Transcatheter Aortic Valve Replacement After Prior Mitral Valve Surgery: Results From the Transcatheter Valve Therapy Registry

BACKGROUND

Due to perceived technical challenges, patients with previous surgical mitral valve repair or replacement (SMVR) have been excluded from most transcatheter aortic valve replacement (TAVR) trials. Our objective was to compare the 30-day and 1-year outcomes of TAVR for patients with and without prior SMVR.

METHODS

In a retrospective review of The Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry, we compared 1097 patients with prior SMVR to 46,327 patients without prior SMVR who underwent TAVR between November 2011 and September 2015 at 394 US centers. Preoperative characteristics, procedural details, and clinical outcomes were analyzed.

RESULTS

Patients with previous SMVR were younger, more often female, and had higher STS predicted risk of mortality (8.6% vs 6.8%, P < .001). However, there was no difference in 30-day mortality (4.6% vs 5.5%, P = .293), myocardial infarction, stroke, reintervention, new dialysis, or readmission. Moderate/severe paravalvular leak at discharge was also similar (5.8% vs 4.9%, P = .343). At 1 year, morbidity was similar with slightly higher mortality among patients with prior SMVR (20% vs 17.5%, P = .087) that was significant after adjustment (hazard ratio 1.18, P = .043). The type of prior SMVR (repair, bioprosthetic replacement, or mechanical replacement) had no impact on 30-day or 1-year survival.

CONCLUSIONS

Patients with prior SMVR undergoing TAVR had similar 30-day outcomes, slightly higher 1-year mortality, and no increase in early paravalvular leak compared with patients who did not have previous SMVR. Prior SMVR should not preclude TAVR for appropriately selected patients.

Validation of a low-dose contrast 64-slice cardiac computed tomography angiography protocol for aortic valve annulus sizing

Cardiac computed tomography angiography (CCTA) is the gold standard for accurately sizing the aortic valve annulus prior to aortic valve replacement. A reduction of contrast volume administered for CCTA, without sacrificing image quality, is desirable. Signal-to-noise ratio represents final CCTA image quality. Consecutive patients referred to CCTA for aortic valve annulus sizing were retrospectively analyzed. Patients were grouped into a low-dose contrast (LDCT) group and traditional dose contrast (TDCT) group. In the LDCT group, contrast dose was <50% of the maximal allowable dose (3.7 × estimated glomerular filtration rate). Guided by a time-density curve, the contrast was administered in a two-stage infusion, and retrospectively gated images were acquired with a 64-multidetector computed tomography scanner. Out of 123 patients (age 80 ± 9 years; 46% female), 65 (52.9%) underwent LDCT and 58 (47.2%) underwent TDCT. Contrast volume was significantly lower in the LDCT group (LDCT 41.2 ± 9.8 vs TDCT 76.2 ± 14.2 mL; P < 0.001). The signal-to-noise ratio of the aortic root was 10.4 ± 4.1 for the LDCT group and 8.4 ± 3.3 for the TDCT group (P = 0.004). Aortic root dimensions could be measured in both LDCT and TDCT groups. In conclusion, LDCT with 64-slice CCTA can effectively size the aortic valve annulus to direct aortic valve replacement while offering reduced contrast exposure.

Clinical Leaflet Thrombosis in Transcatheter and Surgical Bioprosthetic Aortic Valves by Four-Dimensional Computed Tomography

BACKGROUND

The incidence of leaflet thrombosis after transcatheter aortic valve replacement (TAVR) with active surveillance by four-dimensional computed tomography (4DCT) ranges from 7% to 14%. The incidence of leaflet thrombosis when 4DCT is performed for clinical and echocardiographic indications is unknown.

METHODS

All patients with prior TAVR or surgical aortic valve replacement (SAVR) who underwent evaluation between October 2015 and January 2017 at our institution and had clinical or echocardiographic indications of leaflet thrombosis were evaluated by 4DCT. Indications for 4DCT by echocardiography included (1) interval increase in mean gradient of 10 mm Hg or more, (2) interval decrease in ejection fraction of 10% or more, (3) thrombus seen on transthoracic echocardiography, (4) persistent or increasing paravalvular leak, or (5) valve dehiscence or thickened leaflets seen on transthoracic echocardiography. Clinical indicators were (1) stroke, (2) transient ischemic attack, or (3) new or worsening heart failure.

RESULTS

During the study period, 612 patients underwent TAVR, and 101 patients (55 TAVR; 46 SAVR) met the criteria for 4DCT imaging. Leaflet thrombosis was seen in 17 of 55 TAVR patients (30.9%) and 15 of 46 SAVR patients (32.6%). Follow-up imaging with 4DCT after treatment with anticoagulation showed improvement or resolution in thrombus burden and leaflet excursion in all TAVR patients and in two-thirds of SAVR patients.

CONCLUSIONS

One-third of patients with clinical or echocardiographic indications suggestive of leaflet thrombosis were found to have evidence of leaflet thrombosis using 4DCT. This allowed tailored anticoagulation therapy with resolution of the thrombus in most patients and avoiding unnecessary anticoagulation in the remaining two-thirds of patients.

Description of a Method to Obtain Complete One-Year Follow-Up in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

The Centers for Medicare and Medicaid Services National Coverage Determination requires centers performing transcatheter aortic valve implantation (TAVI) to report clinical outcomes up to 1 year. Many sites encounter challenges in obtaining complete 1-year follow-up. We report our process to address this challenge. A multidisciplinary process involving clinical personnel, data and quality managers, and research coordinators was initiated to collect TAVI data at baseline, 30 days, and 1 year. This process included (1) planned clinical follow-up of all patients at 30 days and 1 year; (2) query of health-care system-wide integrated data warehouse (IDW) to ascertain last date of clinical contact within the system for all patients; (3) online obituary search, cross-referencing for unique patient identifiers to determine if mortality occurred in remaining unknown patients; and (4) phone calls to remaining unknown patients or patients' families. Between January 2012 and December 2016, 744 patients underwent TAVI. All 744 patients were eligible for 30-day follow-up and 546 were eligible for 1-year follow-up. At routine clinical follow-up of 22 of 744 (3%) patients at 30 days and 180 of 546 (33%) patients at 1 year had unknown survival status. The integrated data warehouse query confirmed status-alive for an additional 1 of 22 patients at 30 days (55%) and 91 of 180 patients at 1 year (51%). Obituaries were identified for 23 of 180 additional patients at 1 year (13%). Phone contact identified the remaining unknown patients at 30 days and 1 year, resulting in 100% known survival status for patients at 30 days (744 of 744) and at 1 year (546 of 546). In conclusion, using a comprehensive approach, we were able to determine survival status in 100% of patients who underwent TAVI.

Novel renal biomarker evaluation for early detection of acute kidney injury after transcatheter aortic valve implantation

Acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI) is associated with increased morbidity and mortality. The biomarkers neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18) are predictive of AKI after cardiac surgery, but there is little data regarding these biomarkers after TAVI. We evaluated the associations between NGAL, KIM-1, and IL-18 levels and the incidence and severity of AKI and changes in serum creatinine after TAVI. This was a prospective pilot study of 66 TAVI cases. Urinary biomarkers were measured at baseline and at 2, 4, and 12 hours after TAVI. Demographics, procedural features, and renal function until discharge were compared between patients with and without subsequent AKI. Seventeen patients (25.8%) developed AKI postoperatively (stage 1, n = 14; stage 2, n = 1; stage 3, n = 2). There were no significant differences in unadjusted mean NGAL, KIM-1, and IL-18 levels between patients with and without AKI at 2, 4, and 12 hours following surgery. After adjusting for the Society of Thoracic Surgeons risk of mortality, this study of three urinary biomarkers showed no association with AKI or creatinine after TAVI. Ongoing efforts to predict and modify the risk of AKI after TAVI remain challenging.

Balloon aortic valvuloplasty to improve candidacy of patients evaluated for transcatheter aortic valve replacement

OBJECTIVES

Evaluate the role of balloon aortic valvuloplasty (BAV) in improving candidacy of patients for transcatheter aortic valve replacement (TAVR).

BACKGROUND

Patients who are not candidates for TAVR may undergo BAV to improve functional and clinical status.

METHODS

117 inoperable or high-risk patients with critical aortic stenosis underwent BAV as a bridge-to-decision for TAVR. Frailty measures including gait speed, serum albumin, hand grip, activities of daily living (ADL); and NYHA functional class before and after BAV were compared.

RESULTS

Mean age was 81.6 ± 8.5 years and the mean Society of Thoracic Surgeons predicted risk of mortality was 9.57 ± 5.51, with 19/117 (16.2%) patients non-ambulatory. There was no significant change in mean GS post-BAV, but all non-ambulatory patients completed GS testing at follow-up. Albumin and hand grip did not change after BAV, but there was a significant improvement in mean ADL score (4.85 ± 1.41 baseline to 5.20 ± 1.17, P = 0.021). The number of patients with Class IV congestive heart failure (CHF) was significantly lower post BAV (71/117 [60.7%] baseline versus 18/117 [15.4%], P = 0.008). 78/117 (66.7%) of patients were referred to definitive valve therapy after BAV.

CONCLUSIONS

When evaluating frailty measures post BAV, we saw no significant improvement in mean GS, however, we observed a significant improvement in non-ambulatory patients and ADL scores. We also describe improved Class IV CHF symptoms. With this improved health status, the majority of patients underwent subsequent valve therapy, demonstrating that BAV may improve candidacy of patients for TAVR.

Pathologic confirmation of valve thrombosis detected by four-dimensional computed tomography following valve-in-valve transcatheter aortic valve replacement

A major concern regarding transcatheter aortic valve replacement (TAVR) is leaflet thrombosis. Four-dimensional computed tomography (4D-CT) is the preferred imaging modality to evaluate patients with suspected valve thrombosis. To date, the abnormal findings visualized by 4D-CT suggestive of leaflet thrombosis have lacked pathologic confirmation from a surgically explanted valve in a surviving patient. Herein, we provide pathologic confirmation of thrombus formation following surgical explantation of a thrombosed TAVR prosthesis that was initially identified by 4D-CT.

Sex Differences in Outcomes Following Percutaneous Coronary Intervention According to Age

BACKGROUND

Women <50 years of age with coronary artery disease may represent a group at higher risk for recurrent ischemic events after percutaneous coronary intervention (PCI); however, no long-term, multicenter outcomes assessment exists in this population.

METHODS AND RESULTS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in 10,963 patients (3797 women, 394 <50 years) undergoing PCI and followed for 5 years. Death, myocardial infarction, coronary artery bypass graft surgery, and repeat PCI were primary outcomes comprising major adverse cardiovascular events. Although procedural success rates were similar by sex, the cumulative rate of major adverse cardiovascular events at 1 year was higher in young women (27.8 versus 19.9%; P=0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P<0.001, adjusted hazard ratio 2.4, 95% confidence interval 1.5-4.0; PCI: 19.0% versus 13.0%, P=0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2-2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P=0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01-2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P=0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24-2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men.

CONCLUSIONS

Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005677.

Should Transcatheter Aortic Valve Replacement Be Performed in Nonagenarians?: Insights From the STS/ACC TVT Registry

BACKGROUND

Data demonstrating the outcome of transcatheter aortic valve replacement (TAVR) in the very elderly patients are limited, as they often represent only a small proportion of the trial populations.

OBJECTIVES

The purpose of this study was to compare the outcomes of nonagenarians to younger patients undergoing TAVR in current practice.

METHODS

We analyzed data from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry. Outcomes at 30 days and 1 year were compared between patients ≥90 years versus <90 years of age using cumulative incidence curves. Quality of life was assessed with the 12-item Kansas City Cardiomyopathy Questionnaire.

RESULTS

Between November 2011 and September 2014, 24,025 patients underwent TAVR in 329 participating hospitals, of which 3,773 (15.7%) were age ≥90 years. The 30-day and 1-year mortality rates were significantly higher among nonagenarians (age ≥90 years vs. <90 years: 30-day: 8.8% vs. 5.9%; p < 0.001; 1 year: 24.8% vs. 22.0%; p < 0.001, absolute risk: 2.8%, relative risk: 12.7%). However, nonagenarians had a higher mean Society of Thoracic Surgeons Predicted Risk of Operative Mortality score (10.9% vs. 8.1%; p < 0.001) and, therefore, had similar ratios of observed to expected rates of 30-day death (age ≥90 years vs. <90 years: 0.81, 95% confidence interval: 0.70 to 0.92 vs. 0.72, 95% confidence interval: 0.67 to 0.78). There were no differences in the rates of stroke, aortic valve reintervention, or myocardial infarction at 30 days or 1 year. Nonagenarians had lower (worse) median Kansas City Cardiomyopathy Questionnaire scores at 30 days; however, there was no significant difference at 1 year.

CONCLUSIONS

In current U.S. clinical practice, approximately 16% of patients undergoing TAVR are ≥90 years of age. Although 30-day and 1-year mortality rates were statistically higher compared with younger patients undergoing TAVR, the absolute and relative differences were clinically modest. TAVR also improves quality of life to the same degree in nonagenarians as in younger patients. These data support safety and efficacy of TAVR in select very elderly patients.

Prognostic Usefulness of Acute Kidney Injury After Transcatheter Aortic Valve Replacement

Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) has been associated with increased postoperative morbidity and mortality. Long-term outcomes after TAVR with the Edwards SAPIEN valve in patients who develop AKI postoperatively are currently not well described. We retrospectively reviewed 384 consecutive patients undergoing TAVR at 2 institutions from August 2006 to April 2012. AKI was defined and staged according to Valve Academic Research Consortium-2 criteria. The incidence, multivariate predictors, and association of AKI with 3-year mortality were evaluated. Stage 1 AKI occurred in 24.0% of patients (92 of 384), stage 2 in 5.5% (21 of 384), and stage 3 in 8.1% (31 of 384). The overall operative mortality rate was 7.6%, with a mortality of 3.0% in patients with no kidney injury, 7.6% in stage 1, 23.8% in stage 2, and 32.3% in stage 3. The incidence of new postoperative dialysis was 3.1%. Survival at 3 years for no-AKI/stage 1/stage 2/stage 3 was 59.2 ± 3.3%, 43.4 ± 5.2%, 27.8 ± 10.0%, and 25.4 ± 7.9%, respectively. Logistic regression modeling for the combination of stage 2 or 3 AKI after surgery demonstrated that the last preoperative creatinine (for each 1 mg/dl increase, odds ratio = 3.23, 95% CI 1.83 to 5.69; p <0.001) and dye load (for each 10 ml increase, odds ratio = 1.04, 95% CI 1.01 to 1.08; p = 0.006) were significant predictors for AKI. In conclusion, AKI after TAVR is associated with increased postoperative and 3-year mortality. Significant multivariate predictors are potentially modifiable before the procedure.

Aortic root rupture after TAVR in two renal transplant patients on chronic immunosuppressant therapy

Patients on chronic immunosuppressant therapy after renal transplantation have a high rate of in-hospital mortality and approximately 20% mortality rate per year after conventional valve surgery. While transcatheter aortic valve replacement (TAVR) is an appealing option to consider for such patients, there are not significant outcome data for the procedure in this patient population. We report two cases of aortic root rupture after TAVR in renal transplant patients on chronic immunosuppressant therapy.

Five-year follow-up of patients treated for coronary artery disease in the face of an increasing burden of co-morbidity and disease complexity (from the NHLBI Dynamic Registry)

Management of coronary artery disease (CAD) has evolved over the past decade, but there are few prospective studies evaluating long-term outcomes in a real-world setting of evolving technical approaches and secondary prevention. The aim of this study was to determine how the mortality and morbidity of CAD has changed in patients who have undergone percutaneous coronary intervention (PCI), in the setting of co-morbidities and evolving management. The National Heart, Lung, and Blood Institute Dynamic Registry was a cohort study of patients undergoing PCI at various time points. Cohorts were enrolled in 1999 (cohort 2, n = 2,105), 2004 (cohort 4, n = 2,112), and 2006 (cohort 5, n = 2,176), and each was followed out to 5 years. Primary outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, repeat PCI, and repeat revascularization. Secondary outcomes were PCI for new obstructive lesions at 5 years, 5-year rates of death and MI stratified by the severity of coronary artery and co-morbid disease. Over time, patients were more likely to have multiple co-morbidities and more severe CAD. Despite greater disease severity, there was no significant difference in death (16.5% vs 17.6%, adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.74 to 1.08), MI (11.0% vs 10.6%, adjusted HR 0.87, 95% CI 0.70 to 1.08), or repeat PCI (20.4% vs 22.2%, adjusted HR 0.98, 95% CI 0.85 to 1.17) at 5-year follow-up, but there was a significant decrease in coronary artery bypass grafting (9.1% vs 4.3%, adjusted HR 0.44, 95% CI 0.32 to 0.59). Patients with 5 co-morbidities had a 40% to 60% death rate at 5 years. There was a modestly high rate of repeat PCI for new lesions, indicating a potential failure of secondary prevention for this population in the face of increasing co-morbidity. Overall 5-year rates of death, MI, repeat PCI, and repeat PCI for new lesions did not change significantly in the context of increased co-morbidities and complex disease.

Comparison of drug-eluting and bare metal stents in large coronary arteries: findings from the NHLBI dynamic registry

OBJECTIVES

This study sought to evaluate the safety and effectiveness of drug-eluting stents (DES) compared to bare-metal stents (BMS) for patients with large coronary vessels.

BACKGROUND

Randomized trials have demonstrated that DES reduce the risk of target vessel revascularization (TVR) compared to BMS. This benefit is less pronounced as artery diameter increases. Whether DES are superior to BMS for larger coronary arteries in the setting of routine clinical practice is unknown.

METHODS

We analyzed data from 869 patients undergoing de novo lesion PCI with reference vessel diameter greater than or equal to 3.5 mm in the NHLBI Dynamic Registry according to whether they were treated with DES or BMS. Patients were followed for 3 years for the occurrence of cardiovascular events.

RESULTS

At 3-year follow-up, rates of TVR at 3 years were similar and low in both groups (4.4% vs. 3.7%, P = 0.62). After adjustment for differences in baseline characteristics, the adjusted hazard ratio for 3-year MI for DES was 1.85 (95% CI 0.93-3.7, P = 0.08), for TVR at 3 years 1.14 (95% CI 0.52-2.49, P = 0.75) and for mortality 0.89 (95%CI 0.49-1.62, P = 0.71).

CONCLUSIONS

In our study of the unrestricted use of DES for patients with lesions in larger diameter coronary arteries, first generation DES did not reduce 3-year risk of TVR. Our findings do not support the preferred use of DES over BMS for patients with lesions located in arteries >3.5 mm. It is unknown whether secondary generation DES can offer better outcome compared to BMS in large coronary vessels. Further study on this issue is warranted.

Randomized trial of surgical cutdown versus percutaneous access in transfemoral TAVR

OBJECTIVES

To compare iliofemoral arterial complications with transfemoral transcatheter aortic valve replacement (TF-TAVR) utilizing surgical cutdown versus percutaneous access with closure devices in a randomized trial.

BACKGROUND

Major vascular complications following TAVR are a significant risk of the procedure. There are no randomized data comparing whether access method in TF-TAVR influences the risk of such complications.

METHODS

From June to December 2011, 30 consecutive patients undergoing TF-TAVR were randomized to either surgical cutdown (C) or percutaneous (P) access. Subjects underwent preoperative CT scans, pre- and post-operative bilateral femoral arterial ultrasound and angiography. The primary endpoint was the composite of major and minor vascular complications at 30 days, as defined by the Valve Academic Research Consortium-2. Multivariate predictors of vascular complications were identified.

RESULTS

Of the 30 subjects enrolled, 27 were treated with the randomized method of access as randomized. Iliofemoral complications were observed in eight patients (26.7%; C = 4, P = 4), all of which were dissections and/or stenoses that required percutaneous and/or surgical intervention. There were two (13.3%) major and two (13.3%) minor complications in each group. Two covariates that were significantly associated with vascular complications included female sex and baseline femoral arterial velocity on ultrasound.

CONCLUSIONS

While surgical cutdown in TF-TAVR is the recommended access for new centers initiating a TAVR program, this small randomized pilot study suggests the lesser invasive percutaneous method in an experienced center is equivalent in safety to the surgical method. Doppler ultrasound may be useful in predicting complications prior to the procedure.

A risk score for predicting coronary artery disease in women with angina pectoris and abnormal stress test finding

Women with angina pectoris and abnormal stress test findings commonly have no epicardial coronary artery disease (CAD) at catheterization. The aim of the present study was to develop a risk score to predict obstructive CAD in such patients. Data were analyzed from 337 consecutive women with angina pectoris and abnormal stress test findings who underwent cardiac catheterization at our center from 2003 to 2007. Forward selection multivariate logistic regression analysis was used to identify the independent predictors of CAD, defined by ≥50% diameter stenosis in ≥1 epicardial coronary artery. The independent predictors included age ≥55 years (odds ratio 2.3, 95% confidence interval 1.3 to 4.0), body mass index <30 kg/m(2) (odds ratio 1.9, 95% confidence interval 1.1 to 3.1), smoking (odds ratio 2.6, 95% confidence interval 1.4 to 4.8), low high-density lipoprotein cholesterol (odds ratio 2.9, 95% confidence interval 1.5 to 5.5), family history of premature CAD (odds ratio 2.4, 95% confidence interval 1.0 to 5.7), lateral abnormality on stress imaging (odds ratio 2.8, 95% confidence interval 1.5 to 5.5), and exercise capacity <5 metabolic equivalents (odds ratio 2.4, 95% confidence interval 1.1 to 5.6). Assigning each variable 1 point summed to constitute a risk score, a graded association between the score and prevalent CAD (ptrend <0.001). The risk score demonstrated good discrimination with a cross-validated c-statistic of 0.745 (95% confidence interval 0.70 to 0.79), and an optimized cutpoint of a score of ≤2 included 62% of the subjects and had a negative predictive value of 80%. In conclusion, a simple clinical risk score of 7 characteristics can help differentiate those more or less likely to have CAD among women with angina pectoris and abnormal stress test findings. This tool, if validated, could help to guide testing strategies in women with angina pectoris.

Association of chronic lung disease with treatments and outcomes patients with acute myocardial infarction

BACKGROUND

Although chronic lung disease (CLD) is common among patients with myocardial infarction (MI), little is known about the influence of CLD on patient management and outcomes following MI.

METHODS

Using the National Cardiovascular Data Registry's ACTION Registry-GWTG, demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after acute MI were compared between patients with (n = 22,624) and without (n = 136,266) CLD. Multivariable adjustment was performed to determine the independent association of CLD with treatments and adverse events.

RESULTS

CLD (17.0% of non-ST-elevation MI [NSTEMI] and 10.1% of ST-elevation MI [STEMI] patients) was associated with older age, female sex, and a greater burden of comorbidities. Among NSTEMI patients, those with CLD were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft compared to those without; in contrast, no differences were seen in invasive therapies for STEMI patients with or without CLD. Multivariable-adjusted risk of major bleeding was significantly increased in CLD patients with NSTEMI (13.0% vs 8.1%, OR(adj) = 1.27, 95% CI = 1.20-1.34, P < .001) and STEMI (16.0% vs 10.5%, OR(adj) = 1.19, 95% CI = 1.10-1.29, P < .001). In NSTEMI, CLD was associated with a higher risk of inhospital mortality (OR(adj) = 1.21, 95% CI = 1.11-1.33); in STEMI no association between CLD and mortality was seen (OR(adj) = 1.05, 95% CI = 0.95-1.17).

CONCLUSIONS

CLD is common among patients with MI and is independently associated with an increased risk for major bleeding. In NSTEMI, CLD is also associated with receiving less revascularization and with increased in-hospital mortality. Special attention should be given to this high-risk subgroup for the prevention and management of complications after MI.

Incidence and predictors of 30-day hospital readmission rate following percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Postdischarge outcomes after percutaneous coronary intervention (PCI) are important measurements of quality of care and complement in-hospital measurements. We sought to assess in-hospital and postdischarge PCI outcomes to (1) better understand the relation between acute and 30-day outcomes, (2) identify predictors of 30-day hospital readmission, and (3) determine the prognostic significance of 30-day hospital readmission. We analyzed in-hospital death and length of stay (LOS) and nonelective cardiac-related rehospitalization after discharge in 10,965 patients after PCI in the Dynamic Registry. From 1999 to 2006 in-hospital death rate and LOS decreased. Thirty-day cardiac readmission rate was 4.6%, with considerable variability over time and among hospitals. Risk of rehospitalization was greater in women and those with congestive heart failure, unstable angina, multiple lesions, and emergency PCI. Conversely, a lower risk of rehospitalization was associated with a larger number of treated lesions. Patients readmitted within 30 days had higher 1-year mortality than those free from hospital readmission. In conclusion, although in-hospital mortality and LOS after PCI have decreased over time, the observed 30-day cardiac readmission rate was highly variable and risk of readmission was more closely associated with underlying patient characteristics than procedural characteristics.

Abstract 299: Association of Chronic Lung Disease with Treatments and Outcomes of Acute Coronary Syndromes: Results from the NCDR®

Background: Previous reports are conflicting regarding outcomes, treatments, and processes of care after acute myocardial infarction (MI) for patients with chronic lung disease (CLD).

Methods: Using the NCDR ACTION Registry ® -GWTG ™ (AR-G), demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after NSTEMI and STEMI were compared between patients with (n= 22,624; 14.2%) and without (n= 136,266; 85.8%) CLD. CLD was defined by a history of COPD, chronic bronchitis, or emphysema. Multivariable adjustment using published AR-G in-hospital mortality and major bleeding risk adjustment models was performed to quantify the impact of CLD on treatments and outcomes.

Results: CLD was present in 10.1% of STEMI patients and 17.0% of NSTEMI patients. In both STEMI and NSTEMI, CLD patients were older, more likely to be female, and had more comorbidities including diabetes, renal disease, prior MI and heart failure, compared to those without CLD. Although on admission CLD patients were more likely to be on cardiovascular medications, by discharge slightly fewer CLD patients received composite core measures (aspirin, beta-blockers, ACE-inhibitors, and statins) (table). In NSTEMI, CLD was also associated with less use of invasive procedures and with increased risk of both death and major bleeding. In STEMI, major bleeding but not mortality was increased.

Conclusions: CLD is a common comorbidity and is independently associated with an increased risk for major bleeding after MI. In NSTEMI, CLD is also associated with receiving fewer evidence-based medications, less timely angiography and revascularization, and increased in-hospital mortality. Close attention should be given to this high-risk subgroup for the prevention and management of bleeding complications after MI, and further investigation is needed to determine the reasons for treatment and outcome disparities in NSTEMI.

Comparison of three age groups regarding safety and efficacy of drug-eluting stents (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Limited data exist regarding drug-eluting stent (DES) versus bare metal stent (BMS) use in older patients. From the National Heart, Lung, and Blood Institute Dynamic Registry, 5,089 percutaneous coronary intervention (PCI)-treated patients were studied (October 2001 to August 2006). The differences in 1-year safety (death, myocardial infarction, and their composite) and efficacy (target vessel revascularization [TVR] with PCI and repeat revascularization) outcomes were compared between the patients who received DESs versus BMSs within each age group: <65 years (n = 2,680); 65 to 79 years (n = 1,942); ≥80 years (n = 443). No differences were found in the safety outcomes by stent type in any age group at 1 year. Regarding the effectiveness, lower rates of TVR with PCI and repeat revascularization were observed in the DES patients across all age groups. After propensity-adjusted analysis, the risk of TVR with PCI and repeat revascularization favored DES versus BMS with patients <65 years old (7.4% vs 14.6%, hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.32 to 0.60; 12.3% vs and 17.4%, HR 0.65, 95% CI 0.51 to 0.84, respectively), 65 to 79 years old (4.8% vs 9.5%, HR 0.50, 95% CI 0.31 to 0.80; and 7.6% vs 12.3%, HR 0.62, 95% CI 0.44 to 0.88, respectively), and ≥80 years old (4.5% vs 10.4%, HR 0.15, 95% CI 0.05 to 0.44; and 6.0% vs 14.5%, HR 0.18, 95% CI 0.08 to 0.40, respectively). In conclusion, significant reductions in TVR with PCI and repeat revascularization were noted in all 3 age groups without increases in death or myocardial infarction in this large multicenter PCI registry. Our data support the use of DES, regardless of age.

Outcomes of small coronary artery stenting with bare-metal stents versus drug-eluting stents: results from the NHLBI Dynamic Registry

OBJECTIVES

Examine 1-year outcomes of patients with small coronary arteries in the National Heart, Lung, and Blood Institute Dynamic Registry (NHLBI) undergoing drug-eluting stent (DES) vs. bare-metal stent (BMS) placement.

BACKGROUND

While randomized trials of DES vs. BMS demonstrate reduced target vessel revascularization, it is unclear whether similar outcomes are seen in unselected patients after percutaneous coronary intervention (PCI) for small coronary arteries.

METHODS

Utilizing patients from the NHLBI Registry Waves 1-3 for BMS (1997-2002) and Waves 4-5 for DES (2004 and 2006), demographic, angiographic, in-hospital, and 1-year outcome data of patients with small coronary arteries treated with BMS (n = 686) vs. DES (n = 669) were evaluated. Small coronary artery was defined as 2.50-3.00 mm in diameter.

RESULTS

Compared to BMS-treated patients, the mean lesion length of treated lesions was longer in the DES treated group (16.7 vs. 13.1 mm, P < 0.001) and the mean reference vessel size of attempted lesions was smaller (2.6 vs. 2.7 mm, P < 0.001). Adjusted analyses of 1-year outcomes revealed that DES patients were at lower risk to undergo coronary artery bypass graft surgery (Hazard Ratio [HR] 0.40, 95% confidence interval [CI] 0.17-0.95, P = 0.04), repeat PCI (HR 0.53, 95% CI 0.35-0.82, P = 0.004), and experience the combined major adverse cardiovascular event rate (HR 0.59, 95% CI 0.42-0.83, P = 0.002). There was no difference in the risk of death and myocardial infarction (MI) (HR 0.78, 95% CI 0.46-1.35, P = 0.38).

CONCLUSIONS

In this real-world registry, patients with small coronary arteries treated with DES had significantly lower rates of repeat revascularization and major adverse cardiovascular events at 1 year compared to patients treated with BMS, with no increase in the risk of death and MI. These data confirm the efficacy and safety of DES over BMS in the treatment of small coronary arteries in routine clinical practice.

Increased adverse events after percutaneous coronary intervention in patients with COPD: insights from the National Heart, Lung, and Blood Institute dynamic registry

BACKGROUND

Previous studies have demonstrated that patients with COPD are at higher risk for death after percutaneous coronary intervention (PCI), but other clinical outcomes and possible associations with adverse events have not been described.

METHODS

Using waves 1 through 5 (1999-2006) of the National Heart, Lung, and Blood Institute Dynamic Registry, patients with COPD (n = 860) and without COPD (n = 10,048) were compared. Baseline demographics, angiographic characteristics, and in-hospital and 1-year adverse events were compared.

RESULTS

Patients with COPD were older (mean age 66.8 vs 63.2 years, P < .001), more likely to be women, and more likely to have a history of diabetes, prior myocardial infarction, peripheral arterial disease, renal disease, and smoking. Patients with COPD also had a lower mean ejection fraction (49.1% vs 53.0%, P < .001) and a greater mean number of significant lesions (3.2 vs 3.0, P = .006). Rates of in-hospital death (2.2% vs 1.1%, P = .003) and major entry site complications (6.6% vs 4.2%, P < .001) were higher in pulmonary patients. At discharge, pulmonary patients were significantly less likely to be prescribed aspirin (92.4% vs 95.3%, P < .001), β-blockers (55.7% vs 76.2%, P < .001), and statins (60.0% vs 66.8%, P < .001). After adjustment, patients with COPD had significantly increased risk of death (hazard ratio [HR] = 1.30, 95% CI = 1.01-1.67) and repeat revascularization (HR = 1.22, 95% CI = 1.02-1.46) at 1 year, compared with patients without COPD.

CONCLUSIONS

COPD is associated with higher mortality rates and repeat revascularization within 1 year after PCI. These higher rates of adverse outcomes may be associated with lower rates of guideline-recommended class 1 medications prescribed at discharge.

Clinical implications of the BARI 2D and COURAGE trials: the evolving role of percutaneous coronary intervention

This review outlines the evolving role of percutaneous coronary intervention (PCI) for stable angina in the context of the widely discussed Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trials. Factors outlined include defining the appropriate patient population, the clinical circumstances, and the technical aspects of the procedure to optimize clinical outcomes and minimize risk. The COURAGE Trial, as others reported earlier, reported no difference in death or myocardial infarction with PCI compared with medical therapy for stable angina. In patients with type 2 diabetes mellitus in the BARI 2D Trial, a strategy of revascularization with coronary artery bypass graft surgery (CABG) or PCI resulted in no difference in mortality compared with optimal medical therapy. However, PCI for stable angina was associated with reduced angina and improved quality of life. Procedural aspects of PCI that support its continuing role in the management of patients with stable angina include the frequent advancements in PCI technology that have further enhanced both acute and long-term success. In conclusion, the implications of these findings for clinical practice include evaluating the use of PCI for stable angina in addition to optimal medical therapy to reduce angina and improve quality of life, but individualizing care for higher risk patients with more complex coronary artery disease who were not enrolled in the COURAGE and BARI 2D trials.

Temporal changes in the outcomes of patients with diabetes mellitus undergoing percutaneous coronary intervention in the National Heart, Lung, and Blood Institute dynamic registry

BACKGROUND

Patients with diabetes mellitus (DM) are at higher risk for adverse outcomes following percutaneous coronary intervention (PCI).

METHODS

To determine whether outcomes have improved over time, we analyzed data from 2,838 consecutive patients with medically treated DM, including 1,066 patients (37.6%) treated with insulin, in the National Heart, Lung, and Blood Institute Dynamic Registry undergoing PCI registered in waves 1 (1997-1998), 2 (1999), 3 (2001-2002), 4 (2004), and 5 (2006). We compared baseline demographics and 1-year outcomes in the overall cohort and in analyses stratified by recruitment wave and insulin use.

RESULTS

Crude mortality rates by chronological wave were 9.5%, 12.5%, 8.9%, 11.6%, and 6.6% (P value(trend) = .33) among those treated with insulin and, respectively, 9.7%, 6.5%, 4.1%, 5.4%, and 4.7% (P value(trend) = .006) among patients treated with oral agents,. The adjusted hazard ratios of death, myocardial infarction (MI), and overall major adverse cardiovascular events (death, MI, revascularization) in insulin-treated patients with DM in waves 2 to 5 as compared with wave 1 were either higher or the same. In contrast, the similar adjusted hazard ratios for oral agent-treated patients with DM were either similar or lower.

CONCLUSIONS

Significant improvements over time in adverse events by 1 year were detected in patients with DM treated with oral agents. In insulin-treated diabetic patients, despite lower rates of repeat revascularization over time, death and MI following PCI have not significantly improved. These findings underscore the need for continued efforts at optimizing outcomes among patients with DM undergoing PCI, especially those requiring insulin treatment.

Evolution of percutaneous coronary intervention in patients with diabetes: a report from the National Heart, Lung, and Blood Institute-sponsored PTCA (1985-1986) and Dynamic (1997-2006) Registries

OBJECTIVE

To evaluate the association of successive percutaneous coronary intervention (PCI) modalities with balloon angioplasty (BA), bare-metal stent (BMS), drug-eluting stents (DES), and pharmacotherapy over the last 3 decades with outcomes among patients with diabetes in routine clinical practice.

RESEARCH DESIGN AND METHODS

We examined outcomes in 1,846 patients with diabetes undergoing de novo PCI in the multicenter, National Heart, Lung, and Blood Institute-sponsored 1985-1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry and 1997-2006 Dynamic Registry. Multivariable Cox regression models were used to estimate the adjusted risk of events (death/myocardial infarction [MI], repeat revascularization) over 1 year.

RESULTS

Cumulative event rates for postdischarge (31-365 days) death/MI were 8% by BA, 7% by BMS, and 7% by DES use (P = 0.76) and for repeat revascularization were 19, 13, and 9% (P < 0.001), respectively. Multivariable analysis showed a significantly lower risk of repeat revascularization with DES use when compared with the use of BA (hazard ratio [HR] 0.41 [95% CI 0.29-0.58]) and BMS (HR 0.55 [95% CI 0.39-0.76]). After further adjustment for discharge medications, the lower risk for death/MI was not statistically significant for DES when compared with BA.

CONCLUSIONS

In patients with diabetes undergoing PCI, the use of DES is associated with a reduced need for repeat revascularization when compared with BA or BMS use. The associated death/MI benefit observed with the DES versus the BA group may well be due to greater use of pharmacotherapy.

Paclitaxel-eluting versus sirolimus-eluting stents in diabetes mellitus: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

BACKGROUND

Diabetes is a powerful predictor of adverse events in patients undergoing percutaneous coronary intervention. Drug-eluting stents reduce restenosis rates compared with bare metal stents; however, controversy remains regarding which drug-eluting stents provides greater benefit in patients with diabetes. Accordingly, we compared the safety and efficacy of sirolimus-eluting stents (SES) with paclitaxel-eluting stents (PES) among diabetic patients in a contemporary registry.

METHODS AND RESULTS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 2-year outcomes of diabetic patients undergoing percutaneous coronary interventions with SES (n=677) and PES (n=328). Clinical and demographic characteristics, including age, body mass index, insulin use, left ventricular function, and aspirin/clopidogrel use postprocedure, did not differ significantly between the groups except that PES-treated patients had a greater frequency of hypertension and hyperlipidemia. At the 2-year follow-up, no significant differences were observed between PES and SES with regard to safety or efficacy end points. PES- and SES-treated patients had similar rates of death (10.7% versus 8.2%, P=0.20), death and myocardial infarction (14.9% versus 13.6%, P=0.55), repeat revascularization (14.8% versus 17.8%, P=0.36), and stent thrombosis (1.3% versus 1.3%, P=0.95). After adjustment, no significant differences between the 2 stent types in any outcome were observed.

CONCLUSIONS

PES and SES are equally efficacious and have similar safety profiles in diabetic patients undergoing percutaneous coronary interventions in clinical practice.

Association of a unique cardiovascular risk profile with outcomes in Hispanic patients referred for percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Although previous studies have demonstrated that Hispanic patients have a higher cardiovascular risk profile than Caucasians and present at a younger age for percutaneous coronary intervention (PCI), limited studies exist examining the outcomes of Hispanics after PCI and potential explanations for differences noted. Using patients from the National Heart, Lung, and Blood Institute Dynamic Registry waves 1 to 5 (1997 to 2006), demographic features, angiographic data, and 1-year outcomes of Hispanic patients (n = 542) versus Caucasian patients (n = 1,357) undergoing PCI were evaluated. Compared to Caucasians, Hispanic patients were younger and had more hypertension and diabetes mellitus, including more insulin-treated diabetes mellitus. Although mean lesion length was longer in Hispanics (15.4 vs 14.1 mm, p <0.001), there were no differences in the number of significant lesions or in the use of drug-eluting stents. At follow-up, Hispanics were more likely to report recent anginal symptoms but had a similar incidence of 1-year hospitalizations for angina. Adjusted 1-year hazard ratios for adverse events for Hispanics versus Caucasians revealed lower rates of coronary artery bypass graft surgery (hazard ratio 0.43, confidence interval 0.22 to 0.85, p = 0.02) and a trend toward lower rates of repeat revascularization (hazard ratio 0.76, confidence interval 0.57 to 1.03, p = 0.08). In conclusion, despite the presence of diabetes in almost 50% of Hispanic patients and longer lesions than in Caucasians, Hispanic patients were less likely to undergo coronary artery bypass graft surgery 1 year after PCI and had a trend toward lower rates of repeat revascularization.

Impact of drug-eluting stents among insulin-treated diabetic patients: a report from the National Heart, Lung, and Blood Institute Dynamic Registry

OBJECTIVES

This study sought to evaluate the safety and efficacy of drug-eluting stents (DES) compared with bare-metal stents (BMS) in patients with insulin- and noninsulin-treated diabetes.

BACKGROUND

Diabetes is a powerful predictor of adverse events after percutaneous coronary interventions (PCI), and insulin-treated diabetic patients have worse outcomes. The DES are efficacious among patients with diabetes; however, their safety and efficacy, compared with BMS, among insulin-treated versus noninsulin-treated diabetic patients is not well established.

METHODS

Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated 1-year outcomes of insulin-treated (n = 817) and noninsulin-treated (n = 1,749) patients with diabetes who underwent PCI with DES versus BMS.

RESULTS

The use of DES, compared with BMS, was associated with a lower risk for repeat revascularization for both noninsulin-treated patients (adjusted hazard ratio [HR] = 0.59, 95% confidence interval [CI] 0.45 to 0.76) and insulin-treated subjects (adjusted HR = 0.63, 95% CI 0.44 to 0.90). With respect to safety in the overall diabetic population, DES use was associated with a reduction of death or myocardial infarction (adjusted HR = 0.75, 95% CI 0.58 to 0.96). However, this benefit was confined to the population of noninsulin-treated patients (adjusted HR = 0.57, 95% CI 0.41 to 0.81). Among insulin-treated patients, there was no difference in death or myocardial infarction risk between DES- and BMS-treated patients (adjusted HR = 0.95, 95% CI 0.65 to 1.39).

CONCLUSIONS

Drug-eluting stents are associated with lower risk for repeat revascularization compared with BMS in treating coronary artery disease among patients with either insulin- or noninsulin-treated diabetes. In addition, DES use is not associated with any significant increased safety risk compared with BMS. These findings suggest that DES should be the preferred strategy for diabetic patients.

A comparison of bare-metal and drug-eluting stents for off-label indications

BACKGROUND

Recent reports suggest that off-label use of drug-eluting stents is associated with an increased incidence of adverse events. Whether the use of bare-metal stents would yield different results is unknown.

METHODS

We analyzed data from 6551 patients in the National Heart, Lung, and Blood Institute Dynamic Registry according to whether they were treated with drug-eluting stents or bare-metal stents and whether use was standard or off-label. Patients were followed for 1 year for the occurrence of cardiovascular events and death. Off-label use was defined as use in restenotic lesions, lesions in a bypass graft, left main coronary artery disease, or ostial, bifurcated, or totally occluded lesions, as well as use in patients with a reference-vessel diameter of less than 2.5 mm or greater than 3.75 mm or a lesion length of more than 30 mm.

RESULTS

Off-label use occurred in 54.7% of all patients with bare-metal stents and 48.7% of patients with drug-eluting stents. As compared with patients with bare-metal stents, patients with drug-eluting stents had a higher prevalence of diabetes, hypertension, renal disease, previous percutaneous coronary intervention and coronary-artery bypass grafting, and multivessel coronary artery disease. One year after intervention, however, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with drug-eluting stents as compared with those with bare-metal stents, whereas the risk of repeat revascularization was significantly lower among patients with drug-eluting stents.

CONCLUSIONS

Among patients with off-label indications, the use of drug-eluting stents was not associated with an increased risk of death or myocardial infarction but was associated with a lower rate of repeat revascularization at 1 year, as compared with bare-metal stents. These findings support the use of drug-eluting stents for off-label indications.

Value of vasodilator stress myocardial contrast echocardiography and magnetic resonance imaging for the differential diagnosis of ischemic versus nonischemic cardiomyopathy

OBJECTIVE

Noninvasive differentiation of ischemic versus nonischemic cardiomyopathy (CM) remains challenging because of the low specificity of imaging-based tests in these patients. We hypothesized that myocardial contrast echocardiography (MCE) and cardiac magnetic resonance (CMR), combined with vasodilator stress, could provide accurate alternatives for determining the cause of CM.

METHODS

To allow side-by-side comparisons between these techniques with coronary angiography as a reference, we studied 16 patients referred for coronary angiography after abnormal nuclear perfusion studies. Both MCE and CMR images were acquired within 48 hours with infusion of adenosine. MCE included flash-echo imaging during intravenous infusion of echocardiographic contrast solution. CMR included gadolinium injections for first-pass perfusion and delayed enhancement imaging. MCE and CMR images were reviewed by experienced investigators, blinded to the findings of the other modality and angiography. For each technique, each myocardial segment was classified as normal or abnormal. Sensitivity and specificity of each technique were calculated against the angiography reference. These calculations were also performed using a perfusion territory as a unit of analysis.

RESULTS

Six of 16 patients had normal coronary arteries, and three patients had stenosis < 50%. By using this threshold for abnormal perfusion, segment-by-segment comparisons with angiography resulted in sensitivity of 0.88, 0.61, and 0.71 and specificity of 0.74, 0.86, and 0.94 for CMR perfusion, delayed enhancement scans, and MCE sequences, respectively. Using stenosis > 70% as a threshold resulted in a small decrease in both sensitivity and specificity (0.02-0.04) for all three techniques. Analysis of the ability of these techniques to detect an abnormality in at least one perfusion territory yielded sensitivity of 1.00, 1.00, and 0.86 and specificity of 0.78, 0.78, and 0.89, correspondingly, which were threshold-independent.

CONCLUSIONS

Both CMR and MCE perfusion imaging may be used to differentiate between ischemic and nonischemic CM. These emerging diagnostic tools may prove useful in strategizing treatment in these patients and thus avoiding unnecessary invasive procedures.

Effects of heart failure and diabetes mellitus on long-term mortality after coronary revascularization (from the BARI Trial)

This study evaluated the effect of heart failure (HF) and ejection fraction (EF) at baseline on long-term cardiac mortality in patients undergoing coronary revascularization and investigated the effect of diabetes mellitus (DM) on mortality. We evaluated long-term outcomes of patients without HF, HF and a preserved EF, and HF and a decreased EF who underwent revascularization with percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery after enrollment in the Bypass Angioplasty Revascularization Investigation (BARI) trial. Ten years after initial revascularization, cumulative rates of freedom from cardiac death were 90% in patients without HF, 75% in patients with HF and a preserved EF, and 59% in patients with HF and a decreased EF (p <0.001, 3-way comparison). In diabetic patients with HF and a preserved EF, there was a significant increase in cardiac mortality compared with patients without HF (p <0.001); however, this relation was not seen in patients without DM. In conclusion, patients with HF and a preserved EF have increased mortality over 10 years compared with those without HF. Only in patients with DM did HF with preserved EF confer additional risk.

Effect of gender on prognosis following percutaneous coronary intervention for stable angina pectoris and acute coronary syndromes

Women with non-ST-elevation acute coronary syndromes (NSTACSs) may have better outcomes than men, but the effect of NSTACSs in women undergoing percutaneous coronary intervention (PCI) has not been examined. We performed a prospective, multicenter, cohort study of consecutive patients who underwent PCI for NSTACS and stable angina during 3 National Heart, Lung, and Blood Institute Dynamic Registry recruitment waves (1997 to 2002) to examine the effect of female gender on adverse clinical events after PCI or stable angina for NSTACS. The primary end point was the combined rate of death, myocardial infarction, or rehospitalization for cardiac causes at 1 year. Compared with men with NSTACS (n = 2,124), women (n = 1,338) were older and more often had hypertension, diabetes mellitus, and history of heart failure (p <0.001 for all), whereas multivessel disease was less frequent (p <0.01). Procedural success and in-hospital adverse event rates were similar. Women with NSTACS had the highest 1-year rate of death/myocardial infarction/cardiac rehospitalization compared with women with stable angina pectoris (n = 462) or men (n = 995; women with NSTACS 37.6%, men with NSTACS 29.8%, women with stable angina 29.4%, men with stable angina 27.7%, p <0.001). The higher rate remained after adjustment for differences in baseline characteristics (adjusted hazard ratio 1.37, 95% confidence interval 1.20 to 1.56). Among women, NSTACS conferred a significantly higher risk for adverse events compared with stable angina (adjusted hazard ratio 1.41, p = 0.001), whereas the risk of adverse events was not different in men (adjusted hazard ratio 1.05, p = 0.5). In conclusion, women undergoing PCI for NSTACS have a higher risk of major adverse cardiac events than men or women undergoing PCI for stable angina.

The impact of ejection fraction on outcomes after percutaneous coronary intervention in patients with congestive heart failure: an analysis of the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry and Dynamic Registry

BACKGROUND

Patients with congestive heart failure (CHF) have higher rates of adverse outcomes after percutaneous coronary intervention (PCI). A comprehensive analysis of outcomes in patients with CHF in the current era has not been done. We studied the outcomes of patients with CHF who underwent PCI in the National Heart, Lung, and Blood Institute-sponsored Percutaneous Transluminal Coronary Angioplasty (PTCA) and Dynamic registries.

METHODS

We evaluated demographic and angiographic characteristics and the clinical outcomes of patients with CHF in the Dynamic Registry and the PTCA Registry, excluding patients with acute myocardial infarction. In the Dynamic Registry, patients with CHF (n = 503) were compared with patients without CHF (n = 4194), and patients with CHF with a preserved ejection fraction (EF) (n = 134) were compared with patients with CHF who have a reduced EF (n = 199). The patients with CHF in the 1997 through 2001 Dynamic Registry (n = 236) were then similarly compared with patients with CHF in the earlier PTCA Registry (n = 117).

RESULTS

In the Dynamic Registry, compared with patients without CHF, patients with CHF had a higher-risk clinical and angiographic profile, and a higher mortality rate both inhospital (2.6% vs 0.4%, P < or = .001) and at 1 year (13.1% vs 3.0%, P < .001). Patients with reduced EF had higher inhospital mortality rates and a trend toward higher mortality at 1 year. The patients with CHF in the Dynamic Registry compared with those in the PTCA Registry had a higher risk profile yet had significantly higher procedural success rates and improved clinical outcomes.

CONCLUSIONS

Although CHF remains a strong predictor of adverse outcomes after PCI, significant improvement seen in the past decade is likely related to improved procedural techniques and improved medical therapy.

Percutaneous coronary intervention in women

Cardiovascular disease is currently the leading cause of death in women in the United States, but many women underestimate this risk. The treatment of coronary syndromes with percutaneous coronary intervention (PCI) has increased steadily in the past decade, but women referred for PCI have a different profile of demographic features and clinical presentation than do their male counterparts. Concern has been raised about sex discrepancy in referral of women for invasive cardiology procedures. This may have resulted from the outcomes of initial studies of balloon angioplasty, which demonstrated decreased success and increased risk of angioplasty in women compared with men. However, more recent data have shown no sex difference in outcomes with contemporary PCI practices. Additionally, primary PCI for acute myocardial infarction in women is associated with improved mortality in women when compared to thrombolytic therapy. This review will examine the sex differences in demographics and outcomes of women undergoing PCI.

Glycoprotein IIb/IIIa inhibitors in acute ST segment elevation myocardial infarction

Limitations in the standard treatment of acute myocardial infarction have focused attention on inhibition of platelet activity by its final common pathway of activation, the glycoprotein IIb/IIIa receptor. Animal studies have suggested that a glycoprotein IIb/IIIa inhibitor could accelerate thrombolysis and prevent reocclusion after successful thrombolysis. Studies evaluating the use of a glycoprotein IIb/IIIa inhibitor alone without thrombolysis or percutaneous transluminal coronary revascularization do not suggest that isolated use of glycoprotein IIb/IIIa inhibitors restores TIMI 3 flow in a sufficient proportion of patients. Clinical studies evaluating the combination of thrombolytic therapy and glycoprotein IIb/IIIa inhibitors appear most promising, with evidence of improved angiographic outcomes. Reducing the dose of thrombolytic agents may result in reduction in bleeding risk. Current and future trials will investigate reduced-dose reteplase with abciximab and eptifibatide with reduced-dose alteplase. Available evidence suggests that glycoprotein IIb/IIIa inhibition may facilitate thrombolysis, thus adding a new element to future reperfusion regimens.