accepted: 10/30/2015] [Indexed: 11/20/2022]
Abstract
Intra-aortic balloon pump (IABP) counterpulsation is the most widely used mechanical circulatory support device because of its ease of use, low complication rate, and fast manner of insertion. Its benefit is still subject of debate, and a considerable gap exists between guidelines and clinical practice. Retrospective nonrandomized studies and animal experiments show benefits of IABP therapy. However, recent large randomized trials do not show benefit of IABP therapy, which has led to a downgrading in the guidelines. In our view, this dichotomy between trials and practice might be the result of insufficient understanding of the prerequisites needed for effective IABP therapy, that is, exhausted autoregulation, and of not including the right patient population in trials. The population included in recent large randomized trials has been heterogeneous, also including patients in whom benefit of IABP could not be expected. The clinical condition in which most benefit is expected, that is persistent ischemia in acute ST-elevation myocardial infarction, is discussed in this review. In conclusion, this review aims to explain the physiological principles needed for effective IABP therapy, to reflect critically on the large randomized trials, and to solve some of the controversies in this field.
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Webster L, van der Linde I, Hampton-Till J, Davies JR. Evaluation of the North West Quality Improvement Programme risk prediction model as a 30-day mortality predictor. Interv Cardiol 2015. [DOI: 10.2217/ica.15.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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de Belder MA, Ludman PF, McLenachan JM, Weston CFM, Cunningham D, Lazaridis EN, Gray HH. The national infarct angioplasty project: UK experience and subsequent developments. EUROINTERVENTION 2015; 10 Suppl T:T96-T104. [PMID: 25256542 DOI: 10.4244/eijv10sta15] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The UK had previously established a comprehensive strategy for in-hospital nurse-led thrombolysis for patients with ST-elevation myocardial infarction, with a growing use of pre-hospital thrombolysis by paramedical staff in the ambulance services. The National Infarct Angioplasty Project was sponsored by the government and examined the introduction of primary percutaneous coronary angioplasty (PPCI) in a variety of urban, rural and mixed communities. The project found that PPCI could be delivered within acceptable timelines, would be cost-effective, and could be delivered to the majority of the population. A project was therefore undertaken in England to transform services. There has been a rapid change and by 2012/13 over 95% of eligible patients received PPCI. Survival of patients with STEMI has improved over time and length of stay in hospital halved. However, nearly a quarter of STEMI patients do not receive reperfusion therapy (often because of late presentation) and additional work is needed to minimise delays to treatment. There are unexplained differences between regions in numbers of PPCI procedures per million population, and there is also variance between centres in the proportion of patients who are in shock or on a ventilator. Additional research is needed to ensure a consistent approach for these sick patients, who might have the most to gain from early treatment. The national audit programmes have been instrumental in measuring the changes in strategies, monitoring performance and highlighting the associated improvements in outcomes. A new risk model is being developed to allow a more comprehensive comparison of outcomes in different hospitals.
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Affiliation(s)
- Mark A de Belder
- The James Cook University Hospital, Middlesbrough, United Kingdom
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Comparative outcomes after unprotected left main stem percutaneous coronary intervention: a national linked cohort study of 5,065 acute and elective cases from the BCIS Registry (British Cardiovascular Intervention Society). JACC Cardiovasc Interv 2015; 7:717-30. [PMID: 25060013 DOI: 10.1016/j.jcin.2014.03.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 03/08/2014] [Accepted: 03/13/2014] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The goal of this study was to report outcomes from percutaneous coronary intervention (PCI) to an unprotected left main stem (UPLMS) stenosis according to presenting syndrome, including ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation acute coronary syndrome (NSTEACS), and chronic stable angina (CSA). BACKGROUND There are no published whole-country data concerning patient outcomes following PCI to UPLMS. METHODS This study is a prospective national cohort study using data from the British Cardiovascular Intervention Society (BCIS) registry from January 1, 2005, through December 31, 2010. RESULTS Of 5,065 patients having PCI to an UPLMS, 784 (15.5%) presented with STEMI, 2,381 (47.0%) with NSTEACS, and 1,900 (37.5%) with CSA. Crude 30-day and 1-year mortality rates were STEMI: 28.3% and 37.6%, NSTEACS: 8.9% and 19.5%, and CSA: 1.4% and 7.0%, respectively. Unadjusted in-hospital major adverse cardiovascular and cerebrovascular event rates were STEMI: 26.6%, NSTEACS: 6.6%, and CSA: 3.3%. Risk of 30-day mortality was much greater for STEMI and NSTEACS patients than CSA (STEMI adjusted odds ratio [aOR]: 29.45, 95% confidence interval [CI]: 19.37 to 44.80, NSTEACS aOR: 6.45, 95% CI: 4.27 to 9.76). More than 40% of patients presenting with STEMI had cardiogenic shock, in whom mortality was higher than in STEMI cases without shock (30 days: 52.0% vs. 11.7%, 1 year: 61.1% vs. 20.9%). Radial access, compared with the femoral approach, was associated with a lower risk of 30-day mortality (STEMI aOR: 0.37, 95% CI: 0.21 to 0.62; NSTEACS aOR: 0.66, 95% CI: 0.45 to 0.97). CONCLUSIONS More than one-half of the patients who received UPLMS PCI were acute where outcomes were much worse than elective cases. Cardiogenic shock is common in STEMI patients, of whom more than one-half die at 30 days. The radial approach was associated with reduced early mortality in acute cases.
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The impact of social deprivation on coronary revascularisation treatment outcomes within the National Health Service in England and Wales. Eur J Prev Cardiol 2015; 23:316-27. [DOI: 10.1177/2047487314567000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 12/15/2014] [Indexed: 11/15/2022]
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Mamas MA, Anderson SG, O'Kane PD, Keavney B, Nolan J, Oldroyd KG, Perera D, Redwood S, Zaman A, Ludman PF, de Belder MA. Impact of left ventricular function in relation to procedural outcomes following percutaneous coronary intervention: insights from the British Cardiovascular Intervention Society. Eur Heart J 2014; 35:3004-12a. [DOI: 10.1093/eurheartj/ehu303] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Ludman PF, de Belder MA, McLenachan JM, Birkhead JS, Cunningham D, Gray HH. The importance of audit to monitor applications of procedures and improve primary angioplasty results. EUROINTERVENTION 2014; 8 Suppl P:P62-70. [PMID: 22917794 DOI: 10.4244/eijv8spa11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although clinical trials have demonstrated that primary percutaneous coronary intervention (PPCI) provides better outcomes than thrombolysis for STEMI, it cannot be assumed that similar results can be obtained in day-to-day practice. To determine whether standards are being met, continuous audit of PPCI programmes is necessary, with appropriate feedback to participating centres and operators. Both the MINAP and BCIS national audit projects allow central electronic collection of data on consecutive patients presenting to every hospital involved in the acute management of these patients. Regular programmed feedback is provided to centres performing primary PCI that attempts to take account of statistical variation and differences in case mix between units by making use of funnel plots, statistical process control graphs and risk adjustment models. This reporting of "process" and "outcome" data, both confidentially and within the public domain, has been used to drive up clinical performance and has been associated with steady improvements and reduced inequalities of care.
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Coronary and Microvascular Physiology During Intra-Aortic Balloon Counterpulsation. JACC Cardiovasc Interv 2014; 7:631-40. [DOI: 10.1016/j.jcin.2013.11.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 11/11/2013] [Accepted: 11/21/2013] [Indexed: 01/09/2023]
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Hamid T, Aleem Q, Lau Y, Singh R, McDonald J, Macdonald JE, Sastry S, Arya S, Bainbridge A, Mudawi T, Balachandran K. Pre-procedural fasting for coronary interventions: is it time to change practice? Heart 2014; 100:658-61. [PMID: 24522621 DOI: 10.1136/heartjnl-2013-305289] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Traditionally, patients are kept nil-per-os/nil-by-mouth (NPO/NBM) prior to invasive cardiac procedures, yet there exists neither evidence nor clear guidance about the benefits of this practice. OBJECTIVES To demonstrate that percutaneous cardiac catheterisation does not require prior fasting. METHODS The data source is a retrospective analysis of data registry of consecutive patients who underwent percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) and stable angina at two district general hospitals in the UK with no on-site cardiac surgery services. RESULTS A total of 1916 PCI procedures were performed over a 3-year period. None of the patients were kept NPO/NBM prior to their coronary procedures. The mean age was 67±16 years. 1349 (70%) were men; 38.5% (738/1916) had chronic stable angina, while the rest had ACS. 21% (398/1916) were diabetics while 53% (1017/1916) were hypertensive. PCI was technically successful in 95% (1821/1916) patients. 88.5% (1697/1916) had transradial approach. 77% (570/738) of elective PCI patients were discharged within 6 h postprocedure. No patients required emergency endotracheal intubation and there were no occurrences of intraprocedural or postprocedural aspiration pneumonia. CONCLUSIONS Our observational study demonstrates that patients undergoing PCI do not need to be fasted prior to their procedures.
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Affiliation(s)
- Tahir Hamid
- Royal Blackburn Hospital NHS Trust, , Blackburn, UK
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Recanalisation of coronary chronic total occlusions with new techniques including the retrograde approach via collaterals. Neth Heart J 2013; 19:162-7. [PMID: 22020996 DOI: 10.1007/s12471-011-0091-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts. METHODS AND RESULTS In this single-centre observational study we analysed the prospectively entered data of 331 consecutive patients, undergoing percutaneous coronary intervention (PCI) for CTO in 338 lesions at the Heart Center Wuppertal between June 2007 and July 2010. Nineteen lesions were attempted twice and one lesion three times (=358 procedures). The lesion-related success rates were 81.1%. Single-wire usage was the predominant strategy used in 198 antegrade cases (65.6%) followed by parallel wire technique and see-saw technique in 94 cases (31.1%). In the retrograde procedures, the reverse CART technique was predominantly used (35.7%), followed by retrograde wire passage (17.9%), marker wire (17.9%) and CART (14.3%). The in-hospital complications were low and comparable with conventional PCI data. The presence of blunt stump, severe calcification, severe tortuosity and occlusion length >30 mm were independent predictors of procedural failure. CONCLUSIONS A high degree of success with low in-hospital complications comparable with conventional PCI data can be expected in the hands of experienced CTO operators. A second try with a retrograde approach after antegrade failure should be considered.
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Kovacic JC, Nguyen HT, Karajgikar R, Sharma SK, Kini AS. The Impella Recover 2.5 and TandemHeart ventricular assist devices are safe and associated with equivalent clinical outcomes in patients undergoing high-risk percutaneous coronary intervention. Catheter Cardiovasc Interv 2013; 82:E28-37. [PMID: 21234916 DOI: 10.1002/ccd.22929] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 11/27/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the practical use, safety, and clinical outcomes associated with the TandemHeart (TH) versus Impella Recover 2.5 (IR2.5) devices when used for circulatory support during high-risk percutaneous coronary intervention (PCI). BACKGROUND Small studies and registries suggest safety and efficacy for the TH and IR2.5 percutaneous-left ventricular assist devices (P-LVADs). However, these P-LVADs differ markedly in their insertion, operation, and manner of circulatory augmentation. To date, no study has compared these devices. METHODS We identified 68 patients (49 males, 19 females; age 71.1 ± 12.1 years) from our single-center database that underwent "high-risk" PCI with P-LVAD support from April 2005 to June 2010 (32 with TH, 36 with IR2.5). Relevant data were extracted for analysis. RESULTS Baseline demographics were similar, including low LVEF (overall mean 31.0 ± 13.7%) and elevated STS mortality risk score (4.2 ± 3.7%). Angiographic characteristics were also similar, with a mean of 2.4 ± 1.0 lesions treated per patient, and 29% undergoing left main PCI. PCI success rates were 99% in both groups, with similar in-hospital outcomes and a combined 7% major vascular access site complication rate. A single episode of left atrial perforation occurred during TH use. No patient required emergent CABG and no in-hospital deaths occurred. The 30-day MACE rate (death, myocardial infarction, target lesion revascularization) was 5.8%. There were no differences between the IR2.5 and TH groups with respect to short- or long-term clinical outcomes. CONCLUSIONS The IR2.5 and TH assist devices are safe, equally effective, and associated with acceptable short- and long-term clinical outcomes in patients undergoing "high-risk" PCI.
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Affiliation(s)
- Jason C Kovacic
- Cardiac Catheterization Laboratory, Cardiovascular Institute, Mount Sinai Hospital, New York, New York 10029, USA
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Bawamia B, Mehran R, Qiu W, Kunadian V. Risk scores in acute coronary syndrome and percutaneous coronary intervention: a review. Am Heart J 2013; 165:441-50. [PMID: 23537960 DOI: 10.1016/j.ahj.2012.12.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
Patients with acute coronary syndrome (ACS) need to be risk stratified to deliver the most appropriate therapy. The GRACE and TIMI risk scores have penetrated contemporary guidelines with the former most commonly used in clinical practice. However, ACS prediction models need to be re-evaluated in contemporary practice with evolving diagnostic and treatment options. Moreover, the increased availability of percutaneous coronary intervention (PCI) as a treatment option for ACS combined with an expanding case mix and emphasis on quality control have triggered the creation of PCI specific prognostic models. These allow clinicians and patients to have an understanding of expected outcomes following PCI by predicting outcomes in-hospital to 5 years following intervention. The aim of this review is to evaluate the most recognized and studied ACS/PCI risk models, focusing on their strengths and limitations, and to assess the need for more robust tools to predict outcomes in a period of constantly advancing technologies and changing patient demographics.
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Percutaneous recanalization of chronic total occlusions: wherein lies the body of proof? Am Heart J 2013; 165:133-42. [PMID: 23351815 DOI: 10.1016/j.ahj.2012.10.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 10/05/2012] [Indexed: 01/28/2023]
Abstract
Although interventional technology and skills have markedly advanced, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) lesions remains challenging. Indeed, CTO PCI is technically complex, carries the potential for a relatively high likelihood of failure and acute complications, and requires specifically skilled operators and a demanding use of resources. In addition, controversy persists surrounding appropriate indications for attempting CTO revascularization. Finally, there is a wide uncertainty on the actual benefits achieved with successful CTO recanalization. A growing number of studies have reported procedural results and/or assessed functional effects and long-term clinical outcomes of CTO PCI. We therefore sought to review and critically appraise the evidence base for procedural outcomes and potential clinical benefits of CTO PCI.
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Anastasiadis K, Hadjimiltiades S, Antonitsis P. Successful high-risk percutaneous coronary intervention with the use of minimal extracorporeal circulation system. Catheter Cardiovasc Interv 2012; 80:845-9. [PMID: 22511509 DOI: 10.1002/ccd.24293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 12/10/2011] [Indexed: 11/10/2022]
Abstract
Minimal extracorporeal circulation (MECC) represents a contemporary system which integrates several advances in cardiopulmonary bypass technology in a single circuit. We challenged the efficacy of the MECC system to support the circulation in elective high-risk percutaneous coronary intervention (PCI). A 78-year-old patient with complex coronary disease who would have been otherwise rejected for interventional therapy underwent PCI with rotablation on MECC support. The MECC system provided hemodynamic support at a flow of 1.8 L min(-1) m(-2) while perfusion pressure was kept at a minimum of 70 mm Hg. This allowed for successful angioplasty of the left main stem and a chronically occluded right coronary artery, which otherwise produced significant hemodynamic compromise. This case illustrates that mechanical circulatory support with the MECC system could provide a stable environment and a "safety net" for carrying out complex percutaneous coronary intervention in high-risk patients.
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Affiliation(s)
- Kyriakos Anastasiadis
- Department of Cardiothoracic Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Galassi AR, Tomasello SD, Reifart N, Werner GS, Sianos G, Bonnier H, Sievert H, Ehladad S, Bufe A, Shofer J, Gershlick A, Hildick-Smith D, Escaned J, Erglis A, Sheiban I, Thuesen L, Serra A, Christiansen E, Buettner A, Costanzo L, Barrano G, Di Mario C. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EUROINTERVENTION 2011; 7:472-9. [PMID: 21764666 DOI: 10.4244/eijv7i4a77] [Citation(s) in RCA: 233] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS In comparison with non-occlusive lesions, percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) represents a greater challenge for the interventionalist, due to lower procedural success rates, relatively higher incidence of procedural complications and the increased rate of restenosis. The European Registry of Chronic Total Occlusion (ERCTO) was created with the goal of evaluating the real impact of CTO PCI in the European context, trying to analyse the rates of procedural success, technical information from the CTO procedures and patient outcome. METHODS AND RESULTS Data collection was carried out in 16 centres across Europe, starting from the beginning of January 2008. In two years of activity, a total of 1,914 patients with 1,983 CTO lesions were consecutively enrolled in the registry. Overall procedural success was achieved in 1,607 lesions (82.9%); anterograde procedures obtained higher procedural success of retrograde ones (83.2% versus 64.5%, p<0.001). Coronary perforation occurred more frequently in patients who underwent retrograde approach (4.7% versus 2.1%, p=0.04). Although no differences were observed in terms of 30-day major adverse cardiac events between anterograde and retrograde treated patients, a trend toward higher periprocedural non-Q-wave myocardial infarction was found in patients in which the retrograde approach was attempted (2.1% versus 1% p=0.08). Moreover, retrograde approach was related with longer procedural and fluoroscopy times (156.9±62.5 min vs. 98.2±52.8 min and 73.3±59.9 min vs. 38.2±43.9 min respectively, p<0.001) and higher contrast load administration (402±161 cc vs. 302±184 cc, p<0.001). CONCLUSIONS The first report of the ERCTO registry by the EuroCTO club shows a high procedural success rate obtained by expert European operators in a "real-world" consecutive series of patients, comparable with those reported by Japanese registries. The rate of observed procedural adverse events was low and similar to the non-CTO PCI series. In this registry, retrograde procedures were associated with extended fluoroscopy exposure and procedural time, increased contrast load administration as well as a higher incidence of coronary perforations. Such outcomes should become the standard of care that all centres undertaking CTO PCI should aspire to.
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Affiliation(s)
- Alfredo R Galassi
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy.
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Ito H, Nussbaum M, Hermiller J, Hodes Z, Brodie B, Cheek B, Juk S, Krainin F, Metzger C, Duffy P, Humphrey A, Laurent S, Simonton C. An integer based risk score for predicting 30-day major adverse cardiac or cerebrovascular events after percutaneous coronary intervention with drug-eluting stents: results from a?large prospective multicentre registry, the STENT Group. EUROINTERVENTION 2011; 6:942-8. [DOI: 10.4244/eijv6i8a164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Liu SW, Xu B, Chen J, Hu FH, Wu YJ, Li JJ, Yang YJ, Chen JL, Gao RL, Qiao SB. Trends in in-hospital outcome after percutaneous coronary intervention in the drug-eluting stents era. Clin Cardiol 2010; 33:516-21. [PMID: 20734450 DOI: 10.1002/clc.20786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The introduction of drug-eluting stents (DES) dramatically changed the practice of percutaneous coronary intervention (PCI) in the 2000s. Little is known about trends in in-hospital outcome after PCI in the DES era. HYPOTHESIS The in-hospital outcomes after PCI might be continuously improved over time. METHODS We analyzed in-hospital outcomes of 21,667 patients who underwent PCI at Fu Wai Hospital in the past 5 years. The patients were divided into 5 groups according to the time of their intervention: group 1 (June 2004 to May 2005), group 2 (June 2005 to May 2006), group 3 (June 2006 to May 2007), group 4 (June 2007 to May 2008), and group 5 (June 2008 to May 2009). RESULTS Procedural success rates for the 5 groups were 93.6%, 95%, 94.4%, 94.2%, and 94.3%, respectively (P = 0.39). Significant reduction in in-hospital major adverse cardiac events (3.1%, 3.4%, 2.8%, 1.6%, and 1.0%, P < 0.001) and need for target-vessel revascularization (2.0%, 2.2%, 1.5%, 0.4%, and 0.2%, P < 0.001) was noted over time, which was associated with a significant increase in use of DES (from 56.6% to 97.0%, P < 0.001). On multivariate analysis, use of DES, dissection during procedure, left main lesion, prior myocardial infarction, and age > or = 65 years were independent predictors of major adverse cardiovascular events. CONCLUSIONS There were substantial reductions in in-hospital major adverse cardiac events and target-vessel revascularization over the past 5 years. This reduction was associated with the concurrent increased use of DES.
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Affiliation(s)
- Sheng Wen Liu
- Department of Cardiology, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Min SY, Park DW, Yun SC, Kim YH, Lee JY, Kang SJ, Lee SW, Lee CW, Kim JJ, Park SW, Park SJ. Major predictors of long-term clinical outcomes after coronary revascularization in patients with unprotected left main coronary disease: analysis from the MAIN-COMPARE study. Circ Cardiovasc Interv 2010; 3:127-33. [PMID: 20407112 DOI: 10.1161/circinterventions.109.890053] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The clinical characteristics that identify high-risk subsets of patients with unprotected left main coronary artery disease undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have not been well established. METHODS AND RESULTS Between January 2000 and June 2006, 2240 patients with unprotected left main coronary artery disease underwent PCI (n=1102) or CABG (n=1138). Twenty-six preprocedural parameters were evaluated by univariate and multivariate Cox regression analysis to identify independent predictors of all-cause mortality and target-vessel revascularization. Interaction tests were performed to compare heterogeneities of effects of preprocedural parameters depending on the revascularization methods. During follow-up (median of 3.1 years), 187 patients died (78 PCI and 109 CABG) and 149 patients had target-vessel revascularization (121 PCI and 28 CABG). EuroSCORE > or =6 was an independent predictor of death in both groups. Additional independent predictors were chronic renal failure and previous congestive heart failure in the PCI group and age > or =75 years, atrial fibrillation, right coronary artery disease, and left main distal bifurcation disease in the CABG group. Interaction analysis showed no heterogeneities of the effects of variables depending on the revascularization methods. Independent predictors of target-vessel revascularization were acute coronary syndrome and left main distal bifurcation disease in the PCI group and history of coronary intervention in the CABG group. The interaction between previous PCI and treatment remained after adjustment for all independent predictors of target-vessel revascularization (interaction P=0.0345). CONCLUSIONS Several clinical characteristics were identified as important preprocedural predictors of long-term adverse outcomes after percutaneous or surgical revascularization in patients with unprotected left main coronary artery disease.
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Affiliation(s)
- Sun-Yang Min
- Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, Korea
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Roberts EB, Grayson AD, Alahmar AE, Andron M, Perry R, Stables RH. Predicting angiographic outcome in contemporary percutaneous coronary intervention: a lesion-specific logistic model. J Interv Cardiol 2010; 23:394-400. [PMID: 20642482 DOI: 10.1111/j.1540-8183.2010.00566.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Previous angiographic lesion classification systems were derived from analysis of outcomes and lesion complexity in the early stent era. Advances in equipment design and techniques have altered the association between lesion and target vessel characteristics and procedural outcome in modern percutaneous coronary intervention (PCI). We evaluated the precise relationship between lesion characteristics and technical outcome on a lesion by lesion basis in a large dataset. We developed a multivariate model to predict technical failure in PCI. METHODS Analysis of prospectively collected data on 10,800 lesions in 6,719 consecutive PCI cases between January 2000 and December 2004. Multivariate logistic regression was undertaken to identify predictors of angiographic outcome at each treated lesion (success/failure). Statistical model validation was carried out using data from a further 3,340 treated lesions in 1,940 consecutive cases. RESULTS Independent variables associated with an increased risk of technical failure included total occlusion, severe calcification, proximal vessel tortuosity >90 degrees, lesion in a degenerate vein graft, and lesion angulation > or =90 degrees. The receiver operating characteristics (ROC) curve for the predicted probability of technical failure was 0.85. Failure occurred in 2.2% of treated lesions in the validation set (ROC curve 0.82, model predicted 2.5%). CONCLUSIONS We have re-evaluated the association between lesion characteristics and technical outcome in modern PCI. We have thereby developed a contemporary prediction model for angiographic outcome at each treated lesion.
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Affiliation(s)
- Elved B Roberts
- Department of Cardiology, Glenfield Hospital, University Hospitals of Leicester, United Kingdom.
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Setiadi BM, Han L, Jing C. Adverse events even after percutaneous coronary intervention: is there any way to predict it? J Interv Cardiol 2009; 23:86-94. [PMID: 20040008 DOI: 10.1111/j.1540-8183.2009.00514.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Since its development, the frequency and indication of percutaneous coronary intervention (PCI) have been increasing tremendously. Although generally the procedure shows promising results, some patients still develop cardiovascular events even after PCI. Some risk prediction models have been developed in order to identify this group of patients who possess higher risk of developing cardiovascular events after PCI. This article discusses the available risk prediction models, the difference between risk prediction models, choosing risk prediction models, and also limitations of the available risk prediction models.
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Affiliation(s)
- Benny Mulyanto Setiadi
- Cardiovascular Department of Chongqing Medical University, Chongqing First Affiliated Hospital, Chongqing, China.
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Chambers CE, Dehmer GJ, Cox DA, Harrington RA, Babb JD, Popma JJ, Turco MA, Weiner BH, Tommaso CL. Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation. Catheter Cardiovasc Interv 2009; 73:847-58. [PMID: 19425053 DOI: 10.1002/ccd.22100] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.
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Affiliation(s)
- Charles E Chambers
- Pennsylvania State University Hershey Medical Center, Hershey, Pennsylvania, USA
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Rathore S, Matsuo H, Terashima M, Kinoshita Y, Kimura M, Tsuchikane E, Nasu K, Ehara M, Asakura Y, Katoh O, Suzuki T. Procedural and In-Hospital Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions of Coronary Arteries 2002 to 2008. JACC Cardiovasc Interv 2009; 2:489-97. [PMID: 19539251 DOI: 10.1016/j.jcin.2009.04.008] [Citation(s) in RCA: 145] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 04/06/2009] [Accepted: 04/17/2009] [Indexed: 10/20/2022]
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Abstract
Interest in fetal intervention has become widespread in recent years. Laser therapy for the treatment of severe twin-twin transfusion alone has been the subject of more than 100 peer-reviewed articles in the past 3 years. Significant issues have arisen that affect the availability of these new therapies in the United States. Formal training fellowships have yet to be established. Questions as to the ultimate number of treatment centers that are required to provide reasonable access should be addressed. The establishment of research networks to evaluate new fetal therapies through randomized clinical trials would appear paramount to the advancement of the field.
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Sousa P, Uva AS, Pinto F. Risk-adjustment model in health outcomes evaluation: a contribution to strengthen assessment towards quality improvement in interventional cardiology. Int J Qual Health Care 2008; 20:324-30. [PMID: 18621777 DOI: 10.1093/intqhc/mzn029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The aim of this study was to develop a risk adjustment model for major adverse cardiac and cerebrovascular events following percutaneous coronary intervention (PCI), using data from a national registry, and to highlight the use of the risk adjustment when we evaluate the quality of care in interventional cardiology. DESIGN The STUDY DESIGN was based on a Coorte study. Bivariate and multivariate logistic regression models were used to identify independent risk factors for these major adverse events. SETTING A total of 19 hospitals from the Portuguese National Registry of Interventional Cardiology. PARTICIPANTS Data from 10.641 consecutives procedures collected between June 30, 2003 and June 30, 2006. INTERVENTION Build a risk adjustment model for these major adverse events, following percutaneous coronary intervention. MAIN OUTCOME MEASURE Factors that were associated with major adverse cardiac and cerebrovascular events following percutaneous coronary intervention. RESULTS The rate of in-hospital major adverse cardiac and cerebrovascular events was 1.9%. Factors associated with major adverse cardiac and cerebrovascular events included, among others: age >80 years (adjusted odds ratio = 3.91); female gender (1.72); and cardiogenic shock (6.05). Overall, a good discrimination was achieved with receiver operating characteristics curve = 0.84 and Hosmer-Lemeshow goodness of fit statistic across groups of risk was not significant (P = 0.18) indicating little departure from a perfect fit. CONCLUSIONS These findings will represent an important contribution to quality and safety improvement and should help driving new research and innovative approaches to different subgroups of patients who have higher chances of having an adverse event or poorer outcomes following this intervention.
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Affiliation(s)
- Paulo Sousa
- School of Health Technologies of Lisbon, Lisbon, Portugal.
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Kunadian B, Dunning J, Roberts AP, Morley R, Twomey D, Hall JA, Sutton AGC, Wright RA, Muir DF, de Belder MA. Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary intervention. BMJ 2008; 336:931-4. [PMID: 18367500 PMCID: PMC2335227 DOI: 10.1136/bmj.39512.529120.be] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance. DESIGN Analysis of prospectively collected data. SETTING Tertiary centre NHS hospital in the north east of England. PARTICIPANTS Five cardiologists carrying out percutaneous coronary interventions between January 2003 and December 2006. MAIN OUTCOME MEASURES In-hospital major adverse cardiovascular and cerebrovascular events (in-hospital death, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accident) analysed against the logistic north west quality improvement programme predicted risk, for each operator. Results are displayed as funnel plots summarising overall performance for each operator and cumulative funnel plots for an individual operator's performance on a case series basis. RESULTS The funnel plots for 5198 patients undergoing percutaneous coronary interventions showed an average observed rate for major adverse cardiovascular and cerebrovascular events of 1.96% overall. This was below the predicted risk of 2.06% by the logistic north west quality improvement programme risk score. Rates of in-hospital major adverse cardiovascular and cerebrovascular events for all operators were within the 3sigma upper control limit of 2.75% and 2sigma upper warning limit of 2.49%. CONCLUSION The overall in-hospital major adverse cardiovascular and cerebrovascular events rates were under the predicted event rate. In-hospital rates after percutaneous coronary intervention procedure can be monitored successfully using funnel and cumulative funnel plots with 3sigma control limits to display and publish each operator's outcomes. The upper warning limit (2sigma control limit) could be used for internal monitoring. The main advantage of these charts is their transparency, as they show observed and predicted events separately. By this approach individual operators can monitor their own performance, using the predicted risk for their patients but in a way that is compatible with benchmarking to colleagues, encapsulated by the funnel plot. This methodology is applicable regardless of variations in individual operator case volume and case mix.
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Affiliation(s)
- Babu Kunadian
- Department of Cardiology, James Cook University Hospital, Middlesbrough TS4 3BW
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Abstract
OBJECTIVE To identify opportunities for improvement in quality performance profile while maintaining better clinical outcomes. METHODS A prospective study of 5285 surgical specialty procedures including hip and knee replacement, cholecystectomy, hysterectomy, nonaccess vascular and cardiac procedures, and colorectal resections in 16 Kentucky hospitals was undertaken. The following observations were made after univariate and stepwise logistic regression analysis, from the Surgical Care Improvement Project. RESULTS (1) Impaired functional status, age > or =65, and ASA class 4 or 5 status were significant predictors for both morbidity and mortality. (2) beta blockade medication was maintained in only 70% of patients already receiving such medications; interestingly, vascular surgery and patients with known cardiac history did not have beta blockade initiated 52% of the time. (3) Appropriate blood glucose control was not achieved in 31% of patients with diabetes and in 20% of nondiabetics. (4) deep vein thrombosis (DVT) prophylaxis was independent of high-risk status, with wide variation in practice. Patients undergoing total hip or knee replacement or colorectal resections had highest rates (0.7%) of pulmonary emboli. (5) A poor choice of antibiotic prophylaxis agent occurred in 8% of patients and was associated with a 3-fold increase in mortality (P < 0.01). (6) Hypothermia on arrival in PACU was present in 7% of patients after major colorectal resections and was ominously associated with an over 4-fold increase in mortality (P < 0.01). (7) Preoperative WBC >11,000/mm in elective operations was associated with nearly 3-fold increase in mortality (P < 0.05). CONCLUSION Now more than ever, surgeons must verify performance measures and outcomes. This study of clinical outcomes permits identification of underappreciated contemporary risk factors and some obvious measures by which surgical practices can more objectively be evaluated.
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