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Gonzalez-Manzanares R, Carmona-Artime L, Ruiz-Moreno M, Perea-Armijo J, Piserra A, Rodriguez-Nieto J, Flores G, Pericet-Rodriguez C, Ojeda S, Hidalgo FJ, Suarez De Lezo J, Mazuelos F, Segura JM, Romero M, Pan M. Association between distance to tertiary hospital and cardiovascular outcomes in coronary artery disease patients. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The impact of distance from residence to Tertiary Referral Hospital and cardiovascular (CV) outcomes in patients with coronary artery disease (CAD) is unknow. Despite longer travel distances hinder access to healthcare and may worsen CV outcomes, we hypothesize that Mediterranean lifestyle and behaviors in distant rural areas may be associated with a reduced risk of CV death and events.
Purpose
To investigate the association between travel distance to Tertiary Hospital and mid-term cardiovascular outcomes in a population of CAD patients in Southern Spain.
Methods
Retrospective study including all patients discharged after percutaneous coronary intervention (PCI) at a high-volume center in Southern Spain during 2018. Those belonging to another healthcare area were excluded. One-way driving distances from residence to hospital were computed using Google Maps Distance Matrix API with R package “gmapsdistance”. Patients were stratified into tertiles according to travel distance (short, STD; intermediate, ITD; and long, LTD). Kaplan-Meier (KM) and Multivariable Cox regression (adjusted for age, sex, atrial fibrillation, cancer history, prior revascularization and clinical presentation) were used to assess the impact of travel distance on CV death and a composite outcome of MACE (Myocardial Infarction, unplanned PCI and CV death).
Results
Of 1005 patients discharged after PCI during the study period, 966 met the selection criteria. Flowchart and baseline characteristics by distance groups are presented in Figure 1. Median travel distance tertiles were 6.1 (STD), 41.7 (ITD) and 78.4 (LTD). During a median follow-up of 31 (IQR 28–35) months, 50 cardiovascular deaths [STD 27 (8.4%), ITD 13 (4%), LTD 10 (3.1%), p=0.006)] and 63 MACE occurred [STD 45 (13.9%), ITD 37 (11.5%), LTD 26 (8.1%), p=0.060)]. KM curves for the three distance groups are shown in Figure 2. In univariable and multivariable Cox models, longer travel distances were associated with better outcomes, as for every 10 Km increase, there was a 11% and 7% decrease in the hazards of CV death (HR adj: 0.89, CI 0.82–0.98, p=0.029) and of MACE (HR adj: 0.93, CI 0.87–0.99, p=0.025), respectively.
Conclusion
Travel distance was inversely associated with CV events in a population of CAD patients in Southern Spain. Patients in the first tertile of distance had a higher rate of CV death. Multicenter studies involving other Mediterranean regions are needed to confirm these findings and to look for explanations.
Funding Acknowledgement
Type of funding sources: None. Flowchart and baseline characteristicsSurvival curves by distance groups
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Affiliation(s)
| | | | | | | | - A Piserra
- University Hospital Reina Sofia, Cordoba, Spain
| | | | - G Flores
- University Hospital Reina Sofia, Cordoba, Spain
| | | | - S Ojeda
- University Hospital Reina Sofia, Cordoba, Spain
| | - F J Hidalgo
- University Hospital Reina Sofia, Cordoba, Spain
| | | | - F Mazuelos
- University Hospital Reina Sofia, Cordoba, Spain
| | - J M Segura
- University Hospital Reina Sofia, Cordoba, Spain
| | - M Romero
- University Hospital Reina Sofia, Cordoba, Spain
| | - M Pan
- University Hospital Reina Sofia, Cordoba, Spain
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Gonzalez-Manzanares R, Hidalgo FJ, Ojeda S, Piserra A, Perea-Armijo J, Rodriguez-Nieto J, Flores G, Suarez De Lezo J, Benito-Gonzalez T, Gutierrez-Barrios A, De La Torre JM, Mazuelos F, Segura JM, Romero M, Pan M. Instantaneous wave-free ratio for the assessment of nonculprit lesions in patients with acute coronary syndrome. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
A physiological assessment with the fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is strongly recommended by the European Guidelines of Revascularization to guide percutaneous coronary intervention (PCI) decision making in intermediate coronary stenosis. However, data supporting its use in the pro-inflammatory setting of ACS is weak.
Purpose
To analyze the usefulness of a physiological coronary evaluation with iFR of nonculprit lesions in patients with ACS.
Methods
Retrospective multicenter study including patients with ACS and underwent successful revascularization of the culprit vessel and had other nonculpritlesions physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, stent thrombosis and new revascularization (MACEs).
Results
A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66±11 years. The clinical presentation was non-ST-segment elevation myocardial infarction (NSTEMI) in 235 patients and ST-segment elevation myocardial infarction (STEMI) in 121 patients. After a mean follow-up period of 22±10 months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion deferred for revascularization, 10.5 vs 8.4%, p=0.476).
Conclusion
The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be safe, with an acceptable percentage of MACEs at the mid-term follow-up.
Funding Acknowledgement
Type of funding sources: None. FlowchartSurvival curves by iFR and ACS group
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Affiliation(s)
| | - F J Hidalgo
- University Hospital Reina Sofia, Cordoba, Spain
| | - S Ojeda
- University Hospital Reina Sofia, Cordoba, Spain
| | - A Piserra
- University Hospital Reina Sofia, Cordoba, Spain
| | | | | | - G Flores
- University Hospital Reina Sofia, Cordoba, Spain
| | | | - T Benito-Gonzalez
- Hospital of Leon (Complejo Asistencial Universitario de Leon), Leon, Spain
| | | | | | - F Mazuelos
- University Hospital Reina Sofia, Cordoba, Spain
| | - J M Segura
- University Hospital Reina Sofia, Cordoba, Spain
| | - M Romero
- University Hospital Reina Sofia, Cordoba, Spain
| | - M Pan
- University Hospital Reina Sofia, Cordoba, Spain
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