1
|
Kovach CP, Valle JA, Waldo SW. Reply: Pitfalls of Simplifying the Original SYNTAX Score: A Temptation That Should Be Resisted. JACC Cardiovasc Interv 2023; 16:1004. [PMID: 37100550 DOI: 10.1016/j.jcin.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 04/28/2023]
|
2
|
Swat SA, Hebbe A, Plomondon ME, Park KE, Bricker RS, Waldo SW, Valle JA. Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circ Cardiovasc Qual Outcomes 2023; 16:e008949. [PMID: 36722336 PMCID: PMC10033351 DOI: 10.1161/circoutcomes.122.008949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 12/16/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system. METHODS We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates. RESULTS Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]). CONCLUSIONS Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.
Collapse
Affiliation(s)
- Stanley A. Swat
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO
| | - Annika Hebbe
- Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Mary E. Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Ki E. Park
- Malcom Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Rory S. Bricker
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO
| | - Stephen W. Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO
- Rocky Mountain Regional VA Medical Center, Aurora, CO
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Javier A. Valle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO
- Rocky Mountain Regional VA Medical Center, Aurora, CO
- Michigan Heart and Vascular Institute, Ann Arbor, MI
| |
Collapse
|
3
|
Kovach CP, Hebbe A, Glorioso TJ, Barrett C, Barón AE, Mavromatis K, Valle JA, Waldo SW. Association of Residual Ischemic Disease With Clinical Outcomes After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022; 15:2475-2486. [PMID: 36543441 DOI: 10.1016/j.jcin.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anatomical scoring systems have been used to assess completeness of revascularization but are challenging to apply to large real-world datasets. OBJECTIVES The aim of this study was to assess the prevalence of complete revascularization and its association with longitudinal clinical outcomes in the U.S. Department of Veterans Affairs (VA) health care system using an automatically computed anatomic complexity score. METHODS Patients undergoing percutaneous coronary intervention (PCI) between October 1, 2007, and September 30, 2020, were identified, and the burden of prerevascularization and postrevascularization ischemic disease was quantified using the VA SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score. The association between residual VA SYNTAX score and long-term major adverse cardiovascular events (MACE; death, myocardial infarction, repeat revascularization, and stroke) was assessed. RESULTS A total of 57,476 veterans underwent PCI during the study period. After adjustment, the highest tertile of residual VA SYNTAX score was associated with increased hazard of MACE (HR: 2.06; 95% CI: 1.98-2.15) and death (HR: 1.50; 95% CI: 1.41-1.59) at 3 years compared to complete revascularization (residual VA SYNTAX score = 0). Hazard of 1- and 3-year MACE increased as a function of residual disease, regardless of baseline disease severity or initial presentation with acute or chronic coronary syndrome. CONCLUSIONS Residual ischemic disease was strongly associated with long-term clinical outcomes in a contemporary national cohort of PCI patients. Automatically computed anatomic complexity scores can be used to assess the longitudinal risk for residual ischemic disease after PCI and may be implemented to improve interventional quality.
Collapse
Affiliation(s)
- Christopher P Kovach
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Annika Hebbe
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Thomas J Glorioso
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Christopher Barrett
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Anna E Barón
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | | | - Javier A Valle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA; Michigan Heart and Vascular Institute, Ann Arbor, Michigan, USA
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA; Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA.
| |
Collapse
|
4
|
Chambers JW, Martinsen BJ, Sturm RC, Mandair D, Valle JA, Waldo SW, Guzzetta F, Armstrong EJ. Orbital atherectomy of calcified coronary ostial lesions. Catheter Cardiovasc Interv 2022; 100:553-559. [PMID: 35989487 DOI: 10.1002/ccd.30369] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To evaluate the feasibility and safety of coronary orbital atherectomy (OA) for the treatment of calcified ostial lesions. BACKGROUND Percutaneous coronary intervention (PCI) is increasingly being completed in complex patients and lesions. OA is effective for severely calcified coronary lesions; however, there is a dearth of evidence on the use of OA in ostial lesions, especially with long-term outcome data. METHODS Data were obtained from a retrospective analysis of patients who underwent OA of heavily calcified ostial lesions followed by stent implantation from December 2010 to June 2019 at two high-volume PCI centers. Kaplan-Meier analysis was utilized to assess the primary endpoints of 30-day, 1-year, and 2-year freedom-from (FF) major adverse cardiac events (MACE: death, myocardial infarction, or target vessel revascularization), stroke, and stent thrombosis (ST). RESULTS A total of 56 patients underwent OA to treat heavily calcified ostial coronary lesions. The mean age was 72 years with a high prevalence of diabetes (55%) and heart failure (36%), requiring hemodynamic support (14%). There was high FF angiographic complications (93%), and at 30-day, 1-year, and 2-year, a high FF-MACE (96%, 91%, and 88%), stroke (98%, 96%, and 96%), and ST (100%), respectively. CONCLUSIONS This study represents the largest real-world experience of coronary OA use in heavily calcified ostial lesions with long-term outcomes over 2 years. The main finding in this retrospective analysis is that, despite the complex patients and lesions included in this analysis, OA appears to be a feasible and safe treatment option for calcified coronary ostial lesions.
Collapse
Affiliation(s)
- Jeffrey W Chambers
- Metropolitan Heart and Vascular Institute, Mercy Hospital, Minneapolis, Minnesota, USA.,Clinical & Medical Affairs, Cardiovascular Systems Inc., St. Paul, Minnesota, USA
| | - Brad J Martinsen
- Clinical & Medical Affairs, Cardiovascular Systems Inc., St. Paul, Minnesota, USA
| | - Robert C Sturm
- Denver VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - Divneet Mandair
- Denver VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - Javier A Valle
- Denver VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - Stephen W Waldo
- Denver VA Medical Center, University of Colorado, Denver, Colorado, USA
| | - Francesca Guzzetta
- Metropolitan Heart and Vascular Institute, Mercy Hospital, Minneapolis, Minnesota, USA
| | - Ehrin J Armstrong
- Denver VA Medical Center, University of Colorado, Denver, Colorado, USA.,Adventist Health and Vascular Institute, Adventist Health, St. Helena, California, USA
| |
Collapse
|
5
|
Azzalini L, Seth M, Sukul D, Valle JA, Daher E, Wanamaker B, Tucciarone MT, Zaitoun A, Madder RD, Gurm HS. Trends and outcomes of percutaneous coronary intervention during the COVID-19 pandemic in Michigan. PLoS One 2022; 17:e0273638. [PMID: 36156591 PMCID: PMC9512204 DOI: 10.1371/journal.pone.0273638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/12/2022] [Indexed: 11/20/2022] Open
Abstract
Background The COVID-19 pandemic has severely impacted healthcare delivery and patient outcomes globally. Aims We aimed to evaluate the influence of the COVID-19 pandemic on the temporal trends and outcomes of patients undergoing percutaneous coronary intervention (PCI) in Michigan. Methods We compared all patients undergoing PCI in the BMC2 Registry between March and December 2020 (“pandemic cohort”) with those undergoing PCI between March and December 2019 (“pre-pandemic cohort”). A risk-adjusted analysis of in-hospital outcomes was performed between the pre-pandemic and pandemic cohort. A subgroup analysis was performed comparing COVID-19 positive vs. negative patients during the pandemic. Results There was a 15.2% reduction in overall PCI volume from the pre-pandemic (n = 25,737) to the pandemic cohort (n = 21,822), which was more pronounced for stable angina and non-ST-elevation acute coronary syndromes (ACS) presentations, and between February and May 2020. Patients in the two cohorts had similar clinical and procedural characteristics. Monthly mortality rates for primary PCI were generally higher in the pandemic period. There were no significant system delays in care between the cohorts. Risk-adjusted mortality was higher in the pandemic cohort (aOR 1.26, 95% CI 1.07–1.47, p = 0.005), a finding that was only partially explained by worse outcomes in COVID-19 patients and was more pronounced in subjects with ACS. During the pandemic, COVID-19 positive patients suffered higher risk-adjusted mortality (aOR 5.69, 95% CI 2.54–12.74, p<0.001) compared with COVID negative patients. Conclusions During the COVID-19 pandemic, we observed a reduction in PCI volumes and higher risk-adjusted mortality. COVID-19 positive patients experienced significantly worse outcomes.
Collapse
Affiliation(s)
- Lorenzo Azzalini
- Division of Cardiology, VCU Health Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Javier A. Valle
- Michigan Heart and Vascular, Ann Arbor, MI, United States of America
- University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Edouard Daher
- Cardiac Catheterization Laboratory, Ascension St John Hospital, Detroit, MI, United States of America
| | - Brett Wanamaker
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | | | - Anwar Zaitoun
- Covenant Cardiology, Saginaw, MI, United States of America
| | - Ryan D. Madder
- Spectrum Health Hospitals Fred and Lena Meijer Heart Center, Grand Rapids, MI, United States of America
| | - Hitinder S. Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| |
Collapse
|
6
|
Valle JA, Morrison JT. Paclitaxel Therapy in Peripheral Arterial Disease. JACC Cardiovasc Interv 2022; 15:2103-2104. [DOI: 10.1016/j.jcin.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022]
|
7
|
Ingle MP, Carroll AM, Matlock DD, Gama KD, Valle JA, Allen LA, Knoepke CE. Decision Support Needs for Patients with Severe Symptomatic Aortic Stenosis. J Gerontol Soc Work 2022; 65:589-603. [PMID: 34809525 DOI: 10.1080/01634372.2021.1995095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 06/13/2023]
Abstract
Social workers in healthcare settings often support patient decision-making processes for complex medical decisions. The objective of this study was to examine decision support needs for patients considering aortic valve replacement (AVR) for aortic stenosis. Seventeen qualitative interviews were conducted to explore treatment decision experiences of patients who accepted AVR. Analysis was conducted using a mixed inductive-deductive approach. Fear was a prevalent response for most participants in the face of AVR. Two general paths of decision making emerged: an "active" information seeking approach, or a "passive" simplicity seeking approach. Patients with unique clinical presentations felt alienated by the decision-making process. Acknowledging fear while understanding different decision-making styles provide opportunities for social workers and other members of multidisciplinary teams to support complex patient decisions.
Collapse
Affiliation(s)
- M Pilar Ingle
- Graduate School of Social Work, University of Denver, Denver, Colorado, USA
| | - Adam M Carroll
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniel D Matlock
- Adult & Child Consortium for Outcomes Research & Delivery Science (Accords), University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Eastern Colorado, Denver, Colorado, USA
| | - Kristy D Gama
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Javier A Valle
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Interventional Cardiology, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Larry A Allen
- Graduate School of Social Work, University of Denver, Denver, Colorado, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christopher E Knoepke
- Graduate School of Social Work, University of Denver, Denver, Colorado, USA
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
8
|
Valle JA, Fullerton D, Cleveland J, Messenger JC, Carroll JD. Reply: Rational Dispersion of TAVR: The Role of Training Centers. J Am Coll Cardiol 2022; 79:e187. [PMID: 35210042 DOI: 10.1016/j.jacc.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
|
9
|
Kovach CP, Hebbe A, Barón AE, Strobel A, Plomondon ME, Valle JA, Waldo SW. Clinical Characteristics and Outcomes Among Patients Undergoing High-Risk Percutaneous Coronary Interventions by Single or Multiple Operators: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2021; 10:e022131. [PMID: 34775783 PMCID: PMC9075385 DOI: 10.1161/jaha.121.022131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background High-risk percutaneous coronary intervention (HR-PCI) is increasingly common among contemporary patients with coronary artery disease. Experts have advocated for a collaborative 2-operator approach to support intraprocedural decision-making for these complex interventions. The impact of a second operator on patient and procedural outcomes is unknown. Methods and Results Patients who underwent HR-PCI from 2015 to 2018 within the Veterans Affairs Healthcare System were identified. Propensity-matched cohorts were generated to compare the outcomes following HR-PCI performed by a single or multiple (≥2) operators. The primary end point was the 12-month rate of major adverse cardiovascular events. We identified 6672 patients who underwent HR-PCI during the study period; 6211 (93%) were treated by a single operator, and 461 (7%) were treated by multiple operators, with a nonsignificant trend toward increased multioperator procedures over time. A higher proportion of patients treated by multiple operators underwent left main (10% versus 7%, P=0.045) or chronic total occlusion intervention (11% versus 5%, P<0.001). Lead interventionalists participating in multioperator procedures practiced at centers with higher annual HR-PCI volumes (124±71.3 versus 111±69.2; standardized mean difference, 0.197; P<0.001) but otherwise performed a similar number of HR-PCI procedures per year (34.4±35.3 versus 34.7±30.7; standardized mean difference, 0.388; P=0.841) compared with their peers performing single-operator interventions. In a propensity-matched cohort, there was no significant difference in major adverse cardiovascular events (32% versus 30%, P=0.444) between patients who underwent single-operator versus multioperator HR-PCI. Adjusted analyses accounting for site-level variance showed no significant differences in outcomes. Conclusions Patients who underwent multioperator HR-PCI had similar outcomes compared with single-operator procedures. Further studies are needed to determine if the addition of a second operator offers clinical benefits to a subset of HR-PCI patients undergoing left main or chronic total occlusion intervention.
Collapse
Affiliation(s)
| | - Annika Hebbe
- Department of Biostatistics and Informatics University of Colorado Aurora CO.,CART Program Office of Quality and Patient Safety Veterans Health Administration Washington DC
| | - Anna E Barón
- Department of Biostatistics and Informatics University of Colorado Aurora CO
| | - Aaron Strobel
- Division of Cardiology Department of Medicine University of Colorado Aurora CO
| | - Mary E Plomondon
- CART Program Office of Quality and Patient Safety Veterans Health Administration Washington DC
| | - Javier A Valle
- Division of Cardiology Department of Medicine University of Colorado Aurora CO.,Department of Medicine, Michigan Heart and Vascular Institute Ann Arbor MI
| | - Stephen W Waldo
- Division of Cardiology Department of Medicine University of Colorado Aurora CO.,CART Program Office of Quality and Patient Safety Veterans Health Administration Washington DC
| |
Collapse
|
10
|
Bhardwaj B, Gunzburger E, Valle JA, Grunwald GK, Plomondon ME, Vidovich MI, Aggarwal K, Karuparthi PR. Radial versus femoral access for left main percutaneous coronary intervention: An analysis from the Veterans Affairs Clinical, Reporting, and Tracking Program. Catheter Cardiovasc Interv 2021; 99:480-488. [PMID: 34847279 DOI: 10.1002/ccd.30024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/23/2021] [Accepted: 11/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We aimed to compare clinical characteristics and procedural outcomes of left main percutaneous interventions (LM-PCI) by transradial (TRA) versus transfemoral (TFA) approach in the VA healthcare system. BACKGROUND TRA for percutaneous coronary intervention (PCI) is steadily increasing. However, the frequency and efficacy of TRA for LM-PCI remain less studied. METHODS All LM-PCIs performed in the VA healthcare system were identified for fiscal year 2008 through 2018. Patients' baseline characteristics and procedure-related variables were compared by access site. Both short- and long-term clinical outcomes were analyzed using propensity score matching. RESULTS A total of 4004 LM-PCI were performed in the VA via either radial or femoral access from 2008 to 2018. Among these, 596 (14.9%) LM PCIs were performed via TRA. Use of TRA for LM-PCI increased from 2.2% to 31.5% over the study period. Propensity matched outcome analysis, comparing TRA versus TFA, showed a similar procedural success (98.4% for TRA vs. 97.8% for TFA; RR: 1.01 [0.98, 1.03]) and 1-year major adverse cardiovascular events (MACE) (25.9% for TRA vs. 26.8% TFA; RR: 0.96 [0.74, 1.25]). There were no statistically significant differences among secondary outcomes analyses including major bleeding. CONCLUSION Use of TRA for LM-PCI has been steadily increasing in the VA healthcare system. These findings demonstrate similar procedural success and 1-year MACE across access strategies, suggesting an opportunity to continue increasing TRA use for LM-PCI.
Collapse
Affiliation(s)
- Bhaskar Bhardwaj
- Section of Cardiology, Harry S. Truman VA Hospital, Columbia, Missouri, USA.,Division of Cardiovascular Disease, Department of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Elise Gunzburger
- VA Eastern Colorado Health Care System, Veterans Health Administration, Aurora, Colorado, USA
| | - Javier A Valle
- VA Eastern Colorado Health Care System, Veterans Health Administration, Aurora, Colorado, USA
| | - Gary K Grunwald
- VA Eastern Colorado Health Care System, Veterans Health Administration, Aurora, Colorado, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mary E Plomondon
- VA CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Mladen I Vidovich
- Section of Cardiology, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Kul Aggarwal
- Section of Cardiology, Harry S. Truman VA Hospital, Columbia, Missouri, USA.,Division of Cardiovascular Disease, Department of Medicine, University of Missouri, Columbia, Missouri, USA
| | - Poorna Raj Karuparthi
- Section of Cardiology, Harry S. Truman VA Hospital, Columbia, Missouri, USA.,Division of Cardiovascular Disease, Department of Medicine, University of Missouri, Columbia, Missouri, USA
| |
Collapse
|
11
|
Kovach CP, O'Donnell CI, Swat S, Doll JA, Plomondon ME, Schofield R, Valle JA, Waldo SW. Impact of operator volumes and experience on outcomes after percutaneous coronary intervention: Insights from the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) program. Cardiovasc Revasc Med 2021; 40:64-68. [PMID: 34774419 DOI: 10.1016/j.carrev.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent analyses of the volume-outcome relationship for percutaneous coronary intervention (PCI) have suggested a less robust association than previously reported. It is unknown if novel factors such as lifetime operator experience influence this relationship. OBJECTIVES To assess the relationship between annual volumes and outcomes for PCI and determine whether lifetime operator experience modulates the association. METHODS Annual PCI volumes for facilities and operators within the Veterans Affairs Healthcare System and their relationship with 30-day mortality following PCI were described. The influence of operator lifetime experience on the volume-outcome relationship was assessed. Hierarchical logistic regression was used to adjust for patient and procedural factors. RESULTS 57,608 PCIs performed from 2013 to 2018 by 382 operators and 63 institutions were analyzed. Operator annualized PCI volume averaged 47.6 (standard deviation [SD] 49.1) and site annualized volume averaged 189.2 (SD 105.2). Median operator experience was 9.0 years (interquartile range [IQR] 4.0-15.0). There was no independent relationship between operator annual volume, institutional volume, or operator lifetime experience with 30-day mortality (p > 0.10). However, the interaction between operator volume and lifetime experience was associated with a marginal decrease in mortality (odds ratio [OR] 0.9998, 95% CI 0.9996-0.9999). CONCLUSIONS There were no significant associations between facility or operator-level procedural volume and 30-day mortality following PCI in a nationally integrated healthcare system. There was a marginal association between the interaction of operator lifetime experience, operator annual volume, and 30-day mortality that is unlikely to be clinically relevant, though does suggest an opportunity to explore novel factors that may influence the volume-outcome relationship.
Collapse
Affiliation(s)
- Christopher P Kovach
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America
| | - Colin I O'Donnell
- Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, United States of America; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States of America
| | - Stanley Swat
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, United States of America; Department of Medicine, Puget Sound VA Medical Center, Seattle, WA, United States of America
| | - Mary E Plomondon
- Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, United States of America; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States of America
| | - Richard Schofield
- University of Florida College of Medicine, Gainesville, FL, United States of America; Department of Veterans Affairs Medical Center, Gainesville, FL, United States of America
| | - Javier A Valle
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America; Michigan Heart and Vascular Institute, Ann Arbor, MI, United States of America
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, CO, United States of America; Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, United States of America; CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States of America.
| |
Collapse
|
12
|
Kovach CP, Hebbe A, O'Donnell CI, Plomondon ME, Hess PL, Rahman A, Mulukutla S, Waldo SW, Valle JA. Comparison of Patients With Nonobstructive Coronary Artery Disease With Versus Without Myocardial Infarction (from the VA Clinical Assessment Reporting and Tracking [CART] Program). Am J Cardiol 2021; 146:1-7. [PMID: 33539858 DOI: 10.1016/j.amjcard.2021.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/31/2020] [Accepted: 01/13/2021] [Indexed: 11/25/2022]
Abstract
Comparisons of the outcomes of patients with myocardial infarction with nonobstructive coronary artery disease (MINOCA) and patients with nonobstructive coronary artery disease (CAD) without myocardial infarction (MI) are limited. Here we compare the outcomes of patients with MINOCA and patients with nonobstructive CAD without MI and assess the influence of medical therapy on outcomes in these patients. Veterans who underwent coronary angiography between 2008 to 2017 with nonobstructive CAD were divided into those with or without pre-procedural troponin elevation. Patients with prior revascularization, heart failure, or who presented with cardiogenic shock, STEMI, or unstable angina were excluded. After propensity matching, outcomes were compared between groups. The primary outcome was major adverse cardiovascular events (MACE: mortality, myocardial infarction, and revascularization) within one year: 3,924 patients with nonobstructive CAD and a troponin obtained prior to angiography were identified (n=1,986 with elevated troponin) and restricted to 1,904 patients after propensity-matching. There was a significantly higher risk of MACE among troponin-positive patients compared with those with a negative troponin (HR 2.37; 95% CI, 1.67 to 3.34). Statin (HR 0.32; 95% CI, 0.22 to 0.49) and ACE inhibitor (HR 0.49; 95% CI, 0.32 to 0.75) therapy after angiography was associated with decreased MACE, while P2Y12 inhibitor, calcium-channel and beta-blocker therapy were not associated with outcomes. In conclusion, Veterans with MINOCA are at increased risk for MACE compared with those with nonobstructive CAD and negative troponin at the time of angiography. Specific medications were associated with a reduction in MACE, suggesting an opportunity to explore novel approaches for secondary prevention in this population.
Collapse
|
13
|
Butala NM, Makkar R, Secemsky EA, Gallup D, Marquis-Gravel G, Kosinski AS, Vemulapalli S, Valle JA, Bradley SM, Chakravarty T, Yeh RW, Cohen DJ. Cerebral Embolic Protection and Outcomes of Transcatheter Aortic Valve Replacement: Results From the Transcatheter Valve Therapy Registry. Circulation 2021; 143:2229-2240. [PMID: 33619968 DOI: 10.1161/circulationaha.120.052874] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), which has persisted despite refinements in technique and increased operator experience. While cerebral embolic protection devices (EPDs) have been developed to mitigate this risk, data regarding their impact on stroke and other outcomes after TAVR are limited. METHODS We performed an observational study using data from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients were included if they underwent elective or urgent transfemoral TAVR between January 2018 and December 2019. The primary outcome was in-hospital stroke. To adjust for confounding, the association between EPD use and clinical outcomes was evaluated using instrumental variable analysis, a technique designed to support causal inference from observational data, with site-level preference for EPD use within the same quarter of the procedure as the instrument. We also performed a propensity score-based secondary analysis using overlap weights. RESULTS Our analytic sample included 123 186 patients from 599 sites. The use of EPD during TAVR increased over time, reaching 28% of sites and 13% of TAVR procedures by December 2019. There was wide variation in EPD use across hospitals, with 8% of sites performing >50% of TAVR procedures with an EPD and 72% performing no procedures with an EPD in the last quarter of 2019. In our primary analysis using the instrumental variable model, there was no association between EPD use and in-hospital stroke (adjusted relative risk, 0.90 [95% CI, 0.68-1.13]; absolute risk difference, -0.15% [95% CI, -0.49 to 0.20]). However, in our secondary analysis using the propensity score-based model, EPD use was associated with 18% lower odds of in-hospital stroke (adjusted odds ratio, 0.82 [95% CI, 0.69-0.97]; absolute risk difference, -0.28% [95% CI, -0.52 to -0.03]). Results were generally consistent across the secondary end points, as well as subgroup analyses. CONCLUSIONS In this nationally representative observational study, we did not find an association between EPD use for TAVR and in-hospital stroke in our primary instrumental variable analysis, and found only a modestly lower risk of in-hospital stroke in our secondary propensity-weighted analysis. These findings provide a strong basis for large-scale randomized, controlled trials to test whether EPDs provide meaningful clinical benefit for patients undergoing TAVR.
Collapse
Affiliation(s)
- Neel M Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA (N.M.B., E.A.S., R.W.Y.).,Massachusetts General Hospital, Harvard Medical School, Boston (N.M.B.)
| | - Raj Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA (R.M.)
| | - Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA (N.M.B., E.A.S., R.W.Y.)
| | - Dianne Gallup
- Duke Clinical Research Institute, Durham, NC (D.G., G.M-G., A.S.K., S.V.)
| | | | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC (D.G., G.M-G., A.S.K., S.V.)
| | | | - Javier A Valle
- University of Colorado School of Medicine, Aurora (J.A.V.).,Michigan Heart and Vascular Institute, Ann Arbor (J.A.V.)
| | | | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA (N.M.B., E.A.S., R.W.Y.)
| | - David J Cohen
- Cardiovascular Research Foundation, New York (D.J.C.).,St. Francis Hospital, Roslyn, NY (D.J.C.)
| |
Collapse
|
14
|
McGuinn E, Warsavage T, Plomondon ME, Valle JA, Ho PM, Waldo SW. Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure. J Am Heart Assoc 2021; 10:e019452. [PMID: 33586468 PMCID: PMC8174286 DOI: 10.1161/jaha.120.019452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new‐onset systolic heart failure. Methods and Results Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high‐performing (90th percentile) and low‐performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90–4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin‐converting enzyme inhibitors (75% versus 64%, P<0.001) or beta blockers (92% versus 82%, P<0.001) and subsequently undergo percutaneous (8% versus 0%, P<0.001) or surgical (2% versus 0%, P<0.001) revascularization. Patients with an ischemic evaluation also had a significantly lower adjusted hazard of all‐cause mortality (hazard ratio, 0.54; 95% CI, 0.47–0.61) compared with those without an evaluation. Conclusions Ischemic evaluations are underutilized in patients admitted with heart failure and a new reduction in left ventricular systolic function. A focused intervention to increase guideline‐concordant care could lead to an improvement in clinical outcomes.
Collapse
Affiliation(s)
- Erin McGuinn
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | | | - Mary E Plomondon
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO.,CART Program VHA Office of Quality and Patient Safety Washington DC
| | - Javier A Valle
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO.,CART Program VHA Office of Quality and Patient Safety Washington DC
| | - P Michael Ho
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO.,CART Program VHA Office of Quality and Patient Safety Washington DC
| |
Collapse
|
15
|
Salahuddin T, Richardson V, McNeal DM, Henderson K, Hess PL, Raghavan S, Saxon DR, Valle JA, Waldo SW, Ho PM, Schwartz GG. Potential unrealized mortality benefit of glucagon-like peptide-1 receptor agonists and sodium-glucose co-transport-2 inhibitors: A report from the Veterans Health Administration Clinical Assessment, Reporting and Tracking program. Diabetes Obes Metab 2021; 23:97-105. [PMID: 32902128 DOI: 10.1111/dom.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/21/2020] [Accepted: 09/04/2020] [Indexed: 11/28/2022]
Abstract
AIM To assess the unrealized potential of glucagon-like peptide-1 receptor agonist (GLP-1RA) or sodium-glucose co-transport-2 inhibitor (SGLT2i) use to reduce mortality in veterans with type 2 diabetes (T2D), coronary artery disease (CAD), and other characteristics congruent with clinical trial cohorts that established the efficacy of these agents. METHODS Veterans with T2D and CAD on angiography in 2014 who were untreated with either a GLP-1RA or a SGLT2i were assessed for key eligibility criteria of the LEADER (GLP-1RA) and EMPA-REG OUTCOME (SGLT2i) trials. Trial hazard ratios and 95% confidence intervals for all-cause death were applied to deaths observed in veterans through 2018 to estimate the potential benefit of GLP-1RA or SGLT2i use. RESULTS Median observation was 4.3 years. Of 15 987 veterans with T2D and CAD, 1186 (7.4%) were excluded for GLP-1RA or SGLT2i treatment, and 1386 lacked glycated haemoglobin measurement. Of the remaining 13 415 patients, 4103 (30.1%) and 5313 (39.6%) fulfilled the key criteria for the LEADER and EMPA-REG OUTCOME trials, respectively. Death occurred in 1009 (24.6%) of LEADER-eligible patients and 1335 (25.1%) of EMPA-REG OUTCOME-eligible patients. Under treatment with liraglutide in LEADER-eligible veterans, a 3.5% (0.7%-6.2%) potential absolute mortality reduction, corresponding to 144 (28-253) fewer deaths (0.88 [0.17-1.56] per 100 person-years), might have been expected. Similarly, under treatment with empagliflozin in EMPA-REG OUTCOME-eligible veterans, a 7.9% (4.5%-10.8%) potential absolute mortality reduction, corresponding to 418 (230-573) fewer deaths (1.98 [1.14-2.72] per 100 person-years), might have been expected. CONCLUSIONS This analysis indicates unrealized opportunities to reduce mortality in selected veterans with T2D and CAD via increased GLP-1RA and SGLT2i use.
Collapse
Affiliation(s)
- Taufiq Salahuddin
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Kamal Henderson
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paul L Hess
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sridharan Raghavan
- University of Colorado School of Medicine, Aurora, Colorado, USA
- Section of Hospital Medicine, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - David R Saxon
- University of Colorado School of Medicine, Aurora, Colorado, USA
- Endocrinology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Javier A Valle
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Stephen W Waldo
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - P Michael Ho
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
- Denver-Seattle Center of Innovation for Veteran Centered and Value Driven Care, Denver, Colorado, USA
| | - Gregory G Schwartz
- Cardiology Section, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
- University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
16
|
Waldo SW, Glorioso TJ, Barón AE, Plomondon ME, Valle JA, Schofield R, Ho PM. Outcomes Among Patients Undergoing Elective Percutaneous Coronary Intervention at Veterans Affairs and Community Care Hospitals. J Am Coll Cardiol 2020; 76:1112-1116. [DOI: 10.1016/j.jacc.2020.05.086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/10/2020] [Indexed: 11/28/2022]
|
17
|
Valle JA, Glorioso TJ, Bricker R, Barón AE, Armstrong EJ, Bhatt DL, Rao SV, Plomondon ME, Serruys PW, Keppetein AP, Sabik JF, Dressler O, Stone GW, Waldo SW. Association of Coronary Anatomical Complexity With Clinical Outcomes After Percutaneous or Surgical Revascularization in the Veterans Affairs Clinical Assessment Reporting and Tracking Program. JAMA Cardiol 2020; 4:727-735. [PMID: 31241721 DOI: 10.1001/jamacardio.2019.1923] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 01/17/2023]
Abstract
Importance Anatomical scoring systems for coronary artery disease, such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention [PCI] With Taxus and Cardiac Surgery) score, are well established tools for understanding patient risk. However, they are cumbersome to compute manually for large data sets, limiting their use across broad and varied cohorts. Objective To adapt an anatomical scoring system for use with registry data, allowing facile and automatic calculation of scores and association with clinical outcomes among patients undergoing percutaneous or surgical revascularization. Design, Setting, and Participants This cross-sectional observational cohort study involved procedures performed in all cardiac catheterization laboratories in the largest integrated health care system in the United States, the Veterans Affairs (VA) Healthcare System. Patients undergoing coronary angiography in the VA Healthcare System followed by percutaneous or surgical revascularization within 90 days were observed and data were analyzed from January 1, 2010, through September 30, 2017. Main Outcomes and Measures An anatomical scoring system for coronary artery disease complexity before revascularization was simplified and adapted to data from the VA Clinical Assessment, Reporting, and Tracking Program. The adjusted association between quantified anatomical complexity and major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and repeat revascularization, was assessed for patients undergoing percutaneous or surgical revascularization. Results A total of 50 226 patients (49 359 men [98.3%]; mean [SD] age, 66 [9] years) underwent revascularization during the study period, with 34 322 undergoing PCI and 15 904 undergoing coronary artery bypass grafting (CABG). After adjustment, the highest tertile of anatomical complexity was associated with increased hazard of MACCEs (adjusted hazard ratio [HR], 2.12; 95% CI, 2.01-2.23). In contrast, the highest tertile of anatomical complexity among patients undergoing CABG was not independently associated with overall MACCEs (adjusted HR, 1.04; 95% CI, 0.92-1.17), and only repeat revascularization was associated with increasing complexity (adjusted HR, 1.34; 95% CI, 1.06-1.70) in this subgroup. Conclusions and Relevance These findings suggest that an automatically computed score assessing anatomical complexity can be used to assess longitudinal risk for patients undergoing revascularization. This simplified scoring system appears to be an alternative tool for understanding longitudinal risk across large data sets.
Collapse
Affiliation(s)
- Javier A Valle
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Thomas J Glorioso
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Rory Bricker
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Anna E Barón
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Ehrin J Armstrong
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Deepak L Bhatt
- Department of Medicine, Division of Cardiology, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Sunil V Rao
- Department of Medicine, Division of Cardiology, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Mary E Plomondon
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Patrick W Serruys
- National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | | | - Joseph F Sabik
- Department of Surgery, University Hospitals of Cleveland Medical Center, Cleveland, Ohio
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Gregg W Stone
- National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London, United Kingdom.,Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.,Center for Interventional Vascular Therapy, New York Presbyterian Hospital, Columbia University Medical Center, New York
| | - Stephen W Waldo
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora
| |
Collapse
|
18
|
Kokkinidis DG, Jawaid O, Cantu D, Martinsen BJ, Igyarto Z, Valle JA, Waldo SW, Armstrong EJ. Two-Year Outcomes of Orbital Atherectomy Combined With Drug-Coated Balloon Angioplasty for Treatment of Heavily Calcified Femoropopliteal Lesions. J Endovasc Ther 2020; 27:492-501. [DOI: 10.1177/1526602820915244] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To examine whether the combination of orbital atherectomy (OA) and drug-coated balloons (DCB) can lead to superior procedural and 2-year outcomes compared with DCB only in heavily calcified femoropopliteal (FP) lesions. Materials and Methods: A retrospective chart review was conducted to identify patients treated with DCB only or OA+DCB for de novo FP lesions at a single center over a 4-year period (2014–2017). In the observation period, 113 patients met the inclusion criteria: 63 treated with DCB only (mean age 69.0±8.6 years; 62 men) vs 50 treated with OA+DCB (mean age 70.3±7.1 years; 48 men). The OA+DCB group had higher calcification rates (78% with severe calcification vs 37% in the DCB only group). Propensity score matching (PSM) was used to adjust for baseline differences between the 2 groups. Cox regression analysis was used to compare the follow-up outcomes between lesions treated with OA+DCB vs DCB only. Results: No difference in procedural complications or success was found. After PSM adjustment, the OA+DCB group was associated with lower bailout stenting rates (39.4% vs 66.7% in the DCB only group; p=0.026). The 2 groups had similar long-term outcomes, although the OA+DCB arm had a trend toward reduced TLR rates that did not reach statistical significance. The Kaplan-Meier estimates for 2-year freedom from TLR were 76.1% for the OA+DCB group vs 55.5% for the DCB only group (p=0.109). Conclusion: OA+DCB is a safe and effective combination for the treatment of calcified FP lesions. The combined therapy decreased the bailout stenting rates in the adjusted analysis. Larger cohorts and randomized trials are needed to examine OA efficacy in FP lesions.
Collapse
Affiliation(s)
- Damianos G. Kokkinidis
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Omar Jawaid
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - David Cantu
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Brad J. Martinsen
- Clinical Scientific Affairs, Cardiovascular Systems, Inc., St Paul, MN, USA
| | - Zsuzsanna Igyarto
- Clinical Scientific Affairs, Cardiovascular Systems, Inc., St Paul, MN, USA
| | - Javier A. Valle
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Stephen W. Waldo
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| |
Collapse
|
19
|
McNeal DM, Peterson P, Ho MM, Saxon D, Henderson KH, Hess P, Valle JA, RAGHAVAN SRIDHARAN, Schwartz GG, Salahuddin T, Richardson V. Abstract 332: Racial Differences in Prescribing of Sodium Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists Among Veterans With Type 2 Diabetes and Coronary Artery Disease: Findings From the Veteran’s Administration Clinical Assessment, Reporting, and Tracking Program. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.332] [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: 11/16/2022]
Abstract
Background:
Recent trials have shown improved cardiovascular benefit associated outcomes with sodium glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) treatment in patients (pts) with type 2 diabetes (T2D) and high cardiovascular (CV) risk. We examined the extent to which this new evidence has been applied in routine clinical care and whether race influenced differences in prescription rates between patients.
Methods and results:
We used data from the US Department of Veterans Affairs’ Clinical Assessment, Reporting, and Tracking (CART) Program (2015-2017 inclusive). Pts were deemed SGLT2i- or GLP-1RA-eligible based on EMPA-REG OUTCOME and LEADER trial criteria. Rates of use were examined among eligible pts by race/ethnicity in unadjusted and multivariable logistic regression models adjusted for age, insurance type, service connection, and clinical site. From 84 sites, 21,053 patients were eligible for an SGLT2i and 1,520 (7.2%) had one prescribed. Recipients of SGLT2i were younger (65.59 years vs 68.29 years) had a higher mean HbA1c (8.27% vs 8.02%) and were more likely white (86.0 % vs 82.6%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.38; 95% CI 1.05,1.85; p < 0.01. Among 11,913 Veterans eligible for an GLP-1RA, 477 (4.0%) had one prescribed. Recipients were younger (65.84 years vs 68.96 years), had a higher mean HbA1c (8.55% vs 8.09%) and were more likely white (83.6% vs 81.8%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.43; 95% CI 1.09, 1.92; p = 0.013. Representation of other racial/ethnic groups was insufficient for comparison.
Conclusion:
Appropriate prescription of SGLT2i or GLP-1RA was less likely among black than white US Veterans at high CV risk. Our results suggest that while overall uptake of these medications has been slow, there are substantial racial differences that exist concerning the prescribing of these medications. In view of these findings, additional research is needed to further investigate both institutional and clinical factors which may adversely affect the prescribing of SGLT2i and GLP-1RA in African American Veterans.
Collapse
Affiliation(s)
| | | | | | | | | | - Paul Hess
- Eastern Colorado Health Care System, Aurora, CO
| | | | | | | | | | | |
Collapse
|
20
|
Prouse A, Gunzburger E, Yang F, Morrison J, Valle JA, Armstrong EJ, Waldo SW. Contemporary Use and Outcomes of Arterial Closure Devices After Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2020; 9:e015223. [PMID: 32063086 PMCID: PMC7070201 DOI: 10.1161/jaha.119.015223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Arterial closure devices reduce the length of bedrest after invasive cardiac procedures via the femoral approach, but there are conflicting data on their association with major bleeding and vascular complications. We thus sought to evaluate the contemporary use of femoral arterial closure devices and their association with major bleeding among patients undergoing percutaneous coronary intervention. Methods and Results We identified patients undergoing percutaneous intervention via the femoral approach within the Veterans Affairs Healthcare System from December 2004 through September 2018. The association between arterial closure device use and major bleeding was evaluated using both propensity matching and instrumental variable analyses, incorporating contrast‐induced nephropathy as a falsification end point. We identified 132 373 percutaneous coronary interventions performed by 681 operators, with closure device use increasing 1.2% each year (linear trend P<0.001). In a propensity‐matched cohort, closure devices were associated with a 1.1% reduction in periprocedural bleeding (95% CI, −1.5% to −0.6%). Closure devices were also associated with a numerical decrease in contrast‐inducted nephropathy that did not reach statistical significance (−0.6%; 95% CI, −1.3% to 0.1%). In an instrumental variable analysis of closure device use, there was no difference in the bleeding rate between those who received a closure device and those who did not (0.2%; 95% CI, −0.9% to 1.2%). Conclusions Arterial closure devices are associated with a reduction in major bleeding within a propensity‐matched cohort. This association dissipates in an instrumental variable analysis, highlighting some of the methodologic limitations of comparative effectiveness research in observational analyses.
Collapse
Affiliation(s)
- Andrew Prouse
- Division of Cardiology Department of Medicine Denver Health Medical Center Denver CO.,Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Elise Gunzburger
- Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO
| | - Fan Yang
- Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO
| | - Justin Morrison
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO
| | - Javier A Valle
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO.,Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO.,Division of Cardiology Department of Medicine Rocky Mountain Regional VA Medical Center Aurora CO
| | - Ehrin J Armstrong
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO.,Division of Cardiology Department of Medicine Rocky Mountain Regional VA Medical Center Aurora CO
| | - Stephen W Waldo
- Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora CO.,Center of Innovation Rocky Mountain Regional VA Medical Center Aurora CO.,Division of Cardiology Department of Medicine Rocky Mountain Regional VA Medical Center Aurora CO
| |
Collapse
|
21
|
Valle JA, Tamez H, Abbott JD, Moussa ID, Messenger JC, Waldo SW, Kennedy KF, Masoudi FA, Yeh RW. Contemporary Use and Trends in Unprotected Left Main Coronary Artery Percutaneous Coronary Intervention in the United States: An Analysis of the National Cardiovascular Data Registry Research to Practice Initiative. JAMA Cardiol 2020; 4:100-109. [PMID: 30601910 DOI: 10.1001/jamacardio.2018.4376] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [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]
Abstract
Importance Recent data support percutaneous revascularization as an alternative to coronary artery bypass grafting in unprotected left main (ULM) coronary lesions. However, the relevance of these trials to current practice is unclear, as patterns and outcomes of ULM percutaneous coronary intervention (PCI) in contemporary US clinical practice are not well studied. Objective To define the current practice of ULM PCI and its outcomes and compare these with findings reported in clinical trials. Design, Setting, and Participants This cross-sectional multicenter analysis included data collected from 1662 institutions participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between April 2009 and July 2016. Data were collected from 33 128 patients undergoing ULM PCI and 3 309 034 patients undergoing all other PCI. Data were analyzed from June 2017 to May 2018. Main Outcomes and Measures Patient and procedural characteristics and their temporal trends were compared between ULM PCI and all other PCI. In-hospital major adverse clinical events (ie, death, myocardial infarction, stroke, and emergent coronary artery bypass grafting) were compared using hierarchical logistic regression. Characteristics and outcomes were also compared against clinical trial cohorts. Results Of the 3 342 162 included patients, 2 223 570 (66.5%) were male, and the mean (SD) age was 64.2 (12.1) years. Unprotected left main PCI represented 1.0% (33 128 of 3 342 162) of all procedures, modestly increasing from 0.7% to 1.3% over time. The mean (SD) annualized ULM PCI volume was 0.5 (1.5) procedures for operators and 3.2 (6.1) procedures for facilities, with only 1808 of 10 971 operators (16.5%) and 892 of 1662 facilities (53.7%) performing an average of 1 or more ULM PCI annually. After adjustment, major adverse clinical events occurred more frequently with ULM PCI compared with all other PCI (odds ratio, 1.46; 95% CI, 1.39-1.53). Compared with clinical trial populations, patients in the CathPCI Registry were older with more comorbid conditions, and adverse events were more frequent. Conclusions and Relevance Use of ULM PCI has increased over time, but overall use remains low. These findings suggest that ULM PCI occurs infrequently in the United States and in an older and more comorbid population than that seen in clinical trials.
Collapse
Affiliation(s)
- Javier A Valle
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado.,University of Colorado School of Medicine, Aurora
| | - Hector Tamez
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - J Dawn Abbott
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Issam D Moussa
- Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Stephen W Waldo
- Rocky Mountain Veterans Affairs Medical Center, Aurora, Colorado.,University of Colorado School of Medicine, Aurora
| | | | | | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
22
|
Kokkinidis DG, Behan S, Jawaid O, Hossain P, Giannopoulos S, Singh GD, Laird JR, Valle JA, Waldo SW, Armstrong EJ. Laser atherectomy and drug‐coated balloons for the treatment of femoropopliteal in‐stent restenosis: 2‐Year outcomes. Catheter Cardiovasc Interv 2019; 95:439-446. [DOI: 10.1002/ccd.28636] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/12/2019] [Accepted: 11/22/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Damianos G. Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Sean Behan
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Omar Jawaid
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Prio Hossain
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis Sacramento California
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Gagan D. Singh
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis Sacramento California
| | - John R. Laird
- Vascular Center and Division of Cardiovascular MedicineUniversity of California Davis Sacramento California
| | - Javier A. Valle
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Stephen W. Waldo
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical CenterUniversity of Colorado Denver Colorado
| |
Collapse
|
23
|
Bricker RS, Glorioso TJ, Jawaid O, Plomondon ME, Valle JA, Armstrong EJ, Waldo SW. Temporal Trends and Site Variation in High-Risk Coronary Intervention and the Use of Mechanical Circulatory Support: Insights From the Veterans Affairs Clinical Assessment Reporting and Tracking (CART) Program. J Am Heart Assoc 2019; 8:e014906. [PMID: 31813312 PMCID: PMC6951079 DOI: 10.1161/jaha.119.014906] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Patients undergoing percutaneous coronary intervention (PCI) are older with greater medical comorbidities and anatomical complexity than ever before, resulting in an increased frequency of nonemergent high-risk PCI (HR-PCI). We thus sought to evaluate the temporal trends in performance of HR-PCI and utilization of mechanical circulatory support in the largest integrated healthcare system in the United States. Methods and Results A cohort of high-risk adult patients that underwent nonemergent PCI in the Veterans Affairs Healthcare System between January 2008 and June 2018 were identified by objective clinical, hemodynamic, and anatomic criteria. Temporal trends in the performance of HR-PCI, utilization of mechanical circulatory support, and site-level variation were assessed. Of 111 548 patients assessed during the study period, 554 met 3 high-risk criteria whereas 4414 met at least 2 criteria for HR-PCI. There was a significant linear increase in the proportion of interventions that met 3 (P<0.001) or at least 2 (P<0.001) high-risk criteria over time, with rates approaching 1.9% and 11.2% in the last full calendar year analyzed. A minority of patients who met all high-risk criteria received PCI with mechanical support (15.7%) without a significant increase over time (P=0.193). However, there was significant site-level variation in the probability of performing HR-PCI (4.0-fold higher likelihood) and utilizing mechanical circulatory support (1.9-fold higher likelihood) between high and low utilization sites. Conclusions The proportion of cases categorized as HR-PCI has increased over time, with significant site-level variation in performance. The majority of HR-PCI cases did not utilize mechanical support, highlighting a discrepancy between current recommendations and clinical practice in an integrated healthcare system.
Collapse
Affiliation(s)
| | - Thomas J Glorioso
- Department of Medicine VA Eastern Colorado Health Care System Denver CO
| | - Omar Jawaid
- University of Colorado School of Medicine Aurora CO
| | - Mary E Plomondon
- Department of Medicine VA Eastern Colorado Health Care System Denver CO
| | - Javier A Valle
- University of Colorado School of Medicine Aurora CO.,Department of Medicine VA Eastern Colorado Health Care System Denver CO
| | - Ehrin J Armstrong
- University of Colorado School of Medicine Aurora CO.,Department of Medicine VA Eastern Colorado Health Care System Denver CO
| | - Stephen W Waldo
- University of Colorado School of Medicine Aurora CO.,Department of Medicine VA Eastern Colorado Health Care System Denver CO
| |
Collapse
|
24
|
Cantu D, Jawaid O, Kokkinidis D, Giannopoulos S, Valle JA, Waldo SW, Singh GD, Armstrong EJ. Outcomes of Drug-Coated Balloon Angioplasty vs. Conventional Balloon Angioplasty for Endovascular Treatment of Common Femoral Artery Atherosclerotic Disease. Cardiovasc Revasc Med 2019; 21:867-874. [PMID: 31761636 DOI: 10.1016/j.carrev.2019.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/27/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Atherosclerotic disease of the common femoral artery (CFA), commonly associated with multilevel disease affecting the femoropopliteal segment, can cause claudication or contribute to critical limb ischemia. Although endovascular therapy for the management of peripheral arterial disease (PAD) has been increasingly utilized, its role in CFA lesions remains controversial. The aim of this study was to investigate the safety and efficacy of drug (DCB) vs non drug coated balloon angioplasty (BA) at the CFA segment. METHODS In this two-center study, we identified 154 patients treated either with DCB (n = 47) or BA (n = 107) for CFA lesions. Hazard ratios (HR) and the respective 95% confidence interval (CI) were synthesized to examine the association between the two groups in terms of target lesion revascularization (TLR), limb loss, and major adverse limb event (MALE) at 12 and 24 months of follow up. RESULTS This real-world population included a high percentage of patients with critical limb ischemia (43%) and moderate to severe lesion calcification (75%). Adjunctive atherectomy was performed in 97.9% of DCB cases (N = 46/47) and 44.7% of BA cases (N = 51/114). The overall procedural success rate was 95% without any differences between the two groups. Post-angioplasty dissections were observed in 15 cases [DCB: 8.5% (N = 4/47) vs BA: 9.7% (N = 11/113); p = .81], while distal embolization occurred in one patient in the DCB group and one in the BA group (p = .52). Provisional stenting was more commonly necessary in BA vs. DCB cases (12.3% vs 2.13%, p = .044). Physiologic assessment during follow up demonstrated a better mean 2-year ABI for the DCB group (mean: 0.9; SD: 0.2) vs BA group (mean: 0.6; SD: 0.4), although statistical significance was not reached (p = .06). No difference between the two groups was detected in terms of freedom from TLR (DCB: 75.5% vs BA: 86.8%; HR: 1.31; 95% CI: 0.46-3.67; p = .61), freedom from limb loss (DCB: 83.8% vs BA: 83.6%; HR: 1.04; 95% CI: 0.36-2.99; p = .94) or freedom from MALE (DCB: 83.5% vs BA: 78%; HR: 0.73; 95% CI: 0.26-1.99; p = .53) at 24 m of follow up. However, at the end of follow up more deaths were observed in patients treated with BA than DCB (DCB: 14.9% vs BA: 31.7%; p = .03). Patients who required provisional stenting were at higher risk for limb loss 2 years after the initial procedure (multivariate: HR: 4.54; 95% CI: 1.09-18.85; p = .04). CONCLUSIONS Both DCB and non-DCB strategies are effective modalities for revascularization of patients with CFA lesions. Larger prospective studies are necessary to determine the relative benefit, if any, of drug-eluting technologies for the treatment of common femoral artery disease.
Collapse
Affiliation(s)
- David Cantu
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Omar Jawaid
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Damianos Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Javier A Valle
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Stephen W Waldo
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Gagan D Singh
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.
| |
Collapse
|
25
|
Valle JA, Ho PM. Supporting Decisions or Decision Support? Challenges of Achieving Meaningful Clinical Decision Support in the Modern Era of the Electronic Health Record. J Am Heart Assoc 2019; 8:e014704. [PMID: 31707944 PMCID: PMC6915295 DOI: 10.1161/jaha.119.014704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Javier A. Valle
- Department of MedicineRocky Mountain Regional Veterans Affairs Medical CenterDenverCO
- University of Colorado School of MedicineAuroraCO
| | - P. Michael Ho
- Department of MedicineRocky Mountain Regional Veterans Affairs Medical CenterDenverCO
- University of Colorado School of MedicineAuroraCO
| |
Collapse
|
26
|
Waldo SW, Gokhale M, O'Donnell CI, Plomondon ME, Valle JA, Armstrong EJ, Schofield R, Fihn SD, Maddox TM. Temporal Trends in Coronary Angiography and Percutaneous Coronary Intervention: Insights From the VA Clinical Assessment, Reporting, and Tracking Program. JACC Cardiovasc Interv 2019; 11:879-888. [PMID: 29747919 DOI: 10.1016/j.jcin.2018.02.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/16/2018] [Accepted: 02/27/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate temporal trends in characteristics and outcomes among patients referred for invasive coronary procedures within a national health care system for veterans. BACKGROUND Coronary angiography and percutaneous coronary intervention remain instrumental diagnostic and therapeutic interventions for coronary artery disease. METHODS All coronary angiographic studies and interventions performed in U.S. Department of Veterans Affairs cardiac catheterization laboratories for fiscal years 2009 through 2015 were identified. The demographic characteristics and management of these patients were stratified by time. Clinical outcomes including readmission (30-day) and mortality were assessed across years. RESULTS From 2009 to 2015, 194,476 coronary angiographic examinations and 85,024 interventions were performed at Veterans Affairs facilities. The median numbers of angiographic studies (p = 0.81) and interventions (p = 0.22) remained constant over time. Patients undergoing these procedures were progressively older, with more comorbidities, as the proportion classified as having high Framingham risk significantly increased among those undergoing angiography (from 20% to 25%; p < 0.001) and intervention (from 24% to 32%; p < 0.001). Similarly, the median National Cardiovascular Data Registry CathPCI risk score increased for diagnostic (from 14 to 15; p = 0.005) and interventional (from 14 to 18; p = 0.002) procedures. Post-procedural medical management was unchanged over time, although there was increasing adoption of transradial access for diagnostic (from 6% to 36%; p < 0.001) and interventional (from 5% to 32%; p < 0.001) procedures. Complications and clinical outcomes also remained constant, with a trend toward a reduction in the adjusted hazard ratio for percutaneous coronary intervention mortality (hazard ratio: 0.983; 95% confidence interval: 0.967 to 1.000). CONCLUSIONS Veterans undergoing invasive coronary procedures have had increasing medical complexity over time, without attendant increases in mortality among those receiving interventions. As the Department of Veterans Affairs moves toward a mix of integrated and community-based care, it will be important to account for these demographic shifts so that quality can be maintained.
Collapse
Affiliation(s)
- Stephen W Waldo
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, Colorado.
| | - Madhura Gokhale
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Colin I O'Donnell
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Mary E Plomondon
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Javier A Valle
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Ehrin J Armstrong
- Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Richard Schofield
- Department of Medicine, Division of Cardiology, VA National Program, Gainesville, Florida
| | - Stephan D Fihn
- Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington
| | - Thomas M Maddox
- Department of Medicine, Division of Cardiology, Washington University, St. Louis, Missouri
| |
Collapse
|
27
|
Morrison J, Plomondon ME, O'Donnell CI, Giri J, Doll JA, Valle JA, Waldo SW. Perceptions of Public and Nonpublic Reporting of Interventional Cardiology Outcomes and Its Impact on Practice: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2019; 8:e014212. [PMID: 31711384 PMCID: PMC6915263 DOI: 10.1161/jaha.119.014212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Physicians have expressed significant mistrust with public reporting of interventional cardiology outcomes. Similar data are not available on alternative reporting structures, including nonpublic quality improvement programs with internally distributed measures of interventional quality. We thus sought to evaluate the perceptions of public and nonpublic reporting of interventional cardiology outcomes and its impact on clinical practice. Methods and Results A standardized survey was distributed to 218 interventional cardiologists in the Veterans Affairs Healthcare System, with responses received from 62 (28%). The majority of respondents (90%) expressed some or a great deal of trust in the analytic methods used to generate reports in a nonpublic quality improvement system within Veterans Affairs, while a minority (35%) expressed similar trust in the analytic methods in a public reporting system that operates outside Veterans Affairs (P<0.001). Similarly, a minority of respondents (44%) felt that in‐hospital and 30‐day mortality accurately reflected interventional quality in a nonpublic quality improvement system, though a smaller proportion of survey participants (15%) felt that the same outcome reflected procedural quality in public reporting systems (P<0.001). Despite these sentiments, the majority of operators did not feel pressured to avoid (82% and 75%; P=0.383) or perform (72% and 63%; P=0.096) high‐risk procedures within or outside Veterans Affairs. Conclusions Interventional cardiologists express greater trust in analytic methods and clinical outcomes reported in a nonpublic quality improvement program than external public reporting environments. The majority of physicians did not feel pressured to avoid or perform high‐risk procedures, which may improve access to interventional care among high‐risk patients.
Collapse
Affiliation(s)
- Justin Morrison
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | | | | | - Jay Giri
- University of Pennsylvania School of Medicine Philadelphia PA
| | | | - Javier A Valle
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| |
Collapse
|
28
|
Affiliation(s)
- Javier A Valle
- 1 Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO.,2 University of Colorado School of Medicine Aurora CO
| | - P Michael Ho
- 1 Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO.,2 University of Colorado School of Medicine Aurora CO
| |
Collapse
|
29
|
Mull HJ, Gellad ZF, Gupta RT, Valle JA, Makarov DV, Silverman T, Branch-Elliman W. Factors Associated With Emergency Department Visits and Hospital Admissions After Invasive Outpatient Procedures in the Veterans Health Administration. JAMA Surg 2019; 153:774-776. [PMID: 29801049 DOI: 10.1001/jamasurg.2018.0874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hillary J Mull
- Center for Healthcare Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts.,Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Ziad F Gellad
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina.,Division of Gastroenterology, Department of Medicine, Duke University, Durham, North Carolina
| | - Rajan T Gupta
- Durham VA Medical Center, Durham, North Carolina.,Department of Radiology, Duke University, Durham, North Carolina
| | - Javier A Valle
- Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado.,Department of Cardiology, University of Colorado School of Medicine, Aurora
| | - Danil V Makarov
- Department of Urology, New York University School of Medicine, New York.,Department of Urology, VA New York Harbor, New York
| | - Tyler Silverman
- Division of Podiatry, Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, Boston, Massachusetts.,Department of Medicine, Section of Infectious Diseases, VA Boston Healthcare System, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
30
|
Mason PJ, Shah B, Tamis-Holland JE, Bittl JA, Cohen MG, Safirstein J, Drachman DE, Valle JA, Rhodes D, Gilchrist IC. An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association. Circ Cardiovasc Interv 2019; 11:e000035. [PMID: 30354598 DOI: 10.1161/hcv.0000000000000035] [Citation(s) in RCA: 299] [Impact Index Per Article: 59.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.
Collapse
|
31
|
Affiliation(s)
- Rory S. Bricker
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (R.B., J.A.V., M.E.P., E.J.A., S.W.W.)
| | - Javier A. Valle
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (R.B., J.A.V., M.E.P., E.J.A., S.W.W.)
- Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., M.E.P., E.J.A., S.W.W.)
| | - Mary E. Plomondon
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (R.B., J.A.V., M.E.P., E.J.A., S.W.W.)
- Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., M.E.P., E.J.A., S.W.W.)
| | - Ehrin J. Armstrong
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (R.B., J.A.V., M.E.P., E.J.A., S.W.W.)
- Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., M.E.P., E.J.A., S.W.W.)
| | - Stephen W. Waldo
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora (R.B., J.A.V., M.E.P., E.J.A., S.W.W.)
- Department of Medicine, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., M.E.P., E.J.A., S.W.W.)
| |
Collapse
|
32
|
Valle JA, Glorioso TJ, Schuetze KB, Grunwald GK, Armstrong EJ, Waldo SW. Contemporary Use of Embolic Protection Devices During Saphenous Vein Graft Intervention. Circ Cardiovasc Interv 2019; 12:e007636. [PMID: 31014092 DOI: 10.1161/circinterventions.118.007636] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Guidelines recommend use of embolic protection devices during percutaneous coronary intervention of saphenous vein grafts, but the use of these devices in contemporary practice is unclear. We thus sought to evaluate the patient characteristics and clinical outcomes associated with embolic protection device use during contemporary saphenous vein graft percutaneous coronary intervention. METHODS AND RESULTS We identified patients undergoing isolated saphenous vein graft percutaneous coronary intervention in the Veterans Affairs Healthcare System from January 2008 to June 2017. Patient and procedural characteristics associated with embolic protection device use were assessed, as well as unmeasured site variation. A propensity-matched cohort was constructed to compare outcomes at 30 days, including unsuccessful intervention, periprocedural myocardial infarction, and death. We identified 7266 vein graft interventions, and embolic protection was used in 37.9% of cases, with a significant decline over time ( P=0.001) that was most pronounced from 2014 to 2017 ( P<0.001). There was significant institutional variation in the use of embolic protection, with a 15.50 (95% credible interval, 9.21-29.71)-fold difference in odds of device use by changing facilities independent of patient or procedural factors. Use of embolic protection was associated with reduced risk of unsuccessful intervention (odds ratio, 0.27; 95% credible interval, 0.17-0.42) and 30-day mortality (odds ratio, 0.56; 95% credible interval, 0.36-0.87). CONCLUSIONS Use of embolic protection is decreasing with time and occurs in less than half of vein graft interventions. There is significant site variation in the use of embolic protection independent of patient characteristics, suggesting opportunities for the development of uniform practices to improve outcomes among those undergoing saphenous vein graft percutaneous coronary intervention.
Collapse
Affiliation(s)
- Javier A Valle
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., T.J.G., E.J.A., S.W.W.).,University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W.)
| | - Thomas J Glorioso
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., T.J.G., E.J.A., S.W.W.)
| | | | - Gary K Grunwald
- University of Colorado School of Public Health, Aurora (G.K.G)
| | - Ehrin J Armstrong
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., T.J.G., E.J.A., S.W.W.).,University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W.)
| | - Stephen W Waldo
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (J.A.V., T.J.G., E.J.A., S.W.W.).,University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W.)
| |
Collapse
|
33
|
Brostow DP, Warsavage TJ, Abbate LM, Starosta AJ, Brenner LA, Plomondon ME, Valle JA. Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program. Clin Obes 2019; 9:e12300. [PMID: 30793500 DOI: 10.1111/cob.12300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/09/2019] [Accepted: 01/12/2019] [Indexed: 12/22/2022]
Abstract
Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.
Collapse
Affiliation(s)
- Diana P Brostow
- Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
- Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
| | - Theodore J Warsavage
- Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Lauren M Abbate
- Geriatric Research, Education, and Clinical Center, Rocky Mountain VA Medical Center, Aurora, CO, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy J Starosta
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lisa A Brenner
- Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
- Rocky Mountain VA Medical Center, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO, USA
- Department of Psychiatry, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
- Department of Neurology, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
| | - Mary E Plomondon
- Rocky Mountain Regional VA Medical Center, Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, CO, USA
| | - Javier A Valle
- Division of Cardiology, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
| |
Collapse
|
34
|
Armstrong EJ, Waldo SW, Valle JA. The Heart and Vascular Team: Time for Endocrinologists to Join the Club? J Am Coll Cardiol 2018; 72:3285-3286. [PMID: 30573031 DOI: 10.1016/j.jacc.2018.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Ehrin J Armstrong
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
| | - Stephen W Waldo
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| | - Javier A Valle
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
35
|
Valle JA, Schofield RS, Waldo SW. Ensuring Optimal Adjustment for Determinations of Institutional Quality. JAMA Cardiol 2018; 3:1129-1130. [DOI: 10.1001/jamacardio.2018.3256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Javier A. Valle
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver, Colorado
- Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) Program, Denver, Colorado
| | - Richard S. Schofield
- North Florida/South Georgia Veterans Health System, Gainesville
- VA Office of Subspecialty Care, National Cardiology Program, Washington, DC
| | - Stephen W. Waldo
- Rocky Mountain Regional Veterans Affairs Medical Center, Denver, Colorado
- Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) Program, Denver, Colorado
| |
Collapse
|
36
|
Valle JA, Glorioso TJ, Maddox TM, Armstrong EJ, Waldo SW, Bradley SM, Ho PM. Impact of Patient Distance From Percutaneous Coronary Intervention Centers on Longitudinal Outcomes. Circ Cardiovasc Qual Outcomes 2018; 11:e004623. [DOI: 10.1161/circoutcomes.118.004623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Javier A. Valle
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| | - Thomas J. Glorioso
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora (T.J.G.)
| | - Thomas M. Maddox
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Current address for Dr Maddox: Division of Cardiology, Washington University School of Medicine, St. Louis, MO
| | - Ehrin J. Armstrong
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| | - Stephen W. Waldo
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| | - Steven M. Bradley
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Current address for Dr Bradley: Minneapolis Heart Institute, Minneapolis, MN
| | - P. Michael Ho
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| |
Collapse
|
37
|
Affiliation(s)
- Javier A. Valle
- Division of CardiologyDepartment of MedicineUniversity of ColoradoAuroraCO
- Division of CardiologyDepartment of MedicineVeterans Affairs Eastern Colorado Health Care SystemDenverCO
| | - Stephen W. Waldo
- Division of CardiologyDepartment of MedicineUniversity of ColoradoAuroraCO
- Division of CardiologyDepartment of MedicineVeterans Affairs Eastern Colorado Health Care SystemDenverCO
| |
Collapse
|
38
|
Prouse AF, Langner P, Plomondon ME, Ho PM, Valle JA, Barón AE, Armstrong EJ, Waldo SW. Temporal trends in the management and clinical outcomes of lower extremity arterial thromboembolism within a national Veteran population. Vasc Med 2018; 24:41-49. [PMID: 30105938 DOI: 10.1177/1358863x18793210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lower extremity arterial thromboembolism is associated with significant morbidity and mortality. We sought to establish temporal trends in the incidence, management and outcomes of lower extremity arterial thromboembolism within the Veterans Affairs Healthcare System (VAHS). We identified patients admitted to VAHS between 2003 and 2014 with a primary diagnosis of lower extremity arterial thromboembolism. Medical and procedural management were ascertained from pharmaceutical and administrative data. Subsequent rates of major adverse limb events (MALE), major adverse cardiovascular events (MACE), and mortality were calculated using Cox proportional hazards models. From 2003 to 2014, there were 10,636 patients hospitalized for lower extremity thromboembolism across 140 facilities, of which 8474 patients had adequate comorbid information for analysis. Age-adjusted incidence decreased from 7.98 per 100,000 patients (95% CI: 7.28-8.75) in 2003 to 3.54 (95% CI: 3.14-3.99) in 2014. On average, the likelihood of receiving anti-platelet or anti-thrombotic therapy increased 2.3% (95% CI: 1.2-3.4%) per year during this time period and the likelihood of undergoing endovascular revascularization increased 4.0% (95% CI: 2.7-5.4%) per year. Clinical outcomes remained constant over time, with similar rates of MALE, MACE and mortality at 1 year after adjustment. In conclusion, the incidence of lower extremity arterial thromboembolism is decreasing, with increasing utilization of anti-thrombotic therapies and endovascular revascularization among those with this condition. Despite this evolution in management, patients with lower extremity thromboembolism continue to experience high rates of amputation and death within a year of the index event.
Collapse
Affiliation(s)
- Andrew F Prouse
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Paula Langner
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Mary E Plomondon
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - P Michael Ho
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Javier A Valle
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Anna E Barón
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Ehrin J Armstrong
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Stephen W Waldo
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| |
Collapse
|
39
|
Valle JA, Graham L, Thiruvoipati T, Grunwald G, Armstrong EJ, Maddox TM, Hawn MT, Bradley SM. Facility-level association of preoperative stress testing and postoperative adverse cardiac events. Heart 2018; 104:2018-2025. [DOI: 10.1136/heartjnl-2018-313047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/20/2018] [Accepted: 05/22/2018] [Indexed: 11/04/2022] Open
Abstract
BackgroundDespite limited indications, preoperative stress testing is often used prior to non-cardiac surgery. Patient-level analyses of stress testing and outcomes are limited by case mix and selection bias. Therefore, we sought to describe facility-level rates of preoperative stress testing for non-cardiac surgery, and to determine the association between facility-level preoperative stress testing and postoperative major adverse cardiac events (MACE).MethodsWe identified patients undergoing non-cardiac surgery within 2 years of percutaneous coronary intervention in the Veterans Affairs (VA) Health Care System, from 2004 to 2011, facility-level rates of preoperative stress testing and postoperative MACE (death, myocardial infarction (MI) or revascularisation within 30 days). We determined risk-standardised facility-level rates of stress testing and postoperative MACE, and the relationship between facility-level preoperative stress testing and postoperative MACE.ResultsAmong 29 937 patients undergoing non-cardiac surgery at 131 VA facilities, the median facility rate of preoperative stress testing was 13.2% (IQR 9.7%–15.9%; range 6.0%–21.5%), and 30-day postoperative MACE was 4.0% (IQR 2.4%–5.4%). After risk standardisation, the median facility-level rate of stress testing was 12.7% (IQR 8.4%–17.4%) and postoperative MACE was 3.8% (IQR 2.3%–5.6%). There was no correlation between risk-standardised stress testing and composite MACE at the facility level (r=0.022, p=0.81), or with individual outcomes of death, MI or revascularisation.ConclusionsIn a national cohort of veterans undergoing non-cardiac surgery, we observed substantial variation in facility-level rates of preoperative stress testing. Facilities with higher rates of preoperative stress testing were not associated with better postoperative outcomes. These findings suggest an opportunity to reduce variation in preoperative stress testing without sacrificing patient outcomes
Collapse
|
40
|
Valle JA, Shetterly S, Maddox TM, Ho PM, Bradley SM, Sandhu A, Magid D, Tsai TT. Postdischarge Bleeding After Percutaneous Coronary Intervention and Subsequent Mortality and Myocardial Infarction: Insights From the HMO Research Network-Stent Registry. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.115.003519. [PMID: 27301394 DOI: 10.1161/circinterventions.115.003519] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bleeding after hospital discharge from percutaneous coronary intervention (PCI) is associated with increased risk of subsequent myocardial infarction (MI) and death; however, the timing of adverse events after these bleeding events is poorly understood. Defining this relationship may help clinicians identify critical periods when patients are at highest risk. METHODS AND RESULTS All patients undergoing PCI from 2004 to 2007 who survived to hospital discharge without a bleeding event were identified from the HMO Research Network-Stent (HMORN-Stent) Registry. Postdischarge rates and timing of bleeding-related hospitalizations, MI, and death were defined. We then assessed the association between postdischarge bleeding-related hospitalizations with death and MI using Cox proportional hazards models. Among 8137 post-PCI patients surviving to hospital discharge without in-hospital bleeding, 391 (4.8%) had bleeding-related hospitalization after discharge, with the highest incidence of bleeding-related hospitalizations occurring within 30 days of discharge (n=79, 20.2%). Postdischarge bleeding-related hospitalization after PCI was associated with subsequent death or MI (hazard ratio, 3.09; 95% confidence interval, 2.41-3.96), with the highest risk for death or MI occurring in the first 60 days after bleeding-related hospitalization (hazard ratio, 7.16; confidence interval, 3.93-13.05). CONCLUSIONS Approximately 1 in 20 post-PCI patients are readmitted for bleeding, with the highest incidence occurring within 30 days of discharge. Patients having postdischarge bleeding are at increased risk for subsequent death or MI, with the highest risk occurring within the first 60 days after a bleeding-related hospitalization. These findings suggest a critical period after bleeding events when patients are most vulnerable for further adverse events.
Collapse
Affiliation(s)
- Javier A Valle
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.).
| | - Susan Shetterly
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| | - Thomas M Maddox
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| | - P Michael Ho
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| | - Steven M Bradley
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| | - Amneet Sandhu
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| | - David Magid
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| | - Thomas T Tsai
- From the Division of Cardiology, University of Colorado, Aurora (J.A.V, T.M.M., P.M.H., S.M.B., A.S., T.T.T.); The Institute For Health Research, Kaiser Permanente Colorado, Denver (S.S., D.M., T.T.T.); Department of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H., S.M.B.); and The Colorado Cardiovascular Outcomes Research Consortium, Denver (J.A.V., T.M.M., P.M.H., S.M.B., A.S., D.M., T.T.T.)
| |
Collapse
|
41
|
Valle JA, Graham L, DeRussy A, Itani K, Hawn MT, Maddox TM. Triple Antithrombotic Therapy and Outcomes in Post-PCI Patients Undergoing Non-cardiac Surgery. World J Surg 2017; 41:423-432. [PMID: 27734083 DOI: 10.1007/s00268-016-3725-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown. METHODS We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics. RESULTS Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16-2.34] or bleeding (OR 1.52, 95 % CI 1.17-1.99) as compared to surgery in DAPT patients. CONCLUSIONS One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.
Collapse
Affiliation(s)
- Javier A Valle
- VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO, USA. .,Division of Cardiology, University of Colorado Hospital, 12631 E. 17th Street, B130, Aurora, CO, 80045, USA.
| | - Laura Graham
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Aerin DeRussy
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Kamal Itani
- Veterans Affairs Boston Health Care System, Boston University and Harvard Medical School, Boston, MA, USA
| | - Mary T Hawn
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO, USA
| |
Collapse
|
42
|
Valle JA, Kaltenbach LA, Bradley SM, Yeh RW, Rao SV, Gurm HS, Armstrong EJ, Messenger JC, Waldo SW. Variation in the Adoption of Transradial Access for ST-Segment Elevation Myocardial Infarction: Insights From the NCDR CathPCI Registry. JACC Cardiovasc Interv 2017; 10:2242-2254. [PMID: 29102582 DOI: 10.1016/j.jcin.2017.07.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/26/2017] [Accepted: 07/02/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The study sought to define patient, operator, and institutional factors associated with transradial access (TRA) in ST-segment elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI), the variation in use across operators and institutions, and the relationship with mortality and bleeding. BACKGROUND TRA for PCI in STEMI is underutilized. Factors associated with TRA are not well described, nor is there variation across operators and institutions or their relationship with outcomes. METHODS The authors used hierarchical logistic regression to identify patient, operator, and institutional characteristics associated with TRA use as well as determine the variation in TRA for STEMI PCI from 2009 to 2015. They also described the relationship between operator- and institution-level use and risk-adjusted bleeding and mortality. RESULTS Among 692,433 patients undergoing STEMI PCI, 12% (n = 82,618) utilized TRA. TRA increased from 2% to 23% from 2009 to 2015, but with significant geographic variation. Age, sex, cardiogenic shock, cardiac arrest, operators entering practice before 2012, and nonacademically affiliated institutions were associated with lower rates of TRA. There was significant operator and institutional variation, wherein identical patients would have >8-fold difference in odds of TRA for STEMI PCI by changing operators (median odds ratio: 8.7), and >5-fold difference by changing institutions (median odds ratio: 5.1). Greater TRA use across operators was associated with reduced bleeding (rho = -0.053), whereas TRA use across institutions was associated with reduced mortality (rho = -0.077). CONCLUSIONS Transradial access for STEMI PCI is increasing, but remains underutilized with significant geographic, operator, and institutional variation. These findings suggest an ongoing opportunity to standardize STEMI care.
Collapse
Affiliation(s)
- Javier A Valle
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sunil V Rao
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Ehrin J Armstrong
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado; Section of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Stephen W Waldo
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado; Section of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.
| |
Collapse
|
43
|
Affiliation(s)
- Javier A Valle
- University of Colorado School of Medicine and VA Eastern Colorado Health Care System Denver, CO, USA
| | - Ehrin J Armstrong
- University of Colorado School of Medicine and VA Eastern Colorado Health Care System Denver, CO, USA
| |
Collapse
|
44
|
Valle JA, McCoy LA, Maddox TM, Rumsfeld JS, Ho PM, Casserly IP, Nallamothu BK, Roe MT, Tsai TT, Messenger JC. Longitudinal Risk of Adverse Events in Patients With Acute Kidney Injury After Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004439. [PMID: 28404621 DOI: 10.1161/circinterventions.116.004439] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) remains a common complication after percutaneous coronary intervention (PCI) and is associated with adverse in-hospital patient outcomes. The incidence of adverse events after hospital discharge in patients having post-PCI AKI is poorly defined, and the relationship between AKI and outcomes after hospital discharge remains understudied. METHODS AND RESULTS Using the National Cardiovascular Data Registry CathPCI registry, we assessed the incidence of AKI among Medicare beneficiaries after PCI from 2004 to 2009 and subsequent post-discharge adverse events at 1 year. AKI was defined using Acute Kidney Injury Network (AKIN) criteria. Adverse events included death, myocardial infarction, bleeding, and recurrent kidney injury. Using Cox methods, we determined the relationship between in-hospital AKI and risk of post-discharge adverse events by AKIN stage. In a cohort of 453 475 elderly patients undergoing PCI, 39 850 developed AKI (8.8% overall; AKIN stage 1, 85.8%; AKIN 2/3, 14.2%). Compared with no AKI, in-hospital AKI was associated with higher post-discharge hazard of death, myocardial infarction, or bleeding (AKIN 1: hazard ratio [HR], 1.53; confidence interval [CI], 1.49-1.56 and AKIN 2/3: HR, 2.13; CI, 2.01-2.26), recurrent AKI (AKIN 1: HR, 1.70; CI, 1.64-1.76; AKIN 2/3: HR, 2.22; CI, 2.04-2.41), and AKI requiring dialysis (AKIN 1: HR, 2.59; CI, 2.29-2.92; AKIN 2/3: HR, 4.73; CI, 3.73-5.99). For each outcome, the highest incidence was within 30 days. CONCLUSIONS Post-PCI AKI is associated with increased risk of death, myocardial infarction, bleeding, and recurrent renal injury after discharge. Post-PCI AKI should be recognized as a significant risk factor not only for in-hospital adverse events but also after hospital discharge.
Collapse
Affiliation(s)
- Javier A Valle
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.).
| | - Lisa A McCoy
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - Thomas M Maddox
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - John S Rumsfeld
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - P Michael Ho
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - Ivan P Casserly
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - Brahmajee K Nallamothu
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - Matthew T Roe
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - Thomas T Tsai
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| | - John C Messenger
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., T.M.M., J.S.R., P.M.H., T.T.T., J.C.M.); Duke Clinical Research Institute, Durham, NC (L.A.M., M.T.R.); Division of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver (T.M.M., P.M.H.); Division of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland (I.P.C.); Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (B.K.N.); Division of Cardiology, Duke University, Durham, NC (M.T.R.); and Department of Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T.)
| |
Collapse
|
45
|
Holcomb CN, Hollis RH, Graham LA, Richman JS, Valle JA, Itani KM, Maddox TM, Hawn MT. Association of Coronary Stent Indication With Postoperative Outcomes Following Noncardiac Surgery. JAMA Surg 2017; 151:462-9. [PMID: 26720292 DOI: 10.1001/jamasurg.2015.4545] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Current guidelines for delaying surgery after coronary stent placement are based on stent type. However, the indication for the stent may be an important risk factor for postoperative major adverse cardiac events (MACE). OBJECTIVE To determine whether the clinical indication for a coronary stent is associated with postoperative MACE. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in patients at US Veterans Affairs hospitals who had a coronary stent placed between January 1, 2000, and December 31, 2010, and underwent noncardiac surgery within the following 24 months. The association between the indication for stent and postoperative MACE rates was examined using logistic regression to control for patient and procedure factors. EXPOSURES Three subgroups of stent indication were examined: (1) myocardial infarction (MI); (2) unstable angina; and (3) revascularization not associated with acute coronary syndrome (non-ACS). MAIN OUTCOMES AND MEASURES Composite 30-day postoperative MACE rates including all-cause mortality, MI, or revascularization. RESULTS Among 26 661 patients (median [IQR] age, 68 [61.0-76.0] years; 98.4% male; 88.1% white) who underwent 41 815 surgical procedures within 24 months following coronary stent placement, the stent indication was MI in 32.8% of the procedures, unstable angina in 33.8%, and non-ACS in 33.4%. Postoperative MACE rates were significantly higher in the MI group (7.5%) compared with the unstable angina (2.7%) and non-ACS (2.6%) groups (P < .001). When surgery was performed within 3 months of percutaneous coronary intervention, adjusted odds of MACE were significantly higher in the MI group compared with the non-ACS group (odds ratio [OR] = 5.25; 95% CI, 4.08-6.75). This risk decreased over time, although it remained significantly higher at 12 to 24 months from percutaneous coronary intervention (OR = 1.95; 95% CI, 1.58-2.40). The adjusted odds of MACE for the unstable angina group were similar to those for the non-ACS group when surgery was performed within 3 months (OR = 1.11; 95% CI, 0.80-1.53) or between 12 and 24 months (OR = 1.08; 95% CI, 0.86-1.37) from stent placement. Stent type was not significantly associated with MACE regardless of indication. CONCLUSIONS AND RELEVANCE Surgery in patients with a coronary stent placed for MI was associated with increased postoperative MACE rates compared with other stent indications. The risk declined over time from PCI, and delaying surgery up to 6 months in this cohort of patients with stents may be important regardless of stent type.
Collapse
Affiliation(s)
- Carla N Holcomb
- Department of Surgery, University of Alabama at Birmingham2Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Hospital, Birmingham, Alabama
| | - Robert H Hollis
- Department of Surgery, University of Alabama at Birmingham2Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Hospital, Birmingham, Alabama
| | - Laura A Graham
- Department of Surgery, University of Alabama at Birmingham2Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Hospital, Birmingham, Alabama
| | - Joshua S Richman
- Department of Surgery, University of Alabama at Birmingham2Center for Surgical, Medical Acute Care Research and Transitions (C-SMART), Birmingham VA Hospital, Birmingham, Alabama
| | - Javier A Valle
- VA Eastern Colorado Health Care System, Denver4University of Colorado School of Medicine, Denver
| | - Kamal M Itani
- Department of Surgery, VA Boston Healthcare System, Boston University and Harvard Medical School, Boston, Massachusetts
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, Denver4University of Colorado School of Medicine, Denver
| | - Mary T Hawn
- Department of Surgery, Stanford School of Medicine, Stanford, California
| |
Collapse
|
46
|
Affiliation(s)
- Javier A. Valle
- From the Division of Cardiology, Interventional Cardiology, University of Colorado School of Medicine, Aurora, (J.A.V., J.D.C.); and the Department of Cardiovascular Medicine, Section of Clinical Cardiology, Cleveland Clinic Foundation, OH (R.L.M.)
| | - Rhonda L. Miyasaka
- From the Division of Cardiology, Interventional Cardiology, University of Colorado School of Medicine, Aurora, (J.A.V., J.D.C.); and the Department of Cardiovascular Medicine, Section of Clinical Cardiology, Cleveland Clinic Foundation, OH (R.L.M.)
| | - John D. Carroll
- From the Division of Cardiology, Interventional Cardiology, University of Colorado School of Medicine, Aurora, (J.A.V., J.D.C.); and the Department of Cardiovascular Medicine, Section of Clinical Cardiology, Cleveland Clinic Foundation, OH (R.L.M.)
| |
Collapse
|
47
|
Abstract
Critical limb ischemia (CLI) is a relatively prevalent and highly morbid condition. Patients with CLI have a poor prognosis, especially in the setting of incomplete revascularization. Traditionally, achieving optimal revascularization has been limited by the high prevalence of small-vessel disease in this population. More recently, advanced endovascular techniques, increased operator experience, and new technologies have enabled complete revascularization of inframalleolar disease with encouraging clinical results. In this article, we present an approach to endovascular therapy for inframalleolar revascularization of patients with CLI.
Collapse
Affiliation(s)
- Javier A Valle
- Division of Cardiology, University of Colorado School of Medicine, 12361 East 17th Avenue, Box 130, Aurora, CO 80045, USA
| | - Andrew F Prouse
- Division of Cardiology, University of Colorado School of Medicine, University of Colorado, Mail Stop B132, Academic Office 1, Office 7104, Aurora, CO 80045, USA
| | - Robert K Rogers
- Vascular Medicine & Intervention, Interventional Cardiology, Division of Cardiology, University of Colorado School of Medicine, University of Colorado, Mail Stop B132, Leprino Building, 12401 East 17th Avenue, Room 560, Aurora, CO 80045, USA.
| |
Collapse
|
48
|
Armstrong EJ, Graham LA, Waldo SW, Valle JA, Maddox TM, Hawn MT. Incomplete Revascularization Is Associated With an Increased Risk for Major Adverse Cardiovascular Events Among Patients Undergoing Noncardiac Surgery. JACC Cardiovasc Interv 2017; 10:329-338. [PMID: 28161261 DOI: 10.1016/j.jcin.2016.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether incomplete revascularization is associated with a higher risk for major adverse cardiovascular events (MACE) and myocardial infarction (MI) among patients undergoing noncardiac surgery. BACKGROUND Patients with coronary artery disease and prior percutaneous coronary intervention (PCI) frequently undergo noncardiac surgery. These patients may have had PCI either on all obstructive lesions (i.e., complete revascularization) or only on some (i.e., incomplete revascularization). METHODS Patients were identified using the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. Veterans Affairs and non-Veterans Affairs surgical records were used to link patients who underwent noncardiac surgery within 2 years after stent placement. Incomplete revascularization was defined as a residual stenosis of ≥50% in the left main coronary artery or ≥70% in another major epicardial coronary artery on the basis of operator visual estimate. RESULTS In total, 4,332 patients (34.7%) had incomplete revascularization. A total of 567 MACE occurred within 1 month post-operatively. Patients with incomplete revascularization had an unadjusted 19% increased odds of post-operative MACE, compared with those with complete revascularization (odds ratio: 1.19; 95% confidence interval [CI]: 1.00 to 1.41). Among the MACE components, post-operative MI appears to contribute the most, with a 37% increased risk for post-operative MI among patients with incomplete revascularization (odds ratio: 1.37; 95% CI: 1.10 to 1.70). After adjustment, there was a significant interaction between time from PCI and outcomes after noncardiac surgery; incomplete revascularization was associated with significantly increased risk for post-operative MI primarily if surgery was performed within 6 weeks after PCI (adjusted odds ratio: 1.84; 95% CI: 1.04 to 2.38). The number of vessels with incomplete revascularization was also associated with an increased risk for post-operative MI: for each additional vessel with incomplete revascularization, there was a 17% increased odds of post-operative MI. CONCLUSIONS Incomplete revascularization among patients with coronary artery disease is associated with an increased risk for MI after noncardiac surgery.
Collapse
Affiliation(s)
- Ehrin J Armstrong
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado.
| | | | - Stephen W Waldo
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Javier A Valle
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Thomas M Maddox
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, California
| |
Collapse
|
49
|
Abstract
Acute limb ischemia is a vascular emergency, threatening the viability of the affected limb and requiring immediate recognition and treatment. Even with revascularization of the affected extremity, acute limb ischemia is associated with significant morbidity and mortality resulting in up to a 15% risk of amputation during the initial hospitalization and a 1 in 5 risk of mortality within 1 year of the index event. This review summarizes the current management of acute limb ischemia. Understanding the diagnosis and therapeutic options will aid clinicians in treating these critically ill patients.
Collapse
Affiliation(s)
- Javier A Valle
- Division of Cardiology, VA Eastern Colorado Healthcare System, University of Colorado, 1055 Clermont Street, Denver, CO 80220, USA
| | - Stephen W Waldo
- Division of Cardiology, VA Eastern Colorado Healthcare System, University of Colorado, 1055 Clermont Street, Denver, CO 80220, USA.
| |
Collapse
|
50
|
Valle JA, Armstrong EJ, Waldo SW. Orbital Atherectomy in the Renal Artery: A New Frontier for an Emerging Technology? J Invasive Cardiol 2017; 29:E10-E12. [PMID: 28045673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Orbital atherectomy has been developed as a method to modify calcified plaque in the peripheral vasculature, with extensive experience and data supporting its use in infrainguinal peripheral arterial disease. However, calcific atherosclerotic disease occurs in other vascular beds and may benefit from the application of this technology. In this case report, we describe the first reported use of orbital atherectomy in a renal artery. A 55-year-old male with severe drug-refractory hypertension was found to have renal artery stenosis, with severe calcification of the right renal artery. Orbital atherectomy was utilized for initial plaque modification, and he underwent stenting of the renal artery lesion with an excellent angiographic and clinical result at follow-up. In conclusion, orbital atherectomy is a safe and effective means of plaque modification for severely calcified lesions. The safe and effective use of orbital atherectomy in the renal vasculature suggests an opportunity for ongoing evaluation into expanded roles for this technology beyond the coronary and lower-extremity arterial beds.
Collapse
Affiliation(s)
- Javier A Valle
- University of Colorado School of Medicine, 12361 East 17th Avenue, B130, Denver, CO 80045 USA.
| | | | | |
Collapse
|