Abstract P252: Discharge Antithrombotic Therapy for Ischemic Stroke Patients With Prior Aspirin Failure

Introduction: Aspirin is one of the most commonly used medications for cardiovascular disease and stroke prevention. Many older patients who present with a first or recurrent stroke are already on aspirin monotherapy, yet little evidence is available to guide antithrombotic strategies for these patients.

Method: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we described discharge antithrombotic treatment pattern among Medicare beneficiaries without atrial fibrillation who were discharged alive for acute ischemic stroke from 1734 hospitals in the United States between October 2012 and December 2017.

Results: Of 261,634 ischemic stroke survivors, 100,016 (38.2%) were on prior aspirin monotherapy (median age 78 years; 53% women; 79.4% initial stroke and 20.6% recurrent stroke). The most common discharge antithrombotics (Figure) were 81 mg aspirin monotherapy (20.9%), 325 mg aspirin monotherapy (18.2%), clopidogrel monotherapy (17.8%), and dual antiplatelet therapy (DAPT) of 81 mg aspirin and clopidogrel (17.1%). Combined, aspirin monotherapy, clopidogrel monotherapy, and DAPT accounted for 86.8% of discharge antithrombotics. The rest of 13.2% were discharged on either aspirin/dipyridamole, warfarin or non-vitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotics at all. Among patients with documented stroke etiology (TOAST criteria), 81 mg aspirin monotherapy (21.2-24.0%) was the most commonly prescribed antithrombotic for secondary stroke prevention. The only exception was those with large-artery atherosclerosis, in which, 25.3% received DAPT of 81 mg aspirin and clopidogrel at discharge.

Conclusion: Substantial variations exist in discharge antithrombotic therapy for secondary stroke prevention in ischemic stroke with prior aspirin failure. Future research is needed to identify best management strategies to care for this complex but common clinical scenario.

Patterns of antidepressant therapy and clinical outcomes among ischaemic stroke survivors

Background and purpose

Depression is common after stroke and is often treated with antidepressant medications (AD). ADs have also been hypothesised to improve stroke recovery, although recent randomised trials were neutral. We investigated the patterns of in-hospital AD initiation after ischaemic stroke and association with clinical and readmission outcomes.

Methods

All Medicare fee-for-service beneficiaries aged 65 or older hospitalised for ischaemic stroke in participating Get With The Guidelines-Stroke hospitals between April and December 2014 were eligible for this analysis. Outcome measures included days alive and not in a healthcare institution (home time), all-cause mortality and readmission within 1-year postdischarge. Propensity score (PS)-adjusted logistic regression models were used to evaluate the associations between AD use and each outcome measure. We also compared outcomes in patients prescribed selective serotonin reuptake inhibitors (SSRIs) AD versus those prescribed non-SSRI ADs.

Results

Of 21 805 AD naïve patients included in this analysis, 1835 (8.4%) were started on an AD at discharge. Patients started on an AD had higher rates of depression and prior ischaemic stroke, presented with higher admission National Institutes of Health Stroke Scale score and were less likely to be discharged home. Similarly, patients started on an SSRI had lower rates of discharge to home. Adjusting for stroke severity, patients started on an AD had worse all-cause mortality, all-cause readmission, major adverse cardiac events, readmission for depression and decreased home-time. However, AD use was also associated with an increased risk for the sepsis, a falsification endpoint, suggesting the presence of residual confounding.

Conclusions

Patients with ischaemic stroke initiated on AD therapy are at increased risk of poor clinical outcomes and readmission even after PS adjustment, suggesting that poststroke depression requiring medication is a poor prognostic sign. Further research is needed to explore the reasons why depression is associated with worse outcome, and whether AD treatment modifies this risk or not.

Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure

Importance

Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care.

Objective

To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare.

Design, Setting, and Participants

Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry.

Exposures

Medicare Advantage enrollment.

Main Outcomes and Measures

In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures.

Results

Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42).

Conclusions and Relevance

Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.

Elevated Uric Acid Prevalence and Clinical Outcomes in Patients with Heart Failure with Preserved Ejection Fraction: Insights from RELAX

PURPOSE

We aimed to 1) describe characteristics of patients with heart failure with preserved ejection fraction (HFpEF) enrolled in RELAX stratified by normal or elevated baseline serum uric acid (sUA) level; 2) evaluate the association between sUA level and surrogate clinical measures; and 3) assess associations between changes in sUA level over time and changes in surrogate clinical measures.

METHODS

We analyzed 212 patients with HFpEF and normal or elevated (>6 mg/dL) baseline sUA measurements from the RELAX trial. Variables examined included clinical characteristics, cardiopulmonary exercise testing, 6-minute walk testing, quality of life, echocardiography, and serum biomarker testing. Baseline characteristics between groups were compared and scatter plots with quadratic regression lines and linear regression modeling were used to assess the relationship between baseline sUA and clinical measures. Kaplan-Meier curves were used to describe composite death or cardiovascular/renal hospitalization.

RESULTS

The prevalence of elevated baseline sUA was 68.9%. Patients with elevated sUA had more baseline comorbidities and poorer functional status on cardiopulmonary exercise testing than those without. After adjustment, significant associations between baseline sUA levels and cystatin C, N-terminal pro B-type natriuretic peptide, high-sensitivity troponin I, and high-sensitivity C-reactive protein were identified. Higher baseline sUA was also associated with worsening peak VO₂, 6-minute walk testing, and left ventricular mass. No significant association was found between baseline sUA levels and the composite of death or cardiovascular/renal hospitalization at 24 weeks.

CONCLUSION

sUA is an important marker of comorbidities and functional status in patients with HFpEF. Clinical trials of sUA-lowering therapies in patients with HFpEF are promising.

Home Health Care Use and Post-Discharge Outcomes After Heart Failure Hospitalizations

OBJECTIVES

This study compared the characteristics of Medicare beneficiaries who were hospitalized for heart failure (HF) and then discharged home who received home health care (HHC) to the characteristics of those who did not, and examined associations among HHC and readmission and mortality rates.

BACKGROUND

After hospitalization for HF, some patients receive HHC. However, the use of HHC over time, the factors associated with its use, and the post-discharge outcomes after receiving it are not well studied.

METHODS

This study used Get With The Guidelines-HF data, merged with Medicare fee-for-service claims. Propensity score matching and Cox proportional hazards models were used to evaluate the associations between HHC and post-discharge outcomes.

RESULTS

From 2005 to 2015, 95,531 patients were admitted for HF, and 32,697 (34.2%) received HHC after discharge. The rate of HHC increased over time from 31.4% to 36.1% (p < 0.001). HHC recipients were older, more likely to be female, and had more comorbidities. HHC was associated with a higher risk of all-cause 30-day readmission (hazard ratio [HR]: 1.25; 95% confidence interval [CI]: 1.20 to 1.30), HF-specific 30-day readmission (HR: 1.20; 95% CI: 1.13 to 1.28), all-cause 90-day readmission (HR: 1.23; 95% CI: 1.19 to 1.26), HF-specific 90-day readmission (HR: 1.16; 95% CI: 1.11 to 1.22), and all-cause 30-and 90-day mortality, respectively (HR: 1.70; 95% CI: 1.56 to 1.86) and HR: 1.49; 95% CI: 1.41 to 1.57) compared to those who did not receive HHC.

CONCLUSIONS

Use of HHC after HF hospitalization increased among Medicare beneficiaries. HHC recipients were older and sicker than non-HHC recipients. Although HHC was associated with a higher risk of readmissions and mortality, this finding should be interpreted cautiously, given the presence of unmeasured variables that could affect receipt of HHC. Research is needed to determine whether the results reflect appropriate health care use.

Comparison of Characteristics and Outcomes of Patients With Heart Failure With Preserved Ejection Fraction With Versus Without Hyperuricemia or Gout

Hyperuricemia and gout are common in patients with heart failure (HF) and are associated with poor outcomes. Data describing hyperuricemia and gout in patients with HF with preserved ejection fraction (HFpEF) are limited. We used data from the Duke University Health System to describe characteristics of patients with HFpEF and hyperuricemia (serum uric acid >6 mg/dl) or gout (gout diagnosis or gout medication within the previous year) and to explore associations with 5-year outcomes (death and hospitalization). We identified 7,004 patients in the Duke University Health System with a known diagnosis of HFpEF who underwent transthoracic echocardiography between January 1, 2005 and December 31, 2017. A total of 1,136 (16.2%) patients with HFpEF also had hyperuricemia or gout. Patients with HFpEF and hyperuricemia or gout had a greater co-morbidity burden, more echocardiographic findings of cardiac remodeling, and higher unadjusted rates of all-cause death, all-cause hospitalization, and HF hospitalization compared with those with HFpEF without hyperuricemia or gout. After multivariable adjustment, patients with HFpEF and hyperuricemia or gout had a significantly higher rates of first all-cause hospitalization (adjusted hazard ratio 1.10 [95% confidence interval 1.02 to 1.19]; p = 0.020) and recurrent all-cause hospitalization (associated rate ratio 1.13 [95% confidence interval 1.01 to 1.25]; p = 0.026). After adjustment, no significant differences in death or HF hospitalization were observed. In conclusion, patients with HFpEF and hyperuricemia or gout were found to have a higher burden of co-morbidities and a higher rate of all-cause hospitalization, even after multivariable adjustment, compared to patients with HFpEF without hyperuricemia or gout.

Cryptogenic stroke: Contemporary trends, treatments, and outcomes in the United States

Background

Nationwide data on patients with cryptogenic stroke (CS) are lacking. We evaluated patient and hospital characteristics, in-hospital treatments, and discharge outcomes among patients with CS compared with other subtypes in the Get With The Guidelines (GWTG)-Stroke registry.

Methods

We identified patients with ischemic stroke (IS) admitted to GWTG-Stroke participating hospitals between January 1, 2016, and September 30, 2017, with documented National Institutes of Health Stroke Scale (NIHSS) scale and stroke etiology (cardioembolic [CE], large artery atherosclerosis [LAA], small vessel occlusion [SVO], other determined etiology [OTH], or CS). Using multivariable logistic regression, we compared hospital treatments and discharge outcomes by subtype, adjusted for patient and hospital characteristics.

Results

Among 316,623 patients from 1,687 hospitals, there were 63,301 (20.0%) patients with CS. In multivariable analysis, patients with CS received IV thrombolysis more often than other subtypes and had lower mortality than CE, LAA, and OTH but higher mortality than SVO. They were more likely to be discharged home than all other subtypes and be independent at discharge than LAA, OTH, or SVO.

Conclusions

In a large contemporary nationwide registry, CS accounted for 20% of ISs among patients with a documented stroke etiology. Patients with CS had a distinct profile of treatments and outcomes relative to other subtypes. Improved subtype documentation and further research into CS are warranted to improve care and outcomes for patients with stroke.

Abstract WP380: Hospital-Level Variability in Diagnostic Testing and Ischemic Stroke Subtype Documentation

Objective: Documentation of ischemic stroke subtype has clinical and research implications. We aimed to assess hospital-level variability in subtype documentation and diagnostic testing patterns in the Get With The Guidelines (GWTG)-Stroke registry.

Methods: We identified patients admitted with ischemic stroke to GWTG-Stroke participating hospitals between January 1, 2016 and September 30, 2017. Sites were instructed on use of the TOAST criteria for subtype documentation. We assessed hospital-level variability in TOAST subtype documentation and, among those with subtype documented, the performance of echocardiography, cerebrovascular imaging, and cardiac rhythm monitoring.

Results: Among 607,563 patients with ischemic stroke from 1,906 sites, 348,715 (57.4%) had documented ischemic stroke subtype. Considerable hospital-level variability was observed in subtype documentation (Figure A). Patients with subtype documentation were more likely to be inter-facility transfers and treated at higher volume and academic centers, have complete medical history data, and have higher rates on achievement and quality measures. Carotid and intracranial vascular imaging (69.1% and 58.7%, respectively), echocardiography (74.3%), and cardiac rhythm monitoring (76.2%) were performed most frequently in cryptogenic stroke (CS) patients compared to other subtypes (Figure B; p<0.001 for each comparison). Among CS patients, short-term cardiac rhythm monitoring (65.7%) was most common with only 6.1% undergoing extended surface cardiac rhythm monitoring and 4.4% receiving extended implantable cardiac rhythm monitoring.

Conclusions: In a large contemporary nationwide dataset of acute ischemic stroke hospitalizations, we observed that stroke subtype is documented in 57.4% of records, raising an important opportunity for quality improvement. Furthermore, diagnostic testing patterns suggest incomplete evaluation is common, even among patients with CS.

Abstract WP381: Cryptogenic Stroke: Contemporary Characteristics, Treatments, and Outcomes in the United States

Objective: Nationwide data on patients with cryptogenic stroke (CS) are lacking. We evaluated patient and hospital characteristics, in-hospital treatments, and discharge outcomes among CS patients compared to other subtypes in the Get With The Guidelines (GWTG)-Stroke registry.

Methods: We identified patients admitted to GWTG-Stroke participating hospitals between January 1, 2016 and September 30, 2017 with 1) ischemic stroke and 2) documented stroke etiology (cardioembolic [CE], large artery atherosclerosis [LAA], small vessel occlusion [SVO], other determined etiology [OTH], or CS). Using multivariable logistic regression, we compared discharge outcomes by subtype adjusted for patient and hospital characteristics.

Results: Among 348,715 patients from 1,725 hospitals with documented stroke subtype, there were 69,857 (20.0%) patients with CS. Compared to CE subtype, patients with CS were younger, less likely to arrive by ambulance, less often white, more privately insured, and milder by NIHSS score. In multivariable analysis (Table), patients with CS had lower mortality than CE, LAA, and OTH subtypes but higher mortality than SVO. Patients with CS were more likely to be discharged home than all subtypes and be independent at discharge than patients with LAA or OTH subtypes.

Conclusions: In a large nationwide registry, CS accounted for 20% of ischemic stroke subtypes. Patients with CS had lower stroke severity than CE stroke subtype and had intermediate outcomes at discharge being better than CE and LAA subtypes, but worse than SVO subtype.

Early transition to comfort measures only in acute stroke patients: Analysis from the Get With The Guidelines-Stroke registry

BACKGROUND

Death after acute stroke often occurs after forgoing life-sustaining interventions. We sought to determine the patient and hospital characteristics associated with an early decision to transition to comfort measures only (CMO) after ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With The Guidelines-Stroke registry.

METHODS

We identified patients with IS, ICH, or SAH between November 2009 and September 2013 who met study criteria. Early CMO was defined as the withdrawal of life-sustaining treatments and interventions by hospital day 0 or 1. Using multivariable logistic regression, we identified patient and hospital factors associated with an early (by hospital day 0 or 1) CMO order.

RESULTS

Among 963,525 patients from 1,675 hospitals, 54,794 (5.6%) had an early CMO order (IS: 3.0%; ICH: 19.4%; SAH: 13.1%). Early CMO use varied widely by hospital (range 0.6%-37.6% overall) and declined over time (from 6.1% in 2009 to 5.4% in 2013; p < 0.001). In multivariable analysis, older age, female sex, white race, Medicaid and self-pay/no insurance, arrival by ambulance, arrival off-hours, baseline nonambulatory status, and stroke type were independently associated with early CMO use (vs no early CMO). The correlation between hospital-level risk-adjusted mortality and the use of early CMO was stronger for SAH (r = 0.52) and ICH (r = 0.50) than AIS (r = 0.15) patients.

CONCLUSIONS

Early CMO was utilized in about 5% of stroke patients, being more common in ICH and SAH than IS. Early CMO use varies widely between hospitals and is influenced by patient and hospital characteristics.

Use of Strategies to Improve Door-to-Needle Times With Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice

Background—

The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-needle (DTN) times, was associated with an average 15-minute reduction in DTN times. Target: Stroke phase II was launched in April 2014 with a goal of promoting further reduction in treatment times for tissue-type plasminogen activator (tPA) administration.

Methods and Results—

We conducted a second survey of Get With The Guidelines-Stroke hospitals regarding strategies used to reduce delays after Target: Stroke and quantify their association with DTN times. A total of 16 901 ischemic stroke patients were treated with intravenous tPA within 4.5 hours of symptom onset from 888 surveyed hospitals between June 2014 and April 2015. The patient-level median DTN time was 56 minutes (interquartile range, 42–75), with 59.3% of patients receiving intravenous tPA within 60 minutes and 30.4% within 45 minutes after hospital arrival. Most hospitals reported routinely using a majority of Target: Stroke key practice strategies, although direct transport of patients to computed tomographic/magenetic resonance imaging scanner, premix of tPA ahead of time, initiation of tPA in brain imaging suite, and prompt data feedback to emergency medical services providers were used less frequently. Overall, we identified 16 strategies associated with significant reductions in DTN times. Combined, a total of 20 minutes (95% confidence intervals 15–25 minutes) could be saved if all strategies were implemented.

Conclusions—

Get With The Guidelines-Stroke hospitals have initiated a majority of Target: Stroke–recommended strategies to reduce DTN times in acute ischemic stroke. Nevertheless, certain strategies were infrequently practiced and represent a potential immediate target for further improvements.

Abstract WMP34: Use of Intravenous Tissue Plasminogen Activator in Patients Without a Stroke (Stroke Mimics): Findings From the get With the Guidelines Stroke Registry

Background: The necessity for rapid evaluation and treatment with intravenous tissue plasminogen activator (tPA) in acute ischemic stroke may increase the risk of administrating tPA to patients without a stroke (“stroke mimics”).

Methods: Using data from the Get With The Guidelines Stroke Registry from 2009 to 2015, we identified 90,746 patients treated with tPA within 4.5 hours of symptom onset. We documented use of tPA in stroke mimics, defined as patients initially thought to have a stroke but without a final diagnosis of one, and compared patient characteristics and outcomes between tPA-treated mimics vs. ischemic strokes.

Results: Overall, only 0.8% (728) of all tPA cases were given to stroke mimics, ranging from 0.2% in 2009 Q1 to 1.3% in 2015 Q1. The most common documented diagnoses in tPA-treated mimics were migraine (15.6%), functional disorder (9.4%), and seizure (7.2%). Compared with tPA-treated true stroke patients, tPA-treated mimics were younger (median 52 vs. 72 years), had lower prevalence of atrial fibrillation, coronary artery disease, dyslipidemia, hypertension, heart failure, had less severe National Institute of Health Stroke Scale (median 7 vs. 10), but higher prevalence of prior stroke/transient ischemic attack (34.4% vs. 25.5%), all p<0.001. The door-to-needle times were similar in stroke mimics and true stroke groups (median 68 vs. 68 minutes, p=0.82). Rates of symptomatic intracranial hemorrhage (sICH) were quite rare in stroke mimic patients (0.4%, 3/728) as compared with 4.3% (3846/90018) in patients with an ischemic stroke; adjusted OR for sICH (0.19, 95% CI 0.06-0.58). The in-hospital mortality rate was significantly lower in tPA-treated stroke mimics as compared with ischemic stroke patients (0.6% vs. 7.3%, adjusted OR 0.16, 95% CI 0.06-0.43).

Conclusions: In this large nationwide cohort of patients treated with tPA, only 1 in 125 patients who received tPA for presumed stroke was a false positive and complication rates associated with tPA administration to stroke mimics were quite low. Nonetheless, there still may be opportunities to continue to improve the rapid and accurate diagnosis and treatment of ischemic stroke.

Abstract TP314: Current Use of Strategies to Improve Door-to-Needle Times With Tissue Plasminogen Activator in Acute Ischemic Stroke: Findings From the Target: Stroke Phase II Survey

Background: The benefits of intravenous tissue plasminogen activator (IV tPA) in acute ischemic stroke are time-dependent. The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-need (DTN) times, was associated with an average 15 minutes reduction in DTN times. To further reduce DTN delays, Target: Stroke Phase II was launched in 2014 and disseminated additional new best practice strategies.

Methods: All active Get With The Guidelines-Stroke hospitals (n=1701) were invited to participate in Target: Stroke Phase II and completed an online survey regarding their use of DTN strategies. Hospital respondents reported the use of specific strategies in the 6 months preceding the survey as a binary yes/no or a continuous 0 to 100% of the time scale.

Results: A total of 1034 hospitals (61% response rate) completed the survey between Dec 2014 and Apr 2015. The majority of participating hospitals reported routine use of Target: Stroke key practice strategies, although direct transfer to CT scanner, point of care testing, pre-mix of tPA ahead of time, tPA stored in Emergency Department (ED), or initiation of tPA bolus in the imaging suite were used less frequently (Table). Brain imaging located within the ED was reported by 44% of hospitals and 78% had access to an in-house stroke expert 24/7. Among those who did not have stroke expertise at all times, a majority of hospitals used telestroke systems for imaging interpretation (78%) or clinical evaluation (58%).

Conclusions: GWTG-Stroke hospitals reported moderate to extensive use of most Target: Stroke key practice strategies to evaluate acute stroke cases for tPA eligibility and reduce DTN times. Nevertheless, use of point of care testing, pre-mixing of tPA, ED storage of tPA, initiation of tPA in the imaging suite, and direct transfer to CT scanner remained low, representing potential targets for additional improvements.

Use of prehospital 12-lead electrocardiography and treatment times among ST-elevation myocardial infarction patients with atypical symptoms

OBJECTIVES

Guidelines advise that a prehospital electrocardiogram (ECG) should be obtained in any patients with chest pain, yet up to 20% of patients with ST-elevation myocardial infarction (STEMI) do not present with chest pain. The objective was to determine the association of atypical presentations in the prehospital setting on the likelihood of receiving a prehospital ECG and subsequent time to reperfusion therapy.

METHODS

This study used a data set that linked prehospital medical information from a statewide EMS data system with a clinical registry of treatment and outcomes data for patients with STEMI. Among 2,639 STEMI patients from 2008 to 2010, the association between non-chest pain presentations, prehospital ECG use, and reperfusion times among patients undergoing primary percutaneous coronary intervention (PCI) were examined. Inverse probability weights were used to account for observed baseline confounders.

RESULTS

Overall, 318 of 2,639 patients (12.1%) presented without chest pain. A prehospital ECG was obtained in 2,021 of 2,321 (87.1%) patients with chest pain compared with only 230 of 318 (72.3%) without chest pain (odds ratio [OR] = 2.24, 95% confidence interval [CI] = 1.69 to 2.98). Among patients without chest pain, those who received a prehospital ECG had significantly shorter first medical contact (FMC) to device times (30.9% < 90 minutes vs. 11.4% > 90 minutes, adjusted OR = 2.81, 95% CI = 1.29 to 6.11, p < 0.01).

CONCLUSIONS

Over one-quarter of STEMI patients presenting without chest pain did not receive prehospital ECGs and had significantly longer FMC to device times. Future efforts are needed to promote the use of prehospital ECGs to achieve more rapid identification of STEMI patients with atypical presentations in the prehospital setting.

Abstract WP375: Quality of Care and In-Hospital Outcomes by Race and Ethnicity among Patients Hospitalized with Intracerebral Hemorrhage: Findings from 123,623 Patients in the Get With The Guidelines-Stroke Program

Background: The rates of intracerebral hemorrhage (ICH) are disproportionally higher in minorities. While racial/ethnic differences in care persist in many areas of medicine, no study to date has examined whether ICH care processes or outcomes differ by patient race or ethnicity.

Methods: We analyzed data from 123,623 ICH patients (83,216 white; 22,147 black; 10,519 Hispanic; and 7,741 Asian) hospitalized at 1,199 Get With The Guidelines-Stroke hospitals between 2003 and 2012. Multivariate logistic regression with generalized estimating equation was used to evaluate the association between race, stroke performance measures, and in-hospital outcomes.

Results: Relative to white ICH patients, black, Hispanic, and Asian ICH patients were younger, more frequently had diabetes mellitus, hypertension, and more severe stroke (median National Institutes of Health Stroke Scale [NIHSS]:9, 10, 10, and 11, respectively, p<0.001). After adjusting for both patient- and hospital-level characteristics (Table), black ICH patients were more likely than whites to receive deep venous thrombosis prophylaxis, rehabilitation assessment, dysphagia screening, and stroke education, but less likely to receive smoking cessation counseling despite high prevalence of black current smokers. All minority groups had lower rates of in-hospital mortality (27.6%. 23.0%, 22.8%, and 25.3% for white, black, Hispanic, and Asian, respectively; p<0.001), but were more likely to experience a longer length of stay (median 5, 6, 6, and 6 days, respectively; p<0.001) than white patients. These differences remained consistent after further adjustment for NIHSS among NIHSS complete records (N=47,408).

Conclusion: We found no clear pattern of racial or ethnic differences in the quality of care delivered to ICH patients. Black, Hispanic, and Asian ICH patients had lower risk-adjusted mortality compared with their white counterparts.

Downstream testing and subsequent procedures after coronary computed tomographic angiography following coronary stenting in patients ≥65 years of age

Limited data are available on the use of coronary computed tomographic angiography (CCTA) in patients who have received percutaneous coronary intervention (PCI). To evaluate patterns of cardiac testing including CCTA after PCI, we created a retrospective observational dataset linking National Cardiovascular Data Registry CathPCI Registry baseline data with longitudinal inpatient and outpatient Medicare claims data for patients who received coronary stenting from November 1, 2005 through December 31, 2007. In 192,009 patients with PCI (median age 74 years), the first test after coronary stenting was CCTA for 553 (0.3%), stress testing for 89,900 (46.8%), and coronary angiography for 22,308 (11.6%); 79,248 (41.3%) had no further testing. Patients referred to CCTA first generally had similar or lower baseline risk than those referred for stress testing or catheterization first. Compared to patients with stress testing first after PCI, patients who underwent CCTA first had higher unadjusted rates of subsequent noninvasive testing (10% vs 3%), catheterization (26% vs 15%), and revascularization (13% vs 8%) within 90 days of initial testing after PCI (p <0.0001 for all comparisons). In conclusion, despite similar or lesser-risk profiles, patients initially evaluated with CCTA after PCI had more downstream testing and revascularization than patients initially evaluated with stress testing. It is unclear whether these differences derive from patient selection, performance of CCTA compared to other testing strategies, or the association of early adoption of CCTA with distinct patterns of care.

Abstract 4: The Impact of an Emergency Medical Services Hospital Bypass Protocol on Reperfusion Time for Patients with ST-elevation Myocardial Infarction (STEMI)

Background: As part of a statewide STEMI regionalization program, North Carolina implemented statewide emergency medical service protocols, which encouraged that STEMI patients should be sent directly to a PCI-capable hospital, potentially bypassing hospitals without PCI capacities. We assessed EMS adherence to this protocol, predictors of bypass, and subsequent association of this with patient treatment times and outcomes.

Methods: We linked data from the ACTION-GWTG registry and the EMS Pre-hospital Medical Information System (PreMIS) from 06/2008 to 09/2010. Using a Google map application, we selected EMS transported patients that either 1) bypassed a closer non-PCI hospital and went directly to a PCI center, or 2) were first taken to a non-PCI center and subsequently transferred for PCI.’ We determined predictors of bypass using multivariable logistic regression modeling accounting for clustering within hospital referral regions. Time from first-medical-contact (FMC) to PCI/reperfusion and in-hospital mortality were compared between groups.

Results: Among 1224 eligible STEMI patients, 765 (63%) underwent bypass to a PCI facility while 479 (37%) were first treated at a non-PCI hospital and then transferred for PCI. Adjusted predictors of undergoing bypass were white race (OR 1.37, 95% CI 1.02-1.84), chief complaint of chest pain (OR 2.08, 95%CI 1.46-2.95), having received a pre-hospital 12-lead electrocardiogram (OR 2.14, 95%CI 1.10-4.15), cardiogenic shock (OR 1.82, 95% CI 1.22-2.72), and a prior history of PCI (OR 1.66, 95% 1.11-2.50). Time from FMC to PCI was 95 min (IQR 77-117) in the bypass group vs 179 min (IQR 138-288) in the non-bypass group, p-value for difference <0.0001. Time from FMC to initial reperfusion therapy (PCI or fibrinolysis) was 94 min (IQR, 76-116) in the bypass group vs. 124 (IQR, 67-179) in the non-bypass group, p for difference <0.0001. Crude inhospital mortality was lower in the bypass group vs. the non-bypass group (6.3% vs. 9.4%, p-value for difference = 0.046).

Conclusions: After implementation of a statewide STEMI regionalization program, 2/3 of EMS transported patients bypassed a closer non-PCI center and went directly to a PCI-capable center. Patients who bypassed and went directly to PCI capable centers had significantly more rapid reperfusion times and lower mortality compared with patients not undergoing EMS.

Impact of anemia on physical function and survival among patients with coronary artery disease

BACKGROUND

Anemia is a purported risk factor for adverse outcomes, particularly among patients with cardiac disease. Although anemia at the time of discharge has been associated with poor functional status and survival, its impact over time is not clear.

HYPOTHESIS

Among patients with significant coronary artery disease (CAD), anemia (hemoglobin < 11 g/dL) is prevalent, and is associated with poor physical function (PF) and survival over time.

METHODS

Patients with significant CAD at the time of cardiac catheterization (n = 1, 821) were enrolled into a single-center, observational, and prospective study. All patients were followed for up to 1 y for clinical events and self-reported PF. Prevalence of anemia at discharge and its' associations with outcomes over time were examined.

RESULTS

Anemia at the time of discharge was very common (40.4%), and was associated with increased odds of death at 12 mo (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.12-2.15), yet other clinical factors accompanying anemia accounted for this association (adjusted OR 1.13, 95% CI 0.79-1.62). Discharge anemia was also associated with significantly lower self-reported PF at 6 and 12 mo (p < 0.05 for both); however, other clinical factors accompanying anemia also accounted for these associations.

CONCLUSIONS

Although discharge anemia is highly prevalent, its association with adverse outcomes is largely explained by baseline patient characteristics. Further research is needed to clarify the relationship between anemia and outcomes in this population and to identify subpopulations that do not recover independently and for whom available therapies may be beneficial.

Long-term adherence with cardiovascular drug regimens

BACKGROUND

An increasing number of medications are prescribed for patients with coronary artery disease, but poor adherence may limit realization of their benefits.

OBJECTIVE

To characterize adherence to evidence-based cardiovascular medications prescribed at hospital discharge at 1 year.

METHODS

We studied 1326 patients with coronary artery disease undergoing cardiac catheterization between 1998 and 2001. We examined adherence to angiotensin-converting enzyme (ACE) inhibitors, aspirin, beta-blockers (BBs), and statins by comparing baseline prescription at hospital discharge to self-reported medical regimen at 12 months. Patients who reported use of each cardiac medication at 1 year were considered adherent. Clinical and demographic predictors of nonadherence are described.

RESULTS

The population had a mean age of 65.7 +/- 10.5 years, and 36% were women. At discharge, aspirin was prescribed in 95%, BBs in 86%, ACE inhibitors in 65%, and statins in 55%. The proportion of patients who discontinued medications was lowest for aspirin (18%) and BBs (22%) and highest for ACE inhibitors/angiotensin receptor blockers (28%) and statins (28%). Only 54% were adherent to all of their initial medications. Patients who discontinued medications were more likely to be older, women, unmarried, and less educated. Multivariable predictors of better adherence were higher mental health, education level, marital status, and no antidepressant use. A higher number of prescribed medications were associated with lower adherence to the recommended regimen. Insurance coverage and physical function did not correlate with adherence.

CONCLUSIONS

Patients frequently stop medications within 1 year of prescription. Adherence is influenced by marital status, mental health, education, and total number of medications prescribed. Physicians need to be aware of patient factors which influence adherence to facilitate higher use of evidence-based medications.

Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery

OBJECTIVES

This study was conducted to evaluate follow-up results in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent either percutaneous transluminal septal myocardial ablation (PTSMA) or septal myectomy.

BACKGROUND

Controversy exists with regard to these two forms of treatment for patients with HOCM.

METHODS

Of 51 patients with HOCM treated, 25 were treated by PTSMA and 26 patients via myectomy. Two-dimensional echocardiograms were performed before both procedures, immediately afterwards and at a three-month follow-up. The New York Heart Association (NYHA) functional class was obtained before the procedures and at follow-up.

RESULTS

Interventricular septal thickness was significantly reduced at follow-up in both groups (2.3 +/- 0.4 cm vs. 1.9 +/- 0.4 cm for septal ablation and 2.4 +/- 0.6 cm vs. 1.7 +/- 0.2 cm for myectomy, both p < 0.001). Estimated by continuous-wave Doppler, the resting pressure gradient (PG) across the left ventricular outflow tract (LVOT) significantly decreased immediately after the procedures in both groups (64 +/- 39 mm Hg vs. 28 +/- 29 mm Hg for PTSMA, 62 +/- 43 mm Hg vs. 7 +/- 7 mm Hg for myectomy, both p < 0.0001). At three-month follow-up, the resting PG remained lower in the PTSMA and myectomy groups (24 +/- 19 mm Hg and 11 +/- 6 mm Hg, respectively, vs. those before procedures, both p < 0.0001). The NYHA functional class was also significantly improved in both groups (3.5 +/- 0.5 vs. 1.9 +/- 0.7 for PTSMA, 3.3 +/- 0.5 vs. 1.5 +/- 0.7 for myectomy, both p < 0.0001).

CONCLUSIONS

Both myectomy and PTSMA reduce LVOT obstruction and significantly improve NYHA functional class in patients with HOCM. However, there are benefits and drawbacks for each therapeutic method that must be counterbalanced when deciding on treatment for LVOT obstruction.

Severe valvular and aortic arch calcification in a patient with Gaucher's disease homozygous for the D409H mutation

Gaucher's disease is an autosomal recessive inherited defect of the lysosomal enzyme glucocerebrosidase, which leads to glucocerebroside accumulation in the reticuloendothelial system. Homozygosity for the D409H mutation has been associated with cardiovascular valvular disease. We present a case of a 17-year-old Palestinian patient who presented with severe aortic and mitral valvular calcification, as well as calcification of the ascending aorta, the aortic arch and the ostia of his coronary arteries. The patient was confirmed to be homozygous for the D409H mutation in the glucocerebrosidase gene. The patient's enzyme assay for glucocerebrosidase activity was 5 nm/h/mg protein (normal 13-22 nm/h/mg). The patient presented with symptoms of dyspnea and chest pain. He had a 6-year history of documented aortic valve calcification by echocardiogram after two of his older brothers died of congestive heart failure and severe valvular calcification. Cardiac catheterization showed a severely calcified aorta with almost no motion of the aortic valve leaflets and severe calcification of the mitral valve and the mitral valvular apparatus. The patient underwent extensive cardiac surgery with aortic and mitral valve replacements and intraoperative findings confirmed calcification of the entire aortic root. Electron microscopy of the valves confirmed the presence of Gaucher's cells. Enzyme therapy with imiglucerase was initiated. The patient is in stable condition, 20 months post-operatively.

Does coronary angiography before emergency aortic surgery affect in-hospital mortality?

OBJECTIVES

To study the relationship between coronary angiography and in-hospital mortality in patients undergoing emergency surgery of the aorta without a history of coronary revascularization or coronary angiography before the onset of symptoms.

BACKGROUND

In the setting of acute ascending aortic dissection warranting emergency aortic repair, coronary angiography has been considered to be desirable, if not essential. The benefits of defining coronary anatomy have to be weighed against the risks of additional delay before surgical intervention.

METHODS

Retrospective analysis of patient charts and the Cardiovascular Information Registry (CVIR) at the Cleveland Clinic Foundation.

RESULTS

We studied 122 patients who underwent emergency surgery of the aorta between January 1982 and December 1997. Overall, in-hospital mortality was 18.0%, and there was no significant difference between those who had coronary angiography on the day of surgery compared with those who had not (No: 16%, n = 81 vs. Yes: 22%, n = 41, p = 0.46). Multivariate analysis revealed that a history of myocardial infarction (MI) was the only predictor of in-hospital mortality (relative risk: 4.98 95% confidence interval: 1.48-16.75, p = 0.009); however, coronary angiography had no impact on in-hospital mortality in patients with a history of MI. Furthermore, coronary angiography did not significantly affect the incidence of coronary artery bypass grafting (CABG) during aortic surgery (17% vs. 25%, Yes vs. No). Operative reports revealed that 74% of all CABG procedures were performed because of coronary dissection, and not coronary artery disease.

CONCLUSIONS

These data indicate that determination of coronary anatomy may not impact on survival in patients undergoing emergency surgery of the aorta and support the concept that once diagnosed, patients should proceed as quickly as possible to surgery.

Prediction of global left ventricular function after bypass surgery in patients with severe left ventricular dysfunction. Impact of pre-operative myocardial function, perfusion, and metabolism

AIMS

Previous studies have compared the accuracy of various tests of viability for the prediction of recovery of regional left ventricular function; global left ventricular recovery has been less well studied, although it has important prognostic and functional ramifications. We sought to identify the relative contribution of ischaemia, regional and global contractile reserve, perfusion and metabolic function to changes in left ventricular volumes and global function after coronary artery bypass surgery in patients with severe left ventricular dysfunction.

METHODS AND RESULTS

Dipyridamole stress Rb-82, fluorodeoxyglucose positron emission tomography and low and high-dose dobutamine-atropine stress echocardiography were obtained in 66 patients with left ventricular impairment. Myocardial segments were considered viable if ischaemia or either metabolic or contractile reserve were present, on positron emission tomography or dobutamine echocardiography. Resting left ventricular function was reassessed after surgery (mean 10+/-3 weeks) in the 59 patients who had not suffered a major peri-operative event; functional improvement was defined by a 5% increment of ejection fraction. Myocardial viability was found in 37 (63%) patients using positron emission tomography and in 42 (71%) patients using dobutamine echocardiography; post-operative functional improvement was noted in 28 (47%) patients. In univariate analyses, predictors of global post-operative functional recovery included: the extent of viability according to positron emission tomography [OR (odds ratio): 2.08 for each additional viable segment, 95% CI (confidence interval): 1.33-3. 25, P=0.001] or dobutamine echocardiography (OR: 2.06 for each additional viable segment, 95% CI: 1.28-3.30, P=0.003) and the increase in ejection fraction with low-dose dobutamine (OR: 1.9 for each 1% increase in ejection fraction with low dose dobutamine, 95% CI 1.39-2.61, P<0.0001). In a multivariate model which included evidence of viability by either technique, and change in ejection fraction with low-dose dobutamine echocardiography, only change in ejection fraction with low-dose dobutamine echocardiography was predictive of post-operative left ventricular functional recovery (adjusted OR: 1.81, 95% CI: 1.30-2.52, P=0.0005).

CONCLUSION

Among patients with severe left ventricular dysfunction who are referred for surgical revascularization, the overall accuracies of positron emission tomography and dobutamine echocardiography for the prediction of post-operative myocardial recovery are comparable. However, the strongest predictor of overall improvement of post-operative left ventricular function is an increase of ejection fraction with a low-dose dobutamine infusion.

Involvement of both dockerin subdomains in assembly of the Clostridium thermocellum cellulosome

Clostridium thermocellum produces an extracellular cellulase complex termed the cellulosome. It consists of a scaffolding protein, CipA, containing nine cohesin domains and a cellulose-binding domain, and at least 14 different enzymatic subunits, each containing a conserved duplicated sequence, or dockerin domain. The cohesin-dockerin interaction is responsible for the assembly of the catalytic subunits into the cellulosome structure. Each duplicated sequence of the dockerin domain contains a region bearing homology to the EF-hand calcium-binding motif. Two subdomains, each containing a putative calcium-binding motif, were constructed from the dockerin domain of CelS, a major cellulosomal catalytic subunit. These subdomains, called DS1 and DS2, were cloned by PCR and expressed in Escherichia coli. The binding of DS1 and DS2 to R3, the third cohesin domain of CipA, was analyzed by nondenaturing gel electrophoresis. A stable complex was formed only when R3 was combined with both DS1 and DS2, indicating that the two halves of the dockerin domain interact with each other and such interaction is required for effective binding of the dockerin domain to the cohesin domain.

Identifying the cause of left ventricular systolic dysfunction after coronary artery bypass surgery: the role of myocardial contrast echocardiography

OBJECTIVE

Intraoperative myocardial contrast echocardiography was used to determine whether the identification of regional myocardial flow patterns during revascularization could predict myocardial contractile function immediately after separation from cardiopulmonary bypass (CPB) and at 1 month after coronary artery bypass grafting (CABG) surgery.

DESIGN

A prospective, open-labeled, longitudinal analysis.

SETTING

Two independent university hospitals.

PARTICIPANTS

Twenty patients, during and up to 1 month after CABG.

INTERVENTIONS

The contrast agent Albunex (Mallenckrodt Medical, Inc, St Louis, MO) was injected into the aortic root during CPB.

MEASUREMENTS AND MAIN RESULTS

Myocardial contrast echocardiography opacification of flow was graded from intraoperative transesophageal echocardiographic images of the left ventricle in the short-axis, midpapillary view. The same myocardial images were also evaluated for regional wall motion abnormalities at 15, 30, and 60 minutes, 24 hours, 5 to 8 days, and 1 month after CPB. Logistic regression analysis was used to analyze the flow scores and regional function data from identical segments. Regional flow represented by contrast enhancement was assessed in 70% of the myocardial regions (55 of 80 possible segments; 95% confidence interval [CI], 61 to 76). Flow was more easily evaluated in the posterior region (95%) than in the anterior (70%) or septal regions (60%), and least likely evaluated in the lateral regions (50%). Regional wall motion was scored in 84% of the myocardial regions (469 of 560 possible regions). Function (segmental wall motion) was assessed in all regions with equal success. Segmental function and flow scores were matched to the same regions 66% of the time (53 of 80 possible series; 95% CI, 55 to 76). Regional myocardial contrast flow patterns did not predict myocardial function at 15, 30, or 60 minutes after separation from CPB. However, contrast opacification of flow did predict regional myocardial function at 1 week (p < or = 0.05) and at 1 month (p < or = 0.01) after CABG surgery. The probability that myocardial function would be normal at 1 month was 0.62 when intraoperative flow opacification was abnormal and 0.98 when flow opacification was normal. For patients with normal flow, the estimated odds of having normal myocardial function were 3.33 times those of patients with abnormal flow at 1 week (odds ratio, 3.33; 95% CI, 1.09 to 10.19) and 18.5 times those of patients with abnormal flow at 1 month (95% CI, 2.44 to 140.48).

CONCLUSION

Intraoperative application of myocardial contrast echocardiography to determine regional flow patterns after revascularization may help differentiate conditions of left ventricular systolic dysfunction immediately after separation from CPB for CABG surgery and appear to predict myocardial function at 1 month.

Prediction of death and myocardial infarction by screening with exercise-thallium testing after coronary-artery-bypass grafting

BACKGROUND

The role of myocardial-perfusion imaging in calculating risk in symptom-free patients who have had coronary-artery-bypass grafting (CABG) is unclear. Practice guidelines have argued against routine screening of these patients. We sought to find out the independent and incremental prognostic value of exercise thallium-201 single-photon-emission computed tomography (SPECT) for prediction of death and non-fatal myocardial infarction (MI) in these patients.

METHODS

Analyses were based on 873 symptom-free patients undergoing symptom-limited exercise thallium-201 SPECT between September, 1990, and December, 1993. All had undergone CABG and none had recurrent angina or other major intercurrent coronary events. Exercise and thallium-perfusion variables were analysed to determine their prognostic importance during 3 years of follow-up.

FINDINGS

Myocardial-perfusion defects were noted in 508 (58%) patients. There were 57 deaths and 72 patients had major events (death or non-fatal MI). Patients with thallium-perfusion defects were more likely to die (9% vs 3%, p=0.0004) or suffer a major event (11% vs 4%, p=0.0002). Reversible defects were also predictive of death (12% vs 5%, p=0.002) and major events (13% vs 7%, p=0.004). The exercise variable with the strongest predictive power was an impaired (< or = 6 METs [measure of oxygen consumption equal to 3.5 mL/kg/min]) exercise capacity; poor exercise capacity was predictive of death (18% vs 4%, p<0.0001) and death or non-fatal MI (19% vs 5%, p<.00001). After adjusting for baseline clinical variables, surgical variables, time elapsed since CABG, and standard cardiovascular risk factors, thallium-perfusion defects remained predictive of death (adjusted relative risk 2.78, 95% CI 1.44-5.39) and major events (2.63, 1.49-4.66). Similarly, impaired exercise remained strongly predictive of death (4.16, 2.38-7.29) and major events (3.61, 2.22-5.87) after adjusting for confounders.

INTERPRETATION

In this group of patients who were symptom-free after CABG, thallium-perfusion defects and impaired exercise capacity were strong and independent predictors of subsequent death or non-fatal MI. Recommendations against routine screening exercise myocardial-perfusion studies in this setting should be reconsidered.

Predictors of outcome in cardiac surgical patients with prolonged intensive care stay

OBJECTIVE

To determine the predictors of outcome in cardiac surgical patients with prolonged ICU stay.

DESIGN

Inception cohort with retrospective chart review.

SETTING

Adult cardiovascular ICU.

PATIENTS

All patients admitted after cardiac surgery who stayed in ICU for at least 14 consecutive days.

INTERVENTIONS

Collection of data, including preoperative demographics, comorbidity, routine laboratory testing, surgical procedure, duration of cardiopulmonary bypass and aortic cross-clamping, postoperative requirement for transfusion and intra-aortic balloon counterpulsation, and postoperative indexes of organ dysfunction 14 and 28 days after surgery. An organ failure score (OFS) was calculated for days 1, 14, and 28.

OUTCOME MEASURES

Hospital mortality.

RESULTS

One hundred forty-one of 324 (43.5%) ICU admissions lasting at least 14 days resulted in hospital mortality. Seventy-four of 166 (45%) ICU admissions lasting at least 28 days resulted in hospital mortality. Preoperative demographics, morbidity, and indexes of organ failure in the first 24 h after surgery were not predictive of hospital mortality. Indexes of organ failure predictive of hospital death at 14 days included requirement for epinephrine infusion, diminished Glasgow coma scale, requirement for dialysis, greater value of BUN, lower value of creatinine, greater value of bilirubin, greater value of arterial PCO2, lower platelet count, and lower value of serum albumin. After a 28-day stay in ICU, the indexes of organ failure predictive of hospital mortality included requirement for dopamine or norepinephrine infusions, diminished Glasgow coma score, greater value of bilirubin, greater value of arterial PCO2, lower value of serum albumin, and advanced age. The area under the receiver operating characteristic curve for the OFS on day 1 was 0.55+/-0.04 (p=0.12), on day 14 it was 0.75+/-0.03 (p<0.0001), and on day 28 it was 0.76+/-0.04 (p<0.0001).

CONCLUSION

Preoperative health status and early organ failure were not predictive of late hospital mortality. The pattern of late organ failure associated with hospital mortality changed with time.

Assessing myocardial perfusion with Albunex during coronary artery bypass surgery: technical considerations and safety of aortic root injections

OBJECTIVE

To test the safety and report on limiting technical considerations, including optimal dosing of Albunex (Molecular Biosystems, Inc, Mallinckrodt Medical, St. Louis, MO) for myocardial opacification after intra-aortic root injections during cardiac surgery.

DESIGN

This was a prospective randomized study with a control group who did not receive Albunex and a group who received intra-aortic root injections of Albunex.

SETTING

Multicenter (two) independent university hospitals.

PARTICIPANTS

32 patients scheduled for elective coronary artery bypass surgery were evaluated after individual informed consent was obtained.

INTERVENTIONS

2 to 8 mL of Albunex were injected before and after coronary revascularization.

MEASUREMENTS AND MAIN RESULTS

Quality of enhancement in each of four regions of the left ventricle was assessed from a short-axis mid-papillary ultrasound image by three experienced observers blinded to dose. Electrocardiogram (ECG), creatine phosphokinase (CPK) (MB fraction), and hemodynamics were evaluated at baseline and throughout the study period for up to 72 hours. No differences were noted between groups with respect to preoperative and postoperative CPK enzymes (CPK-MB fraction), ECG changes, hemodynamics, requirements for separation from CPB, need for postoperative inotropes, time to extubation, and time to discharge from the intensive care unit. The average total dose of Albunex injected was 19 mL +/- 4 (0.25 mL/kg). A single dose of 4.2 +/- 1.2 mL (0.05 mL/kg) appeared to offer optimal enhancement of contrast effect for myocardial perfusion assessment.

CONCLUSION

Albunex is safe and easy to use for myocardial opacification when administered via an antegrade cardioplegia catheter into the aortic root during CPB.

Interactions of the CelS binding ligand with various receptor domains of the Clostridium thermocellum cellulosomal scaffolding protein, CipA

The Clostridium thermocellum cellulosomal scaffolding protein, CipA, acts as an anchor on the cellulose surface for the various catalytic subunits of the cellulosome, a large extracellular cellulase complex. CipA contains nine repeated domains that serve as receptors for the cellulosomal catalytic subunits, each of which carries a conserved, duplicated ligand sequence (DS). Four representative CipA receptor domains with sequence dissimilarity were cloned and expressed in Escherichia coli. The interaction of these cloned receptor domains with the duplicated ligand sequence of CelS (expressed as a thioredoxin fusion protein, TRX-DSCelS), was studied by nondenaturing polyacrylamide gel electrophoresis. TRX-DSCelS formed a stable complex with each of the four receptor domains, indicating that CelS, the most abundant cellulosomal catalytic subunit, binds nonselectively to all of the CipA receptors. Conversely, the duplicated sequence of CipA (in the form of TRX-DSCipA), which is homologous to that of CelS, did not bind to any of the receptors under the experimental conditions.

Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes

BACKGROUND

Since 1989, New York State has disseminated comparative information on outcomes of coronary bypass surgery to the public. It has been suggested that this program played a significant role in the 41% decrease in the risk-adjusted mortality rate between 1989 and 1992. We hypothesized that some high-risk patients had migrated out of state for surgery.

METHODS AND RESULTS

We reviewed 9442 isolated coronary bypass operations performed from 1989 through 1993 to assess referral patterns of case-mix and outcome. Expected and risk-adjusted mortality rates were computed using logistic regression models derived from the Cleveland Clinic and New York State databases. A mortality comparison was performed using the 1980 to 1988 time period as a historical control. Patients from New York (n=482) had a higher frequency of prior open heart surgery (44.0%) than patients from Ohio (n=6046) (21.5%, P<.001), other states (n=1923) (37.4%, P=.008), and other countries (n=991) (17.3%, P<.001). They were also more likely to be in NYHA functional class III or IV (47.6% versus Ohio 42.7%, P=.037; other states, 41.2%, P=.011; other countries, 34.1%, P=.001). The expected mortality rate was thus higher than among other referral cohorts. The observed 5.2% mortality rate among these patients was significantly greater than the 2.9%, 3.1%, and 1.4% mortality rates observed for patients from Ohio (P=.004), other states (P=.028), and other countries (P<.001). These differences in outcome were not apparent between 1980 and 1988 among referrals from within the United States.

CONCLUSIONS

Public dissemination of outcome data may have been associated with increased referral of high-risk patients from New York to an out-of-state regional medical center.

Bypass Angioplasty Revascularization Investigation (BARI): baseline clinical and angiographic data

This report presents baseline clinical and angiographic data from the Bypass Angioplasty Revascularization Investigation (BARI), a multicenter international trial assessing the relative efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG) in selected patients with multivessel coronary artery disease. PTCA is commonly performed in patients with multivessel coronary artery disease, yet its long-term efficacy in comparison to CABG is unknown. From August 1988 through August 1991, 1,829 qualifying patients with multivessel disease suitable for either procedure were randomized to PTCA or CABG; sample size estimates were based on anticipated 5-year mortality. Two registry populations were also defined for follow-up: (1) 2,013 patients eligible for randomization but not randomized; and (2) 422 patients considered by angiography as unsuitable for randomization. Patients randomized in BARI were at relatively high risk for subsequent cardiac events: 39% were > or = 65 years old, 55% had prior myocardial infarction, 69% presented with unstable angina or non-Q wave myocardial infarction, and 43% had 3-vessel coronary artery disease. Patients randomized to PTCA and CABG were equally matched in all the important baseline variables. The randomized and the eligible but not randomized groups were similar in most respects. However, the nonrandomized group had a higher proportion with college education; fewer with a history of myocardial infarction, heart failure, diabetes, and smoking; and a somewhat better average ejection fraction. At the 3-month follow-up, PTCA had been performed more commonly in the nonrandomized eligible patients, especially those with 2-vessel disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum Lp(a) level as a predictor of vein graft stenosis after coronary artery bypass surgery in patients

Although the serum lipoprotein fraction Lp(a) has been associated with coronary artery atherosclerosis, its relationship to narrowing of saphenous vein grafts has not previously been elucidated. We therefore measured serum Lp(a) levels in 167 symptomatic patients undergoing cardiac catheterization who had had coronary artery bypass surgery 0.7 to 14.3 years earlier. Lp(a), total cholesterol, and total triglyceride levels were compared with the degree of saphenous vein graft stenosis to test for any association. Serum Lp(a) levels were significantly associated with the degree of stenosis of saphenous vein grafts (r = .24, p = .002). Mean Lp(a) levels (mg/dl) in the 135 patients with stenosis were almost double (32.0 +/- 32.7, mean +/- SD) those in the 32 patients with no graft stenosis (16.7 +/- 22.6; p = .002). Graft stenosis was not associated with previous myocardial infarction, hypertension, obesity, diabetes, or smoking. Serum cholesterol levels (mg/dl) were slightly higher in the stenosis group (251.3 +/- 69) than in the no-stenosis group (231.8 +/- 48.8), but the difference was of borderline significance (p = .06). A stepwise increase in mean Lp(a) was found in groups of patients with increasing vein graft stenosis. At a serum Lp(a) level of 31.6 mg/dl or above, 92% of the patients demonstrated vein graft stenosis. Thus, patients with elevated Lp(a) levels have an increased risk of developing saphenous vein graft stenosis after coronary bypass surgery.