Twenty-Five–Year Trends in In-Hospital and Long-Term Outcome After Percutaneous Coronary Intervention

Stretching to Reduce Pain-Related Disability Among Echocardiographic and Interventional Laboratory Employees-A Pilot Study

Background

Stretching improves range of motion and changes the viscoelastic properties of muscle-tendon units. We hypothesized that a regular stretching program would reduce the functional consequences of pain for employees working in echocardiographic, ultrasound, and interventional laboratories. This exploratory, proof-of-concept study was meant to inform expectations for future randomized, controlled studies.

Methods

In this unblinded, nonrandomized, observational study, we enrolled 196 health care professionals working in the interventional and echocardiographic laboratories in the departments of cardiology and radiology at Mayo Clinic and Mayo Clinic Health System to perform 15-minute neck, upper extremity, low back, and lower extremity stretches for 1 year. The functional consequences of pain were self-reported by using the Disability of Arm, Shoulder, and Hand; Neck Disability Index; and Roland-Morris Questionnaire, which was administered at baseline and at 1 year to measure response to stretching. Monitoring with an assessment plan for injuries was undertaken. Employees who were pregnant, unable to do exercises, or under active orthopedic treatment, were excluded.

Results

Of the 196 enrolled, 68 (35%) provided complete data at both baseline and follow-up. The majority of participants were over 40 years (n = 51; 72%) and female (n = 51; 72%). Participants performed stretches for 120.5 (IQR, 52-184) days over the year. The number of days of doing the stretches was well distributed across the study period with median quarters 1, 2, 3, and 4 of 32 (19-51), 32 (20-51), 31 (17-45), and 32.5 (12-47) days, respectively. The majority of participants (52.3%) stretched before, 18.9% stretched during and 28.8% stretched after work. Self-reported upper extremity disability improved in the treatment group with a significant decrease in the median Disability of Arm, Shoulder, and Hand score (5.2 to 2.6; P = .002). There was an absolute 4% decrease in the Neck Disability Index score, between baseline and 1-year follow-up (10% to 6%, P = .017). There was not a significant change in the Roland-Morris Questionnaire from baseline to follow-up (1 to 0; P = .287). No participant reported any stretch-related injuries.

Conclusions

A routine stretching program may represent an attractive, low-cost, noninvasive option to reduce upper extremity musculoskeletal disability of employees working in the echocardiographic, ultrasound, and interventional laboratories. Larger randomized trials are needed to confirm the association.

Mean Activated Clotting Time of Patients Receiving Intravenous Heparin and Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction

Introduction The most prevalent cause of death is acute myocardial infarction (AMI). Primary percutaneous coronary intervention (PPCI) has replaced thrombolysis as the recommended therapeutic option for individuals with ST-segment elevation myocardial infarction (STEMI). However, more effective anticoagulation regimes are required for PCI due to the limitations of unfractionated heparin. Objective This study aimed to ascertain the connection between the mean activated clotting time and the risk of bleeding and infarcts in individuals receiving intravenous heparin during PPCI for STEMI. Methods This was a one-year prospective observational study carried out at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Results The majority (70.15%) were male, with a mean age of 56.08 ± 8.92 years. Following PPCI, the average active clotting time (ACT) was 350.56 ± 39.62 seconds (range 255 to 453), compared to the pre-PPCI mean of 504.15 ± 38.98 seconds. ACT was considerably higher in female patients, smokers, and overweight patients. The mean ACT was not significantly higher in patients with hypertension (HTN) and dyslipidemia (DLD). Conclusion The ACT range in this investigation was 255 to 453 seconds, and there was no discernible relationship between ACT readings and problems related to bleeding and ischemia. To determine who is more at risk, bleeding risk models should be used and improved further before catheterization.

Combined nutritional and frailty screening improves assessment of short-term prognosis in older adults following percutaneous coronary intervention

BACKGROUND

Frailty and malnutrition are well-known factors influencing outcomes of myocardial infarction (MI) in older adults. Due to considerable overlap between both entities, whether the simultaneous assessment of frailty and nutrition adds nonredundant value to risk assessment is unknown.

METHODS

We performed a prospective cohort study on 402 patients aged at least 65 years diagnosed with ST-elevation MI that underwent percutaneous coronary intervention. Nutritional status was assessed by Controlling Nutritional Status score (CONUT), Prognostic Nutritional Index, and Geriatric Nutritional Response Index. Frailty was assessed by Clinical Frailty Scale (CFS), Derby frailty index, and acute frailty network. Primary outcome was major adverse cardiac events (MACE), comprising all-cause mortality, non-fatal MI, and unplanned repeat revascularization during 28-day follow-up. Increment in Global Registry of Acute Coronary Events (GRACE) score performance following the addition of nutrition and frailty was assessed.

RESULTS

The incidence of MACE was 8.02 (6.38-9.95) per 1000 person-days. The CONUT score and CFS were the best predictors of MACE and independent predictors in the multivariate Cox-regression models [hazard ratios, 2.80 (1.54-5.09) and 2.54 (1.50-4.29)]. CONUT score classified 151 (37.6%) patients as malnourished, and CFS classified 131 (32.6%) as frail. The addition of both CONUT and CFS to the GRACE score led to better model discrimination and calibration through improved c-statistic (+0.165) ( P < 0.0001) and Akaike and Bayesian information criteria.

CONCLUSION

Combining CONUT and CFS provides nonredundant prognostic value despite their overlapping nature. Combined nutritional and frailty screening may improve risk prognostication in older adults following MI.

Adverse Impact of Peri-Procedural Stroke in Patients Who Underwent Percutaneous Coronary Intervention

Peri-procedural stroke (PPS) is an important complication in patients who underwent percutaneous coronary intervention (PCI). The extent to which PPS impacts mortality and outcomes remains to be defined. Consecutive patients who underwent PCI enrolled in the Victorian Cardiac Outcomes Registry (2014 to 2018) were categorized into PPS and no PPS groups. The primary outcome was 30-day major adverse cardiovascular events (MACEs) (composite of mortality, myocardial infarction, stent thrombosis, and unplanned revascularization). Of 50,300 patients, PPS occurred in 0.26% patients (n = 133) (71% ischemic, and 29% hemorrhagic etiology). Patients who developed PPS were older (69 vs 66 years) compared with patients with no PPS, and more likely to have pre-existing heart failure (59% vs 29%), chronic kidney disease (33% vs 20%), and previous cerebrovascular disease (13% vs 3.6%), p <0.01. Among those with PPS, there was a higher frequency of presentation with ST-elevation myocardial infarction (49% vs 18%) and out-of-hospital cardiac arrest (14% vs 2.2%), PCI by way of femoral access (59% vs 46%), and adjunctive thrombus aspiration (12% vs 3.6%), all p = <0.001. PPS was associated with incident 30-day MACE (odds ratio [OR] 2.97, 95% confidence intervals [CIs] 1.86 to 4.74, p <0.001) after multivariable adjustment. Utilizing inverse probability of treatment weighting analysis, PPS remained predictive of 30-day MACE (OR 1.91, 95% CI 1.31 to 2.80, p = 0.001) driven by higher 30-day mortality (OR 2.0, 95% CI 1.35 to 2.96, p = 0.001). In conclusion, in this large, multi-center registry, the incidence of PPS was low; however, its clinical sequelae were significant, with a twofold increased risk of 30-day MACE and all-cause death.

Effects of cardiac surgical support on long-term outcomes of emergent or complex percutaneous coronary intervention cases: a sub-analysis of the SHINANO 5-year registry

Significant improvements in percutaneous coronary intervention (PCI) technology have enabled cardiovascular procedures to be performed without onsite cardiac surgery facilities. However, little is known about the association between onsite cardiac surgical support and long-term outcomes of PCI, particularly among emergent and complex cases. We investigated whether the presence or absence of cardiovascular surgery affects the long-term prognosis after PCI, emergent and complex elective cases. The SHINANO 5-year registry, a prospective, observational, and multicenter cohort study registry in Nagano, Japan, consecutively included 1665 patients who underwent PCI between August 2012 and July 2013. The procedures were performed at 11 hospitals with onsite cardiac surgery facilities [onsite surgery (+) group; n = 1257] and 8 hospitals without onsite cardiac surgery facilities [onsite surgery (-) group; n = 408]. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiac and cerebrovascular events [MACCE: all-cause death, Q-wave myocardial infarction, non-fatal stroke, and target lesion revascularization]. The onsite surgery group (+) had a lower rate of emergent PCI and ST-segment elevation myocardial infarction (40.8% vs. 51.7%, p < 0.01 and 24.9% vs. 39.2%, p < 0.01, respectively), and a higher prevalence of hemodialysis and history of peripheral artery disease (7.6% vs. 2.45%, p < 0.01 and 12.1% vs. 6.9%, p < 0.01, respectively). However, the Kaplan-Meier analysis showed no difference in the 5-year mortality rate (16.4% vs. 15.2%, p = 0.421) and MACCE incidence (31.6% vs. 28.9%, p = 0.354) between the groups. Also, there were no differences in the mortality rate and incidence of MACCE among emergent cases of ST-segment elevation myocardial infarction and complex elective cases who underwent PCI. Long-term outcomes of PCI appear to be comparable between institutions with and without onsite cardiac surgical facilities.

Temporal Trends, Clinical Characteristics, and Outcomes of Emergent Coronary Artery Bypass Grafting for Acute Myocardial Infarction in the United States

Background There are limited contemporary data on the use of emergent coronary artery bypass grafting (CABG) in acute myocardial infarction. Methods and Results Adult (aged >18 years) acute myocardial infarction admissions were identified using the National (Nationwide) Inpatient Sample (2000-2017) and classified by tertiles of admission year. Outcomes of interest included temporal trends of CABG use; age-, sex-, and race-stratified trends in CABG use; in-hospital mortality; hospitalization costs; and hospital length of stay. Of the 11 622 528 acute myocardial infarction admissions, emergent CABG was performed in 1 071 156 (9.2%). CABG utilization decreased overall (10.5% [2000] to 8.7% [2017]; adjusted odds ratio [OR], 0.98 [95% CI, 0.98-0.98]; P<0.001), in ST-segment-elevation myocardial infarction (10.2% [2000] to 5.2% [2017]; adjusted OR, 0.95 [95% CI, 0.95-0.95]; P<0.001) and non-ST-segment-elevation myocardial infarction (10.8% [2000] to 10.0% [2017]; adjusted OR, 0.99 [95% CI, 0.99-0.99]; P<0.001), with consistent age, sex, and race trends. In 2012 to 2017, compared with 2000 to 2005, admissions receiving emergent CABG were more likely to have non-ST-segment-elevation myocardial infarction (80.5% versus 56.1%), higher rates of noncardiac multiorgan failure (26.1% versus 8.4%), cardiogenic shock (11.5% versus 6.4%), and use of mechanical circulatory support (19.8% versus 18.7%). In-hospital mortality in CABG admissions decreased from 5.3% (2000) to 3.6% (2017) (adjusted OR, 0.89; 95% CI, 0.88-0.89 [P<0.001]) in the overall cohort, with similar temporal trends in patients with ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction. An increase in lengths of hospital stay and hospitalization costs was seen over time. Conclusions Utilization of CABG has decreased substantially in acute myocardial infarction admissions, especially in patients with ST-segment-elevation myocardial infarction. Despite an increase in acuity and multiorgan failure, in-hospital mortality consistently decreased in this population.

Contribution of Age-Related Microvascular Dysfunction to Abnormal Coronary: Hemodynamics in Patients With Ischemic Heart Disease

OBJECTIVES

This study sought to investigate the contribution of age-related microcirculatory dysfunction to abnormal coronary hemodynamics in patients with coronary atherosclerosis.

BACKGROUND

Impairment in myocardial blood supply in patients with coronary atherosclerosis can be accentuated due to age-related changes in microcirculatory function.

METHODS

Intracoronary pressure and flow were measured with the Doppler technique in 299 vessels (228 patients), and the thermodilution technique in 120 vessels (99 patients). In 172 patients, Doppler measurements were also performed in unobstructed vessels. Associations of coronary hemodynamics with aging were studied in both the stenosed and unobstructed arteries.

RESULTS

Aging was associated with a progressive increase in minimal microvascular resistance and a progressive decrease in hyperemic flow in both obstructed and nonobstructed coronary arteries. As such, coronary flow reserve decreased with advancing age. Epicardial stenosis severity assessed by resting Pd/Pa, basal stenosis resistance index, and hyperemic stenosis resistance index was equivalent across age groups. By contrast, fractional flow reserve increased with advancing age. Consequently, the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of concomitant focal epicardial and diffuse or microvascular disease (relative risk: 1.6; 95% confidence interval: 1.1 to 2.3; p = 0.017) increased with advancing age, whilst the adjusted risk of a fractional flow reserve/coronary flow reserve pattern reflective of non-flow-limiting stenosis with a healthy microcirculation decreased (relative risk: 0.7; 95% CI: 0.5 to 1.0; p = 0.022).

CONCLUSIONS

Aging is associated with progressive pan-myocardial impairment of coronary vasodilatory capacity due to an increase in minimal microvascular resistance. Concomitant aging-related impairment in microvascular function impacts the pathophysiology of ischemic heart disease in the individual patient and is not adequately identified by hyperemic coronary pressure measurements alone.

Outcome of Percutaneous Coronary Intervention in Relation to the Institutional Volume of Coronary Artery Bypass Surgery

BACKGROUND

Percutaneous coronary intervention (PCI) is performed in a wide range of institutions. We sought to assess the relationship between coronary artery bypass grafting (CABG) volume relative to PCI volume and clinical outcome using nationally representative PCI and CABG registries in Japan.

METHODS

This was a collaborative, registry-based cohort study enrolling patients undergoing percutaneous coronary intervention in 2013-2014 using Japanese nationwide registry (J-PCI) with follow up until discharge. The absolute volume of CABG for each hospital was calculated using additional data from Japan CardioVascular Surgery Database (JCVSD). Patients undergoing their first PCI registered in the registry (N = 220,934), at 943 facilities were studied. Main outcomes were in-hospital mortality, and incidence of composite of in-hospital death and postprocedural complications.

RESULTS

Among the 220,934 patients, 162,411 were men, with a mean age of 69.7 (SD 11.6) years. Patients underwent PCI at hospitals with varying CABG volume: The overall in-hospital mortality and composite event rate for PCI patients was 0.9% and 2.4%, respectively. CABG volume was associated with the in-hospital mortality of PCI at facilities performing less than 200 PCIs per year, but not at facilities performing 200 or more. Similarly, in-hospital mortality or complication was associated with PCI volume <200 only if no CABG is done at the facility. The result remained largely consistent in subgroup of patients presenting with acute coronary syndrome or even after excluding these institutions with extremely low number of PCI (<50 cases/year) or CABG (<15 cases / year).

CONCLUSIONS

In a nationwide registry-based analysis, the surgical volume was associated with patients' clinical outcome after PCI, when limited number of PCIs were performed at the facility.

Stroke After Percutaneous Coronary Intervention in the Era of Transradial Intervention

BACKGROUND

Periprocedural stroke is a rare but life-threatening complication of percutaneous coronary intervention (PCI). Transradial intervention (TRI) is more beneficial than transfemoral intervention for periprocedural bleeding and acute kidney injuries, but its effect on periprocedural stroke has not been fully investigated. Our study aimed to assess risk predictors of periprocedural stroke according to PCI access site.

METHODS AND RESULTS

Between 2008 and 2016, 17 966 patients undergoing PCI were registered in a prospective multicenter database. Periprocedural stroke was defined as loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms lasting at least 24 hours after onset. Periprocedural stroke was observed in 42 patients (0.3%). Stroke patients were older and had a higher incidence of chronic kidney disease, peripheral artery disease, and acute coronary syndrome but were less likely to undergo TRI. Multivariable logistic regression analysis revealed TRI (odds ratio; 0.33; 95% CI, 0.16-0.71; P=0.004) was significantly associated with a lower occurrence of periprocedural stroke. Finally, propensity score-matching analysis showed that TRI was associated with a reduced risk of periprocedural stroke compared with transfemoral intervention (0.1% versus 0.4%; P=0.014). According to our sensitivity analysis, this finding was robust to the presence of an unmeasured confounder in almost all plausible scenarios.

CONCLUSIONS

TRI was associated with a reduced risk of periprocedural stroke compared with transfemoral intervention. Increased TRI use may reduce overall PCI complications and should be recommended as the optimal access site for both urgent/emergent and elective PCIs.

Total and Cause-Specific Mortality After Percutaneous Coronary Intervention: Observations From the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease Registry

Background

Patients undergoing percutaneous coronary intervention (PCI) are increasingly older and have a higher comorbidity burden. This study evaluated trends in 30-day, 1-year, and 2-year total and cause-specific mortality using a large, contemporary cohort of patients who underwent PCI in Alberta, Canada.

Methods

We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry to identify patients aged ≥ 20 years who underwent PCI between 2005 and 2013. All patients were followed until death or being censored by August 2016. Cause of death was from the Vital Statistics database and classified as cardiac or noncardiac. Multivariable logistic regression was used to calculate predicted mortality at 30 days, 1 year, and 2 years post-PCI.

Results

Of the 35,602 patients who underwent PCI, 5284 (14.8%) had died. Mean (standard deviation) follow-up was 74.9 (35.1) months. Over the study period, patients were older and more likely to undergo PCI for an acute coronary syndrome indication. Thirty-day (2005: 1.3%; 2013: 3.2%; P < 0.001), 1-year (2005: 2.7%; 2013: 5.7%; P < 0.001), and 2-year (2005: 4.5%; 2013: 7.5%; P < 0.001) predicted mortality after PCI increased over the study period. Cardiac cause of death dominated in the short-term, but the proportion of noncardiac deaths increased as time from PCI to death increased (30 days = 11.5%, 1 year = 31.5%, 2 years = 39.6%; P < 0.001).

Conclusions

In this population-based study, we found all-cause mortality at 30 days, 1 year, and 2 years after PCI increased over time. Cardiac causes of death dominate in the short-term after PCI; however, noncardiac cause becomes a major driver of mortality in the long-term.

The influence of Elixhauser comorbidity index on percutaneous coronary intervention outcomes

BACKGROUND

Clinical outcomes with respect to the evolution of comorbidity burden in national cohorts of patients undergoing PCI have not been reported.

OBJECTIVES

We sought to explore the association between comorbidity burden and periprocedural outcomes in patients treated with PCI in the National Inpatient Sample.

METHODS

6,601,526 PCI procedures were identified between 2004 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, length of stay and cost. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1-5, ECS IV = 6-13, and ECS V ≥ 14).

RESULTS

Patients with a score over 13 had a fivefold increase in the odds of mortality (OR: 5.13, 95% CI: 4.76-5.54), major bleeding (OR: 11.46, 95% CI: 10.66-12.33) and doubled the hospitalization costs ($31,452 vs $17.566).

CONCLUSIONS

Our study of over six million PCI procedures demonstrates that patients with the greatest comorbid burden (as defined by an ECS of >13) have a fivefold increase risk of in-hospital mortality, a fourfold increase in in-hospital periprocedural complications and an 11-fold increase in major bleeding events once differences in baseline patient characteristics are adjusted for. In addition, ECS significantly impacts the length of stay and doubles the healthcare costs. Comorbid burden is an important predictor of poor outcomes after PCI and should be considered as part of the decision-making processes in patients undergoing PCI.

Temporal Changes in Co-Morbidity Burden in Patients Having Percutaneous Coronary Intervention and Impact on Prognosis

This study aims to evaluate the impact of co-morbidity burden on outcomes in patients who undergo percutaneous coronary intervention (PCI). We used the Nationwide Inpatient Sample to identify all PCI procedures undertaken in the United States from 2004 to 2014. We then determined co-morbidity burden for each patient record based on the Charlson Co-morbidity Score. Multivariable logistic regression models were used to examine the association between co-morbidity burden and in-hospital mortality other in-hospital complications. A total of 6,601,526 PCI procedures were included in the analysis. Overall co-morbidity burden increased over time, with severe co-morbidity burden (defined as a CCI score ≥3) increasing from 5.3% in 2004 to 14.2% in 2014 (p <0.0001). After adjustment for confounding factors increasing co-morbidity burden was independently associated with increased odds of in-hospital mortality, complications, length of hospital stay, and total cost of hospitalization post PCI. A CCI score of 1 was independently associated with an increase in the odds of in hospital mortality (odds ratio [OR] 1.19 [95% confidence interval [CI] 1.15 to 1.25]), a score of 2 associated with an almost 1.5-fold increase (OR 1.41 [95% CI 1.34 to 1.48]) and a score of ≥3 a 2-fold increase (OR 1.96 [95% CI 1.86 to 2.07]) compared with no co-morbid burden (CCI score of 0). In conclusion, our results show that co-morbid burden is independently associated with increased risk of in-hospital mortality, in-hospital complications, length of stay, and healthcare costs.

Comparison of radial access versus femoral access with the use of a vascular closure device for the prevention of vascular complications and mortality after percutaneous coronary intervention

BACKGROUND

Radial access (RA) and vascular closure devices (VCD) have been shown to be superior to transfemoral access (TFA) with regard to the prevention of vascular complications after percutaneous coronary intervention (PCI).

OBJECTIVE

The present study evaluates whether RA is associated with less vascular complications and a lower mortality than VCD.

METHODS

A total of 6999 consecutive PCI patients were studied through a single-centre prospective registry from January 2011 to August 2015. RA was applied in 1385 patients (20%), VCDs with Angio-Seal were implanted in 2145 patients (30%) and manual compression of TFA was performed in 3468 patients (50%).

RESULTS

RA and VCD patients had comparable baseline risk profiles. The overall vascular complication rate was 2.0% (n = 137) and was composed of false aneurysms (n = 85), clinically relevant haematomas (n = 27), arteriovenous fistulas (n = 12), arterial occlusions (n = 11) and local infections (n = 2). Vascular complications occurred in 0.6% of RA patients, 1.8% of VCD patients and 2.6% of TFA patients (p < .01). In-hospital mortality was 0.8% in RA patients, 0.8% in VCD patients and 3.8% in TFA patients (p < .01). In a multivariate logistic regression model, RA, compared to VCD, was found to be independently associated with a lower rate of vascular complications (OR: 0.34, 95% CI: 0.16-0.75), but not with lower mortality rates (OR: 1.20, 95% CI: 0.51-2.85).

CONCLUSION

In this large all-comers PCI population, the radial approach, compared to the femoral approach with VCD use (Angio-Seal), was independently associated with a reduction of vascular complications, but not with lower mortality rates.

Cangrelor in Older Patients Undergoing Percutaneous Coronary Intervention: Findings From CHAMPION PHOENIX

BACKGROUND

Older patients treated with percutaneous coronary intervention are at increased risk of periprocedural events.

METHODS AND RESULTS

CHAMPION (cangrelor versus standard therapy to achieve optimal management of platelet inhibition) PHOENIX randomized 11 145 patients to cangrelor or clopidogrel. We sought to determine the outcomes in the prespecified subgroup of patients ≥75 years old (n=2010; 18%). Cangrelor resulted in directionally consistent effects on the primary end point (death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) in patients ≥75 years old (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.50-1.02) and in those <75 years old (OR, 0.81; 95% CI, 0.67-0.98; P [interaction]=0.55). Age ≥75 years was an independent predictor of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate/severe bleeding (1.0% versus 0.3%; adjusted OR, 2.94; 95% CI, 1.28-6.77; P=0.01) when compared with patients <75 years old. There was no significant difference in GUSTO moderate/severe bleeding with cangrelor versus clopidogrel (1.1% versus 1.0%; OR, 1.07; 95% CI 0.45-2.53) in patients ≥75 years old or in those <75 years old (0.4% versus 0.2%; OR, 2.24; 95% CI, 1.02-4.93; P [interaction]=0.21). For the net composite end point of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis plus GUSTO moderate/severe bleeding, the OR for cangrelor in those ≥75 years old was 0.75 (6.4% versus 8.3%; 95% CI, 0.54-1.05; P=0.09). The effects were similar in those <75 years old (4.9% versus 5.8%; OR, 0.85; 95% CI, 0.70-1.02; P=0.08; P [interaction]=0.53).

CONCLUSIONS

Patients ≥75 years old have an overall ≈3-fold increased odds of moderate/severe bleeding. Cangrelor, when compared with clopidogrel, provides similar efficacy and in patients ≥75 years old as in those <75 years old but does not increase the risk of major bleeding.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01156571.

Comparison of the Predictive Roles of Risk Scores of In-Hospital Major Adverse Cardiovascular Events in Patients with Non-ST Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

OBJECTIVE

We evaluated the relationship between various risk scores (SYNTAX score [SS], SYNTAX score-II [SS-II], thrombolysis in myocardial infarction [TIMI] risk scores, and Global Registry of Acute Coronary Events [GRACE] risk scores) and major adverse cardiovascular events (MACE) in non-ST elevation myocardial infarction (NSTEMI) patients undergoing percutaneous coronary intervention (PCI).

SUBJECTS AND METHODS

The study population were selected from among 589 patients who underwent coronary angiography with a diagnosis of NSTEMI. TIMI and GRACE risk scores were calculated. SS and SS-II were calculated in all patients, and points were added according to the predefined algorithm, taking into account the other 6 clinical variables being monitored (age, sex, left ventricular ejection fraction, creatinine clearance, chronic obstructive pulmonary disease, and peripheral artery disease). Patients were classified into tertile 1 (SS < 22), tertile 2 (SS 23-32), and tertile 3 (SS > 32).

RESULTS

The group with high SS-II for PCI values in the risk scores were observed from tertile 1 to tertile 3 (from 25.0 ± 7.7 to 31.6 ± 9.4, p < 0.001, respectively). The SS-II score in patients with PCI was an independent predictor of MACE, in-hospital mortality, nonfatal myocardial infarction, and stent thrombosis (OR 1.082, 95% CI 1.036-1.131, p < 0.001). The overall MACE, in-hospital mortality, and nonfatal myocardial infarction rates were significantly higher in the high SS-II for PCI group (p < 0.001).

CONCLUSION

TIMI and GRACE risk scores were able to predict MACE. In addition to these, SS-II was also able to predict in-hospital mortality, nonfatal myocardial infarction, and stent thrombosis.

Sex Differences in 1-Year Outcomes After Percutaneous Coronary Intervention in the Veterans Health Administration

BACKGROUND

Advancements in percutaneous coronary intervention (PCI) for treating obstructive coronary artery disease have reduced major adverse events, including mortality. Yet, evidence as to whether women and men experience similar outcomes is mixed. The objective was to examine sex differences in 1-year major adverse cardiac outcomes for the national population of patients undergoing PCI at Veterans Health Administration (VA) cardiac catheterization laboratories.

METHODS

All Veterans undergoing PCI at VA hospitals between October 1, 2007 and September 30, 2013 (N = 64,757; Women = 1,040) were included. Cox proportional hazards models compared 1-year postprocedural outcomes [rehospitalization for myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE)] by sex.

RESULTS

Women Veterans undergoing PCI were more likely to be younger, black, obese, and have chronic depression and less likely to have common cardiovascular risk factors and to have had prior cardiac events than Veteran men. One-year rates for women versus men were 2.1% and 2.5% for rehospitalization (p-value = 0.57); 3.5% and 4.9% for mortality (p-value = 0.14), and 5.4% and 6.9% for MACE (p-value = 0.18). There were no significant sex differences in any of the outcomes in Cox proportional hazards models.

CONCLUSIONS

Despite differences in clinical risk factors at the time of PCI, women and men Veterans treated at VA cardiac catheterization laboratories experienced comparable 1-year rehospitalization for MI, mortality, and MACE post-PCI. These results demonstrated similar 1-year post-PCI outcomes for men and women in a national population of patients who have more comorbidities and mental health issues than the general population.

Barriers to Early Discharge after Elective Percutaneous Coronary Intervention (BED PCI): A Single-Center Study

Objective

To identify patient characteristics and procedural factors that may play a role in hindering same-day discharge (SDD) practices.

Background

Multiple studies have shown the safety and cost effectiveness of SDD following elective percutaneous coronary intervention (PCI), but factors that hinder SDD practices have not been thoroughly studied.

Material and Methods

A retrospective comparative analysis of elective PCI patients who had an overnight stay (OS) (n = 345) vs. SDD patients (n = 222) was conducted to identify significant differences between the two groups in baseline patient characteristics, procedural, and postprocedural factors.

Results

Comparing OS to SDD patients, OS patients had a lower prevalence of radial access (20.29% vs. 39.64%, P < 0.0001); a higher incidence of suboptimal angiographic results (14.49% vs. 1.80%, P = 0.0027); CRCL values lower than 60 mL/min (26.38% vs. 15.32%, P = 0.0019); and greater femoral vascular site hemostasis with manual compression (69.09% vs. 36.57%, P = 0.0027). OS patients received larger sheath sizes (P = 0.0209), more bivalirudin (45.80% vs. 36.70%) and glycoprotein IIb/IIIa inhibitors (5.51% vs. 2.25%), but less heparin (51.30% vs. 53.21%). Chest pain (8.12% vs. 0.92%, P = 0.0042) and vascular access site concerns (20.58% vs. 0%, P = 0.0027) were more common among OS patients.

Conclusions

Pre-, peri-, and post-procedural factors play a role in SDD eligibility. Understanding factors that limit as well as those that facilitate SDD may enable institutions to establish or enhance a SDD program.

Temporal Trends, Predictors, and Outcomes of In-Hospital Gastrointestinal Bleeding Associated With Percutaneous Coronary Intervention

Since the introduction of new antiplatelet and anticoagulant agents in the last decade, large-scale data studying gastrointestinal bleeding (GIB) in patients undergoing percutaneous coronary intervention (PCI) are lacking. Using the Nationwide Inpatient Sample, we identified all hospitalizations from 2006 to 2012 that required PCI. Temporal trends in the incidence and multivariate predictors of GIB associated with PCI were analyzed. A total of 4,376,950 patients underwent PCI in the United States during the study period. The incidence of GIB was 1.1%. Mortality rate in the GIB group was significantly higher (9.71% vs 1.1%, p <0.0001). Although the incidence of GIB remained stable during the study period (0.97% in 2006 to 1.19% in 2012), in-hospital mortality rate increased significantly from 7.9% in 2006 to 10.78% in 2012, with a peak of 12% in 2010. The GIB group had a longer median length of stay (5.80 vs 1.57 days) and an increased median cost of hospitalization ($26,564 vs $16,879). The predictors of GIB included cardiovascular co-morbidities such as acute myocardial infarction, cardiogenic shock, atrial fibrillation, congestive heart failure, valvular heart diseases, and a history of transient ischemic attack/stroke. Gastrointestinal co-morbidities including diverticulosis, esophageal cancer, stomach cancer, small intestine cancer, large intestine cancer, rectosigmoid cancer, gastrointestinal ulcer, and liver disease were predictors of GIB. Interestingly, a lower risk of GIB was associated with obese patients and patients with private insurance. A higher risk of GIB was noted in urgent versus elective admissions and weekend versus weekday admissions. In conclusion, the incidence of GIB in patients who underwent PCI remained stable from 2006 to 2012; however, the in-hospital mortality increased significantly. Identifying patients at higher risk for GIB is critically important to develop preventive strategies to reduce morbidity and mortality.

Factors Associated with Early Adverse Events after Coronary Artery Bypass Grafting Subsequent to Percutaneous Coronary Intervention

BACKGROUND

A previous percutaneous coronary intervention (PCI) may affect the outcomes of patients who undergo coronary artery bypass grafting (CABG). The objective of this study was to compare the early in-hospital postoperative outcomes between patients who underwent CABG with or without previous PCI.

METHODS

The present study included 160 patients who underwent isolated elective on-pump CABG at the department of cardiothoracic surgery, Minia University Hospital from January 2010 to December 2014. Patients who previously underwent PCI (n=38) were compared to patients who did not (n=122). Preoperative, operative, and early in-hospital postoperative data were analyzed. The end points of the study were in-hospital mortality and postoperative major adverse events.

RESULTS

Non-significant differences were found between the study groups regarding preoperative demographic data, risk factors, left ventricular ejection fraction, New York Heart Association class, EuroSCORE, the presence of left main disease, reoperation for bleeding, postoperative acute myocardial infarction, a neurological deficit, need for renal dialysis, hospital stay, and in-hospital mortality. The average time from PCI to CABG was 13.9±5.4 years. The previous PCI group exhibited a significantly larger proportion of patients who experienced in-hospital major adverse events (15.8% vs. 2.5%, p=0.002). On multivariate analysis, only previous PCI was found to be a significant predictor of major adverse events (odds ratio, 0.16; 95% confidence interval, 0.03 to 0.71; p=0.01).

CONCLUSION

Previous PCI was found to have a significant effect on the incidence of early major adverse events after CABG. Further large-scale and long-term studies are recommended.

Determinants and Outcomes of Stroke Following Percutaneous Coronary Intervention by Indication

Background and Purpose—

Stroke after percutaneous coronary intervention (PCI) is a serious complication, but its determinants and outcomes after PCI in different clinical settings are poorly documented.

Methods—

The British Cardiovascular Intervention Society (BCIS) database was used to study 560 439 patients who underwent PCI in England and Wales between 2006 and 2013. We examined procedural-type specific determinants of ischemic and hemorrhagic stroke and the likelihood of subsequent 30-day mortality and in-hospital major adverse cardiovascular events (a composite of in-hospital mortality, myocardial infarction or reinfarction, and repeat revascularization).

Results—

A total of 705 stroke cases were recorded (80% ischemic). Stroke after an elective PCI or PCI for acute coronary syndrome indications was associated with a higher risk of adverse outcomes compared with those without stroke; 30-day mortality and major adverse cardiovascular events outcomes in fully adjusted model were odds ratios 37.90 (21.43–67.05) and 21.05 (13.25–33.44) for elective and 5.00 (3.96–6.31) and 6.25 (5.03–7.77) for acute coronary syndrome, respectively. Comparison of odds of these outcomes between these 2 settings showed no differences; corresponding odds ratios were 1.24 (0.64–2.43) and 0.63 (0.35–1.15), respectively.

Conclusions—

Hemorrhagic and ischemic stroke complications are uncommon, but serious complications can occur after PCI and are independently associated with worse mortality and major adverse cardiovascular events outcomes in both the elective and acute coronary syndrome setting irrespective of stroke type. Our study provides a better understanding of the risk factors and prognosis of stroke after PCI by procedure type, allowing physicians to provide more informed advice around stroke risk after PCI and counsel patients and their families around outcomes if such neurological complications occur.

Incidence and Predictors of Catheterization-Related Cerebral Infarction on Diffusion-Weighted Magnetic Resonance Imaging

Introduction. The aim of this study was to examine the incidence and risk factors of catheterization-related CI in the contemporary era, using diffusion-weighted magnetic resonance imaging. Methods. We retrospectively analyzed consecutive 84 patients who underwent MRI (magnetic resonance imaging) after 2.81 ± 2.4 days (mean ± SD) of catheterization via aortic arch. We categorized the patients by the presence or absence of acute CI determined by diffusion-weighted MRI and analyzed the incidence and predictors. Results. Of 84 patients that underwent MRI after catheterization, acute CI was determined in 27 (32.1%) patients. In univariate analysis, dyslipidemia, age, coronary artery disease, antiplatelet agents, number of catheters used, urgent settings, and interventional procedures were significantly different. Multivariate analysis revealed dyslipidemia (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.41–16.03; p = 0.01), higher age (OR, 1.09; 95% CI, 1.007–1.19; p = 0.03), and the number of catheters used (OR, 2.21; 95% CI, 1.21–4.36; p = 0.01) as independent predictors of the incidence of catheterization-related acute CI. Conclusions. Dyslipidemia, higher age, and number of catheters used were independent predictors for acute CI after catheterization. These findings imply that managing dyslipidemia and comprehensive planning to minimize the numbers of catheters are important.

Impact of transradial coronary intervention on bleeding complications in octogenarians

Percutaneous coronary intervention (PCI) in the elderly is a major hospital burden since this group of patients exhibits high mortality rates and many comorbidities. The aim of this study was to analyze the impact of a transradial intervention (TRI) approach for PCI on bleeding complications in octogenarians. We retrospectively analyzed a consecutive cohort of 2530 patients who underwent PCI at a tertiary care center in Japan. Octogenarians constituted 12 % (291 cases) of the total PCI cases during the study period. Bleeding complications and all-cause mortality were observed at 30 days after PCI. Average age was 83 ± 3 years and female gender was 32 %. Stable coronary artery disease was 59 %. TRI was performed in 218 patients (75 %) and transfemoral intervention (TFI) in 73 (25 %). Bleeding Academic Research Consortium (BARC) major bleeding unrelated to bypass surgery were observed in 7.6 %, which were significantly lower in TRI than TFI (5.1 vs. 15.1 %, P = 0.005). The 30-day mortality rate was significantly low in patients without bleeding (4.9 vs. 31 %, p < 0.0001). In octogenarians, major bleeding complication was significant at 30 days after PCI. TRI had lower bleeding complication rate than TFI in this population. Octogenarians may be a subgroup of patients who derive benefits from TRI.

Temporal Trends in Clinical Outcome After Percutaneous Coronary Intervention 1984-2010 - Report From the Juntendo PCI Registry

BACKGROUND

Since the introduction of PCI in 1977, it has evolved along with advances in the technology, improvement in operator technique and establishment of medical therapy. However, little is known of the improvement in clinical outcome following PCI.

METHODS AND RESULTS

Data from the Juntendo PCI Registry during 1984-2010 were analyzed. The patients were divided into 3 groups according to date of index PCI: POBA era, January 1984-December 1997; BMS era, January 1998-July 2004; and DES era, August 2004-February 2010. The primary endpoint was a composite of MACE including all-cause mortality, non-fatal MI, non-fatal stroke and revascularization. A total of 3,831 patients were examined (POBA era, n=1,147; BMS era, n=1,180; DES era, n=1,504). Mean age was highest in the DES era. The prevalence of diabetes and hypertension was higher in the DES and BMS eras than in the POBA era. Unadjusted cumulative event-free survival rate for 2-year MACE was significantly different across the 3 eras. Adjusted relative risk reduction for 2-year MACE was 56% in the DES era and 34% in the BMS era, both compared with the POBA era. Age, ACS, and LVEF were associated with the incidence of MACE.

CONCLUSIONS

Clinical outcome of PCI improved across the 26-year study period, despite the higher patient risk profile in the recent era.

History and Development of Coronary Flow Reserve and Fractional Flow Reserve for Clinical Applications

We discuss the historical development of clinical coronary physiology, emphasizing coronary flow reserve (CFR) and fractional flow reserve (FFR). Our analysis focuses on the clinical motivations and technologic advances that prompted and enabled the application of physiology for patient diagnosis. CFR grew from the general concepts of physiologic and coronary reserve, linking the anatomic severity of a lesion to its impact on hyperemic flow. FFR developed from existing models relating pressure measurements to the potential for flow to increase after removing a stenosis. Because pressure measurements have proved easier and more robust than flow measurements, FFR has become the dominant metric.

Impact of Diabetes Mellitus on Hospitalization for Heart Failure, Cardiovascular Events, and Death: Outcomes at 4 Years From the Reduction of Atherothrombosis for Continued Health (REACH) Registry

BACKGROUND

Despite the known association of diabetes mellitus with cardiovascular events, there are few contemporary data on the long-term outcomes from international cohorts of patients with diabetes mellitus. We sought to describe cardiovascular outcomes at 4 years and to identify predictors of these events in patients with diabetes mellitus.

METHODS AND RESULTS

The Reduction of Atherothrombosis for Continued Health (REACH) registry is an international registry of patients at high risk of atherothrombosis or established atherothrombosis. Four-year event rates in patients with diabetes mellitus were determined with the corrected group prognosis method. Of the 45 227 patients in the REACH registry who had follow-up at 4 years, 43.6% (n=19 699) had diabetes mellitus at baseline. The overall risk and hazard ratio (HR) of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke were greater in patients with diabetes compared with patients without diabetes (16.5% versus 13.1%; adjusted HR, 1.27; 95% confidence interval [CI] 1.19-1.35). There was also an increase in both cardiovascular death (8.9% versus 6.0%; adjusted HR, 1.38; 95% CI, 1.26-1.52) and overall death (14.3% versus 9.9%; adjusted HR, 1.40; 95% CI, 1.30-1.51). Diabetes mellitus was associated with a 33% greater risk of hospitalization for heart failure (9.4% versus 5.9%; adjusted odds ratio, 1.33; 95% CI, 1.18-1.50). In patients with diabetes mellitus, heart failure at baseline was independently associated with cardiovascular death (adjusted HR, 2.45; 95% CI, 2.17-2.77; P<0.001) and hospitalization for heart failure (adjusted odds ratio, 4.72; 95% CI, 4.22-5.29; P<0.001).

CONCLUSIONS

Diabetes mellitus substantially increases the risk of death, ischemic events, and heart failure. Patients with both diabetes mellitus and heart failure are at particularly elevated risk of cardiovascular death, highlighting the need for additional therapies in this high-risk population.

Safety and outcomes of day care based coronary angioplasty--First report from India

BACKGROUND

The concept of day care based coronary angioplasty might be frugal especially in countries like India where epidemic of coronary disease is enduring and healthcare delivery systems are limited. Published literature addressing the feasibility and safety of day care percutaneous coronary interventions (PCI) is lacking from our country.

OBJECTIVES

To study the safety and outcomes in stable cardiac patients undergoing day care coronary angioplasty.

METHODS

A single centre nonrandomized active controlled trial of patients undergoing elective transradial coronary angioplasty and same day discharge after triaging was compared with a conventional arm of hospital overnight stay.

RESULTS

Fifty six patients with stable coronary artery disease underwent day care angioplasty. There were no major immediate adverse cardiac and cerebral events noted in the first 24 h. The procedural result followed by a 6-h observation period allowed adequate triage of patients to same-day discharge or to extended clinical observation. Apart from one possible stent thrombosis on day 3 in the treatment arm where the patent received fibrinolytic treatment in a local hospital, there were no major adverse cardiac or cerebral vascular events in the study group. The six month clinical follow up in the day care procedure group was also unevenful for any major adverse cardiac events.

CONCLUSION

The study albeit small shows the feasibility and safety of day care PCI in the Indian scenario. It did not lead to additional complications compared with overnight stay. Triage of patients for an extended observation period can be performed adequately on the basis of clinical and procedural criteria.

Trends in cause of death after percutaneous coronary intervention

BACKGROUND

The impact of changing demographics on causes of long-term death after percutaneous coronary intervention (PCI) remains incompletely defined.

METHODS AND RESULTS

We evaluated trends in cause-specific long-term mortality after index PCI performed at a single center from 1991 to 2008. Deaths were ascertained by scheduled prospective surveillance. Cause was determined via telephone interviews, medical records, autopsy reports, and death certificates. Competing-risks analysis of cause-specific mortality was performed using 3 time periods of PCI (1991-1996, 1997-2002, and 2003-2008). Final follow-up was December 31, 2012. A total of 19 077 patients survived index PCI hospitalization, of whom 6988 subsequently died (37%, 4.48 per 100 person-years). Cause was determined in 6857 (98.1%). Across 3 time periods, there was a 33% decline in cardiac deaths at 5 years after PCI (incidence: 9.8%, 7.4%, and 6.6%) but a 57% increase in noncardiac deaths (7.1%, 8.5%, and 11.2%). Only 36.8% of deaths in the recent era were cardiac. Similar trends were observed regardless of age, extent of coronary disease, or PCI indication. After adjustment for baseline variables, there was a 50% temporal decline in cardiac mortality but no change in noncardiac mortality. The decline in cardiac mortality was driven by fewer deaths from myocardial infarction/sudden death (P<0.001) but not heart failure (P=0.85). The increase in noncardiac mortality was primarily attributable to cancer and chronic diseases (P<0.001).

CONCLUSIONS

This study found a marked temporal switch from predominantly cardiac to predominantly noncardiac causes of death after PCI over 2 decades. The decline in cardiac mortality was independent of changes in baseline clinical characteristics. These findings have implications for patient care and clinical trial design.

The impact of vascular access for in-hospital major bleeding in patients with acute coronary syndrome at moderate- to very high-bleeding risk

The aim of our study was to determine the impact of vascular access on in-hospital major bleeding (IHMB) in acute coronary syndrome (ACS). We analyzed 995 patients with non-ST elevation myocardial infarction and unstable angina at the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) moderate- to very high-bleeding risk scores in trans-radial intervention (TRI) retrospective registry from 16 centers in Korea. A total of 402 patients received TRI and 593 patients did trans-femoral intervention (TFI). The primary end-point was IHMB as defined in the CRUSADE. There were no significant differences in in-hospital and 1-yr mortality rates between two groups. However, TRI had lower incidences of IHMB and blood transfusion than TFI (6.0% vs 9.4%, P = 0.048; 4.5% vs 9.4%, P = 0.003). The patients suffered from IHMB had higher incidences of in-hospital and 1-yr mortality than those free from IHMB (3.1% vs 15.0%, P < 0.001; 7.2% vs 30.0%, P < 0.001). TRI was an independent negative predictor of IHMB (odds ratio, 0.305; 95% confidence interval, 0.109-0.851; P = 0.003). In conclusions, IHMB is still significantly correlated with in-hospital and 1-yr mortality. Our study suggests that compared to TFI, TRI could reduce IHMB in patients with ACS at moderate- to very high-bleeding risk.

Temporal trends in percutaneous coronary intervention outcomes among older patients in the United States

BACKGROUND

New percutaneous coronary intervention (PCI) device technologies are often rapidly adopted into clinical practice, yet few studies have examined the overall impact of these new technologies on patient outcomes in community practice.

METHODS

In hopes of determining temporal trends in PCI outcomes, we used data from the Centers for Medicare & Medicaid Service's Chronic Condition Warehouse (n = 3,250,836) by comparing patient characteristics and rates of 3-year major adverse cardiac events (MACE) across the balloon angioplasty (POBA) era (01/1991-09/1995), the bare metal stent (BMS) era (02/1998-04/2003), and the drug-eluting stent (DES) era (05/2004-10/2006). The adjusted association between era and outcomes was determined with Cox proportional hazards modeling (POBA era as reference).

RESULTS

Compared with the POBA era, patients undergoing PCI were significantly older and had more medical comorbidities, and the risk for 3-year MACE was significantly lower during the BMS and DES eras (BMS vs. POBA adjusted HR [95% CI]: 0.930 [0.926-0.935]; DES vs. BMS: 0.831 [0.827-0.835]). Compared with males, the adjusted risk for 3-year MACE among females was lower during the POBA era, but slightly higher during the BMS and DES eras. Across all three eras, patients ≥75 years of age had higher adjusted risk for MACE compared with younger patients, and the risk for revascularization was lower for both females and older patients.

CONCLUSIONS

Despite its application in older and sicker Medicare beneficiaries, there has been a significant decrease in post-PCI MACE over time. The risk for death or myocardial infarction is higher among females and older patients compared with males and younger patients; therefore, future studies should focus on improving clinical outcomes in these high-risk subgroups.

Outcome and safety of same-day-discharge percutaneous coronary interventions with femoral access: a single-center experience

BACKGROUND

Ongoing development in percutaneous coronary intervention (PCI) techniques and closing devices facilitates same-day-discharge in patients undergoing uncomplicated PCI procedures. We examined the safety and outcome in low-risk patients discharged the same day as PCI with femoral access was performed.

METHODS

From January 1, 2010, through December 31, 2010, the outcomes of same-day discharge in 355 (19.6%) of in total 1,809 patients undergoing PCI were analyzed. Composite end point included major adverse cardiac or cerebral events and/or bleeding/vascular complications within 24 hours and 30 days. Major adverse cardiac and cerebral events were defined as cardiac death, myocardial infarction, stroke, coronary artery bypass grafting, or repeat PCI.

RESULTS

The mean age of the study population was 64.5 years (40.0-93.0 years), 17.3% of the patients were ≥75 years old. The indication for PCI was: stable angina pectoris (n = 277, 78.0%) and unstable angina pectoris/non-ST-segment elevation myocardial infarction (n = 78, 22.0%). In all patients femoral access was used, and the puncture site was closed with the closing-device AngioSeal. No major adverse cardiac and cerebral events were seen within 24 hours or 30 days except in 1 patient who had target lesion revascularization done as PCI 4 days post-procedure. Three patients had bleeding/vascular complications; 2 patients were re-admitted within 24 hours due to access-site hematomas, which were treated with manual compression and bed-rest regimes. One patient developed a pseudoaneurysm within 12 hours post-procedure.

CONCLUSIONS

Same-day-discharge after uncomplicated PCI using femoral access is safe when patients are properly selected. The strategy may improve and benefit health costs in the future.

Ischemic stroke associated with left cardiac catheterization: the importance of modifiable and non-modifiable risk factors

BACKGROUND

Stroke associated with left cardiac catheterization is a devastating complication, and its incidence has not changed over the decades. We investigated the incidence, in-hospital outcomes and the modifiable and non-modifiable risk factors for periprocedural ischemic stroke.

METHODS

Our retrospective cohort study included all patients experiencing periprocedural ischemic stroke among the 24,500 patients who underwent left cardiac catheterization between January 2003 and October 2010. The case group was compared with a group of control patients randomly selected among those who underwent the procedure during this period.

RESULTS

Ischemic cerebrovascular events attested by brain imaging occurred in 37 patients (0.15% of procedures), transient ischemic attack occurred in 9 cases, and persistent neurological deficit occurred in 28 cases. Patients who developed strokes were more likely to be older and were more often female with a greater prevalence of comorbidities. Emergency and longer procedures were more frequent in patients in the case group who had more coronary complications. A multivariate analysis identified diabetes mellitus (adjusted odds ratio (OR) 4.2; 95% CI 1.8-9.9; P < .001), chronic renal dysfunction (OR 2.4; 95% CI 1.1-5.4; P < .001), known cerebrovascular disease (OR 5.1; 95% CI 2.3-11.5; P < .001), emergency procedure (OR 3.1; 95% CI 1.4-9.2; P < .01) and recent congestive heart failure (OR 6.1; 95% CI 2.9-13; P < .001) as independent predictors for stroke. The independent modifiable predictive factors were represented by left ventricular angiography (OR 7.5; 95% CI 2.7-21; P < .001), and low operator volume (OR 3.1; 95% CI 1.3-7.4; P < .01).

CONCLUSION

Limiting the performance of left cardiac catheterization to high volume operators and avoiding unnecessary left ventricular angiography may reduce periprocedural ischemic stroke.