Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines

The appropriate use criteria: Improvements for its integration into real world clinical practice

The purpose of this position statement is to suggest ways in which future appropriate use criteria (AUC) for coronary revascularization might be restructured to: (1) incorporate improvement in quality of life and angina relief as primary goals of therapy, (2) integrate the findings of recent trials into quality appraisal, (3) employ the combined information of the coronary angiogram and invasive physiologic measurements together with the results of stress test imaging to assess risk, and (4) recognize the essential role that patient preference plays in making individualized therapeutic decisions. The AUC is a valuable tool within the quality assurance process; it is vital that interventionists ensure that percutaneous coronary intervention case selection is both evidence-based and patient oriented. Appropriate patient selection is an important quality indicator and adherence to evidence-based practice should be one metric in a portfolio of process and outcome indicators that measure quality.

The Utilization of Stress Tests Prior to Percutaneous Coronary Intervention for Stable Coronary Artery Disease in Taiwan

Background

Ischemia shown in non-invasive tests is considered to be a fundamental requirement for treating patients with stable coronary artery disease (CAD) with a percutaneous coronary intervention (PCI). In a nationwide cohort, we investigated the utilization of stress tests, including myocardial perfusion imaging (MPI), treadmill exercise test (TET) and stress echocardiography (SE) prior to elective PCI.

Methods

This retrospective study used the Longitudinal Health Insurance Database 2000 (LHID2000) of the National Health Insurance program in Taiwan. The LHID2000 is comprised of one million randomly sampled beneficiaries. We enrolled patients receiving elective PCI for stable CAD from 2000 to 2013. Stress tests performed within 90 days prior to PCI and patient characteristics correlated with the utilization of stress tests were investigated.

Results

During the investigation period, 3,163 patients received elective PCI for stable CAD and 1,847 (58.4%) patients had at least one stress test within 90 days prior to PCI. Among them, 1,461 (79.1%) had MPI, 1,228 had TET (66.4%) and only 1 had SE (0.05%). Age < 80 years, regional hospital and hyperlipidemia were independently associated with an increased likelihood of receiving stress tests. On the other hand, Charlson-comorbidity index score ≥ 1, prior catheterization and heart failure were independently associated with a decreased likelihood of receiving stress tests.

Conclusions

In the setting of stable CAD, almost 60% of our patients received stress tests within 90 days prior to elective PCI, and MPI was the most commonly used test.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Symptoms and angiographic findings of patients undergoing elective coronary angiography without prior stress testing

Many patients undergo elective coronary angiography without preprocedural stress testing that may be suitable if performed in patients with more angina pectoris or more frequently identified obstructive coronary artery disease (CAD). Patients in the National Cardiovascular Data Registry CathPCI Registry undergoing elective coronary angiography from July 2009 to April 2013 were assessed for differences in angina (Canadian Cardiovascular Society [CCS] class) and severity of obstructive CAD in those with and without preprocedural stress testing, stratified by CAD history. Given the large sample size, differences were considered clinically meaningful if the standardized difference (SD) was >10%. Of 790,601 patients without CAD history, 36.9% did not undergo preprocedural stress testing. Compared with patients with preprocedural stress testing, patients without preprocedural stress testing were more frequently angina free (CCS class 0; 28.2% with stress test vs 38.5% without, SD = 14.8%) and had similar rates of obstructive CAD (40.1% with stress test vs 35.7% without, SD = 9.0). Of 449,579 patients with CAD history, 44.2% did not undergo preprocedural stress testing. Patients without preprocedural stress testing reported more angina (CCS class III/IV angina: 17.8% vs 13.4%; SD = 11.3%) but were not more likely to have obstructive CAD (78.7% vs 81.1%; SD = 5.8%) than patients with preprocedural stress testing. In conclusion, approximately 40% of patients undergoing elective coronary angiography did not have preprocedural risk stratification with stress testing. For these patients, the clinical decision to proceed directly to invasive evaluation was not driven primarily by severe angina and did not result in higher detection rates for obstructive CAD.

Investigation route of the coronary patient in the public health system in Curitiba, São Paulo and in InCor--IMPACT study

Background:

The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization.

Objective:

To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP.

Methods:

Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies.

Results:

There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure.

Conclusion:

Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Systemic approach to identify serum microRNAs as potential biomarkers for acute myocardial infarction

Background. Recent studies have revealed the role of microRNAs (miRNAs) in a variety of biological and pathological processes, including acute myocardial infarction (AMI). We hypothesized that ST-segment elevation myocardial infarction (STEMI) may be associated with an alteration of miRNAs and that circulating miRNAs may be used as diagnostic markers for STEMI. Methods. Expression levels of 270 serum miRNAs were analyzed in 8 STEMI patients and 8 matched healthy controls to identify miRNAs differentially expressed in the sera of patients with AMI. The differentially expressed miRNAs were evaluated in a separate cohort of 62 subjects, including 31 STEMI patients and 31 normal controls. Results. The initial profiling study identified 12 upregulated and 13 downregulated serum miRNAs in the AMI samples. A subsequent validation study confirmed that serum miR-486-3p and miR-150-3p were upregulated while miR-126-3p, miR-26a-5p, and miR-191-5p were significantly downregulated in the sera of patients with AMI. Ratios between the level of upregulated and downregulated miRNAs were also significantly different in those with AMI. Receiver operator characteristics curve analysis using the expression ratio of miR-486-3p and miR-191-5p showed an area under the curve of 0.863. Conclusion. Our results suggest that serum miRNAs may be used as potential diagnostic biomarkers for STEMI.

The heart team approach to coronary revascularization--have we crossed the lines of evidence-based medicine?

Evidence-based medicine demands considerable time and decision-making skills to navigate through the proliferating data. A hierarchical "pyramid of evidence" has been formulated to help categorize data quality. The hierarchical data are processed into recommendations in Practice Guideline statements. Recently, both American College of Cardiology/American Heart Association/Society for Cardiac Angiography and Interventions and European Society of Cardiology guidelines for percutaneous coronary intervention embraced a new "heart team approach" as the preferred method to optimize revascularization decision making in cases of complex coronary anatomy. This extrapolation of a research method to the broad clinical practice has potential limitations. We suggest that both the need for a new method to optimize patient triage for the various revascularization strategies and the method to optimize decision making should be discussed. Published data suggest only minor deviations from guideline-based indications. Furthermore, traditional clinical judgment may result in a better patient outcome than arbitrary treatment assignment by rigid set of criteria. In conclusion, the need for a new decision-making process in the choice of revascularization strategy should be further explored and supported by scientific evidence.

Appropriateness of coronary revascularization for patients without acute coronary syndromes

OBJECTIVES

The purpose of this study was to determine appropriateness of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery performed in New York for patients without acute coronary syndrome (ACS) or previous CABG surgery.

BACKGROUND

The American College of Cardiology Foundation (ACCF) and 6 other societies recently published joint appropriateness criteria for coronary revascularization.

METHODS

Data from patients who underwent CABG surgery and PCI without acute coronary syndrome or previous CABG surgery in New York in 2009 and 2010 were used to assess appropriateness and to examine the variation across hospitals in inappropriateness ratings.

RESULTS

Of the 8,168 patients undergoing CABG surgery in New York without ACS/prior CABG who could be rated, 90.0% were appropriate for revascularization, 1.1% were inappropriate, and 8.6% were uncertain. Of the 33,970 PCI patients eligible for rating, 28% lacked sufficient information to be rated. Of the patients who could be rated, 36.1% were appropriate, 14.3% were inappropriate, and 49.6% were uncertain. A total of 91% of the patients undergoing PCI who were classified as inappropriate had 1- or 2-vessel disease without proximal left anterior descending artery disease and had no or minimal anti-ischemic medical therapy.

CONCLUSIONS

For patients without ACS/prior CABG, only 1% of patients undergoing CABG surgery who could be rated were found to be inappropriate for the procedure according to the ACCF appropriateness criteria, but 14% of the PCI patients who could be rated were found to be inappropriate, and 28% lacked enough noninvasive test information to be rated.

Impact of Independent Data Adjudication on Hospital-Specific Estimates of Risk-Adjusted Mortality Following Percutaneous Coronary Interventions in Massachusetts

Background—

As part of state-mandated public reporting of outcomes after percutaneous coronary interventions (PCIs) in Massachusetts, procedural and clinical data were prospectively collected. Variables associated with higher mortality were audited to ensure accuracy of coding. We examined the impact of adjudication on identifying hospitals with possible deficiencies in the quality of PCI care.

Methods and Results—

From October 2005 to September 2006, 15 721 admissions for PCI occurred in 21 hospitals. Of the 864 high-risk variables from 822 patients audited by committee, 201 were changed, with reassignment to lower acuities in 97 (30%) of the 321 shock cases, 24 (43%) of the 56 salvage cases, and 73 (15%) of the 478 emergent cases. Logistic regression models were used to predict patient-specific in-hospital mortality. Of 241 (1.5%) patients who died after PCI, 30 (12.4%) had a lower predicted mortality with adjudicated than with unadjudicated data. Model accuracy was excellent with either adjudicated or unadjudicated data. Hospital-specific risk-standardized mortality rates were estimated using both adjudicated and unadjudicated data through hierarchical logistic regression. Although adjudication reduced between-hospital variation by one third, risk-standardized mortality rates were similar using unadjudicated and adjudicated data. None of the hospitals were identified as statistical outliers. However, cross-validated posterior-predicted P values calculated with adjudicated data increased the number of borderline hospital outliers compared with unadjudicated data.

Conclusions—

Independent adjudication of site-reported high-risk features may increase the ability to identify hospitals with higher risk-adjusted mortality after PCI despite having little impact on the accuracy of risk prediction for the entire population.

Adherence of Catheterization Laboratory Cardiologists to American College of Cardiology/American Heart Association Guidelines for Percutaneous Coronary Interventions and Coronary Artery Bypass Graft Surgery

Background— The American College of Cardiology and the American Heart Association have issued guidelines for the use of coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCI) for many years, but little is known about the impact of these evidence-based guidelines on referral decisions.

Methods and Results— A cardiac catheterization laboratory database used by 19 hospitals in New York State was used to identify treatment (CABG surgery, PCI, medical treatment, or nothing) recommended by the catheterization laboratory cardiologist for patients undergoing catheterization with asymptomatic/mild angina, stable angina, and unstable angina/non–ST-elevation myocardial infarction between January 1, 2005, and August 31, 2007. The recommended treatment was compared with indications for these patients based on American College of Cardiology/American Heart Association guidelines. Of the 16 142 patients undergoing catheterization who were found to have coronary artery disease, the catheterization laboratory cardiologist was the final source of recommendation for 10 333 patients (64%). Of these 10 333 patients, 13% had indications for CABG surgery, 59% for PCI, and 17% for both CABG surgery and PCI. Of the patients who had indications for CABG surgery, 53% were recommended for CABG and 34% for PCI. Of the patients with indications for PCI, 94% were recommended for PCI. For the patients who had indications for both CABG surgery and PCI, 93% were recommended for PCI and 5% for CABG surgery. Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI than hospitals in which only catheterization was performed.

Conclusions— Patients with coronary artery disease receive more recommendations for PCI and fewer recommendations for CABG surgery than indicated in the American College of Cardiology/American Heart Association guidelines.

Comparison of long-term mortality after percutaneous coronary intervention in patients treated for acute ST-elevation myocardial infarction versus those with unstable and stable angina pectoris

Data remain limited regarding the comparative long-term mortality across the spectrum of patients with different indications for percutaneous coronary intervention (PCI). We evaluated early and late mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary PCI compared with early and late mortality in patients undergoing PCI for unstable angina (UA) or non-STEMI (NSTEMI) and stable angina. A total of 10,549 consecutive patients undergoing PCI from 1997 to 2005 at a single institution were followed up prospectively (median 3.2 years, interquartile range 1.5 to 5.6) to assess all-cause mortality. The indication for PCI was STEMI in 28%, UA/NSTEMI in 32%, and stable angina in 40%. The mortality rate at 6 years was 18.9% in patients with STEMI, 16.2% in patients with UA/NSTEMI, and 11.7% in those with stable angina. During the initial 6 months, patients with STEMI had an increased risk of death compared with patients with UA/NSTEMI (relative risk [RR] 3.09, 95% confidence interval [CI] 2.46 to 3.89) and stable angina (RR 5.82, 95% CI 4.45 to 7.62). However, between 6 months and 6 years, mortality accrued at an almost similar rate among patients with STEMI and those with stable angina (RR 1.06, 95% CI 0.86 to 1.32) and mortality was greatest in patients with UA/NSTEMI (UA/NSTEMI vs stable angina: RR 1.33, 95% CI 1.11 to 1.58; STEMI vs UA/NSTEMI: RR 0.80, 95% CI 0.65 to 0.99). In conclusion, we have demonstrated that the inferior survival rates in patients with STEMI after primary PCI are mainly attributed to greater mortality in the first months after the event. These observations highlight that new adjunctive therapeutic strategies should aim at mortality reduction in the first months after primary PCI.

Recent advances in the management of coronary artery disease: highlights from the literature

The recent advances in the multidisciplinary management of coronary artery disease (CAD) have been significant. The assessment of patients before percutaneous coronary intervention is likely to change significantly. National compliance with clinical guidelines in the preprocedural assessment of myocardial ischemia should be encouraged. Multislice computed tomographic coronary angiography continues to improve and is already an excellent screening test for CAD. Coronary stenting has an increasing role in multivessel and left main CAD, although further outcome trials are indicated, especially in the elderly. Although off-pump coronary artery bypass graft (CABG) surgery reduces postoperative atrial fibrillation, further major outcome advantages have not been shown in comprehensive meta-analyses when compared with on-pump CABG surgery. Although an intra-aortic balloon pump reduces mortality in high-risk CABG surgery, it may be replaced gradually by the percutaneous left ventricular-assist device, which has shown clinical benefit in this challenging setting. Statin therapy significantly improves clinical outcome after CABG surgery, even when begun postoperatively. There is strong evidence that, unless contraindicated, all CABG patients should receive statin therapy. Clopidogrel therapy just before CABG surgery is still associated with prolonged hospital stay because of significant bleeding complications. This risk will be exacerbated with the advent of the more potent platelet inhibitor, prasugrel. There is a clinical necessity for readily reversible platelet blockade to minimize the bleeding risks in CABG surgery.

Guidelines to practice gap in the use of glycoprotein IIb/IIIa inhibitors: from ISAR-REACT to overreact?

Adjunctive use of glycoprotein IIb/IIIa inhibitors (GPI) is associated with favorable outcomes following percutaneous coronary intervention (PCI). Guidelines for use of GPI have been published by various national societies including National Institute of Clinical Excellence (NICE), United Kingdom. The latter has not been updated since publication. The impact of contemporary trials such as ISAR-REACT (which showed no benefit of abciximab and 600 mg of clopidogrel compared with 600 mg of clopidogrel alone, in elective patients) on adherence to NICE guidelines is unknown.

METHODS

We audited use of GPI against NICE guidelines following publication in May 2002. Data were collected from 1,685 patients between September and November in years 2002, 2003, 2004, and 2007.

RESULTS

In 2002 and 2003, only 10.2% and 11.8%, respectively, of patients were noncompliant to NICE guidelines. Over time, there was an increase in patients not given GPI despite meeting NICE criteria. After publication of ISAR-REACT, the comparative figures for noncompliance in 2004 and 2007 were 40.0% and 44.5%. A similar pattern was seen in patients with diabetes; in 2002 and 2003 noncompliance was 16.7% and 11.1%, respectively, and in 2004 and 2007 noncompliance was 38.0% and 44.7%, respectively. Qualitatively, similar findings were recorded in patients with NSTE-ACS. The overall noncompliance to NICE guidelines increased from 11.0% to 42.1% (P < 0.0001) after the ISAR-REACT study.

CONCLUSIONS

We found a decline in compliance to NICE guidelines on GPI usage during PCI. This was likely influenced by contemporary trials demonstrating little or no benefit of GPI in patients undergoing elective PCI who are adequately pretreated with clopidogrel. Our findings suggest the need for a mechanism whereby regular updates to guidelines can be disseminated following new trial evidence.

Review of the 2005 American College of Cardiology, American Heart Association, and Society for Cardiovascular Interventions guidelines for adjunctive pharmacologic therapy during percutaneous coronary interventions: practical implications, new clinical data, and recommended guideline revisions

In 2006, the American College of Cardiology, American Heart Association, and Society for Cardiovascular Interventions published the 2005 update of the evidence-based guidelines for the treatment of patients undergoing percutaneous coronary intervention (PCI). Together with procedural recommendations, these guidelines for percutaneous coronary intervention provide clinicians with guidance in the appropriate use of adjunctive pharmacologic therapy in patients undergoing PCI. However, there remain substantial variations in practice among clinicians and within and across institutions. Furthermore, the guidelines (being a static document) cannot incorporate additional evidence that has accumulated since their publication. Several landmark trials, notably Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment (ISAR-REACT 2) and Acute Catheterization and Urgent Intervention Triage strategY (ACUITY), have added substantially to the knowledge base about pharmacologic therapy since publication of the guidelines. This article is therefore intended to discuss implementation into clinical practice of the revised guidelines for antiplatelet and antithrombotic pharmacologic therapy during PCI and to evaluate recent clinical evidence and make recommendations for revision of the guidelines incorporating the outcomes of recently completed trials.

Ethical issues, justification, referral criteria for budget limited and high-dose procedures

This paper reviews some of the issues connected with questions of ethics, health economics, radiation dose and referral criteria arising from a workshop held under the auspices of the Sentinel Research Program FP6-012909. An extensive bibliography of further reading is included.

Immediate removal of femoral-sheath following protamine administration in patients undergoing intracoronary paclitaxel-eluting-stent implantation

BACKGROUND

Immediate sheath-removal using post-procedural reversal of heparin with protamine reduces groin complications, shortens bed rest and hospital stay after percutaneous coronary intervention (PCI) with bare-metal stents. No data are available with newer and possibly more thrombogenic paclitaxel-eluting stents (PES).

AIM

We assessed the safety and efficacy of post-procedural protamine administration after successful coronary PES implantation in elective PCI and in patients with acute coronary syndromes (ACS).

METHODS

A consecutive series of 291 patients received 0.5 mg of protamine per 100 units of heparin whenever the post-procedural ACT was > 180 seconds, followed by immediate removal of the sheath (protamine group). Outcomes were compared to a historic control group comprising 291 consecutive patients, who also underwent PCI with PES, but without reversal of anticoagulation by protamine (non protamine group). The incidence of post-procedural vascular complications and bleeding complications, as well as hospital stay, were compared; as were the incidence of major cardiac events at 24 h, 30 days and 6 months.

RESULTS

The post-procedural bleeding complications were significantly higher in the non-protamine group. Vascular complications were also more frequent in patients who were not treated with protamine. Hospitalisation length was significantly lower in the protamine group than in the non-protamine group (13.6 +/- 7 h versus 20.41 +/- 3.9 h; p < 0.001). The protamine-group patients also had a significantly reduced bed rest (10.3 h +/- 5.6 h versus 18 h +/- 3.5 h; p < 0.001). During hospitalisation, after PES implantation, no deaths or acute stent thrombosis were observed in either group. The overall incidence of thrombosis and major adverse cardiac events at follow-up were similar in the two groups.

CONCLUSIONS

Immediate heparin neutralisation by protamine after successful PES implantation appears to be safe and feasible, also in patients with ACS. Use of protamine and early sheath removal after PCI confers early deambulation and may significantly limit healthcare cost, reduce vascular complications, bedrest, delayed discharge and patient discomfort.

Weekend versus weekday admission and mortality from myocardial infarction

BACKGROUND

Management of acute myocardial infarction requires urgent diagnostic and therapeutic procedures, which may not be uniformly available throughout the week.

METHODS

We examined differences in mortality between patients admitted on weekends and those admitted on weekdays for a first acute myocardial infarction, using the Myocardial Infarction Data Acquisition System. All such admissions in New Jersey from 1987 to 2002 (231,164) were included and grouped in 4-year intervals.

RESULTS

There were no significant differences in demographic characteristics, coexisting conditions, or infarction site between patients admitted on weekends and those admitted on weekdays. However, patients admitted on weekends were less likely to undergo invasive cardiac procedures, especially on the first and second days of hospitalization (P<0.001). In the interval from 1999 to 2002 (59,786 admissions), mortality at 30 days was significantly higher for patients admitted on weekends (12.9% vs. 12.0%, P=0.006). The difference became significant the day after admission (3.3% vs. 2.7%, P<0.001) and persisted at 1 year (1% absolute difference in mortality). The difference in mortality at 30 days remained significant after adjustment for demographic characteristics, coexisting conditions, and site of infarction (hazard ratio, 1.048; 95% confidence interval [CI], 1.022 to 1.076; P<0.001), but it became nonsignificant after additional adjustment for invasive cardiac procedures (hazard ratio, 1.023; 95% CI, 0.997 to 1.049; P=0.09).

CONCLUSIONS

For patients with myocardial infarction, admission on weekends is associated with higher mortality and lower use of invasive cardiac procedures. Our findings suggest that the higher mortality on weekends is mediated in part by the lower rate of invasive procedures, and we speculate that better access to care on weekends could improve the outcome for patients with acute myocardial infarction.

Risk-adjusted mortality analysis of percutaneous coronary interventions by American College of Cardiology/American Heart Association guidelines recommendations

An American College of Cardiology (ACC)/American Heart Association (AHA) task force on practice guidelines in 2001 published evidence-based recommendations for performing percutaneous coronary interventions (PCIs). These guidelines grouped the indications for PCI into 4 classes (I, IIa, IIb, and III) based on analyses of risks and benefits. In a previous study, we found that clinical success and in-hospital adverse events varied by indications class. However, no adjustment for risk was used in those comparisons. The ACC/National Cardiovascular Data Registry (ACC-NCDR) previously developed a risk-adjustment model for the adverse event of in-hospital PCI mortality. We investigated how the 14 individual risk factors in the ACC-NCDR PCI mortality model might differ across the 4 indications classes and whether estimated mortality for each class approximated the observed mortality for that class. We analyzed the ACC-NCDR PCI database for January 1, 2001 to December 31, 2004. We excluded procedures performed for treatment of acute ST-segment elevation myocardial infarction; all others were included, yielding 559,273 procedures for analysis. An algorithm derived from the 2001 guidelines was used to assign procedures to an indications class. Increasing frequencies of risk components were observed across classes I, IIa, IIb, and III. Expected mortalities for each class calculated by the risk-adjustment model were close to observed values (expected 0.52%, 0.59%, 1.72%, and 1.96%, respectively; observed 0.49%, 0.63%, 1.88%, and 1.60%, respectively). In conclusion, the ACC-NCDR risk-adjusted mortality model can be linked to the ACC/AHA PCI guidelines, and together these produce mortality risk estimates by indications classes that are close to actual observed values. With further refinement, these methods should be able to be used as powerful analytic tools for quality assurance and appropriateness purposes.

Interventional cardiology in Israel at 2005 - state of practice

OBJECTIVE

To assess the current practice of interventional cardiology in Israel.

METHOD

Under the auspices of the 'Working group of interventional cardiology' of the 'Israel Heart Society,' a questionnaire regarding the practice of interventional cardiology sent to directors of interventional cardiology in all public hospitals.

RESULTS

Twenty centers received the questionnaires; however, complete data was obtained from 18. Most interventional cardiology units in Israel are merely engaged in percutaneous coronary interventions (PCIs). PCIs are executed mostly via the femoral artery, using almost exclusively stents, of which 36% were drug eluting. Noted was an infrequent use of other therapeutic, diagnostic devices, or femoral arteriotomy closure devices. Only 22% of the patients receive glycoprotein IIb/IIIa blockers (GPB). Most centers used conventional unfractionated heparin dosing (70 u/kg) and did not routinely monitor activated clotting time. Abciximab, bivalirudin or enoxaparine were rarely used. All laboratories performed both elective and emergency-PCI, although 12 facilities were not supported by on-site surgical backup.

CONCLUSION

Most cardiovascular intervention programs have restricted their activity to the coronary stenting, and are using a limited array of diagnostic and therapeutic devices, along with patient-tailored adjunctive pharmacotherapy, to sustain cost-effectiveness. Currently, ambulatory angiography and coronary interventions are not widely practiced in Israel.

[Implementation of clinical guidelines]

Clinical guidelines play an important supportive role in improving everyday clinical practice. Their benefits are beyond doubt because failure to implement them is associated with a poorer prognosis. Nevertheless, clinical guidelines have their critics and limitations. Simply publishing guidelines does not mean that they will be implemented. It is essential, therefore, to understand the difficulties that can impede implementation in practice. Both the assessment of guideline implementation and the design of programs for improving implementation require a specific methodology. Use of this methodology to devise programs that encourage the implementation of clinical guidelines has resulted in improved adherence to guideline recommendations and, significantly, in a reduction in morbidity and mortality.

Non ST segment elevation acute coronary syndromes: A simplified risk-orientated algorithm

Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography. The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.