P2832Outcomes of catheter ablation for atrial fibrillation based on sex: data from the cabana trial

Background

Sex-specific outcomes may differ amongst patients receiving catheter ablation for atrial fibrillation (AF).

Purpose

Assess sex-specific outcomes in the patients randomized to catheter ablation or drug therapy in CABANA.

Methods

CABANA randomized 2204 pts with AF to catheter ablation or drug therapy (rate/rhythm-control). The outcomes of combined death, disabling stroke, severe bleeding, or cardiac arrest (intention to treat-ITT) or all-cause death were not different. But, ablation significantly improved combined death or CV hospitalization. This analysis compares clinical characteristics by sex and determines sex-specific hazard ratios based on a comparison of ablation vs drug therapy.

Results

Females were 37.3% of ablation and 37.0% of drug therapy patients. Females were older, more often white race, had less CAD, or sleep apnea, but had higher NYHA Class, higher CHA2DS2VASc, and more often had paroxysmal (v. persistent) AF, and prior AF hospitalization. (Table) HTN, CVA and diabetes were the same (Table).

For the CABANA primary endpoint, an ITT comparison of ablation vs. drug therapy, showed a female hazard ratio (HR) of 1.14 (95% confidence interval (CI) 0.70–1.86), and a male HR of 0.74, (95% CI 0.52–1.06). For all-cause mortality, the female HR was 0.75 (95% CI 0.41–1.40) and male HR was 0.91 (95% CI 0.59–1.40) and for all-cause mortality or CV hospitalization, the female HR was 0.90 (95% CI 0.75–1.09) and male HR was 0.79 (95% CI 0.69–0.92). All interaction p values were non-significant.

Recurrent AF (post 90-day blanking) was significantly reduced for both females and males: female HR 0.64 (95% CI 0.51–0.82), male HR 0.46 95% CI 0.39–0.56), p=0.035

Clinical Characteristics and Outcomes Baseline Characteristics Female (N=818) Male (N=1385) p-value Age: Median (Q1, Q3) 69 (65, 74) 66 (60, 71) <0.001 White 766 (93.9%) 1259 (91.0%) 0.015 CAD 92 (11.2%) 332 (24.0%) <0.001 NYHA ≥II 345 (42.4%) 433 (31.5%) <0.001 Sleep apnea 136 (16.6%) 372 (26.9%) <0.001 CHA2DS2-VASc: Median (Q1, Q3) 3 (3, 4) 2 (1, 3) <0.001 Paroxysmal AF 406 (49.6%) 540 (39.0%) <0.001 Persistent AF 412 (50.4%) 845 (61.0%) AF Hospitalization 353 (43.2%) 521 (37.7%) 0.011

Conclusion

Significant sex-specific outcomes differences were not observed. Sex should not be used as a determining factor in selecting patients for AF therapy.

Acknowledgement/Funding

NIH, St Jude Medical Foundation and Corporation, Biosense Webster Inc., Medtronic Corporation, and Boston Scientific Corporation

484Impact of AF type on the outcome of atrial fibrillation ablation: insights from the CABANA trial

Background

Prior studies suggest that catheter ablation (ABL) for atrial fibrillation (AF) is a treatment option for patients (pts) with paroxysmal AF (PAF). Pts with persistent (Per) or long-standing persistent (LSP) were routinely excluded from most ABL based clinical trials. The effectiveness of ABL compared to drug therapy (MED) in relation to underlying AF type has not been evaluated in a large randomized clinical trial.

Objective

To assess the impact of AF type on clinical outcomes of ABL vs. MED in pts with AF.

Methods

The CABANA trial randomized 2204 pts with AF at 126 sites worldwide to ABL vs. MED with rate or rhythm control drugs. The primary endpoint was a composite of death, disabling stroke, severe bleeding, or cardiac arrest. Key secondary endpoints included mortality and recurrence of AF. Outcomes of ABL vs. MED were compared within subgroups defined by AF type using Intention-to-Treat (ITT) analyses.

Results

Of the 2204 pts, 946 had PAF, 1042 had Per and 215 presented with LSP. There were baseline differences among AF types in age, gender, HTN, LVH, CHF and NYHA Class. For the primary endpoint, there were no significant differences between ABL and MED in pts with PAF (hazard ratio (HR) 0.82; 95% confidence interval (CI) 0.51, 1.31), Per (HR 0.87; 95% CI 0.59, 1.28), or LSP (HR 1.01, 95% CI 0.39, 2.61). Likewise, there were no significant treatment differences in mortality; PAF (HR 0.84; 95% CI 0.46, 1.52), Per (HR 0.90; 95% CI 0.56, 1.46) and LSP (HR 0.67, 95% CI 0.23, 1.94). Post-blanking AF (time to first recurrence) was significantly reduced by ABL compared to MED across all AF types (PAF by 51%), (Per by 47%) and (LSP by 36%).

Clinical Characteristics and Outcomes Clinical Outcomes Comparing ABL vs. MED (HR and 95% CI) Interaction p-value Primary Endpoint 0.82 (0.51, 1.31) 0.87 (0.59, 1.28) 1.01 (0.39, 2.61) 0.925 Mortality 0.84 (0.46, 1.52) 0.90 (0.56, 1.46) 0.67 (0.23, 1.94) 0.881 Recurrent AF 0.49 (0.38, 0.62) 0.53 (0.43, 0.65) 0.64 (0.41, 1.01) 0.564

Conclusion

Pts with LSP have a lower proportion of women, and a higher proportion with manifestations of heart failure despite lower CHA2DS2VASc scores. By ITT analysis, there is no significant effect of ABL compared to MED in the primary endpoint or mortality in any AF group. However, ABL is more effective than MED for reducing recurrences of AF regardless of AF type, but with a greater effect in PAF vs Per vs LSP.

Acknowledgement/Funding

NIH, St Jude Medical Foundation and Corporation, Biosense Webster Inc., Medtronic Corporation, and Boston Scientific Corporation

Relation between baseline risk and treatment decisions in non-ST elevation acute coronary syndromes: an examination of international practice patterns

OBJECTIVES

To examine the interaction between ST segment depression on the baseline ECG and subsequent in-hospital revascularisation on six month mortality among patients with non-ST elevation acute coronary syndromes. To examine whether ST segment depression influenced clinical decision making and whether there was international variation in the use of cardiac procedures across ST segment depression categories.

METHODS

11 453 patients enrolled in GUSTO-IIB (global use of strategies to open occluded coronary arteries), PARAGON (platelet IIb/IIIa antagonism for the reduction of acute coronary syndrome events in a global organisation network) -A, and PARAGON-B were studied. Patients were categorised as having no ST segment depression, 1 mm ST segment depression in two contiguous leads, and ST segment depression > or = 2 mm in two contiguous leads. International practice across four geographic regions was examined: USA, Canada, Europe, and Australia/New Zealand.

RESULTS

Revascularisation appeared to have no impact on survival among patients with no ST segment depression; however, revascularisation was associated with a significant survival benefit among patients with ST segment depression > or = 1 mm. There was an inverse relation between the extent of ST segment depression and the use of angiography as well as angioplasty (p < 0.01). However, patients with ST segment depression > or = 2 mm were more likely to undergo bypass surgery. The only significant trend of increasing use of revascularisation procedures with increasing ST segment depression was observed in the USA.

CONCLUSIONS

International practice patterns in procedure use appear to be insensitive to the extent of ST segment depression. Major opportunities for more efficient delivery of care exist in all regions.

Time-based risk assessment after myocardial infarction. Implications for timing of discharge and applications to medical decision-making

AIMS

We evaluated timing of adverse cardiac events after thrombolysis to guide length of stay after ST-segment elevation myocardial infarction.

METHODS AND RESULTS

Kaplan-Meier survival curves described timing of major postinfarction complications in 41021 fibrinolytic-treated patients in GUSTO-I. Using model-fitting, these data were best explained by a mixed-exponential survival model: an acute curve describing most adverse events and a chronic curve describing a lower background rate. We replicated this strategy in 15059 fibrinolytic-treated patients in GUSTO-III. From the relation between time and events described by the model's acute curve in GUSTO-III, we proposed times for hospital discharge. The acute curve explained 97% of deaths and 68%-96% of various event composites. Of complications within 10 days, 90% of deaths and 70% of acute curve death, stroke, shock, heart failure, or reinfarction occurred by 24 h. By 2.7 days, 95% of deaths, stroke, shock, heart failure, or reinfarction occurred. Most major ventricular arrhythmias occurred within 24 h, after which the hazard curve was flat.

CONCLUSIONS

Mixed-exponential survival modelling describes timing of post-infarction complications and supports discharge 4 days after uncomplicated infarction. Such time-based risk assessment could guide decision-making in other settings in which randomized studies are impractical.

Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery

BACKGROUND AND PURPOSE

The importance of perioperative cognitive decline has long been debated. We recently demonstrated a significant correlation between perioperative cognitive decline and long-term cognitive dysfunction. Despite this association, some still question the importance of these changes in cognitive function to the quality of life of patients and their families. The purpose of our investigation was to determine the association between cognitive dysfunction and long-term quality of life after cardiac surgery.

METHODS

After institutional review board approval and patient informed consent, 261 patients undergoing cardiac surgery with cardiopulmonary bypass were enrolled and followed for 5 years. Cognitive function was measured with a battery of tests at baseline, discharge, and 6 weeks and 5 years postoperatively. Quality of life was assessed with well-validated, standardized assessments at the 5-year end point.

RESULTS

Our results demonstrate significant correlations between cognitive function and quality of life in patients after cardiac surgery. Lower 5-year overall cognitive function scores were associated with lower general health and a less productive working status. Multivariable logistic and linear regression controlling for age, sex, education, and diabetes confirmed this strong association in the majority of areas of quality of life.

CONCLUSIONS

Five years after cardiac surgery, there is a strong relationship between neurocognitive functioning and quality of life. This has important social and financial implications for preoperative evaluation and postoperative care of patients undergoing cardiac surgery.

Prospective randomized trial of normothermic versus hypothermic cardiopulmonary bypass on cognitive function after coronary artery bypass graft surgery

BACKGROUND

Despite significant advances in cardiopulmonary bypass (CPB) technology, surgical techniques, and anesthetic management, central nervous system complications occur in a large percentage of patients undergoing surgery requiring CPB. Many centers are switching to normothermic CPB because of shorter CPB and operating room times and improved myocardial protection. The authors hypothesized that, compared with normothermia, hypothermic CPB would result in superior neurologic and neurocognitive function after coronary artery bypass graft surgery.

METHODS

Three hundred patients undergoing elective coronary artery bypass graft surgery were prospectively enrolled and randomly assigned to either normothermic (35.5-36.5 degrees C) or hypothermic (28-30 degrees C) CPB. A battery of neurocognitive tests was performed preoperatively and at 6 weeks after surgery. Four distinct cognitive domains were identified and standardized using factor analysis and were then compared on a continuous scale.

RESULTS

Two hundred twenty-seven patients participated in 6-week follow-up testing. There were no differences in neurologic or neurocognitive outcomes between normothermic and hypothermic groups in multivariable models, adjusting for covariable effects of baseline cognitive function, age, and years of education, as well as interaction of these with temperature treatment.

CONCLUSIONS

Hypothermic CPB does not provide additional central nervous system protection in adult cardiac surgical patients who were maintained at either 30 or 35 degrees C during CPB.

Advanced coronary artery disease: Appropriate end points for trials of novel therapies

BACKGROUND

The segment of patients with advanced coronary artery disease, or disease that is not amenable to conventional revascularization therapies, continues to grow. Because the natural history of these patients is less defined, the appropriate end points for trials of novel revascularization therapies involving patients with advanced coronary artery disease are not certain.

METHODS AND RESULTS

The Mediators of Social Support Study (MOSS) prospectively followed up outcomes of long-term survival, quality of life, resource use, and costs for 1189 patients and compared outcomes of patients with advanced coronary artery disease with those of a reference group who underwent bypass surgery or angioplasty.

CONCLUSIONS

Despite greater disease burden, cost, and mortality for patients with advanced coronary artery disease, a number of self-reported measures of general health status improved in a similar fashion to that of patients eligible for angioplasty or bypass surgery. These findings should inform the design of trials involving novel therapies, suggesting that angina status and mortality be included as primary end points in the consideration of efficacy. This work also suggests that additional studies of novel therapies involving larger sample sizes may be required to confidently characterize efficacy.

Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography

BACKGROUND

Renal artery stenosis (RAS) is a relatively uncommon but potentially reversible cause of renal failure. In a previous report, we demonstrated that the presence of RAS is independently associated with mortality in a group of patients undergoing coronary angiography. Our current study expands on this cohort, investigating the effect of the severity of RAS on all-cause mortality.

METHODS

A total of 3987 patients underwent abdominal aortography immediately following coronary angiography. For the purpose of survival analysis, significant RAS was defined as > or =75% narrowing in the luminal diameter.

RESULTS

Significant RAS was present in 4.8% of patients studied and was bilateral in 0.8%. Factors associated with the presence of RAS included female gender, older age, hypertension, congestive heart failure, elevated serum creatinine, and congestive heart failure. The four-year unadjusted survivals for patients with and without significant RAS were 57 and 89%, respectively (P < 0.001). Using the Cox proportional hazards model, the factors independently associated with decreased survival were the presence of RAS, increased age, the severity of coronary artery disease, the presence of comorbid disease, reduced ejection fraction, symptoms of congestive cardiac failure, and the mode of treatment of coronary artery disease. In the multivariate model, the presence of RAS conferred a hazard ratio of 2.01 (95% CI, 1.51 to 2.67, P < 0.001). We demonstrated an incremental effect on mortality according to the severity of RAS at baseline. Four-year adjusted survival for patients with 50%, 75%, and > or =95% stenosis was 70%, 68%, and 48%, respectively. In addition, bilateral disease was associated with four-year survival of 47% as compared with 59% for patients with unilateral disease (P < 0.001). The impact of RAS on survival remained robust regardless of the manner of treatment of coronary artery disease [that is, medical, percutaneous transluminal coronary angioplasty (PTCA), or coronary artery bypass graft (CABG)].

CONCLUSIONS

In this patient population, the presence of RAS is a strong independent predictor of mortality. Increasing severity of RAS has an incremental effect on survival probability.

Using observational data to estimate prognosis: an example using a coronary artery disease registry

With the proliferation of clinical data registries and the rising expense of clinical trials, observational data sources are increasingly providing evidence for clinical decision making. These data are viewed as complementary to randomized clinical trials (RCT). While not as rigorous a methodological design, observational studies yield important information about effectiveness of treatment, as compared with the efficacy results of RCTs. In addition, these studies often have the advantage of providing longer-term follow-up, beyond that of clinical trials. Hence, they are useful for assessing and comparing patients' long-term prognosis under different treatment strategies. For patients with coronary artery disease, many observational comparisons have focused on medical therapy versus interventional procedures. In addition to the well-studied problem of treatment selection bias (which is not the focus of the present study), three significant methodological problems must be addressed in the analysis of these data: (i) designation of the therapeutic arms in the presence of early deaths, withdrawals, and treatment cross-overs; (ii) identification of an equitable starting point for attributing survival time; (iii) site to site variability in short-term mortality. This paper discusses these issues and suggests strategies to deal with them. A proposed methodology is developed, applied and evaluated on a large observational database that has long-term follow-up on nearly 10 000 patients.

Assessing the clinical and economic burden of coronary artery disease: 1986-1998

BACKGROUND

The acute phase of coronary artery disease (CAD) is dramatic and receives much attention because of its high mortality and associated treatment cost. However, the acute phase typically resolves within 30 days whereas CAD is a chronic disease, which most patients will live with for more than a decade. We compared the clinical and economic burden of CAD during the acute phase (first 30 days) with that in the postacute phase (31st day through 10 years).

METHODS

We included acute coronary syndrome (ACS) patients with significant CAD receiving an initial cardiac catheterization at Duke University Medical Center between 1986 and 1997 with follow-up continuing through 1998. Inpatient medical costs were estimated from ACS clinical trial and economic study data. Costs were adjusted to 1997 values and discounted at 3% per annum.

RESULTS

Our study included 9,876 ACS patients (5,557 with an acute myocardial infarction [MI] and 4,319 with unstable angina [UA]). Acute MI patients had higher 30-day mortality than UA patients (5.6% vs. 2.3%, P <0.001). In addition, acute MI and UA patients had significant 10-year unadjusted and adjusted survival differences (both P <0.001). For patients who survived to 30 days, there was no difference in 10-year survival between acute MI and UA patients before adjustment (P = 0.472). After adjustment, however, unstable angina patients who survived to 30 days had greater survival than myocardial infarction patients (P = 0.011). Mean 10-year discounted ACS inpatient medical costs were $45,253 ($23,510 acute phase and $21,819 postacute phase, P = 0.002). Ten year costs for unstable angina patients were $46,423 ($21,824 acute phase and $24,599 postacute phase, P = 0.003); ten year costs for myocardial infarction patients were $44,663 ($24,823 acute phase and $19,840 postacute phase, P <0.001).

CONCLUSIONS

We found that the clinical and economic burden of CAD continues long after a patient's acute event has resolved and that postacute CAD cardiac event rates and inpatient medical costs may be higher than previously estimated. With much of all medical costs occurring in the postacute phase, the potential for effective secondary prevention therapies is substantial.

Social support and quality of life in patients with coronary artery disease

The relationship between perceived social support and domain-specific health-related quality of life (HRQOL) was examined in a sample of cardiac catheterization patients after considering age, gender, race, education, and coronary artery disease (CAD) severity. Data was collected on 4,278 cardiac catheterization patients (63% males) and included 1,215 patients with non-significant CAD and 3,063 patients who had significant CAD ( > or = 75% stenosis of at least one major coronary artery). Among the patients with significant CAD, 2,721 were classified as low disease severity and 342 were considered high disease severity. Regression models indicated that a lack of social support was associated with significantly lower levels of HRQOL across all eight SF-36 HRQOL domains after considering disease severity and other demographic factors. The models also indicated that social support and other relevant variables interacted across various HRQOL domains. Physical function and physical role function were lower with age, whereas mental health, emotional role function, and vitality were higher with age. Females reported lower HRQOL than males across all domains. Minority patients reported lower levels of HRQOL than white patients across four domains. Increased disease severity was related to lower levels among four of the eight HRQOL domains. The observed interactions of social support with minority status, disease severity, and education suggest that a subset of individuals may suffer lower levels of HRQOL. These individuals may subsequently require the greatest degree of care and potentially benefit most from intervention.

Risk stratification in patients with chest pain

This article reviews the role of exercise testing in the assessment of patients with suspected coronary disease. To accomplish this, four major topics are considered: the general concept of risk stratification; the estimation of outcomes using data from the initial evaluation of the patient; diagnostic assessment with the exercise test; and prognostic assessment with the exercise test. This review focuses on the standard treadmill exercise test.

Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality

OBJECTIVES

Social isolation has been linked to poor survival in patients with coronary artery disease (CAD). Few studies have closely examined the psychosocial characteristics of CAD patients who lack social contact.

METHODS

Social isolation was examined as a predictor of mortality in 430 patients with significant CAD. More isolated patients were compared with their less isolated counterparts on factors that might help explain the association between isolation and survival.

RESULTS

The mortality rate was higher among isolated individuals. Those with three or fewer people in their social support network had a relative risk of 2.43 (p = .001) for cardiac mortality and 2.11 (p = .001) for all-cause mortality, controlling for age and disease severity. Adjustments for income, hostility, and smoking status did not alter the risk due to social isolation. With the exception of lower income, higher hostility ratings, and higher smoking rates, isolated patients did not differ from nonisolated patients on demographic indicators, disease severity, physical functioning, or psychological distress. Isolated patients reported less social support and were less pleased with the way they got along with network members, but they did not report less satisfaction with the amount of social contact received.

CONCLUSIONS

Patients with small social networks had an elevated risk of mortality, but this greater risk was not attributable to confounding with disease severity, demographics, or psychological distress. These findings have implications for mechanisms linking social isolation to mortality and for the application of psychosocial interventions.

Outcomes of noncardiac surgery after coronary bypass surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI)

PURPOSE

Previous studies have shown that coronary artery bypass surgery reduces the risk of cardiac complications after noncardiac surgery. Whether coronary angioplasty provides equivalent protection is not known.

SUBJECTS AND METHODS

Patients were randomly assigned to undergo cardiac artery bypass surgery or angioplasty as part of the Bypass Angioplasty Revascularization Investigation trial. All subsequent noncardiac surgeries during a mean (+/- SD) follow-up of 7.7 years were recorded among participants in the ancillary Study of Economics and Quality of Life. Rates of mortality and nonfatal myocardial infarction, length of stay, and hospital costs were compared by the original randomized assignment.

RESULTS

A total of 501 patients had noncardiac surgery at a median of 29 months after their most recent coronary revascularization procedure. Mortality and nonfatal myocardial infarction within 30 days of the first noncardiac surgery occurred in 4 of the 250 of the surgery-assigned patients and in 4 of the 251 of the angioplasty-assigned patients (P = 1.0). There were no significant differences in the mean length of hospital stay (6.3 +/- 6.7 versus 6.2 +/- 6.8 days; P = 0.47) or hospital cost ($8,920 +/- $11,511 versus $7,785 +/- $7,643; P = 0.33) between the surgery and angioplasty groups. Similar results were obtained when subsequent noncardiac procedures were included in the analysis.

CONCLUSION

Rates of myocardial infarction and death after noncardiac surgery are similarly low after contemporary bypass surgery or angioplasty in patients with multivessel coronary artery disease.

Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery

BACKGROUND

Cognitive decline complicates early recovery after coronary-artery bypass grafting (CABG) and may be evident in as many as three quarters of patients at the time of discharge from the hospital and a third of patients after six months. We sought to determine the course of cognitive change during the five years after CABG and the effect of perioperative decline on long-term cognitive function.

METHODS

In 261 patients who underwent CABG, neurocognitive tests were performed preoperatively (at base line), before discharge, and six weeks, six months, and five years after CABG surgery. Decline in postoperative function was defined as a drop of 1 SD or more in the scores on tests of any one of four domains of cognitive function. (A reduction of 1 SD represents a decline in function of approximately 20 percent.) Overall neurocognitive status was assessed with a composite cognitive index score representing the sum of the scores for the individual domains. Factors predicting long-term cognitive decline were determined by multivariable logistic and linear regression.

RESULTS

Among the patients studied, the incidence of cognitive decline was 53 percent at discharge, 36 percent at six weeks, 24 percent at six months, and 42 percent at five years. We investigated predictors of cognitive decline at five years and found that cognitive function at discharge was a significant predictor of long-term function (P<0.001).

CONCLUSIONS

These results confirm the relatively high prevalence and persistence of cognitive decline after CABG and suggest a pattern of early improvement followed by a later decline that is predicted by the presence of early postoperative cognitive decline. Interventions to prevent or reduce short- and long-term cognitive decline after cardiac surgery are warranted.

Personality and coping with a common stressor: cardiac catheterization

The association between coping and personality was examined in a sample of 204 cardiac catheterization patients who were asked to evaluate the use of specific coping strategies used to deal with their cardiac catheterization. Personality, as measured by the NEO Five-Factor Inventory (FFI), was moderately correlated with coping measures. In multivariate analyses, after considering confounding factors, Neuroticism was positively and Extraversion was negatively related to avoidance coping and Neuroticism was negatively associated with counting one's blessings as a coping strategy. Personality was not related to either problem solving or seeking social support coping strategies for individuals experiencing a cardiac catheterization. However, important covariates were associated with coping strategies. Not being married was negatively correlated with use of seeking social support and not having a confidant was negatively related with seeking social support and positively with avoidance. These results suggest that there are specific relationships between personality and coping, but these relationships are, for the most part, moderate in persons coping with a cardiac catheterization, and that coping processes are associated with individual differences in available social resources.

Temperature during coronary artery bypass surgery affects quality of life

BACKGROUND

The objective of this study was to examine the effects of temperature on a variety of indices of psychologic adjustment and quality of life.

METHODS

A total of 209 patients randomly received normothermic (warm) or hypothermic (cold) conditions during coronary artery bypass surgery (CABS), and a number of physical, social, and psychologic measures were assessed before as well as 6 weeks and 6 months after CABS.

RESULTS

Repeated measures analyses of covariance revealed significant temperature group main effects for anxiety (p = 0.008) and depression (p = 0.039), with the normothermic group obtaining lower anxiety and depression levels than the hypothermic group at both 6 weeks and 6 months after surgery. Additionally, among patients who entered the study with higher depression levels, those in the hypothermic group tended to have higher depression scores at follow-up compared with patients in the normothermic condition (p = 0.012). No temperature group differences were observed on other quality of life indices.

CONCLUSIONS

The results of the present study indicate that hypothermic conditions during CABS are associated with higher levels of emotional distress after CABS than normothermic conditions, particularly for patients with greater stress to begin with.

Economic assessment of platelet glycoprotein IIb/IIIa receptor blockade with abciximab and low-dose heparin during percutaneous coronary revascularization: results from the EPILOG randomized trial. Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade

BACKGROUND

In the EPILOG trial (Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade), abciximab administered with weight-adjusted heparin diminished the risk of ischemic complications within 30 days by 56% among patients undergoing percutaneous coronary revascularization, without increased bleeding complications.

METHODS AND RESULTS

A prospective economic assessment was performed in the 2792 patients enrolled in EPILOG. Patients were randomized to receive placebo with standard-dose weight-adjusted heparin, abciximab with low-dose weight-adjusted heparin, or abciximab with standard-dose weight-adjusted heparin during percutaneous coronary intervention. Hospital billing data for the baseline hospitalization were collected for 2581 patients (92.4% of total) and imputed for the remainder, with physician fees estimated from the Medicare Fee Schedule. For the baseline hospitalization, medical costs (hospitalization and physician fees) averaged $9632 for the placebo arm compared with $8758 (P:=0.005) and $9092 (P:=0.176) for the abciximab with low-dose and standard-dose heparin arms, respectively. Inclusive of average drug cost ($1454 to $1457), the net incremental baseline cost of these 2 abciximab strategies was $583 with low-dose weight-adjusted heparin and $914 with standard-dose weight-adjusted heparin. During 6-month follow-up, average hospital costs were not significantly different in the 3 treatment groups; cumulative net incremental costs were $1236 and $1268 in the abciximab with low-dose and standard-dose heparin groups, respectively.

CONCLUSIONS

Treatment with abciximab and low-dose, weight-adjusted heparin during percutaneous coronary revascularization reduces ischemic events and associated costs, thereby offsetting some of the cost of the drug. The suppression of bleeding complications associated with this agent by heparin dose reduction optimizes the economic attractiveness of this treatment strategy.

Depressive symptoms and survival of patients with coronary artery disease

OBJECTIVE

Multiple studies have shown that high levels of depressive symptoms increase the mortality risk of patients with established coronary disease. This investigation divided depressive symptoms into groups to assess their relative effectiveness in predicting survival.

METHODS

Questionnaires about the presence of depressive symptoms were administered to 1250 patients with significant coronary disease while they were hospitalized for diagnostic coronary angiography. Follow-up for mortality due to cardiac disease was conducted annually for up to 19.4 years. Factor analysis was used to divide items on the Zung Self-Rating Depression Scale into four groups: Well-Being, Negative Affect, Somatic, and Appetite. In addition, responses to a single item regarding feelings of hopelessness were available for 920 patients.

RESULTS

Well-Being and Somatic symptoms significantly predicted survival (p < or = .01). Negative Affect items were also related to survival (p = .0001) and interacted with age. A 2-SD difference in the Negative Affect term was associated with a relative risk of 1.29 for patients >50 years old and 1.70 for younger ones. Only Negative Affect remained significant in a model with the other symptom groups. Hopelessness also predicted survival with a relative risk of 1.5. Both the Hopelessness and Negative Affect items remained as independent predictors in the same model. All models controlled for severity of disease and treatment. With one exception (income and Hopelessness), results were essentially unchanged by additional controls for age, gender, and income.

CONCLUSIONS

Depressive symptoms differentially predicted survival, with depressive affect and hopelessness being particularly important. These effects were independent of disease severity and somatic symptoms and may be especially important in younger patients.

Temporal evolution in the management of acute ST elevation myocardial infarction: the seven-year GUSTO experience from canada and the united states. The North American GUSTO-I and GUSTO-III investigators

BACKGROUND

Temporal changes in baseline characteristics, treatment and clinical outcomes of patients presenting with acute ST elevation myocardial infarction in Canada and the United States have not been examined comprehensively over time.

OBJECTIVES

To evaluate baseline characteristics, process of care and clinical outcomes. Also, to explore whether earlier process-of-care differences between Canada and the United States had changed and, if so, whether they influenced clinical outcomes.

PATIENTS AND METHODS

A total of 13, 888 American and 3011 Canadian patients enrolled in 184 American and 38 Canadian hospitals that participated in both the Global Utilization of Streptokinase and Tissue Plasminogen Activator (alteplase) for Occluded Coronary Arteries (GUSTO-I) trial (1990 to 1993) and the Global Utilization of Strategies to Open Occluded Coronary Arteries (GUSTO-III) trial (1995 to 1997) were studied. Logistic regression was used to identify significant prognostic factors, to assess illness severity at hospital presentation and to classify trends between Canada and the United States.

RESULTS

In both countries, illness severity on admission increased, door-to-needle time for thrombolysis was reduced, intensive care unit stay was shortened and hospital stay decreased from GUSTO-I to GUSTO-III. Whereas the administration of oral nitrates, calcium blockers and beta-blockers at discharge converged over time between countries, the disparity in the use of angiography and revascularization widened; the rise in American revascularization rate was most evident in patients without in-hospital ischemia. The 30-day and one-year mortality rates were comparable and declined nonsignificantly in both countries.

CONCLUSIONS

Despite increased illness severity and varying medication and procedure rates, there was no increase over time in 30-day or one-year mortality; this remained comparable between countries throughout the seven-year observation period.

Moderators of the effect of social support on depressive symptoms in cardiac patients

Social support and depression have been shown to affect the prognosis of coronary patients, and social support has been found to influence depression in community and patient samples. We investigated the characteristics of coronary patients whose depressive symptomatology was most likely to improve with social support. We predicted that social support would be most beneficial for the most severely depressed, the old, the poor, the most severely ill, and those with poor functional status. Patients (n = 590) with documented coronary artery disease were assessed for depressive symptoms, social support, and functional status while in hospital. They were reassessed for depression 1 month later during a home visit. Depression scores were lower at follow-up (p = 0.001), and improvement was more marked among those reporting more support (p <0.001). The social support effect was strongest among those with high levels of depression at baseline (p <0.001) and those with lower income (p = 0.01). Unexpectedly, social support was more strongly associated with improvement in younger patients (p = 0.01). Social support did not interact with gender, disease severity, or functional status. These findings are partially consistent with the notion that social support is most effective for those who are most vulnerable and/or have few coping resources. These findings also have implications for the design and interpretation of psychosocial interventions.

Coronary catherization patient and wife's perceptions of social support: effects due to characteristics of recipient, provider, and their interaction

This investigation explored relationships between coronary catherization patient and wife's characteristics and their perceptions of social support. Participants were 124 male patients undergoing diagnostic catherization to detect coronary artery disease (CAD) and their wives. Patients and wives' mean ages were fifty-nine and fifty-six years, respectively. While visiting the hospital both patient and wife independently completed a brief questionnaire that assessed psychological and physical health characteristics and perceptions of social support. Congruent with the interdependent and overlapping contexts, and reciprocal relationships assumptions of Revenson's (1994) ecological/contextual framework, results suggested characteristics of patients and wives (e.g., age, mental health, social functioning, hostility, depression, general perceived health) to interactively moderate their perceptions of social support. Overall, perceptions of social support were found to be influenced by characteristics of the perceiver, the support provider, and their interaction. Concerns for supportive and helpful caregiving are discussed.

Use of resources, quality of life, and clinical outcomes in patients with and without new Q waves after thrombolytic therapy for acute myocardial infarction (from the GUSTO-I trial)

Previous reports indicate that patients who do not develop Q waves after thrombolytic therapy are a different population with a better long-term survival than those who do develop Q waves. However, the use of resources, quality of life, and health status of this population have not been fully evaluated. Using data from the Economics and Quality of Life subset of the Global Utilization of Streptokinase and tPA for Occluded Arteries study, we examined 30-day and 1-year mortality, use of resources, and quality-of-life measures among 1,830 of 3,000 patients with acute myocardial infarction and ST-segment elevation treated with thrombolytic therapy. At hospital discharge, 555 patients (30.2%) had not developed Q waves. These patients had lower mortality than patients with Q waves at 30 days (1.6% vs 4.5%, p <0.01) and at 1 year (4.7% vs 6.8%, p <0.04). Recurrent chest pain and dyspnea were similar at 30 days and 1 year. Patients without Q waves had significantly more angiography and trends toward higher readmission, revascularization, and use of calcium antagonists at 30 days. Angiography, revascularization, readmission, and quality of life were equivalent from 30 days to 1 year, with no sign of late instability. Logistic regression analysis showed an association between in-hospital revascularization and better survival and quality of life at 1 year. Conversely, there was no association between in-hospital use of calcium antagonists and outcome to explain the lower mortality in non-Q-wave patients. The absence of Q waves after thrombolytic therapy is a marker of success, implying better prognosis and equivalent quality of life, use of resources, and health status than for patients with Q-wave acute myocardial infarction and no sign of long-term unstable clinical course.

Cost effectiveness of early discharge after uncomplicated acute myocardial infarction

BACKGROUND

Reducing the length of hospitalizations can reduce short-term costs, but there are few data on the long-term clinical and economic consequences of early discharge.

METHODS

Using data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, we identified 22,361 patients with acute myocardial infarction who had an uncomplicated course for 72 hours after thrombolysis. Then, using a decision-analytic model, we examined the cost effectiveness of an additional day of hospitalization in this group. We defined incremental survival attributable to another day of monitored hospitalization, using Kaplan-Meier estimates to determine the rate of resuscitation after cardiac arrest between 72 and 96 hours. Lifetime survival curves for each group in the decision-analytic model were estimated from empirical one-year survival data from GUSTO-1. The costs of key hospital resources (e.g., room and monitoring) were derived from data in the GUSTO-1 cost-effectiveness analysis.

RESULTS

Of the patients with an uncomplicated course within 72 hours after thrombolysis, 16 had ventricular arrhythmias during the next 24 hours; 13 of these patients (81 percent) survived for at least 24 hours. On average, another 0.006 year of life per patient could be saved by keeping patients with an uncomplicated course in the hospital another day. At a cost of $624 for hospital and physicians' services, extending the hospital stay by another day would cost $105,629 per year of life saved. In sensitivity analyses, it was found that a fourth day of hospitalization would be economically attractive only if its cost could be reduced by more than 50 percent or if a high-risk subgroup could be identified in which the estimated survival benefit would be doubled.

CONCLUSIONS

Hospitalization of patients with uncomplicated myocardial infarction beyond three days after thrombolysis is economically unattractive by conventional standards.

Evaluating the potential 'economic attractiveness' of new therapies in patients with non-ST elevation acute coronary syndrome

OBJECTIVE

To evaluate the relationship between how much a new cardiovascular therapy improves clinical outcomes over current therapies and how much more it can cost while still remaining 'economically attractive'.

DESIGN

We developed a decision model to predict the 6-month cumulative cost savings and increased life expectancy that could be associated with new therapies for patients with non-ST elevation acute coronary syndrome.

SETTING

This modelling study used outcome and cost data from US sources.

METHODS

Event probabilities at 30 days and 6 months were estimated from US patients with non-ST elevation in the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO) IIb trial; cost estimates were derived from patients enrolled in the Economics and Quality of Life substudy of this trial. Patient life expectancy estimates were calculated using survival estimates for similar patients treated at Duke University Medical Center.

RESULTS

We found that new therapies costing up to $US2000 per episode that reduce 6-month mortality by 0.5%, death and nonfatal myocardial infarction (MI) by 1%, or death, nonfatal MI and revascularisation by 3%, may be cost effective by current standards. When new therapies costing up to $US1000 per episode reduce the absolute rate of death, nonfatal MI and revascularisation at 6 months by 6.5% or more, they may be cost saving.

CONCLUSION

Our analysis suggests that economic constraints should not inhibit the development of effective new therapies.

Quality of life after coronary revascularization in the United States and Canada

Cardiac procedures are performed less frequently in Canada than in the United States (US), yet rates of cardiac death and myocardial infarction are similar. We therefore sought to compare long-term symptoms and quality of life in Canadian and American patients undergoing initial coronary revascularization. The 161 patients enrolled in the Bypass Angioplasty Revascularization Investigation at the Montreal Heart Institute were compared with 934 patients enrolled at 7 US sites. Patients' outcomes were documented for 5 years after random assignment to percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. Functional status was assessed using the Duke Activity Status Index. Canadian patients were significantly younger and had more angina at study entry. Death and nonfatal myocardial infarction were not significantly different between Canadian and US patients after adjustment for baseline risk. Canadian patients had significantly greater improvements in functional status at 1-year follow-up (Duke Activity Status Index score + 13.5 vs. + 6.0, p = 0.002), but this difference progressively narrowed over 5 years. Angina was equally prevalent in Canadian and US patients at 1 year (16% vs. 19%), but significantly more prevalent in Canadian patients at 5 years (36% vs. 16%, p = 0.001). Repeat revascularization procedures were performed less often over 5 years among Canadian patients (26% vs. 34%, p = 0.08), especially coronary artery bypass graft surgery after initial percutaneous transluminal coronary angioplasty (18% vs. 32%, p = 0.03). These results suggest more anginal symptoms are required in Canada before coronary revascularization, but as a result Canadians receive greater improvements in quality of life after the procedure.

Cost-effectiveness of platelet glycoprotein IIb/IIIa inhibition with eptifibatide in patients with non-ST-elevation acute coronary syndromes

BACKGROUND

In the PURSUIT trial, eptifibatide significantly reduced the 30-day incidence of death and myocardial infarction relative to placebo in 9461 patients with an acute coronary syndrome (unstable angina or non-Q-wave myocardial infarction).

METHODS AND RESULTS

We conducted a 2-part prospective economic substudy of the 3522 US patients enrolled in PURSUIT: (1) an empirical intention-to-treat comparison of medical costs (hospital plus physician) up to 6 months after hospitalization and (2) a lifetime cost-effectiveness analysis. The base-case cost-effectiveness ratio was expressed as the 1996 US dollars required to add 1 life-year with eptifibatide therapy. The 2 treatment arms had equivalent resource consumption and medical costs (exclusive of the cost of the eptifibatide regimen) during the index (enrollment) hospitalization (P=0.78) and up to 6 months afterward (P=0.60). The average wholesale price of the eptifibatide regimen was $1217, but a typical hospital discounted price was $1014. The estimated life expectancy from randomization in the US patients was 15.96 years for eptifibatide and 15.85 years for placebo, an incremental difference of 0.111. The incremental cost-effectiveness ratio for eptifibatide therapy in US PURSUIT patients was $16 491 per year of life saved. This result was robust through a wide range of sensitivity analyses. The cost-utility ratio for eptifibatide (using time trade-off defined utilities) was $19 693 per added quality-adjusted life-year.

CONCLUSIONS

Based on the results observed in the US PURSUIT patients, the routine addition of eptifibatide to standard care for non-ST-elevation acute coronary syndrome patients is economically attractive by conventional standards.

Economics and Quality of Life After Acute Myocardial Infarction: Insights from GUSTO-I

Reperfusion therapy for acute myocardial infarction is one of the most thoroughly studied treatments in all of medicine. The GISSI-1 and ISIS-2 megatrials definitively established the superiority of intravenous streptokinase over conservative care for this condition. Tissue plasminogen activator (t-PA) was introduced with the expectation that it would be substantially more effective than streptokinase. It was also priced at approximately $2000, more than streptokinase, a cost differential that set the stage for a heated and often contentious debate about the added value of t-PA. Two European trials, GISSI-2 and ISIS-3, subsequently found that t-PA and streptokinase provided equivalent health outcomes. It was in this setting that the GUSTO trial was conceived. The major result of GUSTO was the finding that accelerated t-PA saved 11 additional lives per 1000 patients treated. In order to address the question of whether the extra benefits of t-PA were worth its significant extra costs, we performed a detailed cost-effectiveness analysis using the empirical data from the GUSTO-I trial. The net incremental cost for each patient shifted from streptokinase to t-PA in GUSTO-I was;dollar;2845. The majority of this difference was attributable to the difference in the cost of the thrombolytic agents. Survival modeling showed that accelerated t-PA added 0.14 undiscounted years per patient or, alternatively, that each of the 11 extra survivors per 1000 patients shifted from streptokinase to t-PA lived an average of 14 additional years. The incremental cost-effectiveness ratio for routine substitution of t-PA for streptokinase was;dollar;32,678 per added life year. Compared with standard benchmarks, our analysis shows that routine substitution of t-PA for streptokinase is "economically attractive." Subgroups analysis further showed that cost-effectiveness ratios were most favorable in older patients and in anterior myocardial infarctions. Perhaps one of the most important results of the GUSTO-I trial is that it demonstrates that an expensive new biotechnology therapy can have a favorable economic profile if it produces sufficient additional health benefits.

Outcomes at 1 year and economic implications of platelet glycoprotein IIb/IIIa blockade in patients undergoing coronary stenting: results from a multicentre randomised trial. EPISTENT Investigators. Evaluation of Platelet IIb/IIIa Inhibitor for Stenting

BACKGROUND

We assessed in a randomised trial the long-term outcomes for potent adjunctive antiplatelet therapy given at the time of coronary stenting.

METHODS

In 63 hospitals in the USA and Canada, 2399 patients were randomly assigned stenting with abciximab, stenting with placebo, or balloon angioplasty with abciximab. Standard adjunctive therapy with aspirin, ticlopidine, and heparin was used. The major outcomes of death and myocardial infarction were assessed at 1-year follow-up by intention to treat. We also investigated the 1-year cost-effectiveness of combined stenting and abciximab therapy.

FINDINGS

At 1-year follow-up, eight (1.0%) of 794 patients in the stent plus abciximab group had died, compared with 19 (2.4%) of 809 in the stent plus placebo group (hazard ratio 0.43 [95% CI 0.19-0.97], p=0.037). The combined endpoint of death or large myocardial infarction occurred in 42 (5.3%) and 89 (11.0%), respectively (0.46 [0.32-0.67], p<0.001). By multivariate modelling, the factors independently associated with improved survival were assignment to stenting with abciximab (p=0.027) and greater preprocedural stenosis (p=0.002); those associated with worse survival were age greater than 70 years (p<0.001), previous heart failure (p=0.001), diabetes treated with insulin (p=0.02), and postprocedural occlusion (p<0.001). Relative to stenting plus placebo and balloon angioplasty plus abciximab, the incremental 1-year costs of stenting plus abciximab were US$581 and $932. The corresponding cost-effectiveness ratios were US$5291 and $6213 per added life-year.

INTERPRETATION

Coronary stenting with abciximab, compared with stenting alone or balloon angioplasty with abciximab, is associated with improved survival and is an economically attractive therapy by conventional standards.

The association between self-rated health and mortality in a well-characterized sample of coronary artery disease patients

BACKGROUND

The relationship between self-rated health and mortality after adjustment for sociodemographic variables, physician-rated comorbidities, disease severity, health-related quality of life (HRQOL), and psychosocial measures (depression, social support, and functional ability) was examined in the Mediators of Social Support (MOSS) study.

SUBJECTS

The sample consisted of 2,885 individuals (mean age, 62.5 years) who had significant heart disease based upon heart catheterization. RESULTS. Using Cox proportional survival analysis, individuals who rated their health as "fair" or "poor" had a significantly greater likelihood of all-cause mortality (OR = 2.13; CI = 1.40-3.23; OR = 4.92; CI = 3.24-7.46, respectively) across follow-up (mean, 3.5 years) than those who rated their health as "very good" after considering sociodemographic factors. After adjustment for comorbidities, disease severity, HRQOL, psychosocial factors, and demographic variables, only those who rated their health as poor had a significant greater risk of mortality (OR = 2.96, CI = 1.80-4.85). A similar pattern was observed for coronary artery disease (CAD)-related mortality; increased adjustment of variables weakened the relationship between self-rated health and mortality. Individuals who rated their health as poor had a significantly greater risk of CAD-related mortality than did those who rated their health as very good (poor vs. very good OR = 3.58, CI = 2.13-6.02) after adjustment for all available mortality risk factors.

CONCLUSIONS

This study indicates that it is important to include self-rated health when studying risk factors for mortality. Not adjusting for relevant factors may provide an overestimation of the effects of self-rated health on mortality in a sample of CAD patients.

Cost estimates for treatment of cardiac ischemia (from the Asymptomatic Cardiac Ischemia Pilot [ACIP] study)

Costs for management of myocardial ischemia are enormous, yet comparison cost and outcome data for various ischemia treatment strategies from randomized trials are lacking and will require cost and resource utilization data from a large prospective trial. The Asymptomatic Cardiac Ischemia Pilot provided feasibility data for planning such a trial and an opportunity to estimate the long-term costs of different treatment strategies. Economic implications for ischemia management were compared in 558 patients with stable coronary artery disease and myocardial ischemia during both stress testing and daily life. Participants were randomized to 3 different initial treatment strategies and followed for 2 years. Based on cost trends over follow-up, costs for subsequent care were estimated. As expected, due to initial procedural costs, at 3 months, estimated costs for revascularization were approximately 10 times greater than costs for a medical care strategy. Extrapolated costs for anticipated resource consumption for care beyond 2 years, however, were approximately 2 times greater for an initial medical care strategy than for initial revascularization. This was due to increased need for drugs and hospitalizations for both late revascularizations and other ischemia-related events. Estimated costs for anticipated care in the medical strategies reached the anticipated cost of the revascularization strategy within 10 years. Because this cost-equal time period is well within the median life expectancy for such a patient population, these findings could have important public health implications and require testing in a full-scale prognosis trial. We anticipate that over the patients' life expectancy, early revascularization is likely to become either cost-neutral or cost-effective.

The relationship between self-rated health and health status among coronary artery patients

OBJECTIVES

This study examined the descriptive relationship of self-rated health (SRH) with various psychosocial measures, sociodemographic variables, coronary artery disease (CAD) diagnostic/clinical measures, and medically abstracted comorbidities.

METHODS

The sample was 2,855 individuals from the Mediators of Social Support (MOSS) study who had at least 75% narrowing in more than one vessel, as indicated by a cardiac catheterization.

RESULTS

After adjusting for sociodemographic factors, individuals who rated their health as poor/fair had significantly worse performance on all psychosocial measures and were more likely to be female, non-White, and of a lower socioeconomic status than those who rated their health as being good or better. There were few differences on SRH across various diagnostic/clinical measures of health.

DISCUSSION

A single item measure of SRH may be useful; the generalizability of the item must be considered. In this sample of CAD patients, SRH was related more to psychosocial factors than to clinical and disease indicators.

Perception of cognitive function in older adults following coronary artery bypass surgery

This study examined the effects of coronary artery bypass grafting (CABG) on objective and subjective measures of neurocognitive functioning. Participants were 170 older patients (127 men and 43 women; mean age = 61 years) undergoing CABG. Measures of neurocognitive function, depression, anxiety, and perceived cognitive abilities were administered immediately prior to and 6 weeks following surgery. Although objective measures of impaired cognitive performance following CABG were not related to perceived cognitive difficulties, the presence of anxiety and depression was related to the perception of cognitive functioning. Patients who reported high levels of anxiety and depression 6 weeks after surgery perceived themselves as having poorer cognitive function. Interventions designed to reduce emotional distress could improve patient's perceived cognitive abilities following CABG.

Clinical correlates of the initial and long-term cost of coronary bypass surgery and coronary angioplasty

BACKGROUND

Medical costs vary substantially among patients. Understanding the baseline factors that predict subsequent cost may allow better selection of therapy for individual patients. Understanding the postprocedure events that increase cost should help to improve efficiency and effectiveness of coronary revascularization.

METHODS

Data on 4-year costs were collected from patients randomly assigned to coronary angioplasty or bypass surgery as part of the BARI (Bypass Angioplasty Revascularization Investigation) trial. Regression models first examined factors known at the time of randomization that prospectively predicted initial procedure cost and long-term cost. Subsequent models tested the value of postrandomization events as explanatory variables for cost.

RESULTS

The independent baseline predictors of higher initial percutaneous transluminal coronary angioplasty cost included 3-vessel disease (+12%) and acute presentations (+22%), whereas the independent predictors of higher initial coronary artery bypass grafting cost included the number of comorbid conditions (+5% per condition) and female sex (+7%). The independent baseline predictors of 4-year cost included heart failure (+26%), diabetes (+22%), comorbidity (+10%), and angioplasty assignment in patients with 2-vessel disease (-15%). Postrandomization models showed higher initial and long-term costs were strongly correlated with the number of repeat revascularization procedures (+30% to +128%) and the occurrence of clinical complications (+8% to +131%).

CONCLUSIONS

Two-vessel disease identifies patients likely to have lower costs after angioplasty, whereas heart failure, comorbid conditions, and diabetes identify patients likely to accrue higher costs after either angioplasty or bypass surgery. Long-term costs can be potentially reduced by interventions that decrease procedural complications or reduce the need for repeat revascularization.

A comparison of U.S. and Canadian cardiac catheterization practices in detecting severe coronary artery disease after myocardial infarction: efficiency, yield and long-term implications

OBJECTIVES

We sought to compare U.S. and Canada's post-myocardial infarction (MI) cardiac catheterization practices in the detection of severe coronary artery disease (CAD).

BACKGROUND

Little is known about the efficiency with which the aggressive post-MI catheterization strategy observed in the U.S. detects severe CAD compared with the more conservative strategy observed in Canada.

METHODS

From the U.S. and Canadian patients who had participated in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries trial (n = 22,280, 11.5% Canadian), we examined the frequency of in-hospital cardiac catheterization, the prevalence of severe CAD observed at catheterization (diagnostic efficiency) and the total number of MI patients with severe CAD identified (diagnostic yield).

RESULTS

The rate of catheterization in the U.S. was more than 2.5 times that in Canada (71% vs. 27%, respectively, p < 0.001). With identical prevalences of severe CAD at catheterization (17%) in the two countries, the higher frequency of catheterization in the U.S. resulted in the identification of more than two and a half times as many cases of severe CAD compared with Canada (12 severe CAD cases identified per 100 post-MI patients in the U.S., vs. 4.6 per 100 in Canada). If considered in isolation, we estimated that these differences in severe disease detection might effect a small long-term survival advantage in favor of the U.S. strategy (estimated 5.0 lives saved per 1,000 MI patients).

CONCLUSIONS

Canada's more restrictive post-MI cardiac catheterization strategy is no more efficient in identifying severe CAD than the aggressive U.S. strategy, and may fail to identify a substantial number of post-MI patients with high risk coronary anatomy. The long-term impact of these differences in practice patterns requires further evaluation.

Perception of cognitive function in older adults following coronary artery bypass surgery

This study examined the effects of coronary artery bypass grafting (CABG) on objective and subjective measures of neurocognitive functioning. Participants were 170 older patients (127 men and 43 women; mean age = 61 years) undergoing CABG. Measures of neurocognitive function, depression, anxiety, and perceived cognitive abilities were administered immediately prior to and 6 weeks following surgery. Although objective measures of impaired cognitive performance following CABG were not related to perceived cognitive difficulties, the presence of anxiety and depression was related to the perception of cognitive functioning. Patients who reported high levels of anxiety and depression 6 weeks after surgery perceived themselves as having poorer cognitive function. Interventions designed to reduce emotional distress could improve patient's perceived cognitive abilities following CABG.

Acute and long-term cost implications of coronary stenting

OBJECTIVES

We compared the acute and one year medical costs and outcomes of coronary stenting with those for balloon angioplasty (percutaneous transluminal coronary angioplasty) in contemporary clinical practice.

BACKGROUND

While coronary stent implantation reduces the need for repeat revascularization, it has been associated with significantly higher acute costs compared with coronary angioplasty.

METHODS

We studied patients treated at Duke University between September 1995 and June 1996 who received either coronary stent (n = 384) or coronary angioplasty (n = 159) and met eligibility criteria. Detailed cost data were collected initially and up to one year following the procedure. Our primary analyses compared six and 12 month cumulative costs for coronary angioplasty- and stent-treated cohorts. We also compared treatment costs after excluding nontarget vessel interventions; after limiting analysis to those without prior revascularization; and after risk-adjusting cumulative cost estimates.

RESULTS

Baseline clinical characteristics were generally similar between the two treatment groups. The mean in-hospital cost for stent patients was $3,268 higher than for those receiving coronary angioplasty ($14,802 vs. $11,534, p < 0.001). However, stent patients were less likely to be rehospitalized (22% vs. 34%, p = 0.002) or to undergo repeat revascularization (9% vs. 26%, p = 0.001) than coronary angioplasty patients within six months of the procedure. As such, mean cumulative costs at 6 months ($19,598 vs. $19,820, p = 0.18) and one year ($22,140 vs. $22,571, p = 0.26) were similar for the two treatments. Adjusting for baseline predictors of cost and selectively examining target vessel revascularization, or those without prior coronary intervention yielded similar conclusions.

CONCLUSIONS

In contemporary practice, coronary stenting provides equivalent or better one-year patient outcomes without increasing cumulative health care costs.

Effects of stroke on medical resource use and costs in acute myocardial infarction. GUSTO I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Study

BACKGROUND

Stroke occurs concurrently with myocardial infarction (MI) in approximately 30 000 US patients each year. This number is expected to rise with the increasing use of thrombolytic therapy for MI. However, no data exist for the economic effect of stroke in the setting of acute MI (AMI). The purpose of this prospective study was to assess the effect of stroke on medical resource use and costs in AMI patients in the United States.

METHODS AND RESULTS

Medical resource use and cost data were prospectively collected for 2566 randomly selected US GUSTO I patients (from 23 105 patients) and for the 321 US GUSTO I patients who developed non-bypass surgery-related stroke during the baseline hospitalization. Follow-up was for 1 year. All costs are expressed in 1993 US dollars. During the baseline hospitalization, stroke was associated with a reduction in cardiac procedure rates and an increase in length of stay, despite a hospital mortality rate of 37%. Together with stroke-related procedural costs of $2220 per patient, the baseline medical costs increased by 44% ($29 242 versus $20 301, P<0.0001). Follow-up medical costs were substantially higher for stroke survivors ($22 400 versus $5282, P<0.0001), dominated by the cost of institutional care. The main determinant for institutional care was discharge disability status. The cumulative 1-year medical costs for stroke patients were $15 092 higher than for no-stroke patients. Hemorrhagic stroke patients had a much higher hospital mortality rate than non-hemorrhagic stroke patients (53% versus 15%, P<0.001), which was associated with approximately $7200 lower mean baseline hospitalization cost. At discharge, hemorrhagic stroke patients were more likely to be disabled (68% versus 46%, P=0.002).

CONCLUSIONS

In this first large prospective economic study of stroke in AMI patients, we found that strokes were associated with a 60% ($15 092) increase in cumulative 1-year medical costs. Baseline hospitalization costs were 44% higher because of longer mean lengths of stay. Stroke type was a key determinant of baseline cost. Follow-up costs were more than quadrupled for stroke survivors because of the need for institutional care. Disability level was the main determinant of institutional care and thus of follow-up costs.

Value of exercise treadmill testing in women

OBJECTIVES

We sought to determine the ability of a treadmill score to provide accurate diagnostic and prognostic risk estimates in women.

BACKGROUND

Treadmill testing has been reported to have a lower accuracy for diagnosis of chest pain in women. The diagnostic and prognostic value of the Duke Treadmill Score (DTS) in women is unknown.

METHODS

We determined the diagnostic and prognostic value of the DTS in 976 women and 2,249 men who underwent both treadmill testing and cardiac catheterization in a single institution from 1984 to 1994.

RESULTS

Women and men differed significantly in DTS (1.6 vs. -0.3, p < 0.0001), disease prevalence (32% vs. 72% significant coronary artery disease [CAD], p < 0.001), and 2-year mortality (1.9% vs. 4.9%, p < 0.0001). The DTS provided information beyond clinical predictors of both coronary disease and survival in women and men. Although overall women had better survival, the DTS performed equally well in stratifying both genders into prognostic categories. The DTS actually performed better in women than in men for excluding disease, with fewer low risk women having any significant coronary disease (> or = 1 vessel with > or =75% stenosis) (20% vs. 47%, p < 0.001), or severe disease (3-vessel disease or > or =75% left main stenosis) (3.5% vs. 11.4%, p < 0.001).

CONCLUSIONS

By combining several aspects of treadmill testing, the DTS effectively stratifies women into diagnostic and prognostic risk categories.

Social support and hostility as predictors of depressive symptoms in cardiac patients one month after hospitalization: a prospective study

OBJECTIVE

Hospitalization for cardiac disease is associated with an increased risk for depression, which itself confers a poorer prognosis. Few prospective studies have examined the determinants of depression after hospitalization in cardiac patients, and even fewer have examined depression within the weeks after hospital discharge. The present study assessed the prospective relations among perceptions of social support and trait hostility in predicting symptoms of depressive symptoms at 1 month after hospitalization for a diagnostic angiography in 506 coronary artery disease (CAD) patients.

METHOD

A series of structural equation models 1) estimated the predictive relations of social support, hostility, and depressive symptoms while in the hospital to symptoms of depression 1 month after hospitalization, and 2) compared these relations across gender, predicted risk classification, and age.

RESULTS

Social support assessed during hospitalization was independently negatively associated with depressive symptoms 1 month after hospitalization, after controlling for baseline symptoms of depression, gender, disease severity, and age. Hostility was an indirect predictor of postdischarge depressive symptomology by way of its negative relation with social support. This pattern of relations did not differ across gender, predicted risk classification, and age.

CONCLUSIONS

Our findings suggest that a patient's perceived social support during hospitalization is a determinant of depressive symptoms 1 month later. The relation of social support and hostility to subsequent depressive symptoms was similar across a variety of populations.

Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups

BACKGROUND

Exercise testing is useful in the assessment of symptomatic patients for diagnosis of significant or extensive coronary disease and to predict their future risk of cardiac events. The Duke treadmill score (DTS) is a composite index that was designed to provide survival estimates based on results from the exercise test, including ST-segment depression, chest pain, and exercise duration. However, its usefulness for providing diagnostic estimates has yet to be determined.

METHODS AND RESULTS

A logistic regression model was used to predict significant (>/=75% stenosis) and severe (3-vessel or left main) coronary artery disease, and a Cox regression analysis was used to predict cardiac survival. After adjustment for baseline clinical risk, the DTS was effectively diagnostic for significant (P<0.0001) and severe (P<0.0001) coronary artery disease. For low-risk patients (score >/=+5), 60% had no coronary stenosis >/=75% and 16% had single-vessel >/=75% stenosis. By comparison, 74% of high-risk patients (score <-11) had 3-vessel or left main coronary disease. Five-year mortality was 3%, 10%, and 35% for low-, moderate-, and high-risk DTS groups (P<0.0001).

CONCLUSIONS

The composite DTS provides accurate diagnostic and prognostic information for the evaluation of symptomatic patients evaluated for clinically suspected ischemic heart disease.