Healthcare provision of transcatheter aortic valve implantation in Germany

BACKGROUND

Transcatheter aortic valve implantation (TAVI) for aortic stenosis in older patients is the standard of care with a well-established supply density in Germany. In the near future, healthcare reform is planned that may affect TAVI capacities. Therefore, it is important to know how political regulations may interfere with access to services and what the need for TAVI will be in the future, based on demographic trends.

METHODS

The number of TAVI procedures (DRG F98A +F98) and the in-hospital main diagnoses of aortic stenosis (ICD I35) in 2021 were analyzed at the level of county or federal state based on anonymized data from hospital reports, according to § 21 of the German hospital reimbursement law. The number of TAVI and aortic stenosis cases was projected for 2035 based on data from the German Federal Statistical Office on demographic developments. With quality assurance data from hospitals in 2019 and a route planner, the travel time to the next hospital performing TAVI (OPS 5‑35a.0) was calculated, and the consequence of a politically suggested minimum volume cut-off was analyzed.

RESULTS

In 2021, a total of 26,506 TAVI procedures were reported with a mean number of TAVI per 100,000 inhabitants of 32 (range between federal states from 25 to 42). Among the 66,045 diagnoses of aortic stenosis, there was a variation per 100,000 inhabitants from 64 to 108 (mean 79) between federal states. Compared to 2021, an additional 8748 (+13%) diagnoses of aortic stenosis and an increase of 4673 (+18%) TAVI procedures is to be expected in 2035. In 2019, 57% of German citizens could reach a TAVI hospital within 30 min and 91% within 60 min of driving time by car (mean time to hospital 31 min). Applying a minimum number of 150 TAVI/hospital per year would increase the driving time to hospital from 33 to 52 min in Saxony-Anhalt and instantly remove six out of eight hospitals from service in Hesse.

CONCLUSION

Regulation of TAVI services by minimum volume numbers would arbitrarily interfere with access to services, in contradiction to the medical service assurance tasks of federal state governments. These issues should be considered in the upcoming healthcare system reform.

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care

BACKGROUND

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.

METHODS

Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression.

RESULTS

Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations.

CONCLUSION

Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

Transfemoral aortic valve implantation: procedural hospital volume and mortality in Germany

AIMS

Studies assessing transfemoral transcatheter aortic valve implantation (TF-TAVI) showed lower rates of in-hospital mortality at high-volume hospitals and minimum caseloads were recommended to assure quality standards.

METHODS AND RESULTS

All patients in the German mandatory quality assurance registry with elective or urgent TF-TAVI procedures in 2018 and 2019 at 81 and 82 hospitals, respectively, were analysed. Observed in-hospital mortality was adjusted to expected mortality by the German AKL-KATH score (O/E) as well as by the EuroScore II (O/E2). Hospital volume and O/E were correlated by regression analyses and volume quartiles. 18 763 patients (age: 81.1 ± 1.0 years, mean EuroSCORE II: 6.9 ± 1.8%) and 22 137 patients (mean age: 80.7 ± 3.5 years, mean EuroSCORE II: 6.5 ± 1.6%) were analysed in 2018 and 2019, respectively. The average observed in-hospital mortality was 2.57 ± 1.83% and 2.36 ± 1.60%, respectively. Unadjusted in-hospital mortality was significantly inversely related to hospital volume by linear regression in both years. After risk adjustment, the association between hospital volume and O/E was statistically significant in 2019 (R2 = 0.049; P = 0.046), but not in 2018 (R2 = 0.027; P = 0.14). The variance of O/E explained by the number of cases in 2019 was low (4.9%). Differences in O/E outcome between the first and the fourth quartile were not statistically significant in both years (1.10 ± 1.02 vs. 0.82 ± 0.46; P = 0.26 in 2018; 1.16 0 .97 vs. 0.74 ± 0.39; P = 0.084 in 2019). Any chosen volume cut-off could not precisely differentiate between hospitals with not acceptable quality (>95th percentile O/E of all hospitals) and those with acceptable (O/E ≤95th percentile) or above-average (O/E < 1) quality. For example, in 2019 a cut-off value of 150 would only exclude one of two hospitals with not acceptable quality, while 20 hospitals with acceptable or above-average quality (25% of all hospitals) would be excluded.

CONCLUSION

The association between hospital volume and in-hospital mortality in patients undergoing elective TF-TAVI in Germany in 2018 and 2019 was weak and not consistent throughout various analytical approaches, indicating no clinical relevance of hospital volume for the outcome. However, these data were derived from a healthcare system with restricted access to hospitals to perform TAVI and overall high TAVI volumes. Instead of the unprecise surrogate hospital volume, the quality of hospitals performing TF-TAVI should be directly assessed by real achieved risk-adjusted mortality.

[Cardiac rehabilitation during the COVID-19 pandemic in Germany - a quick poll of the German Society of rehabilitation and Prevention of Heart and Circulation Diseases (DGPR)]

Hintergrund

In Deutschland hat die COVID-19-Pandemie die kardiologische Versorgung sowohl im ambulanten als auch im akutstationären Bereich unter anderem durch die Absage elektiver Eingriffe erheblich verändert. Um Hinweise darauf zu bekommen, inwieweit dies auch für Einrichtungen der kardiologischen Rehabilitation gilt, ist diese Untersuchung durchgeführt worden.

Methode

Im August 2020 wurden alle 107 Mitgliedseinrichtungen der DGPR kontaktiert und gebeten, an einer Online-Erhebung teilzunehmen, bei der 12 Fragenkomplexe zum Thema beantwortet werden sollten.

Ergebnisse

Ende August lagen von 45 Einrichtungen Daten vor. 31,1% der befragten Einrichtungen rehabilitierten Patienten mit kardialen Komplikationen/Manifestationen einer COVID-19 Erkrankung, überwiegend nach akutem Koronarsyndrom (29,6%) und Lungenarterienembolie (25,9%). Mehr als 40% der Einrichtungen mussten teilweise oder komplett schließen und 14% befürchteten eine teilweise oder komplette Schließung zum Ende des Jahres 2020. Kosten für die Testung bei Verdacht auf SARS-CoV-2-Infektion hatten die Einrichtungen überwiegend (72,1%) zu tragen.

Schlussfolgerung

Die vorliegende Untersuchung gibt trotz der Limitationen einer sehr kurzfristigen Datenerhebung und einer Rücklaufquote von ca. 45% Hinweise auf die herausfordernde Situation der COVID-19-Pandemie für kardiologische Rehabilitationseinrichtungen in Deutschland.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Long-term effects of a standardized feedback-driven quality improvement program for timely reperfusion therapy in regional STEMI care networks

AIMS

Current European Society of Cardiology guidelines state that repetitive monitoring and feedback should be implemented for ST-elevation myocardial infarction (STEMI) treatment, but no evidence is available supporting this recommendation. We aimed to analyze the long-term effects of a formalized data assessment and systematic feedback on performance and mortality within the prospective, multicenter Feedback Intervention and Treatment Times in STEMI (FITT-STEMI) study.

METHODS

Regular interactive feedback sessions with local STEMI management teams were performed at six participating German percutaneous coronary intervention (PCI) centers over a 10-year period starting from October 2007.

RESULTS

From the first to the 10th year of study participation, all predefined key-quality indicators for performance measurement used for feedback improved significantly in all 4926 consecutive PCI-treated patients - namely, the percentages of patients with pre-hospital electrocardiogram (ECG) recordings (83.3% vs 97.1%, p < 0.0001) and ECG recordings within 10 minutes after first medical contact (41.7% vs 63.8%, p < 0.0001), pre-announcement by telephone (77.0% vs 85.4%, p = 0.0007), direct transfer to the catheterization laboratory bypassing the emergency department (29.4% vs 64.2%, p < 0.0001), and contact-to-balloon times of less than 90 minutes (37.2% vs 53.7%, p < 0.0001). Moreover, this feedback-related continuous improvement of key-quality indicators was linked to a significant reduction in in-hospital mortality from 10.8% to 6.8% (p = 0.0244). Logistic regression models confirmed an independent beneficial effect of duration of study participation on hospital mortality (odds ratio = 0.986, 95% confidence interval = 0.976-0.996, p = 0.0087). In contrast, data from a nationwide PCI registry showed a continuous increase in in-hospital mortality in all PCI-treated STEMI patients in Germany from 2008 to 2015 (n = 398,027; 6.7% to 9.2%, p < 0.0001).

CONCLUSIONS

Our results indicate that systematic data assessment and regular feedback is a feasible long-term strategy and may be linked to improved performance and a reduction in mortality in STEMI management.

[Postacute care after transcatheter aortic valve implantation (TAVI)]

With increasing age valvular heart disease is among the most frequent diseases of the heart. Relevant valvular disease impairs not only the long-term prognosis but also physical resilience, activities of daily living and the quality of life. In cases of middle to high-grade symptomatic cardiac defects, valve replacement or valve reconstruction is still the surgical procedure of choice; however, in recent years the transcatheter percutaneous aortic valve replacement (TAVI) procedure has become more prominent for the most frequent defect, aortic valve stenosis. This article provides an overview of the aftercare and rehabilitation of patients following a TAVI intervention.

In-hospital mortality in propensity-score matched low-risk patients undergoing routine isolated surgical or transfemoral transcatheter aortic valve replacement in 2014 in Germany

AIMS

Recent randomized trials have documented the superiority of TAVR-particularly via transfemoral access-over SAVR in patients with severe aortic stenosis considered to have a high or intermediate operative risk of death. We sought to assess in-hospital outcomes of patients with severe aortic stenosis and a low risk of operative mortality undergoing routine surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR).

METHODS AND RESULTS

We performed a propensity-score matched comparison of all patients undergoing first-time treatment by SAVR or transfemoral TAVR (TF-TAVR) in 2014 in Germany who had a logistic EuroSCORE (logES) ≤ 10%, considered to reflect low surgical risk. The primary endpoint of our analysis was in-hospital mortality. Of 7624 SAVR and 9969 TF-TAVR procedures, 6844 (89.8%) and 2751 patients (27.6%), respectively, were considered low risk with a logES between 1.505 and 10.0%. Matching yielded 805 TF-TAVR/SAVR patient pairs with identical propensity scores and no difference in pertinent baseline characteristics, except for the logES, which was significantly higher in TF-TAVR patients (6.8 ± 1.7 vs. 4.2 ± 1.3% in SAVR patients, P < 0.001). Observed in-hospital mortalities were 1.7% (95% confidence interval, 1.1-3.0%) in SAVR and 2.0% (1.3-3.3%) in TF-TAVR patients (P = 0.85).

CONCLUSION

Our finding of no difference in in-hospital mortality in propensity-score matched low-surgical-risk patients treated by SAVR or TF-TAVR in a routine clinical setting indicates that TF-TAVR can be offered safely to individual patients, despite their operative risk being low. This finding needs to be confirmed in a randomized trial.

Gap between guidelines and practice: attainment of treatment targets in patients with primary hypercholesterolemia starting statin therapy. Results of the 4E-Registry (Efficacy Calculation and Measurement of Cardiovascular and Cerebrovascular Events including Physicians' Experience and Evaluation)

BACKGROUND

The aim of this study was to determine the achievement of National Cholesterol Education Program Adult Treatment Panel III goals in patients with primary hypercholesterolemia starting statin therapy in clinical practice.

METHODS AND RESULTS

Data were collected by 4401 physicians in private practice on 52 848 patients aged 35-65 years (46.3% women, 53.7% men). 56.1% of patients had no manifested atherosclerosis (primary prevention) among whom 34.9% of men and 0.5% of women had a 10-year coronary heart disease risk over 20% (high-risk) as calculated using the Prospective Cardiovascular Münster study (PROCAM) algorithm. After 6 weeks of statins, only 6.9% of these high-risk men and 4.6% of these high-risk women reached their low-density lipoprotein (LDL) cholesterol target of 2.6 mmol/l or below (100 mg/dl). Even after 9 months, only 8.0% of these men and 6.2% of these women achieved their LDL target. No fewer than 57.3% of treated women had a coronary risk below 10%, and 18.8% of women were already at target before statins were prescribed. Of patients 43.9% had manifest atherosclerosis (secondary prevention). After 6 weeks of therapy, only 12.9% of the women and 16.3% of the men in this secondary prevention group reached LDL target levels of 2.6 mmol/l or below. Even after 9 months, only 21.3% of men and 17.3% of women with manifest atherosclerosis reached target LDL.

CONCLUSIONS

Most high-risk patients do not achieve LDL targets. Overtreatment of low-risk groups is also very common.

Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation

BACKGROUND

Current guidelines recommend pulmonary-vein isolation by means of catheter ablation as treatment for drug-refractory paroxysmal atrial fibrillation. Radiofrequency ablation is the most common method, and cryoballoon ablation is the second most frequently used technology.

METHODS

We conducted a multicenter, randomized trial to determine whether cryoballoon ablation was noninferior to radiofrequency ablation in symptomatic patients with drug-refractory paroxysmal atrial fibrillation. The primary efficacy end point in a time-to-event analysis was the first documented clinical failure (recurrence of atrial fibrillation, occurrence of atrial flutter or atrial tachycardia, use of antiarrhythmic drugs, or repeat ablation) following a 90-day period after the index ablation. The noninferiority margin was prespecified as a hazard ratio of 1.43. The primary safety end point was a composite of death, cerebrovascular events, or serious treatment-related adverse events.

RESULTS

A total of 762 patients underwent randomization (378 assigned to cryoballoon ablation and 384 assigned to radiofrequency ablation). The mean duration of follow-up was 1.5 years. The primary efficacy end point occurred in 138 patients in the cryoballoon group and in 143 in the radiofrequency group (1-year Kaplan-Meier event rate estimates, 34.6% and 35.9%, respectively; hazard ratio, 0.96; 95% confidence interval [CI], 0.76 to 1.22; P<0.001 for noninferiority). The primary safety end point occurred in 40 patients in the cryoballoon group and in 51 patients in the radiofrequency group (1-year Kaplan-Meier event rate estimates, 10.2% and 12.8%, respectively; hazard ratio, 0.78; 95% CI, 0.52 to 1.18; P=0.24).

CONCLUSIONS

In this randomized trial, cryoballoon ablation was noninferior to radiofrequency ablation with respect to efficacy for the treatment of patients with drug-refractory paroxysmal atrial fibrillation, and there was no significant difference between the two methods with regard to overall safety. (Funded by Medtronic; FIRE AND ICE ClinicalTrials.gov number, NCT01490814.).

In-hospital outcome of transcatheter vs. surgical aortic valve replacement in patients with aortic valve stenosis: complete dataset of patients treated in 2013 in Germany

BACKGROUND

Transvascular (TV-AVI) or transapical (TA-AVI) aortic valve implantation (TAVI) is a treatment option for patients with aortic stenosis being at high or prohibitive risk for surgical aortic valve implantation (SAVR). Randomized data demonstrated that these subgroups can safely been treated with TAVI. However, a comparison of SAVR and TAVI in intermediate and low-risk patients is missing. Therefore, the aim of the analysis was to compare TAVI and SAVR in all patients who were treated for aortic valve stenosis in Germany throughout 1 year.

METHODS

The mandatory quality assurance collects data on the in-hospital outcome from all patients (n = 20,340) undergoing either SAVR or TAVI in Germany. In order to compare the different treatment approaches patients were categorized into four risk groups using the logistic EuroScore I (ES). In-hospital mortality and peri- and postprocedural complications were analyzed.

RESULTS

The in-hospital mortality did not differ between TV-AVI and SAVR in the low risk group (ES <10 %: TV-AVI 2.4 %, SAVR 2.0 %, p = 0.302) and was significantly higher for SAVR in all other risk groups (ES 10-20 %: TV-AVI 3.5 %, SAVR 5.3 %; p = 0.025; ES 20-30 %: TV-AVI 5.5 %, SAVR 12.2 %, p < 0.001; ES >30 %: TV-AVI 6.5 %, SAVR 12.9 %, p = 0.008). TA-AVI had a significantly higher mortality in all risk groups compared to TV-AVI. In comparison to SAVR, TA-AVI had a higher mortality in patients with ES <10, comparable mortality in ES 10-20 %, and lower mortality in patients with an ES >20 %. The overall stroke rate was 2.3 %. It occurred more frequently in patients with an ES <10 % treated with a transapical approach (SAVR 1.8 %, TV-AVI 1.9 %, TA-AVI 3.1 %, p < 0.01). There were no statistically significant differences in all other comparisons.

CONCLUSIONS

This study demonstrates that TAVI provides excellent outcomes in all risk categories. Compared with SAVR, TV-TAVI yields similar in-hospital mortality among low-risk patients and lower in-hospital mortality among intermediate and high-risk patient populations.

Influence of different approaches of aortic valve replacement on the incidence of post-operative delirium in intermediate risk patients - a matched pair analysis

OBJECTIVES

Evaluation of the risk for post-operative delirium (POD) after surgical or transfemoral aortic valve replacement (AVR) as an additional decision parameter for the choice of treatment in patients with an EuroScore (ES) between 10% and 20%.

BACKGROUND

POD is well known as a not infrequent side effect of cardiac surgery necessitating extracorporeal circulation. In Germany a tendency to treat patients with ES <20% with transfemoral AVR (TF) instead of surgical AVR (SAVR) was observed in 2013. The risk of POD may influence the decision of physician and patient as to which procedure would be appropriate in the individual case. Therefore we performed an analysis of the incidence of POD in patients with comparable risk treated either with surgical or transfemoral aortic valve replacement.

METHODS

Patients with elective or urgent need for AVR and EuroScore between 10% and 20% were extracted from the database of all isolated AVR procedures in Germany of 2013. As a result 3407 cases, 771 SAVR patients and 2636 TF patients with EuroScore 10-20%, were extracted from the complete data-base of the German quality insurance registry for heart surgery. Two homogeneous groups with regard to the risk predicted by ES were built by case-control matches and compared for available variables. In a second step two groups with identical risk/co-morbidity profile for 10 variables were identified and analyzed with respect to POD and in-hospital mortality.

RESULTS

A total of 763 pairs with EuroScore of 13.5% each could be determined. Mean age was 75.6 years (SAVR, 51.6% male) and 78.8 years (TF, 56.5% male). Incidence of POD with need for therapy (POD-T) was 12.8% after SAVR and 3.8% after TF, resulting in numbers needed to harm of 8 and 26 respectively. In-hospital death rate of patients with POD-T was 5.1% after SAVR and 3.3% after TF, and nearly identical compared with patients without POD-T. POD-T had a negative influence on the regular discharge procedure. Further matching resulted in two groups of 470 patients each with identical co-morbidities and an age difference of 1 year but POD-T rates of 14.5% (SAVR) and 4.9% (TF); in-hospital mortality was 6.2% (SAVR) and 2.3% (TF).

LIMITATIONS

The dataset contains valid data only for the period of hospital stay until discharge. Therefore conclusions about the duration and reversibility of POD, which are important parameters of quality of life and resource consumption as well as midterm consequences, cannot be estimated. The documentation of the German Federal Council asks only for POD and POD-T, a predefined definition of POD is not given; this may have some influence on the data. We therefore confined the analysis to only POD-T. In addition only a limited number of co-morbidities are documented.

CONCLUSION

In patients with intermediate risk according to EuroScore (10-20%) the risk of post-operative delirium and in-hospital mortality is significantly higher after surgical aortic valve replacement than after transfemoral procedure. This may be considered for patient guidance and the decision as to which procedure is able to achieve the best result including minimizing side effects.

German Heart Report 2013

OBJECTIVES

The 25th German Heart Report provides a comprehensive analysis of morbidity and mortality in patients with selected heart diseases as well as services and care in cardiology and cardiac surgery in Germany during the period 2011-2012. It is the result of a multidisciplinary collaboration between the German Heart Foundation, the German Cardiac Society, the German Society for Thoracic and Cardiovascular Surgery, and the German Society of Pediatric Cardiology and is based on data from different sources. In addition, trends of the period from 1995 to 2012 are presented.

RESULTS

The trends in morbidity due to cardiac diseases in 2010 and previous years continued in 2011. Compared with data from 1995 to 2010, one can observe: · a slight decrease in ischemic heart disease in every age group.. · a distinct increase in valve diseases, predominantly at age >75 years.. · an increase in arrhythmias from the age of 45 years on.. · an increase in cardiac failure, especially beyond the age of 75 years.. Compared with data from 2009, the mortality rates in 2011 differ somewhat; there is: · a decrease in heart failure and coronary heart disease.. · no change in arrhythmias.. · a distinct increase in valvular heart diseases.. · an additional, small decrease in congenital heart defects.. These data are in agreement with findings from other Western countries. Coronary heart disease, the most frequent cardiac disease, has continuously decreased in frequency and mortality since 2000. The underlying reasons are discussed.

CONCLUSION

This report is an important resource for all parties of the healthcare system regarding heart disease conditions and their treatment in Germany.

Rationale and Design of FIRE AND ICE: A multicenter randomized trial comparing efficacy and safety of pulmonary vein isolation using a cryoballoon versus radiofrequency ablation with 3D-reconstruction

BACKGROUND

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia imposing substantial morbidity and mortality. Catheter-based pulmonary vein isolation (PVI) using radiofrequency current (RFC) has become a standard treatment for drug-resistant and symptomatic paroxysmal AF (PAF). In recent years, the cryoballoon-based technique is increasingly used as a promising alternative with a short learning curve.

METHODS

The FIRE AND ICE trial is a prospective, randomized, controlled, open, blinded outcome assessment, noninferiority trial comparing cryoballoon-, and RFC-based PVI. Patients with drug-resistant PAF will be randomized in a 1:1 matrix in multiple European centers. The primary hypothesis is that cryoballoon ablation is not inferior to RFC ablation using 3-dimensional mapping with respect to clinical efficacy. The primary endpoint is defined as the time to first documented clinical failure, including: (1) recurrence of AF; (2) atrial flutter or atrial tachycardia; (3) prescription of class I or III antiarrhythmic drugs; or (4) re-ablation, whichever comes first, following a blanking period of 3 months after the index ablation procedure. The primary safety endpoint is a composite of death, stroke/transient ischemic attack, cardiac arrhythmias (apart from AF recurrence) causally related to the therapeutic intervention, and procedure-related serious adverse events.

CONCLUSION

The FIRE AND ICE trial compares 2 different technologies to perform catheter ablation of PAF with respect to efficacy and safety. It aims at providing objective data to guide selection and usage of ablation catheters in the treatment of AF.

Should health insurers target prevention of cardiovascular disease? A cost-effectiveness analysis of an individualised programme in Germany based on routine data

BACKGROUND

Cardiovascular diseases are the main cause of death worldwide, making their prevention a major health care challenge. In 2006, a German statutory health insurance company presented a novel individualised prevention programme (KardioPro), which focused on coronary heart disease (CHD) screening, risk factor assessment, early detection and secondary prevention. This study evaluates KardioPro in CHD risk subgroups, and analyses the cost-effectiveness of different individualised prevention strategies.

METHODS

The CHD risk subgroups were assembled based on routine data from the statutory health insurance company, making use of a quasi-beta regression model for risk prediction. The control group was selected via propensity score matching based on logistic regression and an approximate nearest neighbour approach. The main outcome was cost-effectiveness. Effectiveness was measured as event-free time, and events were defined as myocardial infarction, stroke and death. Incremental cost-effectiveness ratios comparing participants with non-participants were calculated for each subgroup. To assess the uncertainty of results, a bootstrapping approach was applied.

RESULTS

The cost-effectiveness of KardioPro in the group at high risk of CHD was € 20,901 per event-free year; in the medium-risk group, € 52,323 per event-free year; in the low-risk group, € 186,074 per event-free year; and in the group with known CHD, € 26,456 per event-free year. KardioPro was associated with a significant health gain but also a significant cost increase. However, statistical significance could not be shown for all subgroups.

CONCLUSION

The cost-effectiveness of KardioPro differs substantially according to the group being targeted. Depending on the willingness-to-pay, it may be reasonable to only offer KardioPro to patients at high risk of further cardiovascular events. This high-risk group could be identified from routine statutory health insurance data. However, the long-term consequences of KardioPro still need to be evaluated.

Lipid management in 13,000 high risk cardiovascular patients treated under daily practice conditions: LIMA Registry

AIMS

We aimed to document the drug management of patients at high cardiovascular risk in daily practice, with the special focus on lipid-lowering treatment.

METHODS AND RESULTS

In this prospective noninterventional study in 2387 outpatient centers throughout Germany, a total of 13,942 high-risk patients (mean age 65.7 years, 61.6% males) were treated with simvastatin 40 mg/day at entry as monotherapy. All patients were followed up for 12 months in terms of drug utilization, laboratory values, target attainment, and clinical events (including death, hospitalization, vascular events, and dialysis). Patients had coronary heart disease in 35.0%, diabetes mellitus in 24.4%, and the combination of coronary heart disease plus diabetes mellitus in 25.7%. In 21% of patients, a cholesterol absorption inhibitor was added to statin therapy at the entry visit, and in 23%, this was added at the follow up visit 6 months later. The target values for low-density lipoprotein-cholesterol (<2.6 mmol/L) were reached by 31.8% of patients at entry and by 50.0% at the end of this registry after 12 months. Mean blood pressure decreased (from 135.9/80.5 mmHg at baseline) by 3.1/1.9 mmHg after 12 months. In patients with documented diabetes, the targeted glycated hemoglobin (HbA1c <6.5%) was reached by 33.5% at baseline and by 40.0% after 12 months. Clinical events occurred in 11.7% of patients between baseline and month 6, and in 12.0% between months 6 and 12.

CONCLUSION

In patients at high risk for cardiovascular events, comprehensive management under daily practice conditions leads to improvement of lipid, glucose, and blood pressure parameters. There is a need to improve secondary prevention among high-risk patients.

[Lipid therapy in daily routine]

Patients with increased cardiovascular risk profile are frequently seen in general practice. Comprehensive management of modifiable risk factors, in particular dyslipidemia, is mandatory. Many studies in clinical practice have shown a gap between the recommendations in clinical guidelines and the actual situation. Current data on the management situation of patients with high cardiovascular risk is provided by the prospective registry LIMA. Primary care physicians in 2,387 offices throughout Germany documented 13,924 patients with coronary artery disease (CAD), diabetes mellitus or peripheral arterial disease (PAD). Treatment with simvastatin 40 mg was an inclusion criterion. Physicians documented drug utilization, laboratory values (lipids, blood glucose), blood pressure and clinical events over one year and received feedback about the target value attainment of their patients after data entry. Mean age of the patients was 65.7 years, and 61.6 % were men. CAD was reported in 70.6 %, diabetes mellitus in 58.2 % and PAD in 14.9 %. Most patients (68 %) received simvastatin as monotherapy also after the inclusion visit; 20.6 % of patients received in addition the cholesterol absorption inhibitor (ezetimibe) in the first 6 months, and 23.3 % in the second 6 months. Patients achieved the LDL-cholesterol target value in 31.8 % at entry and 50.0 % after one year. The blood pressure target < 140 /90 mmHg was reached by 65.8 % after one year. Of patients with diabetes mellitus 40.0 % reached an HbA1c value below 6.5 %. Clinical events (death, hospitalization, (cardio-) vascular events, and dialysis) were reported by 11.7 % of patients between entry and Month 6, and by 12.0 % between Month 7 and 12. In daily practice comprehensive management of risk factors in patients at high cardiovascular risk remains a challenge. For normalization of increased LDL cholesterol values addition of ezetimibe to existing statin therapy improves the chances of patients for target level attainment.

Disparity in risk factor pattern in premature versus late-onset coronary artery disease: a survey of 15,381 patients

BACKGROUND

There are few data available regarding the specificity and modifiability of major cardiovascular (CV) risk factors in patients with premature versus (vs) late-onset coronary artery disease (CAD). This study was designed to analyze and compare these risk factors.

PATIENTS AND METHODS

Data from 15,381 consecutive patients (mean age, 62.3 ± 11.7 years; female, 33.8%) hospitalized with CAD were collected from a large-scale registry (Transparency Registry to Objectify Guideline-Oriented Risk Factor Management) and analyzed. The patients were divided into two groups, depending on age at inclusion: group 1 patients (n = 5725; mean age, 50.5 ± 7.2 years) were males aged < 55 years and females aged < 65 years; group 2 patients (n = 9656; mean age, 69.4 ± 7.4 years) were males aged > 55 years and females aged > 65 years and had a low-density lipoprotein cholesterol level of >100 mg/dL on admission to cardiac rehabilitation. Besides the conventional risk factors, lipoprotein(a) concentrations and glucose tolerance were measured facultatively. Univariate (chi-square test) and multivariate logistic regression models were used.

RESULTS

Cigarette smoking (group 1 at 31.5% vs group 2 at 9.4%; P < 0.001), family history of CAD (group 1 at 43.6% vs group 2 at 26.5%; P < 0.001), and dyslipidemia (group 1 at 92.7% vs group 2 at 91.8%; P < 0.001) were dominant risk factors in the younger group. Arterial hypertension (group 1 at 71.4% vs group 2 at 87.0%; P < 0.001) and diabetes (group 1 at 23.5% vs group 2 at 30.1%; P < 0.001) were dominant risk factors in the older group. Impaired glucose tolerance and diabetes were less frequent in the younger group (P(trend) = 0.038), and identical lipoprotein(a) concentration levels of >30 mg/dL were found in both groups (8.0%; P = 0.810). Modification of lipid profile and blood pressure was more effective in the younger group (low-density lipoprotein cholesterol < 100 mg/dL: group 1 at 66.3% vs group 2 at 61.1%; systolic blood pressure < 140 mmHg: group 1 at 91.7% vs group 2 at 83.0%; P < 0.001).

CONCLUSION

CV risk factors differ markedly between premature and non-premature CAD. Cardiac rehabilitation provides an opportunity to reinforce secondary prevention after acute coronary syndrome.

Current state of cardiac rehabilitation in Germany: patient characteristics, risk factor management and control status, by education level

Background

After the acute hospital stay, most cardiac patients in Germany are transferred for a 3–4-week period of inpatient cardiac rehabilitation. We aim to describe patient characteristics and risk factor management of cardiac rehabilitation patients with a focus on drug treatment and control status, differentiated by education level (low level, elementary school; intermediate level, secondary modern school; high level, grammar school/university).

Methods

Data covering a time period between 2003 and 2008 from 68,191 hospitalized patients in cardiac rehabilitation from a large-scale registry (Transparency Registry to Objectify Guideline- Oriented Risk Factor Management) were analyzed descriptively. Further, a multivariate model was applied to assess factors associated with good control of risk factors.

Results

In the total cohort, patients with a manifestation of coronary artery disease (mean age 63.7 years, males 71.7%) were referred to cardiac rehabilitation after having received percutaneous coronary intervention (51.6%) or coronary bypass surgery (39.5%). Statin therapy increased from 76.3% at entry to 88.9% at discharge, and low density lipoprotein cholesterol < 100 mg/dL rates increased from 31.1% to 69.6%. Mean fasting blood glucose decreased from 108 mg/dL to 104 mg/dL, and mean exercise capacity increased from 78 W to 95 W. Age and gender did not differ by education. In contrast with patients having high education, those with low education had more diabetes, hypertension, and peripheral arterial disease, had lower exercise capacity, and received less treatment with statins and guideline-orientated therapy in general. In the multivariate model, good control was significantly more likely in men (odds ratio 1.38; 95% confidence interval 1.30–1.46), less likely in patients of higher age (0.99; 0.99–0.99), with diabetes (0.90; 0.85–0.95), or peripheral arterial disease (0.88; 0.82–0.95). Compared with a low level education, a mid level education was associated with poor control (0.94; 0.89–0.99), while high education did not have a significant effect (1.08; 0.99–1.17).

Conclusion

Patients with different levels of education treated in cardiac rehabilitation did not differ relevantly in terms of demographics, but did differ in some clinical aspects. With respect to the ultimate goal of cardiac rehabilitation, ie, optimal control of risk factors, education level does not play an important role.

Effects of a secondary prevention combination therapy with an aspirin, an ACE inhibitor and a statin on 1-year mortality of patients with acute myocardial infarction treated with a beta-blocker. Support for a polypill approach

OBJECTIVE

Large randomized clinical trials have shown the efficacy of aspirin, ACE (angiotensin converting enzyme) inhibitors and statins as secondary prevention measures in patients after an acute coronary syndrome with and without ST elevations. Therefore we aimed to determine the effect of a combination therapy with these three drugs on 1-year mortality after acute myocardial infarction (AMI).

METHODS

We prospectively followed 9998 survivors of acute myocardial infarction treated with a beta-blocker for 1 year. Patients were divided into three groups according to their therapy with aspirin, ACE inhibitors and statins: 3 drugs, 2 drugs or 0-1 drug.

RESULTS

The majority of patients (n = 6260, 62.6%) were treated with 3 drugs, 2986 (29.9%) with 2 drugs and 752 (7.5%) with 0-1 drug. In the univariate analysis 1-year mortality was 4.9%, 9.7% and 13.6%, respectively. After adjusting for confounding factors in the propensity score analysis the odds ratios for 1-year mortality were significantly increased with 0-1 drug (odds ratio 1.67, 95% CI 1.24-2.27) and with 2 drugs (odds ratio 1.54, 95% CI 1.26-1.87) in comparison with the group treated with all 3 drugs. However, in the ACOS registry the treatment was left to the discretion of the physician. This could lead to a selection bias, which cannot be fully eliminated by using multiple regression analysis.

CONCLUSIONS

A combination therapy with aspirin, an ACE inhibitor and a statin reduces 1-year mortality in patients after AMI. Therefore a polypill approach with these three agents should be considered to increase drug compliance and reduce mortality after acute myocardial infarction.

[Regional differences in the treatment of dyslipidemia in Germany]

BACKGROUND AND OBJECTIVE

DYSIS (Dyslipidemia International Study) is an international multicenter cross-sectional trial. The objective of the regional analysis was to identify differences in lipid-lowering therapy and attainment of goal/normal lipid levels in Germany.

METHODS

4,260 patients who were at least 45 years of age and receiving regular statin therapy at 748 centers (office practices / outpatient clinics) in Germany were assessed at a routine ambulant appointment. Results from centers in the northern, eastern, southern, and western part of Germany were compared.

RESULTS

The mean age of the patients was 66.6 - 67.9 years (p < 0.01, range over the four regions) and the proportion of males was 53 - 60 % (p < 0.01). There were significant regional differences in the number of cardiovascular risk factors and cardiovascular conditions, e. g. arterial hypertension (82 - 88 %), smoking (12 - 17 %), family history of coronary heart disease (CHD) (30 - 42 %), lack of exercise (38 - 48 %), CHD (only in women, 27 - 42 %), peripheral artery vascular disease (11 - 15 %), and heart failure (16 - 20 %). No regional differences were found for body mass index (BMI), waist circumference, metabolic syndrome, or diabetes mellitus. The mean LDL-cholesterol level in the four regions was 107 - 108 mg/dl (p = 0.53), HDL-cholesterol was 50 - 51 mg/dl (p = 0.62), and triglycerides 141 - 148 mg/dl (p = 0.68). The mean simvastatin (or simvastatin-equivalent) dosage was approximately 27 mg/day (p = 0.62). About half of the patients (49 - 53 %, p = 0.11) failed to attain their LDL-cholesterol target despite statin therapy. In addition to elevated LDL-cholesterol, 30 % of the patients had elevated triglycerides and/or low HDL-cholesterol.

CONCLUSION

DYSIS showed the existence of significant regional differences in the characteristics of statin-treated patients but not in the type or dosage of statin therapy or in adherence to target/normal lipid levels as per guidelines. In a high proportion of patients the lipid-lowering therapy will need to be reviewed, as guideline target levels have not been attained.

Comparable short-term prognosis in diabetic and non-diabetic patients with acute coronary syndrome after cardiac rehabilitation

BACKGROUND

Patients with pathological glucometabolism are at increased risk of recurrent cardiovascular events after acute coronary syndrome (ACS). The goal of this study was to investigate the association of glucometabolism and the one-year outcome of cardiac rehabilitation patients.

DESIGN

Prospective multicentre registry from four German rehabilitation clinics.

METHODS

During 2005-2006, 1614 consecutive patients (85.9% male, mean age 55 ± 10.3 years) were included after the first ACS (mean 18.9 days) and classified into group 1 (apparent diabetes mellitus, n = 268), group 2 (no diabetes, impaired oral glucose tolerance [OGT], n = 185), and group 3 (normal fasting glucose and normal OGT, n = 1161). The mean follow-up was 13.4 months and the follow-up events were analysed by multivariate logistic regression models with backward elimination.

RESULTS

The overall mortality was 1.3% (group 1: 1.2%; group 2: 1.8%; group 3: 1.5%; p(Trend) = NS). The target blood pressure values at discharge (<140/90 mmHg) were achieved by 88.7%, 89.1% and 90.8% of patients in groups 1, 2 and 3, respectively (p(Trend) = NS). The target value for LDL cholesterol (<100 mg/dl) was attained by 87.0%, 80.8% and 81.5% of the patients in groups 1, 2 and 3, respectively (p(Trend) = NS). There was a trend of a lower proportion of patients reaching the target values for HDL-C of 46.1%, 51.4% and 60.8% (p(Trend) < 0.001) and triglycerides of 65.1%, 79.9% and 74.6% (p(Trend) = 0.004) for groups 1, 2 and 3, respectively. The strongest multivariate predictors for overall mortality were patients experiencing a previous stroke (OR, 6.29 [95% CI: 1.06-37.19]; p = 0.042) and, with a trend, peripheral arterial disease (OR, 3.60 [95% CI: 0.95-13.68]; p = 0.061). In the multivariate analysis, the diabetic state had no association with poor outcomes (i.e. death or rehospitalization).

CONCLUSION

The short-term prognosis for both diabetic and non-diabetic patients was good and was determined by end organ damage rather than by glucometabolic status. Diabetic patients received comparable (and not more aggressive) pharmacotherapy and therefore achieved target values for cardiovascular risk factors to a lesser extent than the non-diabetic and pre-diabetic patients.

Atherogenic dyslipidemia as evidenced by the lipid triad: prevalence and associated risk in statin-treated patients in ambulatory care

OBJECTIVE

The prevalence of atherogenic dyslipidaemia (AD) can be assessed using the lipid triad (low high-density lipoprotein cholesterol [HDL-C] < 35 mg/dl, high triglyceride (TG) levels (≥ 200 mg/dl) and a high total cholesterol HDL-C ratio (TC/HDL-C>5). The aim of the present analysis was (1) to describe the prevalence of the lipid triad, (2) to quantify the associated cardiovascular risk on the basis of the PROCAM score, and (3) to calculate the additional risk reduction that can be obtained by adding nicotinic acid (NA) to a pre-existing statin therapy (model based on the outcomes of a previous randomized controlled study).

METHODS

Descriptive post-hoc analysis of the German 4E registry in 24,500 patients receiving statins for primary cardiovascular prevention in ambulatory care.

RESULTS

The sample comprised 24,500 patients in primary prevention, who had an overall 10-year risk of 16.2%. The prevalence of patients with lipid triad was 24.0%. The mean estimated risk reduction in the total sample (calculated on the basis of a mean LDL-C decrease by 24.3% and other lipid parameter changes) achieved after 6-week statin treatment was 46.6%, the estimated additional relative risk reduction by NA 45.1% (total effect compared to baseline about 70%). In the lipid triad group, the additional relative risk reduction by NA treatment was 42.9%. Relative treatment effects were consistent, irrespective of age and gender. Limitations of this analysis include the use of the TC/HDL-C ratio instead of the direct small dense LDL-C measurements, and the unknown variations of effect size of NA induced lipid reduction when used in combination with statins.

CONCLUSIONS

Our model calculations indicate that the residual risk which persists after statin treatment could be substantially lowered if besides LDL-C also HDL-C and TG would be addressed, e.g. by adding NA to statin therapy. Definitive prospective studies are needed to confirm this hypothesis.

Adherence of hospital-based cardiologists to lipid guidelines in patients at high risk for cardiovascular events (2L registry)

OBJECTIVES

According to various national and international guidelines, the target LDL-C level is <100 mg/dl for patients with established coronary heart disease (CHD) or CHD risk equivalent (CE). We aimed to investigate aspects of the lipid-lowering management of patients at high cardiovascular risk in-hospital care and the achievement of target values.

METHODS

In the internet-based 2L registry in Germany (2005-2006), cardiologists in 42 hospitals documented at a single visit 3,131 consecutive patients with known CHD, and/or diabetes mellitus, peripheral arterial disease, or a 10-year CHD risk >20% (summarized as CE), who were on chronic statin treatment. They received instructions on the guidelines and instant feedback on the effect of their treatment decisions (educational study component).

RESULTS

The three groups comprised 1,458 patients with CHD + CE (46.6%; median LDL-C 107 mg/dl), 1,104 patients with CHD only (35.3%; median LDL-C 104 mg/dl), and 569 with CE only (18.2%; median LDL-C 111 mg/dl). At admission, LDL-C levels <100 mg/dl were observed in 43.1, 44.8 and 37.9% of patients in the three groups, respectively. Statin doses at admission were usually in the low to intermediate range (e.g., simvastatin 10-20 mg/day). Cardiologists switched to another statin in 14.6%, increased the dose of statins (if same drug) in 22.9% (mean increase from 26.8 mg/day at baseline to 31.6 mg/day) and/or added a cholesterol absorption inhibitor (CAI) in 11.6%. The cardiologists' intervention improved estimated LDL-C levels (using a lipid calculator); however, the 100 mg/dl LDL-C target was only reached in 49.0, 48.5, and 42.9%.

CONCLUSIONS

When compared with earlier studies in the outpatient setting, the treatment to target for LDL-C of high-risk CHD patients has improved, but is not satisfactory.

[Memorandum registry for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by their member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. Registries in Health Services Research vary in their aims and research questions as well as in their designs, methods of data collection, and statistical analyses. This paper aims to provide both a methodological guideline for developers to ensure a high quality of a planned registry and, to provide an instrument for users of data from registries to assess their overall quality. First, the paper provides a definition of registries and presents an overview of objectives in Health Services Research where registries can be useful. Second, several areas of methodological importance for the development of registries are presented. This includes the different phases of a registry (i. e., conceptual and preliminary design, implementation), technical organisation of a registry, statistical analysis, reporting of results, data protection, and ethical/legal aspects. From these areas, several criteria are deduced to allow the assessment of the quality of a registry. Finally, a checklist to assess a registry's quality is presented.

[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

Prevalence and overlap of different lipid abnormalities in statin-treated patients at high cardiovascular risk in clinical practice in Germany

Background

In line with current guideline recommendations, patients at high cardiovascular risk are usually treated with statins for secondary as well as for primary prevention. While many studies investigated treatment goal achievement with regards to low-density lipoprotein (LDL-C) and total cholesterol (TC) there is paucity of data regarding high density lipoprotein (HDL-C), and/or triglycerides (TG).

Setting

Prospective, cross-sectional study (Dyslipidemia International Survey, DYSIS) with data provided by 748 office-based physicians throughout Germany.

Methods

Consecutive patients were eligible for participation, if they were at least 45 years old, currently treated with a statin and had had a documented lipid profile (at least 1 parameter) within the last 6 months. Besides descriptive analyses, logistic regression was performed with backward selection to assess predictors for lipid abnormalities (non-attainment of goals for TC, LDL-C, low HDL-C or elevated TG) classified according to current European Society of Cardiology guidelines.

Results

The 4,282 documented patients (98.6% Caucasian, 56.4% male; 86.6% at high cardiovascular risk) were predominantly treated with simvastatin (83.9%), pravastatin (7.7%) or atorvastatin (3.9%), usually with doses equivalent to simvastatin 20–40 mg daily. Non-statins were used in at most 12% of patients. No lipid abnormalities were found in 21.0% of patients, one abnormality in 38.5%, two in 31.9%, and all three in 8.5%. LDL-C goals were not attained in 58.1%, elevated TC was found in 66.6%, low HDL-C in 22.7%, and elevated TG in 47.3%. In the multivariate logistic regression model, non-attainment of LDL-C levels was predicted by hypertension (odds ratio, OR 1.4), current smoking (OR 1.3), sedentary lifestyle (OR 1.3), and female gender (OR 1.3). On the other hand, a reduced risk for missing LDL-C targets was noted in the presence of ischemic heart disease (OR 0.6), diabetes (0.5), higher statin doses, ezetimibe treatment, or specialist care, respectively.

Conclusion

A substantial proportion of statin-treated patients not only missed targets for LDL-C, but also did not attain the normal levels for HDL-C and/or TG. There is a large disconnect between high prevalence of HDL and/or TG disorders, with or without elevated LDL-C, and utilization of therapies targeting these lipids. Particularly in high-risk patients, additional efforts should be made to improve their lipid profile.

Impact of chronic antithrombotic therapy on hospital course of patients with acute myocardial infarction

BACKGROUND

Little is known about the influence of chronic antithrombotic therapy on treatment and clinical outcome in patients with acute ST-elevation myocardial infarction (STEMI).

HYPOTHESIS

The purpose of this study was to investigate the hospital course of STEMI patients on antithrombotics.

METHODS

We analyzed data of consecutive patients with STEMI, who were prospectively enrolled in the German Acute Coronary Syndromes registry between July 2000 and November 2002. Overall, 8224 patients were stratified into 3 groups: group 1 had no prior chronic antithrombotic medication (n = 6004), group 2 was on chronic acetylsalicylic acid (ASA) therapy (n = 2022), and group 3 was on chronic oral anticoagulation therapy (n = 198).

RESULTS

Patients on antithrombotic medication were older and had a higher baseline risk profile. The rate of patients receiving early reperfusion (group 1: 74.6%, group 2: 61.2%, group 3: 52.0%) and guideline-adherent adjustment therapy was lower among patients on antithrombotics. Age and left bundle branch block were strong negative predictors for early reperfusion therapy in patients with prior antithrombotic treatment. Infarct size measured by peak creatine kinase level was lower in patients on antithrombotics. Hospital mortality (group 1: 8.0%, group 2: 12.8%, group 3: 16.2%) and major bleeding complications (group 1: 1.6%, group 2 2.0%, group 3 4.1%) were highest in patients on oral anticoagulants. However, after adjustment for confounding factors, prior ASA (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.80-1.21) and oral anticoagulant treatment (OR: 1.06, 95% CI: 0.66-1.71) were not independent predictors for in-hospital death.

CONCLUSIONS

Despite a higher risk profile, patients with STEMI on a chronic antithrombotic therapy were less likely to receive early reperfusion therapy. However, after adjustment, prior ASA or oral anticoagulant therapy was not associated with higher in-hospital mortality.

Effect of early short-term cardiac rehabilitation after acute ST-elevation and non-ST-elevation myocardial infarction on 1-year mortality

OBJECTIVES

The aim was to evaluate the effect of short-term cardiac rehabilitation (CR) on clinical events during a 1-year follow-up after acute myocardial infarction.

METHODS

From the observational, prospective Acute COronary Syndromes (ACOS) registry, 4547 consecutive patients after ST-elevation (STEMI: n = 2432) or non-ST-elevation myocardial infarction (NSTEMI: n = 2115), recruited between June 2000 and December 2002, were characterised and evaluated for clinical outcomes during a 1-year follow-up. From the STEMI group 67.8% and from the NSTEMI group 52.3% participated in cardiac rehabilitation (CR+).

RESULTS

Age > 70 years and previous myocardial infarction were independent predictors not to attend CR in STEMI and NSTEMI patients, whereas early revascularisation (<48 hours after hospital admission) was associated with increased likelihood to undergo CR. Multivariable analysis adjusting for propensity score shows that CR+ was independently associated with a significant reduction of all-cause mortality (STEMI: OR 0.41, 95% CI 0.28-0.60; NSTEMI: OR 0.53, 95% CI 0.38-0.76) and major adverse cardiac and cerebrovascular events (MACCE; STEMI: OR 0.66, 95% CI 0.49-0.89; NSTEMI: OR 0.73, 95% CI 0.55-0.98) during a 1-year follow-up.

CONCLUSION

The study shows an independent and strong association of CR+ with markedly reduced total mortality and MACCE during a 1-year follow-up after STEMI or NSTEMI. The limitation of the study is that it is not a prospective randomised trial. Furthermore, unequal distribution of risk factors relevant for long-term prognosis had to be corrected by multivariable analysis adjusting for propensity score.

Elevated risk profile of women in secondary prevention of coronary artery disease: a 6-year survey of 117,913 patients

BACKGROUND AND AIMS

The prognosis of female patients after acute coronary syndrome (ACS) has been shown to be inferior to that of male patients. Little is known about gender differences during the secondary prevention phase.

METHODS

After ACS, 117,913 patients (30.7% female) were enrolled in two large-scale German registries from 2000 to 2005 during phase II cardiac rehabilitation (CR). Demographic parameters, reperfusion strategies, cardiovascular risk factors, exercise capacity, and medication use at admission and discharge were assessed. Temporary changes (trends) and gender-specific differences were determined.

RESULTS

Compared to 2000, patients in 2005 were significantly older (females: 66.4 vs. 68.0 years; males: 62.3 vs. 63.3 years; p = 0.001) and had a higher body mass index (BMI) (females: 27.7 vs. 28.6 kg/m(2); males: 27.6 vs. 28.1 kg/m(2), in 2000 and 2005, respectively, p < 0.001). Target blood pressure <140/90 mm Hg at discharge was obtained in a smaller proportion of women than men (81.0 vs. 83.0%, p < 0.001). Low-density lipoprotein cholesterol (LDL-C) levels at discharge were significantly higher in female patients (95.0 vs. 93.2 mg/dL, p < 0.001); 80.9% of female vs. 83.8% of male patients achieved a target fasting glucose <126 mg/dL during the CR (p < 0.001). Large between-center variability was noted for age, total cholesterol at entry, and exercise capacity at entry and discharge.

CONCLUSIONS

Although control of cardiovascular risk factors has improved in both genders, over a recent 6-year period, female patients compared with males were less likely to achieve target values for blood pressure, fasting glucose, and lipid values in the early period after acute coronary events.

Characteristics, management and attainment of lipid target levels in diabetic and cardiac patients enrolled in Disease Management Program versus those in routine care: LUTZ registry

Background

Since 2002 the sick funds in Germany have widely implemented disease management programs (DMPs) for patients with type 2 diabetes mellitus (DM) and coronary heart disease (CHD). Little is known about the characteristics, treatment and target attainment lipid levels of these patients enrolled in DMPs compared to patients in routine care (non-DMP).

Methods

In an open, non-interventional registry (LUTZ) in Germany, 6551 physicians documented 15,211 patients with DM (10,110 in DMP, 5101 in routine care) and 14,222 (6259 in DMP, 7963 in routine care) over a follow-up period of 4 months. They received the NCEP ATP III guidelines as a reminder on lipid level targets.

Results

While demographic characteristics of DMP patients were similar to routine care patients, the former had higher rates of almost all cardiovascular comorbidities. Patients in DMPs received pharmacological treatment (in almost all drug classes) more often than non-DMP patients (e.g. antiplatelets: in DM 27.0% vs 23.8%; in CHD 63.0% vs. 53.6%). The same applied for educational measures (on life style changes and diet etc.). The rate of target level attainment for low density lipoprotein cholesterol (LDL-C) < 100 mg/dl was somewhat higher in DMP patients at inclusion compared to non-DMP patients (DM: 23.9% vs. 21.3%; CHD: 30.6% vs. 23.8%) and increased after 4 months (DM: 38.3% vs. 36.9%; CHD: 49.8% vs. 43.3%). Individual LDL-C target level attainment rates as assessed by the treating physicians were higher (at 4 months in DM: 59.6% vs. 56.5%; CHD: 49.8% vs 43.3%). Mean blood pressure (BP) and HbA_1c values were slightly lowered during follow-up, without substantial differences between DMP and non-DMP patients.

Conclusion

Patients with DM, and (to a greater extent) with CHD in DMPs compared to non-DMP patients in routine care have a higher burden of comorbidities, but also receive more intensive pharmacological treatment and educational measures. The present data support that the substantial additional efforts in DMPs aimed at improving outcomes resulted in quality gains for achieving target LDL-C levels, but not for BP or HbA_1c. Longer-term follow-up is needed to substantiate these results.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment

INTRODUCTION

Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR).

METHODS

During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed.

RESULTS

At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%).

CONCLUSION

Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.

Efficacy and safety of losartan 100 mg or losartan 100 mg plus hydrochlorothiazide 25 mg in the treatment of patients with essential arterial hypertension and CV risk factors: observational, prospective study in primary care

BACKGROUND

Patients with high cardiovascular risk are prevalent in ambulatory care. To achieve adequate blood pressure control, such patients require higher drug doses and/or combination therapy. We aimed to assess the efficacy and safety of losartan 100 mg as monotherapy or in fixed-dose combination with hydrochlorothiazide 25 mg.

DESIGN AND METHODS

Multicentre, prospective, open observational study over 13 weeks in patients with essential hypertension, whose blood pressure was not adequately controlled despite pretreatment. Main outcome parameters were the systolic (SBP) and diastolic (DBP) blood pressure reduction, the rate of normalized patients at study end compared to baseline, and the number and type of adverse events (AEs).

RESULTS

Of the 7702 documented patients, 53.1% (N = 4088) were men, with a mean age of 63.5 +/- 10.7 years. Comorbidities were frequent (diabetes mellitus in 57.4% [N = 4418], coronary heart disease in 30.3% [N = 2330], left ventricular hypertrophy in 28.2% [N = 2172], heart failure in 14.0% [N = 1079], and peripheral arterial disease in 9.0% [N = 690]). Patients received losartan 100 mg in 45.7% (N = 3521), losartan/HCTZ in 53.8% (N = 4143); additional antihypertensive drugs were given in 45.5% (N = 3505). Physicians reported somewhat lower target values than those stipulated by the guidelines (irrespective of age, gender, and concomitant diseases except for diabetes). Mean SBP/DBP decreased from a baseline value of 158/93 mmHg by 24/12 mmHg at study end. The BP lowering effect was similar in subgroups by treatment or comorbidity, respectively, however target attainment rates were substantially higher in non-diabetic patients. Metabolic and renal parameters (fasting glucose, HbA(1c), serum creatinine and albumin in urine) showed trends for improvement. Tolerability was very good, as only 0.43% (N = 33) experienced an AE (in 0.31% [N = 24] serious AEs), and 0.08% (N = 6) discontinued therapy due to reasons related to study drug.

CONCLUSION

In high-risk patients, treatment with losartan 100 mg or losartan/HCTZ 100/25 mg was effective and well tolerated, irrespective of comorbidity. These findings from a real-life setting are in line with those from randomized controlled trials.

Efficacy of a 24-h primary percutaneous coronary intervention service on outcome in patients with ST elevation myocardial infarction in clinical practice

BACKGROUND

Primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) improves outcome in comparison to fibrinolysis. However, it is unclear whether patients treated in interventional facilities with 24-h primary PCI service have lower rates of adverse events.

METHODS

We analyzed data of consecutive patients with STEMI prospectively enrolled in the German Acute Coronary Syndromes registry between July 2000 and November 2002 who were admitted to hospitals with catheterisation laboratory.

RESULTS

Overall 6,350 patients were divided into two groups: 2,779 (43.8%) were treated in hospitals with and 3,571 (56.2%) without 24-h on-call cardiac catheter laboratories. 83.0% of the patients at facilities with and only 69.9% of the patients at facilities without 24-h PCI service received early reperfusion therapy (P < 0.001). Hospital death (7.4% vs. 9.9%, P < 0.001), non-fatal myocardial reinfarction (2.5% vs. 6.4%, P < 0.0001) and stroke (0.3 vs. 1.0%, P < 0.01) occurred significantly less often in patients treated in hospitals with 24-h primary PCI service. After adjustment for the confounding factors in the propensity score analysis the 24-h on-call strategy remained superior for the combined endpoint of death, reinfarction and stroke (OR 0.63, 95% CI 0.54-0.75).

CONCLUSIONS

In clinical practice the rate of patients receiving reperfusion therapy was significantly higher in hospitals with 24-h primary PCI service which was associated with an improved in-hospital outcome. Though the data was collected at a time that does not completely represent current clinical practice, these results could have an impact on planning efficient infarct networks in the future.