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Shah T, Nathan A. Considering Initial "PCI Turndown" as a Risk Factor for Subsequent PCI. J Am Heart Assoc 2024; 13:e035891. [PMID: 38818930 DOI: 10.1161/jaha.124.035891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
- Tayyab Shah
- Hospital of the University of Pennsylvania Philadelphia PA USA
| | - Ashwin Nathan
- Hospital of the University of Pennsylvania Philadelphia PA USA
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Mark DG, Huang J, Ballard DW, Vinson DR, Rana JS, Sax DR, Rauchwerger AS, Reed ME. Emergency Department Referral of Patients With Chest Pain for Noninvasive Cardiac Testing and 2-Year Clinical Outcomes. Circ Cardiovasc Qual Outcomes 2024; 17:e010457. [PMID: 38779848 DOI: 10.1161/circoutcomes.123.010457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing. METHODS A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events. RESULTS Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48-68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02-1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99-1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%). CONCLUSIONS Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population.
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Affiliation(s)
- Dustin G Mark
- Departments of Emergency Medicine (D.G.M., D.R.S.), Kaiser Permanente Medical Center, Oakland, CA
- Critical Care Medicine (D.G.M.), Kaiser Permanente Medical Center, Oakland, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Dustin W Ballard
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
- Department of Emergency Medicine, Kaiser Permanente Medical Center, San Rafael, CA (D.W.B.)
| | - David R Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
- Department of Emergency Medicine, Kaiser Permanente Medical Center, Roseville, CA (D.R.V.)
| | - Jamal S Rana
- Cardiology (J.S.R.), Kaiser Permanente Medical Center, Oakland, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Dana R Sax
- Departments of Emergency Medicine (D.G.M., D.R.S.), Kaiser Permanente Medical Center, Oakland, CA
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland (D.G.M., J.H., D.W.B., D.R.V., J.S.R., D.R.S., A.S.R., M.E.R.)
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Spagnolo M, Occhipinti G, Laudani C, Greco A, Capodanno D. Periprocedural myocardial infarction and injury. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:433-445. [PMID: 38323856 DOI: 10.1093/ehjacc/zuae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/08/2024]
Abstract
Periprocedural myocardial infarction (PMI) and injury, pertinent to both cardiac and non-cardiac procedures, have gained increasing recognition in clinical practice. Over time, diverse definitions for diagnosing PMI have been developed and validated among patient populations undergoing coronary revascularization. However, this variety in definitions presents considerable challenges in clinical settings and complicates both the design and interpretation of clinical trials. The necessity to accurately diagnose PMI has spurred significant interest in establishing universally accepted and prognostically meaningful thresholds for cardiac biomarkers elevation and supportive ancillary criteria. In fact, elevations in cardiac biomarkers in line with the 4th Universal Definition of Myocardial Infarction, have been extensively confirmed to be associated with increased mortality and cardiovascular events. In the context of non-coronary cardiac procedures, such as Transcatheter Aortic Valve Implantation, there is a growing acknowledgment of both the high incidence rates and the adverse impact of PMI on patient outcomes. Similarly, emerging research underscores the significance of PMI and injury in non-cardiac surgery, highlighting the urgent need for effective prevention and risk management strategies in this domain.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Claudio Laudani
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Antonio Greco
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia 78, Catania - 95123, Italy
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4
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Melidoniotis E, Kalogeropoulos K, Tsatsaris A, Zografakis-Sfakianakis M, Lazopoulos G, Tzanakis N, Anastasiou I, Skalidis E. Geospatial epidemiology of coronary artery disease treated with percutaneous coronary intervention in Crete, Greece. GEOSPATIAL HEALTH 2024; 19. [PMID: 38752863 DOI: 10.4081/gh.2024.1251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/02/2024] [Indexed: 05/18/2024]
Abstract
Coronary artery disease (CAD) constitutes a leading cause of morbidity and mortality worldwide. Percutaneous coronary intervention (PCI) is indicated in a significant proportion of CAD patients, either to improve prognosis or to relieve symptoms not responding to optimal medical therapy. Thus the annual number of patients undergoing PCI in a given geographical area could serve as a surrogate marker of the total CAD burden there. The aim of this study was to analyze the potential, spatial patterns of PCItreated CAD patients in Crete. We evaluated data from all patients subjected to PCI at the island's sole reference centre for cardiac catheterization within a 4-year study period (2013-2016). The analysis focused on regional variations of yearly PCI rates, as well as on the effect of several clinical parameters on the severity of the coronary artery stenosis treated with PCI across Crete. A spatial database within the ArcGIS environment was created and an analysis carried out based on global and local regression using ordinary least squares (OLS) and geographically weighted regression (GWR), respectively. The results revealed significant inter-municipality variation in PCI rates and thus potentially CAD burden, while the degree and direction of correlation between key clinical factors to coronary stenosis severity demonstrated specific geographical patterns. These preliminary results could set the basis for future research, with the ultimate aim to facilitate efficient healthcare strategies planning.
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Affiliation(s)
- Evangelos Melidoniotis
- Faculty of Medicine, University of Crete, Heraklion; University Hospital of Heraklion, Voutes, Heraklion.
| | - Kleomenis Kalogeropoulos
- Department of Surveying and Geoinformatics Engineering, University of West Attica, Egaleo, Athens.
| | - Andreas Tsatsaris
- Department of Surveying and Geoinformatics Engineering, University of West Attica, Egaleo, Athens.
| | | | - George Lazopoulos
- Faculty of Medicine, University of Crete, Heraklion; Cardiac Surgery Division, University Hospital of Heraklion, Voutes, Heraklion.
| | - Nikolaos Tzanakis
- Faculty of Medicine, University of Crete, Heraklion; Respiratory Department, University Hospital of Heraklion, Voutes, Heraklion.
| | - Ioannis Anastasiou
- Cardiology Department, University Hospital of Heraklion, Voutes, Heraklion.
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5
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Chow C, Doll J. Contemporary Risk Models for In-Hospital and 30-Day Mortality After Percutaneous Coronary Intervention. Curr Cardiol Rep 2024; 26:451-457. [PMID: 38592570 DOI: 10.1007/s11886-024-02047-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Risk models for mortality after percutaneous coronary intervention (PCI) are underutilized in clinical practice though they may be useful during informed consent, risk mitigation planning, and risk adjustment of hospital and operator outcomes. This review analyzed contemporary risk models for in-hospital and 30-day mortality after PCI. RECENT FINDINGS We reviewed eight contemporary risk models. Age, sex, hemodynamic status, acute coronary syndrome type, heart failure, and kidney disease were consistently found to be independent risk factors for mortality. These models provided good discrimination (C-statistic 0.85-0.95) for both pre-catheterization and comprehensive risk models that included anatomic variables. There are several excellent models for PCI mortality risk prediction. Choice of the model will depend on the use case and population, though the CathPCI model should be the default for in-hospital mortality risk prediction in the United States. Future interventions should focus on the integration of risk prediction into clinical care.
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Affiliation(s)
- Christine Chow
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jacob Doll
- Department of Medicine, University of Washington, Seattle, WA, USA.
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6
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Andersen PJ, Attar R, Jensen SE, Eftekhari A, Polcwiartek C, Søndergaard MM, Pareek M, Torp-Pedersen C, Kragholm K. Temporal trends in characteristics and outcomes after myocardial infarction in patients with and without peripheral artery disease - A Nationwide, register-based follow-up study. Int J Cardiol 2024; 401:131812. [PMID: 38280530 DOI: 10.1016/j.ijcard.2024.131812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/14/2023] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
AIM Patients with peripheral artery disease (PAD) represent a high-risk population with increased morbidity and mortality. We aimed to examine trends in myocardial infarction (MI), PAD and adverse clinical outcomes from years 2000 to 2019. METHODS This nationwide Danish-based registry study included all patients with MI from years 2000-2019. Patients with PAD were compared to patients without PAD. Temporal changes in PAD prevalence over time was examined using the Cochrane-Armitage trend test, and Cox regression was used to test for between-group significance in all care and outcome measures. RESULTS A total of 196,635 patients experienced an MI within the study time frame; the prevalence of PAD over time showed a slight increase (p < 0.01). Patients with MI and a concurrent PAD diagnosis elicited a heavier burden of comorbidities. The primary MACE endpoint showed significant decreases in both patients with and without PAD (p < 0.01); the decrease was more marked in patients without a concurrent PAD diagnosis (p < 0.01) alongside with 1-year all-cause mortality (p < 0.01). There was a slight increase in initiation of preventive pharmacotherapy with a prominent increase in initiation of P2Y12-inhibitors post discharge in patients without PAD in comparison to patients with PAD, and the same pattern applied for lipid lowering agents (p < 0.01). Also, there was an increase in revascularization in patients with MI but more markedly in patients without coexisting PAD. CONCLUSIONS Despite significant decreases in MACE and mortality and significant increases in guideline-recommended care and revascularization over time for MI patients both with and without PAD, improvement in all these measures was less prominent in patients with MI and concomitant PAD.
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Affiliation(s)
| | - Rubina Attar
- Skane University Hospital, Department of Cardiology, Sweden
| | | | | | | | | | - Manan Pareek
- Rigshospitalet, Department of Cardiology, Denmark
| | | | - Kristian Kragholm
- Aalborg University Hospital, Department of Clinical Medicine, Denmark
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7
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Hong D, Lee J, Lee H, Cho J, Guallar E, Choi KH, Lee SH, Shin D, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Park TK, Yang JH, Choi SH, Gwon HC, Song YB, Hahn JY, Kang D, Lee JM. Cost-Effectiveness of Intravascular Imaging-Guided Complex PCI: Prespecified Analysis of RENOVATE-COMPLEX-PCI Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010230. [PMID: 38477162 DOI: 10.1161/circoutcomes.123.010230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 11/30/2023] [Indexed: 03/14/2024]
Abstract
BACKGROUND Although clinical benefits of intravascular imaging-guided percutaneous coronary intervention (PCI) in patients with complex coronary artery lesions have been observed in previous trials, the cost-effectiveness of this strategy is uncertain. METHODS RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance vs Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) was conducted in Korea between May 2018 and May 2021. This prespecified cost-effectiveness substudy was conducted using Markov model that simulated 3 states: (1) post-PCI, (2) spontaneous myocardial infarction, and (3) death. A simulated cohort was derived from the intention-to-treat population, and input parameters were extracted from either the trial data or previous publications. Cost-effectiveness was evaluated using time horizon of 3 years (within trial) and lifetime. The primary outcome was incremental cost-effectiveness ratio (ICER), an indicator of incremental cost on additional quality-adjusted life years (QALYs) gained, in intravascular imaging-guided PCI compared with angiography-guided PCI. The current analysis was performed using the Korean health care sector perspective with reporting the results in US dollar (1200 Korean Won, ₩=1 dollar, $). Willingness to pay threshold was $35 000 per QALY gained. RESULTS A total of 1639 patients were included in the trial. During 3-year follow-up, medical costs ($8661 versus $7236; incremental cost, $1426) and QALY (2.34 versus 2.31; incremental QALY, 0.025) were both higher in intravascular imaging-guided PCI than angiography-guided PCI, resulting incremental cost-effectiveness ratio of $57 040 per QALY gained within trial data. Conversely, lifetime simulation showed total cumulative medical cost was reversed between the 2 groups ($40 455 versus $49 519; incremental cost, -$9063) with consistently higher QALY (8.24 versus 7.89; incremental QALY, 0.910) in intravascular imaging-guided PCI than angiography-guided PCI, resulting in a dominant incremental cost-effectiveness ratio. Consistently, 70% of probabilistic iterations showed cost-effectiveness of intravascular imaging-guided PCI in probabilistic sensitivity analysis. CONCLUSIONS The current cost-effectiveness analysis suggests that imaging-guided PCI is more cost-effective than angiography-guided PCI by reducing medical cost and increasing quality-of-life in complex coronary artery lesions in long-term follow-up. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.
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Affiliation(s)
- David Hong
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Jin Lee
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
| | - Hankil Lee
- College of Pharmacy, Ajou University, Suwon, South Korea (H.L.)
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
| | - Eliseo Guallar
- Department of Epidemiology and Medicine, and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD (E.G.)
| | - Ki Hong Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Seung Hun Lee
- Chonnam National University Hospital, Gwangju, Korea (S.H.L.)
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC (D.S.)
| | - Jong-Young Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.L., S.-J.L.)
| | - Seung-Jae Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.L., S.-J.L.)
| | - Sang Yeub Lee
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (S.Y.L., S.M.K.)
- Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Korea (S.Y.L.)
| | - Sang Min Kim
- Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea (S.Y.L., S.M.K.)
| | - Kyeong Ho Yun
- Wonkwang University Hospital, Iksan, Korea (K.H.Y., J.Y.C.)
| | - Jae Young Cho
- Wonkwang University Hospital, Iksan, Korea (K.H.Y., J.Y.C.)
| | - Chan Joon Kim
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea (C.J.K., H.-S.A.)
| | - Hyo-Suk Ahn
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea (C.J.K., H.-S.A.)
| | - Chang-Wook Nam
- Keimyung University Dongsan Hospital, Daegu, Korea (C.-W.N., H.-J.Y.)
| | - Hyuck-Jun Yoon
- Keimyung University Dongsan Hospital, Daegu, Korea (C.-W.N., H.-J.Y.)
| | - Yong Hwan Park
- Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Korea (Y.H.P.)
| | - Wang Soo Lee
- Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea (W.S.L.)
| | - Taek Kyu Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Jeong Hoon Yang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Seung-Hyuk Choi
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Young Bin Song
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Joo-Yong Hahn
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea (J.L., J.C., D.K.)
| | - Joo Myung Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (D.H., K.H.C., T.K.P., J.H.Y., S.-H.C., H.-C.G., Y.B.S., J.-Y.H., J.M.L.)
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8
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Alzahrani AH, Alabbadi S, Itagaki S, Egorova N. Temporal Trend in Revascularization for Patients With Ischemic Cardiomyopathy and Multivessel Coronary Artery Disease. J Am Heart Assoc 2024; 13:e032212. [PMID: 38240212 PMCID: PMC11056153 DOI: 10.1161/jaha.123.032212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/14/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Current guidelines recommend revascularization in patients with ischemic cardiomyopathy (ICM). However, there is limited information about the trends and outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in ischemic cardiomyopathy patients with multivessel coronary artery disease. METHODS AND RESULTS Using New Jersey state mandatory registries, 8083 patients with ischemic cardiomyopathy with CABG or PCI revascularization for multivessel coronary artery disease from 2007 to 2018 were included in the analysis. Joinpoint regression and multivariable logistic regression analyses were performed to assess the annual percentage change in trends and predictors of the 30-day mortality rate, respectively. A decline in CABG procedures was observed from 2007 to 2011 (annual percentage change, -11.5%; P=0.003), followed by stabilization. The PCI trend remained unchanged from 2007 to 2010 and then increased significantly (annual percentage change, 3.2%; P=0.02). In the subsample of patients with proximal left anterior descending artery plus circumflex and right coronary artery, CABG was a predominant procedure until 2011, and the proportion of both procedures did not differ thereafter. In the subsample of patients with left anterior descending artery and any other artery stenosis, PCI remained dominant from 2007 to 2018, while in patients with left main and any other artery stenosis, CABG remained dominant from 2007 to 2018 (P<0.001). The 30-day risk-adjusted mortality rate was higher after PCI versus CABG for each year, but after adjustment for completeness of revascularization, there was no difference between groups. CONCLUSIONS The patterns of revascularization procedures for patients with ischemic cardiomyopathy with multivessel coronary artery disease have changed over the years, as evidenced by the changes in CABG and PCI trends. CABG and PCI had comparable 30-day risk-adjusted mortality risks.
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Affiliation(s)
- Anas H. Alzahrani
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
- Department of Surgery, Faculty of MedicineKing Abdulaziz UniversityJeddahSaudi Arabia
| | - Sundos Alabbadi
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Shinobu Itagaki
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount Sinai, The Mount Sinai HospitalNew YorkNY
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount SinaiNew YorkNY
| | - Natalia Egorova
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNY
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9
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Kovach CP, Azzalini L. Persistent Challenges in Defining High-Risk Percutaneous Coronary Intervention. Can J Cardiol 2023; 39:1380-1381. [PMID: 37172645 DOI: 10.1016/j.cjca.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Affiliation(s)
- Christopher P Kovach
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.
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10
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Moady G, Ovdat T, Rubinshtein R, Eitan A, Daud E, Arow Z, Atar S. The impact of on-site cardiac surgical backup on clinical outcomes of acute coronary syndrome-analysis of the ACSIS national registry. Front Cardiovasc Med 2023; 10:1207473. [PMID: 37727307 PMCID: PMC10505675 DOI: 10.3389/fcvm.2023.1207473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023] Open
Abstract
Background The availability of advanced technologies for mechanical support in hospitals with on-site cardiac surgery (CS), along with the ability to perform urgent coronary artery bypass graft (CABG) surgery, may result in improved clinical outcomes in patients with acute coronary syndrome (ACS). Methods We conducted a retrospective analysis of the bi-annually Acute Coronary Syndrome Israeli Survey (ACSIS) registry from the year 2000 to 2020, performed in hospitals with and without CS. Mortality rates and major adverse cardiac and cerebrovascular events (MACCE) rates are reported. We evaluated two periods of the study-early (2000-2010) vs. late (2011-2020). Propensity score matching was performed to reduce bias between the two groups. Results The study included 16,979 patients (52.3% in the on-site CS group). Patients in the on-site CS group were more likely to undergo percutaneous coronary intervention (PCI), (odds ratio [OR], 1.26 [95% CI, 1.18-1.35]; p < 0.001) and CABG [OR, 1.91 (95%CI, 1.63-2.24); P < 0.001], and patients in hospitals without on-site CS had higher 30-day MACCE [OR, 1.17 (95% CI, 1.07-1.27); p < 0.0005]. Overall, there was no difference in 1-year mortality (hazard ratio [HR], 0.98 [95% CI, 0.89-1.08]; p = 0.71) between the groups. During the late period of the study, patients in the group without on-site CS had lower 30-day mortality [OR, 0.69 (95% CI, 0.49-0.97); P = 0.04], yet with no difference in 1-year mortality [HR, 0.81 (95% CI, 0.65-1.01); p = 0.07]. Conclusions The availability of on-site CS resulted in variations in treatment modality, yet it did not affect the clinical outcomes of ACS. A trend to a better short-term outcomes was noted in hospitals without CS during the late period of the study, which warrants further investigation.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Tal Ovdat
- The Israeli Center of Cardiovascular Research, Tel Hashomer, Israel
| | - Ronen Rubinshtein
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Heart Institute, Edith Wolfson Medical Center, Holon, Israel
| | - Amnon Eitan
- Department of Cardiology, Carmel Medical Center, Haifa, Israel
| | - Elias Daud
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Ziad Arow
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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11
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Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
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Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
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12
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease. Korean Circ J 2023; 53:113-133. [PMID: 36914602 PMCID: PMC10011221 DOI: 10.4070/kcj.2022.0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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13
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Kim HL, Joh HS, Lim WH, Seo JB, Kim SH, Zo JH, Kim MA. One-month changes in blood pressure-adjusted pulse wave velocity for predicting long-term cardiovascular outcomes in patients undergoing percutaneous coronary intervention. J Hypertens 2023; 41:437-442. [PMID: 36728780 DOI: 10.1097/hjh.0000000000003354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The prognostic value of changes in arterial stiffness has not been well evaluated. This study was conducted to investigate whether the change in arterial stiffness one month after percutaneous coronary intervention (PCI) affects the long-term cardiovascular prognosis. METHODS A total of 405 patients (mean age, 62.0 ± 11.0 years; female sex, 27.7%) who underwent PCI with drug-eluting stent (DES) implantation was prospectively enrolled. The measurement of brachial-ankle pulse wave velocity (baPWV) was taken in all the study patient at the time of admission for index PCI. Major adverse cardiovascular event (MACE), a composite of cardiac death, nonfatal myocardial infarction, coronary revascularization and ischemic stroke, was assessed during clinical follow-up after index PCI. RESULTS During the median follow-up duration of 5.3 years (interquartile range. 2.9-7.9 years), there was 65 MACE (16.0%). There was no significant difference in clinical characteristics between patients with and without MACE except for higher prevalence of triple vessel disease in those with MACE. The baPWV value decreased at one month after index PCI (1560 ± 305 to 1530 ± 318 cm, P < 0.001). In multivariable cox regression analysis, the change of baPWV at one month was not associated with MACE occurrence ( P > 0.05). However, the change in systolic blood pressure (SBP)-adjusted baPWV (baPWV/SBP) at one month (increased vs . decreased) was significantly associated with MACE occurrence even after controlling for potential confounders (hazard ratio, 2.25; 95% confidence interval, 1.37-3.69; P = 0.001). CONCLUSION The baPWV/SBP change at one month was associated with long-term MACE in patients undergoing DES implantation. The results of this study suggest that baPWV/SBP changes at one month may be helpful in risk stratification of patients at a high coronary risk.
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Affiliation(s)
- Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
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14
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Lin RZ, Gallagher C, Tu SJ, Pitman BM, Nelson AJ, Roberts-Thomson RL, Worthley MI, Lau DH, Sanders P, Wong CX. Trends in myocardial infarction and coronary revascularisation procedures in Australia, 1993-2017. Heart 2023; 109:283-288. [PMID: 36344268 DOI: 10.1136/heartjnl-2022-321393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/28/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Prior data have shown rising acute myocardial infarction (MI) trends in Australia; whether these increases have continued in recent years is not known. This study thus sought to characterise contemporary nationwide trends in MI hospitalisations and coronary procedures in Australia and their associated economic burden. METHODS The primary outcome measure was the incidence and time trends of total MI, ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) hospitalisations from 1993 to 2017. The incidence and time trends of coronary procedures were additionally collected, alongside MI hospitalisation costs. RESULTS Adjusted for population changes, annual MI incidence increased from 216.2 cases per 100 000 to a peak of 270.4 in 2007 with subsequent decline to 218.7 in 2017. Similarly, NSTEMI incidence increased from 68.0 cases per 100 000 in 1993 to a peak of 192.6 in 2007 with subsequent decline to 162.6 in 2017. STEMI incidence decreased from 148.3 cases per 100 000 in 1993 to 56.2 in 2017. Across the study period, there were annual increases in MI hospitalisations of 0.7% and NSTEMI hospitalisations of 5.6%, and an annual decrease in STEMI hospitalisations of 4.8%. Angiography and percutaneous coronary intervention increased by 3.4% and 3.3% annually, respectively, while coronary artery bypass graft surgery declined by 2.2% annually. MI hospitalisation costs increased by 100% over the study period, despite a decreased average length of stay by 45%. CONCLUSIONS The rising incidence of MI hospitalisations appear to have stabilised in Australia. Despite this, associated healthcare expenditure remains significant, suggesting a need for continual implementation of public health policies and preventative strategies.
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Affiliation(s)
- Richard Z Lin
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Celine Gallagher
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel J Tu
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Bradley M Pitman
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Adam J Nelson
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Ross L Roberts-Thomson
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew I Worthley
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Dennis H Lau
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
| | - Christopher X Wong
- Department of Cardiology, Royal Adelaide Hospital and the University of Adelaide, Adelaide, South Australia, Australia
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15
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Shawon MSR, Falster MO, Hsu B, Yu J, Ooi SY, Jorm L. Trends and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in New South Wales from 2008 to 2019. Am J Cardiol 2023; 187:110-118. [PMID: 36459733 DOI: 10.1016/j.amjcard.2022.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/27/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022]
Abstract
Risk profiles are changing for patients who undergo percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). In Australia, little is known of the nature of these changes in contemporary practice and of the impact on patient outcomes. We identified all CABG (n = 40,805) and PCI (n = 142,399) procedures in patients aged ≥18 years in New South Wales, Australia, during 2008 to 2019. Between 2008 and 2019, the age- and gender-standardized revascularization rate increased by 20% (from 267/100,000 to 320/100,000 population) for all revascularizations. The increase in revascularization was particularly driven by a 35% increase (from 194/100,000 to 261/100,000) in PCI, whereas the rate of CABG decreased by 20% (from 73/100,000 to 59/100,000). Mean age and the prevalence of co-morbidities (especially diabetes and atrial fibrillation) increased for patients with PCI in more recent years but remained consistently lower than for patients with CABG. CABGs performed in patients presenting with a non-ST-segment-elevation acute coronary syndrome halved from 34.3% to 18.7% during the study period, whereas PCIs in this group decreased from 36.5% to 29.6%. Risk-adjusted in-hospital mortality decreased by 7.5 deaths/1,000 procedures per month for CABG but remained unchanged for PCI. Risk-adjusted readmission rates were consistently higher for CABG than for PCI and did not change significantly over time. In conclusion, we observed a dramatic shift over time from CABG to PCI as the revascularization procedure of choice, with the patient base for PCI extending to older and sicker patients. There was a large decrease in mortality after CABG, whereas mortality after PCI remained unchanged.
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Affiliation(s)
- Md Shajedur Rahman Shawon
- Centre for Big Data Research in Health (CBDRH), University of New South Wales (UNSW) Medicine, UNSW Sydney, Sydney, New South Wales, Australia.
| | - Michael O Falster
- Centre for Big Data Research in Health (CBDRH), University of New South Wales (UNSW) Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Benjumin Hsu
- Centre for Big Data Research in Health (CBDRH), University of New South Wales (UNSW) Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jennifer Yu
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia; University of New South Wales (UNSW) Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sze-Yuan Ooi
- Department of Cardiology, Prince of Wales Hospital, Sydney, New South Wales, Australia; University of New South Wales (UNSW) Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health (CBDRH), University of New South Wales (UNSW) Medicine, UNSW Sydney, Sydney, New South Wales, Australia
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16
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Park DY, An S, Warraich MS, Aldeen ZS, Maghari I, Khanal S, Arif AW, Almoghrabi A. Impact of cardiac and noncardiac cirrhosis on coronary revascularization outcomes from the National Inpatient Sample, 2016 to 2018. Proc AMIA Symp 2023; 36:195-200. [PMID: 36876247 PMCID: PMC9980685 DOI: 10.1080/08998280.2022.2139989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Data on coronary revascularization in patients with cirrhosis are scarce because it is often deferred in the setting of significant comorbidities and coagulopathies. It is unknown whether patients with cardiac cirrhosis have a worse prognosis. The National Inpatient Sample was surveyed to identify patients who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) from 2016 to 2018. Those with and without liver cirrhosis were propensity score-matched and compared within the PCI and CABG cohorts. Primary outcome was in-hospital mortality. Patients with cirrhosis were further classified into cardiac and noncardiac cirrhosis and their in-hospital mortalities were compared. A total of 1,069,730 PCIs and 273,715 CABGs were performed for ACS, of which 0.6% and 0.7%, respectively, were performed in patients with cirrhosis. In both the PCI cohort (odds ratio = 1.56; 95% confidence interval, 1.10-2.25; P = 0.01) and the CABG cohort (odds ratio = 2.34; 95% confidence interval, 1.19-4.62; P = 0.01), cirrhosis was associated with higher in-hospital mortality. In-hospital mortality was greatest in cardiac cirrhosis (8.4% and 7.1%), followed by noncardiac cirrhosis (5.5% and 5.0%) and no cirrhosis (2.6% and 2.3%) in PCI and CABG cohorts, respectively. Higher in-hospital mortality and periprocedural morbidities should be considered when performing coronary revascularization in patients with cirrhosis.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County , Chicago , Illinois
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School , Seoul , Korea
| | | | - Ziad Sad Aldeen
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County , Chicago , Illinois
| | - Ibrahim Maghari
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County , Chicago , Illinois
| | - Smriti Khanal
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County , Chicago , Illinois
| | - Abdul Wahab Arif
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County , Chicago , Illinois
| | - Anas Almoghrabi
- Department of Gastroenterology, Cook County Health , Chicago , Illinois
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17
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Naranjo D, Doll J, Maynard C, Beaver K, Bansal A, Helfrich CD. Practice Pattern Variation in Adoption of New and Evolving Percutaneous Coronary Intervention Procedures. J Interv Cardiol 2023; 2023:2488045. [PMID: 37181493 PMCID: PMC10175015 DOI: 10.1155/2023/2488045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/22/2023] [Accepted: 04/13/2023] [Indexed: 05/16/2023] Open
Abstract
Objective Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Background Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Methods Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. Results A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. Conclusions The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.
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Affiliation(s)
- Diana Naranjo
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jacob Doll
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Charles Maynard
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Kristine Beaver
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Aasthaa Bansal
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Christian D. Helfrich
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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18
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Bhattacharya A, Sadasivuni S, Chao CJ, Agasthi P, Ayoub C, Holmes DR, Arsanjani R, Sanyal A, Banerjee I. Multi-modal fusion model for predicting adverse cardiovascular outcome post percutaneous coronary intervention. Physiol Meas 2022; 43. [PMID: 36317320 DOI: 10.1088/1361-6579/ac9e8a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/28/2022] [Indexed: 12/24/2022]
Abstract
Background.Clinical medicine relies heavily on the synthesis of information and data from multiple sources. However, often simple feature concatenation is used as a strategy for developing a multimodal machine learning model in the cardiovascular domain, and thus the models are often limited by pre-selected features and moderate accuracy.Method.We proposed a two-branched joint fusion model for fusing the 12-lead electrocardiogram (ECG) signal data with clinical variables from the electronic medical record (EMR) in an end-to-end deep learning architecture. The model follows the joint fusion scheme and learns complementary information from ECG and EMR. Retrospective data from the Mayo Clinic Health Systems across four sites for patients that underwent percutaneous coronary intervention (PCI) were obtained. Model performance was assessed by area under the receiver-operating characteristics (AUROC) and Delong's test.Results.The final cohort included 17,356 unique patients with a mean age of 67.2 ± 12.6 year (mean ± std) and 9,163 (52.7%) were male. The joint fusion model outperformed the ECG time-domain model with statistical margin. The model with clinical data obtained the highest AUROC for all-cause mortality (0.91 at 6 months) but the joint fusion model outperformed for cardiovascular outcomes - heart failure hospitalization and ischemic stroke with a significant margin (Delong's p < 0.05).Conclusion.To the best of our knowledge, this is the first study that developed a deep learning model with joint fusion architecture for the prediction of post-PCI prognosis and outperformed machine learning models developed using traditional single-source features (clinical variables or ECG features). Adding ECG data with clinical variables did not improve prediction of all-cause mortality as may be expected, but the improved performance of related cardiac outcomes shows that the fusion of ECG generates additional value.
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Affiliation(s)
| | - Sudarsan Sadasivuni
- Electrical Engineering, University at Buffalo, Buffalo, United States of America
| | - Chieh-Ju Chao
- Mayo Clinic Rochester, Rochester, Minnesota, United States of America
| | - Pradyumna Agasthi
- Mayo Clinic Rochester, Rochester, Minnesota, United States of America
| | - Chadi Ayoub
- Mayo Clinic Arizona, Scottsdale, Arizona, United States of America
| | - David R Holmes
- Mayo Clinic Rochester, Rochester, Minnesota, United States of America
| | - Reza Arsanjani
- Mayo Clinic Arizona, Scottsdale, Arizona, United States of America
| | - Arindam Sanyal
- Arizona State University, Phoenix, Arizona, United States of America
| | - Imon Banerjee
- Mayo Clinic Arizona, Scottsdale, Arizona, United States of America.,Arizona State University, Phoenix, Arizona, United States of America
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Avtaar Singh SS, Nappi F. Pathophysiology and Outcomes of Endothelium Function in Coronary Microvascular Diseases: A Systematic Review of Randomized Controlled Trials and Multicenter Study. Biomedicines 2022; 10:biomedicines10123010. [PMID: 36551766 PMCID: PMC9775403 DOI: 10.3390/biomedicines10123010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Coronary macrovascular disease is a concept that has been well-studied within the literature and has long been the subject of debates surrounding coronary artery bypass grafting (CABG) vs. Percutaneous Coronary Intervention (PCI). ISCHEMIA trial reported no statistical difference in the primary clinical endpoint between initial invasive management and initial conservative management, while in the ORBITA trial PCI did not improve angina frequency score significantly more than placebo, albeit PCI resulted in more patient-reported freedom from angina than placebo. However, these results did not prove the superiority of the PCI against OMT, therefore do not indicate the benefit of PCI vs. the OMT. Please rephrase the sentence. We reviewed the role of different factors responsible for endothelial dysfunction from recent randomized clinical trials (RCTs) and multicentre studies. METHODS A detailed search strategy was performed using a dataset that has previously been published. Data of pooled analysis include research articles (human and animal models), CABG, and PCI randomized controlled trials (RCTs). Details of the search strategy and the methods used for data pooling have been published previously and registered with Open-Source Framework. RESULTS The roles of nitric oxide (NO), endothelium-derived contracting factors (EDCFs), and vasodilator prostaglandins (e.g., prostacyclin), as well as endothelium-dependent hyperpolarization (EDH) factors, are crucial for the maintenance of vasomotor tone within the coronary vasculature. These homeostatic mechanisms are affected by sheer forces and other several factors that are currently being studied, such as vaping. The role of intracoronary testing is crucial when determining the effects of therapeutic medications with further studies on the horizon. CONCLUSION The true impact of coronary microvascular dysfunction (CMD) is perhaps underappreciated, which supports the role of medical therapy in determining outcomes. Ongoing trials are underway to further investigate the role of therapeutic agents in secondary prevention.
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Affiliation(s)
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord of Saint-Denis, 93200 Saint-Denis, France
- Correspondence: ; Tel.: +33-(14)-9334104; Fax: +33-149334119
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Hagerman A, Schorer R, Putzu A, Keli-Barcelos G, Licker M. Cardioprotective Effects of Glucose-Insulin-Potassium Infusion in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. Semin Thorac Cardiovasc Surg 2022; 36:167-181. [PMID: 36356908 DOI: 10.1053/j.semtcvs.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
The infusion of glucose-insulin-potassium (GIK) has yielded conflicting results in terms of cardioprotective effects. We conducted a meta-analysis to examine the impact of perioperative GIK infusion in early outcome after cardiac surgery. Randomized controlled trials (RCTs) were eligible if they examined the efficacy of GIK infusion in adults undergoing cardiac surgery. The main study endpoint was postoperative myocardial infarction (MI) and secondary outcomes were hemodynamics, any complications and hospital resources utilization. Subgroup analyses explored the impact of the type of surgery, GIK composition and timing of administration. Odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) were calculated with a random-effects model. Fifty-three studies (n=6129) met the inclusion criteria. Perioperative GIK infusion was effective in reducing MI (k=32 OR 0.66[0.48, 0.89] P=0.0069), acute kidney injury (k=7 OR 0.57[0.4, 0.82] P=0.0023) and hospital length of stay (k=19 MD -0.89[-1.63, -0.16] days P=0.0175). Postoperatively, the GIK-treated group presented higher cardiac index (k=14 MD 0.43[0.29, 0.57] L/min P<0.0001) and lesser hyperglycemia (k=20 MD -30[-47, -13] mg/dL P=0.0005) than in the usual care group. The GIK-associated protection for MI was effective when insulin infusion rate exceeded 2 mUI/kg/min and after coronary artery bypass surgery. Certainty of evidence was low given imprecision of the effect estimate, heterogeneity in outcome definition and risk of bias. Perioperative GIK infusion is associated with improved early outcome and reduced hospital resource utilization after cardiac surgery. Supporting evidence is heterogenous and further research is needed to standardize the optimal timing and composition of GIK solutions.
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Affiliation(s)
- Andres Hagerman
- Dept. of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Raoul Schorer
- Dept. of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Dept. of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Marc Licker
- University of Geneva, Faculty of Medicine, Geneva, Switzerland.
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21
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Avances en cirugía coronaria. Cirugía coronaria sin bomba y sin manipulación de la aorta ascendente. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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22
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Coronary Stenting: Reflections on a 35-Year Journey. Can J Cardiol 2022; 38:S17-S29. [PMID: 34375695 DOI: 10.1016/j.cjca.2021.07.224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 01/09/2023] Open
Abstract
Stenting was introduced as a therapy for coronary artery disease 35 years ago, and is currently the most commonly performed minimally invasive procedure globally. Percutaneous coronary revascularization, initially with plain old balloon angioplasty and later with stenting, has dramatically affected the outcomes of acute myocardial infarction and acute coronary syndromes. Coronary stenting is probably the most intensively studied therapy in medicine on the basis of the number of randomized clinical trials for a broad range of indications. Continuous improvements in stent materials, design, and coatings concurrent with procedural innovations have truly been awe-inspiring. The story of stenting is replete with high points and some low points, such as the initial experience with stent thrombosis and restenosis, and the more recent disappointment with bioabsorbable scaffolds. History has shown rapid growth of stent use with expansion of indications followed by contraction of some uses in response to clinical trial evidence in support of bypass surgery or medical therapy. In this review we trace the constantly evolving story of the coronary stent from the earliest experience until the present time. Undoubtedly, future iterations of stent design and materials will continue to move the stent story forward.
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23
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Eng MH. Foreword. Interv Cardiol Clin 2022; 11:xi. [PMID: 36243492 DOI: 10.1016/j.iccl.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Marvin H Eng
- Banner University Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA.
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24
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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25
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Rashid M, Stevens C, Wijeysundera HC, Curzen N, Khoo CW, Mohamed MO, Aktaa S, Wu J, Ludman P, Mamas MA. Rates of Elective Percutaneous Coronary Intervention in England and Wales: Impact of COURAGE and ORBITA Trials. J Am Heart Assoc 2022; 11:e025426. [DOI: 10.1161/jaha.122.025426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background
There are limited data about how COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trials have impacted percutaneous coronary intervention (PCI) practices at regional or national level. We evaluated temporal trends in elective PCI rates for stable angina and, specifically, examined the impact of the COURAGE and ORBITA trials on PCI practices in England and Wales.
Methods and Results
We used national PCI data comprising >1.2 million patients undergoing PCI between January 2006 and December 2019. Patient demographics, procedural details, and clinical outcomes were analyzed, and temporal trends in PCI rates for stable angina were compared before and after the publication of the COURAGE and ORBITA trials. Of 1 245 802 PCI procedures, 430 248 (34.5%) were performed for stable angina. Over the study period, the number of elective PCI procedures per year (30 823 in 2006 to 34 103 in 2019) and per 100 000 population estimates (50.7 in 2006 to 58.4 in 2019) remained stable. The proportion of patients undergoing elective PCI without angina symptoms almost doubled from 5.1% to 9.7%. The incidence rate of elective PCI volume after the COURAGE trial, published in 2007, was not different from before the trial was published (incidence rate ratio, 1.06 [95% CI, 0.69–1.62]). It also remained stable after the publication of the ORBITA trial in 2017 (incidence rate ratio, 0.96 [95% CI, 0.74–1.23]).
Conclusions
In this nationwide analysis, rates of elective PCI for stable angina remained stable over 14 years. Publication of the COURAGE and ORBITA trials had no impact on elective PCI activity.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Chris Stevens
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton & Department of Cardiology University Hospital NHS Trust Southampton UK
| | - Chee Wah Khoo
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Mohamed Osama Mohamed
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | - Suleman Aktaa
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
- School of Dentistry University of Leeds UK
| | - Peter F. Ludman
- Department of Cardiology Queen Elizabeth University Hospital Birmingham UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
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26
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Kataruka A, Maynard CC, Hira RS, Dean L, Dardas T, Gurm H, Brown J, Ring ME, Doll JA. Government Regulation and Percutaneous Coronary Intervention Volume, Access and Outcomes: Insights From the Washington State Cardiac Care Outcomes Assessment Program. J Am Heart Assoc 2022; 11:e025607. [PMID: 36056726 PMCID: PMC9496421 DOI: 10.1161/jaha.122.025607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background It is unclear how to geographically distribute percutaneous coronary intervention (PCI) programs to optimize patient outcomes. The Washington State Certificate of Need program seeks to balance hospital volume and patient access through regulation of elective PCI. Methods and Results We performed a retrospective cohort study of all non‐Veterans Affairs hospitals with PCI programs in Washington State from 2009 to 2018. Hospitals were classified as having (1) full PCI services and surgical backup (legacy hospitals, n=17); (2) full services without surgical backup (new certificate of need [CON] hospitals, n=9); or (3) only nonelective PCI without surgical backup (myocardial infarction [MI] access hospitals, n=9). Annual median hospital‐level volumes were highest at legacy hospitals (605, interquartile range, 466–780), followed by new CON, (243, interquartile range, 146–287) and MI access, (61, interquartile range, 23–145). Compared with MI access hospitals, risk‐adjusted mortality for nonelective patients was lower for legacy (odds ratio [OR], 0.59 [95% CI, 0.48–0.72]) and new‐CON hospitals (OR, 0.55 [95% CI, 0.45–0.65]). Legacy hospitals provided access within 60 minutes for 90% of the population; addition of new CON and MI access hospitals resulted in only an additional 1.5% of the population having access within 60 minutes. Conclusions Many PCI programs in Washington State do not meet minimum volume standards despite regulation designed to consolidate elective PCI procedures. This CON strategy has resulted in a tiered system that includes low‐volume centers treating high‐risk patients with poor outcomes, without significant increase in geographic access. CON policies should re‐evaluate the number and distribution of PCI programs.
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Affiliation(s)
- Akash Kataruka
- Division of Cardiology University of Washington Seattle WA
| | | | | | - Larry Dean
- Division of Cardiology University of Washington Seattle WA
| | - Todd Dardas
- Division of Cardiology University of Washington Seattle WA
| | - Hitinder Gurm
- Division of Cardiology University of Michigan Ann Arbor MI
| | - Josiah Brown
- Division of Cardiology Cedars Sinai Los Angeles CA
| | | | - Jacob A Doll
- Division of Cardiology University of Washington Seattle WA.,VA Puget Sound Health Care System Seattle WA
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Gao M, Gao X, Taniguchi R, Brahmandam A, Matsubara Y, Liu J, Liu H, Zhang W, Dardik A. Sex differences in arterial identity correlate with neointimal hyperplasia after balloon injury. Mol Biol Rep 2022; 49:8301-8315. [PMID: 35715609 PMCID: PMC9463237 DOI: 10.1007/s11033-022-07644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endovascular treatment of atherosclerotic arterial disease exhibits sex differences in clinical outcomes including restenosis. However, sex-specific differences in arterial identity during arterial remodeling have not been described. We hypothesized that sex differences in expression of the arterial determinant erythropoietin-producing hepatocellular receptor interacting protein (Ephrin)-B2 occur during neointimal proliferation and arterial remodeling. METHODS AND RESULTS Carotid balloon injury was performed in female and male Sprague-Dawley rats without or 14 days after gonadectomy; the left common carotid artery was injured and the right carotid artery in the same animal was used as an uninjured control. Arterial hemodynamics were evaluated in vivo using ultrasonography pre-procedure and post-procedure at 7 and 14 days and wall composition examined using histology, immunofluorescence and Western blot at 14 days after balloon injury. There were no significant baseline sex differences. 14 days after balloon injury, there was decreased neointimal thickness in female rats with decreased smooth muscle cell proliferation and decreased type I and III collagen deposition, as well as decreased TNFα- or iNOS-positive CD68+ cells and increased CD206- or TGM2-positive CD68+ cells. Female rats also showed less immunoreactivity of VEGF-A, NRP1, phosphorylated EphrinB2, and increased Notch1, as well as decreased phosphorylated Akt1, p38 and ERK1/2. These differences were not present in rats pretreated with gonadectomy. CONCLUSIONS Decreased neointimal thickness in female rats after carotid balloon injury is associated with altered arterial identity that is dependent on intact sex hormones. Alteration of arterial identity may be a mechanism of sex differences in neointimal proliferation after arterial injury.
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Affiliation(s)
- Mingjie Gao
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Xixiang Gao
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ryosuke Taniguchi
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular Surgery, The University of Tokyo, Tokyo, Japan
| | - Anand Brahmandam
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Yutaka Matsubara
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery and Sciences, Kyushu University, Fukuoka, Japan
| | - Jia Liu
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Hao Liu
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weichang Zhang
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA.
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
- Department of Surgery, VA Connecticut Healthcare Systems, West Haven, CT, USA.
- Yale School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT, 06520-8089, USA.
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28
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Alasnag M, Ahmed W, Al-Bawardy R, Shammeri OA, Biswas S, Johnson TW. Optimising PCI by Intracoronary Image-guidance. Front Cardiovasc Med 2022; 9:878801. [PMID: 35647055 PMCID: PMC9136172 DOI: 10.3389/fcvm.2022.878801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Evidence to support the use of intracoronary imaging (ICI) in guiding percutaneous coronary intervention (PCI) is growing, with observational and randomized controlled trials demonstrating a benefit in acute procedural and clinical outcomes. ICI provides an opportunity to guide PCI, detailing the nature of the coronary disease, potentially influencing lesion preparation and stent selection. Following stent deployment, ICI offers a detailed assessment of lesion coverage, associated vessel trauma and stent expansion. Consensus statements have emphasized the role of ICI and detailed the parameters of stent optimization. However, intracoronary imaging is not adopted widely yet. Significant global differences in the uptake of ICI have been reported, with the vast majority of PCI being angiographically-guided. The three major barriers to the implementation of ICI include, in order of impact, prohibitive cost, prolongation of procedure time and local regulatory issues for use. However, it is our belief that a lack of education and the associated challenges of ICI interpretation provide the greatest barrier to adoption. We hope that this review of the role of ICI in PCI optimization will provide a platform for PCI operators to gain confidence in the utilization of ICI to enhance outcomes for their patients.
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Affiliation(s)
- Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
- *Correspondence: Mirvat Alasnag
| | - Waqar Ahmed
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Rasha Al-Bawardy
- King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, King Saud bin Abdulaziz University for Health Science, Jeddah, Saudi Arabia
| | | | - Sinjini Biswas
- Bristol Heart Institute, Translational Health Science, University of Bristol, Bristol, United Kingdom
| | - Thomas W. Johnson
- Bristol Heart Institute, Translational Health Science, University of Bristol, Bristol, United Kingdom
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29
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Choi JM, Lee SH, Choi JH. Ten-year trends of clinical outcomes after percutaneous coronary intervention: a Korean nationwide longitudinal cohort study. BMJ Open 2022; 12:e056972. [PMID: 35443956 PMCID: PMC9021814 DOI: 10.1136/bmjopen-2021-056972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Mortality following percutaneous coronary intervention (PCI) is a key quality measurement in clinical practice. This study investigated the 10-year trends of mortality following PCI in an unselected nationwide cohort. DESIGN Retrospective cohort study. SETTING A nationwide study in South Korea. PARTICIPANTS PCI claim data from 2006 to 2015 of the National Health Insurance Service and the Statistics of Korea. MEASURES 1-year cardiovascular or non-cardiovascular death. RESULTS In total, 437 436 patients were included. The annual number of PCI cases increased from 32 098 to 51 990 over the decade studied (p<0.001). Patients were divided into quartile subgroups according to an estimated adjusted probability for predicting 1-year all-cause death. The proportion of patients in the high-risk quartiles increased whereas those in the low-risk quartiles decreased (p<0.001). The 1-year cumulative incidence rate of all-cause death did not change in the population with risk scores in the 1st (0.9% to 0.8%) and 2nd (1.3% to 1.3%) quartiles, whereas it increased in the population with risk scores in the 3rd (3.4% to 5.1%) and 4th (15.5% to 19.4%) quartiles (p<0.001). Compared with year 2006, the mean survival time in year 2015 was shorter by 0, 3.3 and 12.4 days in patients with risk scores in the 1st or 2nd, 3rd and 4th quartiles, respectively. These findings were also consistent for cardiovascular or non-cardiovascular deaths. CONCLUSION The number, proportion and the overall risk of patients with a high risk for mortality after PCI increased over the decade in Korea.
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Affiliation(s)
- Jung Min Choi
- Department of Medical Device Research and Management, Samsung Advanced Institute for Health Sciences & Technology, Seoul, South Korea
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hwa Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seou, Republic of Korea
| | - Jin-Ho Choi
- Emergency Medicine, Samsung Medical Center, Gangnam-gu, South Korea
- Samsung Advanced Institute for Health Sciences & Technology, Seoul, South Korea
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30
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Furtado RHM, Fagundes AA, Oyama K, Zelniker TA, Tang M, Kuder JF, Murphy SA, Hamer A, Wang H, Keech AC, Giugliano RP, Sabatine MS, Bergmark BA. Effect of Evolocumab in Patients With Prior Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2022; 15:e011382. [PMID: 35209731 DOI: 10.1161/circinterventions.121.011382] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients with prior percutaneous coronary intervention (PCI) are at high residual risk for multiple types of coronary events within and beyond the stented lesion. This risk might be mitigated by more intensive LDL-C (low-density lipoprotein cholesterol)-lowering beyond just with statin therapy. METHODS FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk) randomized 27 564 patients with stable atherosclerotic disease on statin to the PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitor evolocumab or placebo with a median follow-up of 2.2 years. The end points of interest were major adverse cardiovascular events (MACE; a composite of cardiovascular death, myocardial infarction, stroke, unstable angina or coronary revascularization), and major coronary events (a composite of coronary heart death, myocardial infarction, or coronary revascularization). We compared the risk of MACE and the magnitude of relative and absolute risk reductions with evolocumab in patients with and without prior PCI. RESULTS Seventeen thousand seventy-three patients had prior PCI. In the placebo arm, those with prior PCI had higher rates of MACE (13.2% versus 8.3%; hazard ratio [HR]adj 1.61 [95% CI, 1.42-1.84]; P<0.0001) and major coronary events (11.5% versus 6.0%; HRadj, 1.72 [95% CI, 1.49-1.99]; P<0.0001). Relative risk reductions with evolocumab were similar in patients with and without prior PCI (MACE: HR, 0.84 [0.77-0.91] versus HR, 0.88 [0.77-1.01]; Pinteraction 0.51; major coronary events: HR, 0.82 [0.75-0.90] versus HR, 0.88 [0.75-1.04]; Pinteraction 0.42). Absolute risk reductions for MACE were 2.0% versus 0.9% (Pinteraction 0.14) and for major coronary events 2.0% versus 0.7% (Pinteraction 0.045). In those with prior PCI, the effect of evolocumab on coronary revascularization (HR, 0.76 [0.69-0.85]) was directionally consistent across types of revascularization procedures: coronary artery bypass grafting (HR, 0.71 [0.54-0.94]); any PCI (HR, 0.77 [0.69-0.86]); PCI for de novo lesions (HR, 0.76 [0.66-0.88]); and PCI for stent failure or graft lesions (HR, 0.76 [0.63-0.91]). CONCLUSIONS Evolocumab reduces the risk of MACE in patients with prior PCI including the risk of coronary revascularization, with directionally consistent effects across several types of revascularization procedures, including coronary artery bypass grafting and PCI for stent or graft failure. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01764633.
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Affiliation(s)
- Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil (R.H.M.F.).,Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Brazil (R.H.M.F.).,Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Antônio Aurélio Fagundes
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Kazuma Oyama
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.).,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.O.)
| | - Thomas A Zelniker
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.).,Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria (T.A.Z.)
| | - Minao Tang
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Julia F Kuder
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Sabina A Murphy
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Andrew Hamer
- Cardiol Therapeutics, Oakville, ON, Canada (A.H.)
| | | | - Anthony C Keech
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney, Australia (A.C.K.)
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
| | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (R.H.M.F., A.A.F., K.O., T.A.Z., M.T., J.F.K., S.AM., R.P.G., M.S.S., B.A.B.)
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Doll JA, O'Donnell CI, Plomondon ME, Waldo SW. Contemporary Clinical and Coronary Anatomic Risk Model for 30-Day Mortality After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2021; 14:e010863. [PMID: 34903032 DOI: 10.1161/circinterventions.121.010863] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) procedures are increasing in clinical and anatomic complexity, likely increasing the calculated risk of mortality. There is need for a real-time risk prediction tool that includes clinical and coronary anatomic information that is integrated into the electronic medical record system. METHODS We assessed 70 503 PCIs performed in 73 Veterans Affairs hospitals from 2008 to 2019. We used regression and machine-learning strategies to develop a prediction model for 30-day mortality following PCI. We assessed model performance with and without inclusion of the Veterans Affairs SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), an assessment of anatomic complexity. Finally, the discriminatory ability of the Veterans Affairs model was compared with the CathPCI mortality model. RESULTS The overall 30-day morality rate was 1.7%. The final model included 14 variables. Presentation status (salvage, emergent, urgent), ST-segment-elevation myocardial infarction, cardiogenic shock, age, congestive heart failure, prior valve disease, chronic kidney disease, chronic lung disease, atrial fibrillation, elevated international normalized ratio, and the Veterans Affairs SYNTAX score were all associated with increased risk of death, while increasing body mass index, hemoglobin level, and prior coronary artery bypass graft surgery were associated with lower risk of death. C-index for the development cohort was 0.93 (95% CI, 0.92-0.94) and for the 2019 validation cohort and the site validation cohort was 0.87 (95% CI, 0.83-0.92) and 0.86 (95% CI, 0.83-0.89), respectively. The positive likelihood ratio of predicting a mortality event in the top decile was 2.87% more accurate than the CathPCI mortality model. Inclusion of anatomic information in the model resulted in significant improvement in model performance (likelihood ratio test P<0.01). CONCLUSIONS This contemporary risk model accurately predicts 30-day post-PCI mortality using a combination of clinical and anatomic variables. This can be immediately implemented into clinical practice to promote personalized informed consent discussions and appropriate preparation for high-risk PCI cases.
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Affiliation(s)
- Jacob A Doll
- VA Puget Sound Health Care System, Seattle, WA (J.A.D.).,University of Washington, Seattle, WA (J.A.D.).,CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.)
| | - Colin I O'Donnell
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.).,Rocky Mountain Regional VA Medical Center, Aurora, CO (C.I.O., M.E.P., S.W.W.)
| | - Meg E Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.).,Rocky Mountain Regional VA Medical Center, Aurora, CO (C.I.O., M.E.P., S.W.W.)
| | - Stephen W Waldo
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington DC (J.A.D., C.I.O., M.E.P., S.W.W.).,Rocky Mountain Regional VA Medical Center, Aurora, CO (C.I.O., M.E.P., S.W.W.).,University of Colorado School of Medicine, Aurora (S.W.W.)
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Doll JA, Nelson AJ, Kaltenbach LA, Wojdyla D, Waldo SW, Rao SV, Wang TY. Percutaneous Coronary Intervention Operator Profiles and Associations With In-Hospital Mortality. Circ Cardiovasc Interv 2021; 15:e010909. [PMID: 34847693 DOI: 10.1161/circinterventions.121.010909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention is performed by operators with differing experience, technique, and case mix. It is unknown if operator practice patterns impact patient outcomes. We sought to determine if a cluster algorithm can identify distinct profiles of percutaneous coronary intervention operators and if these profiles are associated with patient outcomes. METHODS Operators performing at least 25 annual procedures between 2014 and 2018 were clustered using an agglomerative hierarchical clustering algorithm. Risk-adjusted in-hospital mortality was compared between clusters. RESULTS We identified 4 practice profiles among 7706 operators performing 2 937 419 procedures. Cluster 1 (n=3345) demonstrated case mix and practice patterns similar to the national median. Cluster 2 (n=1993) treated patients with lower clinical acuity and were less likely to use intracoronary diagnostics, atherectomy, and radial access. Cluster 3 (n=1513) had the lowest case volume, were more likely to work at rural hospitals, and cared for a higher proportion of patients with ST-segment-elevation myocardial infarction and cardiogenic shock. Cluster 4 (n=855) had the highest case volume, were most likely to treat patients with high anatomic complexity and use atherectomy, intracoronary diagnostics, and mechanical support. Compared with cluster 1, adjusted in-hospital mortality was similar for cluster 2 (estimated difference, -0.03 [95% CI, -0.10 to 0.04]), higher for cluster 3 (0.14 [0.07-0.22]), and lower for cluster 4 (-0.15 [-0.24 to -0.06]). CONCLUSIONS Distinct percutaneous coronary intervention operator profiles are differentially associated with patient outcomes. A phenotypic approach to physician assessment may provide actionable feedback for quality improvement.
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Affiliation(s)
- Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington (J.A.D.).,Section of Cardiology, VA Puget Sound Health Care System, Seattle, WA (J.A.D.)
| | - Adam J Nelson
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.)
| | - Stephen W Waldo
- University of Colorado School of Medicine (S.W.W.).,Department of Medicine, Rocky Mountain Regional VA Medical Center (S.W.W.).,VA CART Program, VHA Office of Quality and Patient Safety (S.W.W.)
| | - Sunil V Rao
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
| | - Tracy Y Wang
- Duke Clinical Research Institute (A.J.N., L.A.K., D.W., S.V.R., T.Y.W.).,Department of Medicine, Duke University School of Medicine (S.V.R., T.Y.W.)
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Escaned J, Cao D, Baber U, Nicolas J, Sartori S, Zhang Z, Dangas G, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Mehta S, Moliterno DJ, Ohman EM, Oldroyd KG, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Ticagrelor monotherapy in patients at high bleeding risk undergoing percutaneous coronary intervention: TWILIGHT-HBR. Eur Heart J 2021; 42:4624-4634. [PMID: 34662382 DOI: 10.1093/eurheartj/ehab702] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/08/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Patients at high bleeding risk (HBR) represent a prevalent subgroup among those undergoing percutaneous coronary intervention (PCI). Early aspirin discontinuation after a short course of dual antiplatelet therapy (DAPT) has emerged as a bleeding avoidance strategy. The aim of this study was to assess the effects of ticagrelor monotherapy after 3-month DAPT in a contemporary HBR population. METHODS AND RESULTS This prespecified analysis of the TWILIGHT trial evaluated the treatment effects of early aspirin withdrawal followed by ticagrelor monotherapy in HBR patients undergoing PCI with drug-eluting stents. After 3 months of ticagrelor plus aspirin, event-free patients were randomized to 12 months of aspirin or placebo in addition to ticagrelor. A total of 1064 (17.2%) met the Academic Research Consortium definition for HBR. Ticagrelor monotherapy reduced the incidence of the primary endpoint of Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding compared with ticagrelor plus aspirin in HBR (6.3% vs. 11.4%; hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.35-0.82) and non-HBR patients (3.5% vs. 5.9%; HR 0.59, 95% CI 0.46-0.77) with similar relative (Pinteraction = 0.67) but a trend towards greater absolute risk reduction in the former [-5.1% vs. -2.3%; difference in absolute risk differences (ARDs) -2.8%, 95% CI -6.4% to 0.8%, P = 0.130]. A similar pattern was observed for more severe BARC 3 or 5 bleeding with a larger absolute risk reduction in HBR patients (-3.5% vs. -0.5%; difference in ARDs -3.0%, 95% CI -5.2% to -0.8%, P = 0.008). There was no significant difference in the key secondary endpoint of death, myocardial infarction, or stroke between treatment arms, irrespective of HBR status. CONCLUSIONS Among HBR patients undergoing PCI who completed 3-month DAPT without experiencing major adverse events, aspirin discontinuation followed by ticagrelor monotherapy significantly reduced bleeding without increasing ischaemic events, compared with ticagrelor plus aspirin. The absolute risk reduction in major bleeding was larger in HBR than non-HBR patients.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid 28040, Spain
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw 02-507, Poland
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Sigmund Freud University, Medical Faculty, Vienna 1160, Austria
| | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith G Oldroyd
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Richard Shlofmitz
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Giora Weisz
- NewYork Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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Kosyakovsky LB, Austin PC, Ross HJ, Wang X, Abdel-Qadir H, Goodman SG, Farkouh ME, Croxford R, Lawler PR, Spertus JA, Lee DS. Early invasive coronary angiography and acute ischaemic heart failure outcomes. Eur Heart J 2021; 42:3756-3766. [PMID: 34331056 PMCID: PMC8491058 DOI: 10.1093/eurheartj/ehab423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/11/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022] Open
Abstract
Aims While myocardial ischaemia plays a major role in the pathogenesis of heart failure (HF), the indications for coronary angiography during acute HF are not established. We determined the association of early coronary angiography during acute HF hospitalization with 2-year mortality, cardiovascular death, HF readmissions, and coronary revascularization. Methods and results In a two-stage sampling process, we identified acute HF patients who presented to 70 emergency departments in Ontario (April 2010 to March 2013) and determined whether they underwent early coronary angiography within 14 days after presentation using administrative databases. After clinical record review, we defined a cohort with acute ischaemic HF as patients with at least one factor suggesting underlying ischaemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. We oversampled patients undergoing angiography. We used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Of 7239 patients with acute HF, 2994 met inclusion criteria [median age 75 (interquartile range 65–83) years; 40.9% women]. Early angiography was performed in 1567 patients (52.3%) and was associated with lower all-cause mortality [hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.61–0.90, P = 0.002], cardiovascular death (HR 0.72, 95% CI 0.56–0.93, P = 0.012), and HF readmissions (HR 0.84, 95% CI 0.71–0.99, P = 0.042) after IPTW. Those undergoing early angiography experienced higher rates of percutaneous coronary intervention (HR 2.58, 95% CI 1.73–3.86, P < 0.001) and coronary artery bypass grafting (HR 2.94, 95% CI 1.75–4.93, P < 0.001) within 2 years. Conclusions Early coronary angiography was associated with lower all-cause mortality, cardiovascular death, HF readmissions, and higher rates of coronary revascularization in acute HF patients with possible ischaemia.
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Affiliation(s)
| | - Peter C Austin
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Xuesong Wang
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Husam Abdel-Qadir
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Women's College Hospital, University of Toronto, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Shaun G Goodman
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Michael E Farkouh
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Ruth Croxford
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Patrick R Lawler
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John A Spertus
- Division of Cardiology, St. Luke's Mid-America Health Institute/UMKC and Department of Biomedical and Health Informatics at UMKC, 4401 Wornall Road, 9th Floor, Kansas City, MO 64111, USA
| | - Douglas S Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
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Goldsweig AM, Secemsky E, Wadhera R, Cohen DJ. Ordering from the bill instead of from the menu. Catheter Cardiovasc Interv 2021; 98:1141-1143. [PMID: 34138515 DOI: 10.1002/ccd.29822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/06/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Eric Secemsky
- Department of Internal Medicine, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rishi Wadhera
- Department of Internal Medicine, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA.,Division of Cardiovascular Medicine, St. Francis Hospital, Roslyn, New York, USA
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Shawon MSR, Odutola M, Falster MO, Jorm LR. Patient and hospital factors associated with 30-day readmissions after coronary artery bypass graft (CABG) surgery: a systematic review and meta-analysis. J Cardiothorac Surg 2021; 16:172. [PMID: 34112216 PMCID: PMC8194115 DOI: 10.1186/s13019-021-01556-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/30/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Readmission after coronary artery bypass graft (CABG) surgery is associated with adverse outcomes and significant healthcare costs, and 30-day readmission rate is considered as a key indicator of the quality of care. This study aims to: quantify rates of readmission within 30 days of CABG surgery; explore the causes of readmissions; and investigate how patient- and hospital-level factors influence readmission. METHODS We conducted systematic searches (until June 2020) of PubMed and Embase databases to retrieve observational studies that investigated readmission after CABG. Random effect meta-analysis was used to estimate rates and predictors of 30-day post-CABG readmission. RESULTS In total, 53 studies meeting inclusion criteria were identified, including 8,937,457 CABG patients. The pooled 30-day readmission rate was 12.9% (95% CI: 11.3-14.4%). The most frequently reported underlying causes of 30-day readmissions were infection and sepsis (range: 6.9-28.6%), cardiac arrythmia (4.5-26.7%), congestive heart failure (5.8-15.7%), respiratory complications (1-20%) and pleural effusion (0.4-22.5%). Individual factors including age (OR per 10-year increase 1.12 [95% CI: 1.04-1.20]), female sex (OR 1.29 [1.25-1.34]), non-White race (OR 1.15 [1.10-1.21]), not having private insurance (OR 1.39 [1.27-1.51]) and various comorbidities were strongly associated with 30-day readmission rates, whereas associations with hospital factors including hospital CABG volume, surgeon CABG volume, hospital size, hospital quality and teaching status were inconsistent. CONCLUSIONS Nearly 1 in 8 CABG patients are readmitted within 30 days and the majority of these are readmitted for noncardiac causes. Readmission rates are strongly influenced by patients' demographic and clinical characteristics, but not by broadly defined hospital characteristics.
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Affiliation(s)
- Md Shajedur Rahman Shawon
- Centre for Big Data Research in Health, University of New South Wales (UNSW) Sydney, Kensington, Australia.
| | - Michael Odutola
- Centre for Big Data Research in Health, University of New South Wales (UNSW) Sydney, Kensington, Australia
| | - Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales (UNSW) Sydney, Kensington, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales (UNSW) Sydney, Kensington, Australia
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Patlolla SH, Kanwar A, Cheungpasitporn W, Doshi RP, Stulak JM, Holmes DR, Bell MR, Singh M, Vallabhajosyula S. Temporal Trends, Clinical Characteristics, and Outcomes of Emergent Coronary Artery Bypass Grafting for Acute Myocardial Infarction in the United States. J Am Heart Assoc 2021; 10:e020517. [PMID: 33998286 PMCID: PMC8475667 DOI: 10.1161/jaha.120.020517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | | | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension Department of Medicine Mayo Clinic Rochester MN
| | - Rajkumar P Doshi
- Department of Medicine University of Nevada Reno School of Medicine NV
| | - John M Stulak
- Department of Cardiovascular Surgery Mayo Clinic Rochester MN
| | - David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Mandeep Singh
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology Division of Cardiovascular Medicine Department of Medicine Emory University School of Medicine Atlanta GA
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Lemos PA, Franken M, Mariani J, Pitta FG, Oliveira FAP, Cunha-Lima G, Caixeta AM, Almeida BO, Garcia RG. Robotic-assisted intervention strategy to minimize air exposure during the procedure: a case report of myocardial infarction and COVID-19. Cardiovasc Diagn Ther 2020; 10:1345-1351. [PMID: 33224759 DOI: 10.21037/cdt-20-521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Percutaneous coronary interventions (PCI) is traditionally a manual procedure executed by one or more operators positioned at a close distance from the patient. The ongoing pandemic of coronavirus disease 2019 (COVID-19) has imposed severe restrictions to such an interventional environment. The novel SARS-CoV-2 virus that causes COVID-19 is transmitted mainly through expelled respiratory particles, which are known to travel approximately 3-6 feet away from infected persons. During PCI, that contamination range obligatorily poses the team and the patient to direct air exposure. We herein present a case report with the description of a minimum-contact strategy to reduce interpersonal air exposure during PCI. The approach designed to minimize proximity between the patient and the healthcare team included the performance of robotic-assisted PCI, operated by unscrubbed cardiac interventionalists from a control cockpit located outside the catheterization suite. Also included, was the delineation of the potential zone of respiratory particle spread; a circle measuring 4 meters (13.1 feet) in diameter was traced on the floor of the cath lab with red tape, centered on the patient's mouth and nose. The team was rigorously trained and advised to minimize time spent within the 4-meter perimeter as much as possible during the procedure. Following this strategy, a 60-year-old male with non-ST-elevation myocardial infarction and COVID-19 was treated with successful coronary implantation of two stents in the obtuse marginal branch and one stent in the circumflex artery. The total duration of the procedure was 103 minutes and 22 seconds. During most of the procedure, the 4-meter spread zone was not entered by any personnel. For each individual team member, the proposed strategy was effective in ensuring that they stayed outside of the 4-meter area for the majority of their work time, ranging from 96.9% to 59.7% of their respective participation. This case report illustrates the potential of robotic-assisted percutaneous coronary intervention in reducing physical proximity between the team and the patient during the procedure.
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Affiliation(s)
- Pedro A Lemos
- Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | | | - Jose Mariani
- Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Fabio G Pitta
- Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
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Kataruka A, Maynard CC, Kearney KE, Mahmoud A, Bell S, Doll JA, McCabe JM, Bryson C, Gurm HS, Jneid H, Virani SS, Lehr E, Ring ME, Hira RS. Temporal Trends in Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting: Insights From the Washington Cardiac Care Outcomes Assessment Program. J Am Heart Assoc 2020; 9:e015317. [PMID: 32456522 PMCID: PMC7429009 DOI: 10.1161/jaha.119.015317] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Patient selection and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) have changed over the past decade. However, there is limited information on outcomes for both revascularization strategies in the same population. The study evaluated temporal changes in risk profile, procedural characteristics, and clinical outcomes for PCI‐ and CABG‐treated patients. Methods and Results We analyzed all PCI and isolated CABG between 2005 and 2017 in nonfederal hospitals in Washington State. Descriptive analysis was performed to evaluate temporal changes in risk profile and, risk‐adjusted in‐hospital mortality. Over the study period, 178 474 PCI and 36 592 CABG procedures were performed. PCI and CABG volume decreased by 2.9% and 22.6%, respectively. Compared with 2005–2009, patients receiving either form of revascularization between 2014 and 2017 had a higher prevalence of comorbidities including diabetes mellitus and hypertension and dialysis. Presentation with ST‐segment–elevation myocardial infarction (17% versus 20%) and cardiogenic shock (2.4% versus 3.4%) increased for patients with PCI compared with CABG. Conversely, clinical acuity decreased for patients receiving CABG over the study period. From 2005 to 2017, mean National Cardiovascular Data Registry CathPCI mortality score increased for patients treated with PCI (20.1 versus 22.4, P<0.0001) and decreased for patients treated with CABG (18.8 versus 17.8, P<0.0001). Adjusted observed/expected in‐hospital mortality ratio increased for PCI (0.98 versus 1.19, P<0.0001) but decreased for CABG (1.21 versus 0.74, P<0.0001) over the study period. Conclusions Clinical acuity increased for patients treated with PCI rather than CABG. This resulted in an increase in adjusted observed/expected mortality ratio for patients undergoing PCI and a decrease for CABG. These shifts may reflect an increased use of PCI instead of CABG for patients considered to be at high surgical risk.
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Affiliation(s)
- Akash Kataruka
- Division of Cardiology University of Washington Seattle WA
| | - Charles C Maynard
- Department of Health Services University of Washington Seattle WA.,Cardiac Care Outcomes Assessment Program Foundation for Health Care Quality Seattle WA
| | | | - Ahmed Mahmoud
- Division of Cardiology University of Washington Seattle WA
| | - Sean Bell
- Department of Medicine University of Washington Seattle WA
| | - Jacob A Doll
- Division of Cardiology University of Washington Seattle WA.,VA Puget South Health Care System Seattle WA
| | - James M McCabe
- Division of Cardiology University of Washington Seattle WA
| | | | | | - Hani Jneid
- Division of Cardiology Michael E. DeBakey VA& Baylor College of Medicine Houston TX
| | - Salim S Virani
- Division of Cardiology Michael E. DeBakey VA& Baylor College of Medicine Houston TX
| | - Eric Lehr
- Department of Cardiac Surgery Swedish Heart & Vascular Institute Seattle WA
| | | | - Ravi S Hira
- Division of Cardiology University of Washington Seattle WA.,Cardiac Care Outcomes Assessment Program Foundation for Health Care Quality Seattle WA
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Affiliation(s)
- Rony Lahoud
- University of Vermont Larner College of Medicine Burlington VT
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