Variation in Outcomes after Percutaneous Coronary Intervention in the United States and Predictors of Periprocedural Mortality

Volume-Outcome Relations of Percutaneous Coronary Intervention in Patients Presenting With Acute Myocardial Infarction (from the J-PCI Registry)

A lower institutional primary percutaneous coronary intervention (PCI) volume is associated with a higher risk of postprocedural poor outcomes, particularly in urgent or emergent settings (e.g., PCI for acute myocardial infarction [MI]). However, the individual prognostic impact of PCI volume stratified by indication and the relative ratio remains unclear. Using the Japanese nationwide PCI database, we investigated 450,607 patients from 937 institutions who underwent either primary PCI for acute MI or elective PCI. The primary end point was the observed/predicted in-hospital mortality ratio. The predicted mortality per patient was calculated using the baseline variables and averaged for each institution. The relation between the annual primary, elective, and total PCI volumes and institutional in-hospital mortality after acute MI was evaluated. The association between the primary-to-total PCI volume per hospital and mortality was also investigated. Of the 450,607 patients, 117,430 (26.1%) underwent primary PCI for acute MI, of whom 7,047 (6.0%) died during hospitalization. The median total PCI volume and primary-to-total PCI volume ratio were 198 (interquartile range 115 to 311) and 0.27 (0.20 to 0.36). Overall, the observed in-hospital mortality and observed/predicted mortality ratio in patients with acute MI were higher in institutions with lower primary, elective, and total PCI volumes. The observed/predicted mortality ratio was also higher in institutions with lower primary-to-total PCI volume ratios, even in high-PCI volume hospitals. In conclusion, in this nationwide registry-based analysis, lower institutional PCI volumes, regardless of setting, were associated with higher in-hospital mortality after acute MI. The primary-to-total PCI volume ratio provided independent prognostic information.

Impact of Hospital Procedural Volume on Outcomes After Endovascular Revascularization for Critical Limb Ischemia

OBJECTIVES

The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI).

BACKGROUND

There is a paucity of data on the relationship between hospital procedural volume and outcomes of eLER for CLI.

METHODS

The authors queried the Nationwide Readmission Database (2013-2015) for hospitalized patients who underwent eLER for CLI. Hospitals were divided into tertiles according to annual eLER volume: low volume (<100 eLER procedures), moderate volume (100-550 eLER procedures), and high volume (>550 eLER procedures). Stepwise multivariable regression models were used. The main outcomes were in-hospital mortality and 30-day readmission with major adverse limb events, defined as the composite of amputation, acute limb ischemia, or repeat revascularization.

RESULTS

Among 145,785 hospitalizations for eLER for CLI, 5,199 (3.6%) were at low-volume eLER hospitals, 27,857 (19.1%) at moderate-volume eLER hospitals, and 112,728 (77.3%) at high-volume eLER hospitals. On multivariable analysis, there was no difference with regard to in-hospital mortality among moderate-volume hospitals (adjusted odds ratio [OR]: 0.78; 95% CI: 0.60-1.01) and high-volume hospitals (adjusted OR: 0.84; 95% CI: 0.64-1.05) compared with low-volume hospitals. There was lower risk of in-hospital major amputation (adjusted OR: 0.82; 95% CI: 0.70-0.96) and minor amputation at high- versus low-volume hospitals. The length of hospital stay was shorter and discharges to nursing facilities were fewer among moderate- and high-volume hospitals compared with low-volume hospitals. Compared with low-volume hospitals, eLER for CLI at high-volume hospitals had a lower risk for 30-day readmission with major adverse limb events (adjusted OR: 0.83; 95% CI: 0.70-0.99), while there was no difference among moderate-volume hospitals (adjusted OR: 0.92; 95% CI: 0.77-1.10).

CONCLUSIONS

This nationwide observational analysis suggests that annual eLER volume does not influence in-hospital mortality after eLER for CLI. However, high eLER volume (>550 eLER procedures) was associated with better rates of limb preservation after eLER for CLI.

Bivalirudin vs Heparin in Percutaneous Coronary Intervention: A Pooled Analysis

Objective: This study evaluates outcomes with bivalirudin vs heparin in various patient subgroups and the overall population during percutaneous coronary interventions (PCI). Background: Recent data suggest that bivalirudin, a reversible direct thrombin inhibitor, provides ischemic protection superior to heparin and comparable to heparin plus glycoprotein (GP) IIb/IIIa inhibitors but with significantly fewer bleeding complications. Whether this advantage persists in different subgroups has not been fully defined. To our knowledge, this is the largest pooled analysis of bivalirudin to date.

Methods: Four randomized controlled trials were identified that compared bivalirudin to heparin (with or without GP IIb/IIIa inhibitors) in PCI. The incidence of death, myocardial infarction (MI), revascularization, and major bleeding at 48 hours was compared between these two agents overall and in patients with and without diabetes mellitus, hypertension, renal insufficiency, and advanced age.

Results: The trials consisted of 11,638 patients (bivalirudin, 5,861; heparin, 5,777). There were no significant differences in patient characteristics between the two groups. At 48 hours, the incidence of death, MI, revascularization, and major bleeding was significantly reduced in the bivalirudin group (7.8% vs 1.08%, P < .001); individual ischemic end points were significantly reduced for death (0.01% vs 0.02%, P = .049) and revascularization (2.0% vs 2.7%, P = .02), with similar reductions for major bleeding (2.7% vs 5.8%, P < .001). Subgroup analysis was generally consistent with the overall findings.

Conclusion: This analysis further supports the superiority of bivalirudin compared with heparin. Bivalirudin provides excellent ischemic protection with a significant reduction of bleeding complications, even in high-risk subgroups.

Age and sex differences in inhospital complication rates and mortality after percutaneous coronary intervention procedures: evidence from the NCDR(®)

BACKGROUND

Older women experience higher complication rates and mortality after percutaneous coronary intervention (PCI) than men, but there is limited evidence about sex-based differences in outcomes among younger patients. We compared rates of complications and inhospital mortality by sex for younger and older PCI patients.

METHODS

A total of 1,079,751 hospital admissions for PCI were identified in the CathPCI Registry(®) from 2005 to 2008. Complication rates (general, bleeding, bleeding with transfusion, and vascular) and inhospital mortality after PCI were compared by sex and age (<55 and ≥55 years). Analyses were adjusted for demographic and clinical factors and stratified by PCI type (elective, urgent, or emergency).

RESULTS

Overall, 6% of patients experienced complications, and 1% died inhospital. Unadjusted complication rates were higher for women compared with men in both age groups. In risk-adjusted analyses, younger women (odds ratio 1.24, 95% CI 1.16-1.33) and older women (1.27, 1.09-1.47) were more likely to experience any complication than similarly aged men. The increased risk persisted across complication categories and PCI type. Within age groups, risk-adjusted mortality was marginally higher for young women (1.19, 1.00-1.41), but not for older women (1.03, 0.97-1.10). In analyses stratified by PCI type, young women had twice the mortality risk after an elective procedure as young men (2.04, 1.15-3.61).

CONCLUSIONS

Women, regardless of age, experience more complications after PCI than men; young women are at increased mortality risk after an elective PCI. Identifying strategies to reduce adverse outcomes, particularly for women younger than 55 years, is important.

Health Professional Shortage Areas, insurance status, and cardiovascular disease prevention in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Individuals with cardiovascular disease (CVD) living in Health Professional Shortage Areas (HPSA) may receive less preventive care than others. The Reasons for Geographic And Racial Differences in Stroke Study (REGARDS) surveyed 30,239 African American (AA) and White individuals older than 45 years of age between 2003-2007. We compared medication use for CVD prevention by HPSA and insurance status, adjusting for sociodemographic factors, health behaviors, and health status. Individuals residing in partial HPSA counties were excluded. Mean age was 64±9 years, 42% were AA, 55% were women, and 93% had health insurance; 2,545 resided in 340 complete HPSA counties and 17,427 in 1,145 non-HPSA counties. Aspirin, beta-blocker, and ACE-inhibitor use were similar by HPSA and insurance status. Compared with insured individuals living in non-HPSA counties, statin use was lower among uninsured participants living in non-HPSA and HPSA counties. Less medication use for CVD prevention was not associated with HPSA status, but less statin use was associated with lack of insurance.

Percutaneous coronary intervention, comorbidities, and mortality among emergency department-admitted ST-elevation myocardial infarction patients in Florida

BACKGROUND

Risk of mortality following an ST-elevation myocardial infarction (STEMI) can be significantly reduced by prompt percutaneous coronary intervention (PCI). National guidelines specify primary PCI as the preferred recommended treatment for STEMI. In this study, we examined same-day PCI as an independent predictor of in-hospital mortality, after adjustment for comorbidities, other patient factors, and hospital PCI-volume using unselected surveillance data from Florida.

METHODS

We analyzed hospital discharge data for adults, 18+ years old, with a primary diagnosis of STEMI who were admitted to PCI-capable hospitals through the emergency department during 2001-2005 (n = 43,849). Hierarchical (multilevel) logistic regression models were used for analysis.

RESULTS

Overall, 4,143 STEMI patients (9.4%) did not survive to hospital discharge. In late 2005, the in-hospital mortality rates were 1.9% for those who received same-day PCI versus 13.0% for those who did not. After adjustment for multiple patient factors, same-day PCI was a significant predictor of in-hospital survival with a strong protective effect (adjusted OR = 0.35, 95% CI 0.31-0.38 P < 0.0001). Restriction of the analysis to those patients who survived the first day of admission did not appreciably change this result (adjust OR = 0.37, 95% CI 0.33-0.42, P < 0.0001). Hospital PCI-volume did not significantly impact mortality risk.

CONCLUSIONS

Same-day PCI markedly reduced the risk of in-hospital mortality among STEMI patients after multivariate adjustment. Serious comorbidities and complications, older age, and female gender continued to predict elevated risk of mortality after control for treatment status. Our results provide additional evidence in support of national clinical recommendations and aggressive treatment of STEMI.

Impact of high loading and maintenance dose of clopidogrel within the first 15 days after percutaneous coronary intervention on patient outcome

BACKGROUND

An increase in clopidogrel dose results in an improved inhibition of platelet aggregation. However, whether an increase in clopidogrel dose may improve patient outcome is still debated. The aim of this study was to analyze the impact on patient outcome of an increase in clopidogrel loading and maintenance doses within the first 15 days after percutaneous coronary intervention (PCI).

METHODS

Between 2003 and 2007, we included 2,954 consecutive patients who underwent PCI and stent implantation. We compared 2 historical groups. In the "low-dose" group (2003-2005, n = 1,984), patients were pretreated with a 300-mg clopidogrel loading dose followed by 75 mg/d after PCI. In the "high-dose" group (2006-2007, n = 970), patients were pretreated with a 600-mg clopidogrel loading dose followed by 150 mg/d within the first 15 days and 75 mg/d thereafter. The composite primary end point (death, myocardial infarction, stent thrombosis) and bleeding were systematically indexed during the 2-month follow-up period.

RESULTS

Clinical and most of angiographic characteristics were similar between the 2 groups. By multivariate analysis, high dose of clopidogrel was associated with a decrease in the composite primary end point (hazard ratio 0.694, 95% CI 0.485-0.993, P = .046). The other predictors were age, left ventricular ejection fraction, diabetes, renal failure, and acute coronary syndrome. Major bleeding was similar in the low- and high-dose groups (2.8% vs 3.4%, respectively, P = .379). After propensity score matching, the high-dose group was still associated with a significant clinical benefit.

CONCLUSION

Our results show that a 600-mg loading dose followed by a 150-mg maintenance dose of clopidogrel within the first 15 days after PCI is independently associated with a decrease in the composite death-myocardial infarction-stent thrombosis at 2 months without increase in hemorrhagic complications.

Impact of race and chronic kidney disease on 1-year outcome in patients undergoing percutaneous coronary interventions: a single tertiary center experience

BACKGROUND

Chronic kidney disease (CKD) is a predictor of morbidity and mortality in patients undergoing percutaneous coronary interventions (PCIs), and African American (AA) patients have been reported to have worse outcomes after PCI.

METHODS

We assessed whether CKD affects the rate of death and major adverse cardiovascular events (MACE = myocardial infarction, revascularization, and death) differently in AA and white (CC) patients 1 year after PCI. Accordingly, we reviewed the database of all patients referred for PCI in the Emory Healthcare System between January 2001 and December 2004.

RESULTS

We identified 800 CC and 116 AA patients with CKD among 4,372 patients referred for PCI. Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) <60 mL/(min 1.73 m(2)) calculated by means of the Cockcroft-Gault equation. The AA patients with CKD were younger and had a larger number of comorbidities than the CC subjects. However, neither mortality nor MACE differed between races (14.7% vs 13.1%, P = .65 and 31.9% vs 31.3%, P = .89, respectively). In multivariable models, eGFR and emergency PCI were the best predictors of any adverse event, whereas prior PCI or coronary artery bypass surgery was a predictor of MACE alone. A test for interaction failed to show a significant effect of race and CKD on outcome.

CONCLUSIONS

In a tertiary referral center, AA and CC patients with CKD had a similar mortality rate and MACE at 1 year after PCI. Race was not a determinant of outcome, whereas CKD was.

Meta-analysis comparing clinical effectiveness of drug-eluting stents, bare metal stents and coronary artery bypass surgery

Objective  To compare clinical outcomes among patients receiving drug-eluting stents, bare metal stents, or coronary artery bypass grafting surgery (CABG) to treat coronary artery disease. Data sources  Randomised controlled trials were systematically selected from electronic database for head-to-head comparisons. The results from these head-to-head comparisons were used for an adjusted indirect comparison. Methods  Published randomised controlled trials were reviewed for outcome data in patients treated for coronary artery disease with drug-eluting stents, bare metal stents, or CABG. Head-to-head comparisons were conducted for drug-eluting stents versus bare metal stents and for CABG versus bare metal stents. Adjusted indirect comparison was used to compare drug-eluting stents and CABG. Mid-term clinical outcomes (range: 6-12 months) were investigated and included rates of mortality, myocardial infarction, thrombosis, target lesion revascularisation, target vessel revascularisation, restenosis and major adverse cardiac events. Results  Systematic literature search identified 23 randomised controlled trials (15 for drug-eluting stents vs. bare metal stents, 8 for CABG vs. bare metal stents). Head-to-head comparisons for both single and multiple vessel disease demonstrated that compared with bare metal stents, drug-eluting stents had better outcomes for target lesion revascularisation, target vessel revascularisation, restenosis and major adverse cardiac events. Except target lesion revascularisation, data were similarly favourable for CABG when compared with bare metal stents. Adjusted indirect comparison between drug-eluting stents and CABG in single vessel disease failed to detect significant differences in any of the measured outcomes. Multiple vessel disease data analysis demonstrated that target vessel revascularisation (odds ratio 3.41 [95% CI 2.29-5.08]) and major adverse cardiac events (1.89 [1.28-2.79]) were superior to drug-eluting stents in patients undergoing CABG. Conclusions  Drug-eluting stents and CABG were superior to bare metal stents in terms of target lesion revascularisation (drug-eluting stents only), target vessel revascularisation, restenosis and major adverse cardiac events. There was no difference in clinical outcomes when comparing CABG and drug-eluting stents in patients with single vessel disease, and CABG may be superior to drug-eluting stents for target vessel revascularisation and major adverse cardiac events in patients with multiple vessel disease. However, results may vary between subpopulations with different clinical or socioeconomic differences.

Chronic Estrogen Supplementation Following Ovariectomy Improves the Emotional Stress-Induced Cardiovascular Responses by Indirect Action on the Nervous System and by Direct Action on the Heart

BACKGROUND

Takotsubo cardiomyopathy is triggered by emotional or physical stress especially in post-menopausal women. A reduction in estrogen levels following menopause might underlie the high incidence of takotsubo cardiomyopathy.

METHODS AND RESULTS

The left ventricular contraction between ovariectomized rats (OVX) and OVX with estrogen supplementation (OVX + E) while subjected to immobilization stress (IMO) was compared. The IMO in combination with general anesthesia impaired the left ventricular contraction in both OVX and OVX + E. Estrogen supplementation tended to improve the IMO-induced cardiac dysfunction and significantly attenuated the increase of blood pressure and heart rate. To understand the protective mechanism of estrogen, the expression of c-fos mRNA, a marker of cellular activation was compared. The mRNA expression of cardioprotective substances in the heart was also investigated. In the OVX + E, the levels of c-fos mRNA were significantly decreased in the paraventricular hypothalamic nucleus, adrenal gland and left ventricle, suggesting that an increase of estrogen attenuates the emotional stress-induced hypothalamo-sympatho-adrenal outflow from the central nervous system to the target organs. An expression of heat shock protein 70 and atrial natriuretic peptide was significantly augmented in the OVX + E.

CONCLUSIONS

These data suggest that estrogen supplementation partially prevents emotional stress-induced cardiovascular responses both by indirect action on the nervous system and by direct action on the heart.

Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17,417 procedures undertaken in Scotland, 1997-2003

OBJECTIVE

To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix.

DESIGN

Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period.

METHODS

All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models.

RESULTS

Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events.

CONCLUSION

Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Ischemic and bleeding outcomes in women treated with bivalirudin during percutaneous coronary intervention: a subgroup analysis of the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 trial

BACKGROUND

Outcomes in women undergoing percutaneous coronary intervention (PCI) in the contemporary era are poorly defined. The REPLACE-2 trial demonstrated that bivalirudin with provisional glycoprotein IIb/IIIa (GpIIb-IIIa) blockade is noninferior to heparin with planned GpIIb-IIIa blockade during PCI, with regard to ischemic and bleeding end points.

OBJECTIVES

The aim of this study was to define sex-based clinical ischemic and bleeding outcomes from the REPLACE-2 trial.

METHODS

A retrospective sex-based subgroup analysis of the REPLACE-2 trial comparing clinical ischemic and inhospital bleeding end points was conducted.

RESULTS

Compared with men in REPLACE-2, women were older, had more diabetes, congestive heart failure and hypertension, and less prior revascularization and myocardial infarction. Female sex was a univariate predictor of death and bleeding complications. Among women treated with either bivalirudin or heparin, there was no significant difference in the individual or composite ischemic end points of death, myocardial infarction, or urgent revascularization at 30 days or 6 months. Protocol-defined major bleeding, minor bleeding, and access site bleeding were less frequent with bivalirudin compared with heparin. Multivariable modeling found no significant interactions between sexes, with the composite ischemic end point, major bleeding, or 1-year mortality.

CONCLUSIONS

Women remain at higher risk for poorer outcomes with contemporary PCI, likely because of comorbidities. Bivalirudin with provisional GpIIb-IIIa confers similar protection against ischemic end points compared with heparin and planned GpIIb-IIIa blockade and significantly reduces the inherent bleeding risk of women undergoing contemporary PCI.