Percutaneous coronary intervention for older adults who present with syncope and coronary artery disease? Insights from the National Cardiovascular Data Registry.

BACKGROUND: We explored the risks/benefits of revascularization versus medical management in syncope patients with obstructive coronary artery disease (CAD). METHODS: We retrospectively examined Medicare patients ≥65 years undergoing percutaneous coronary intervention (PCI) for syncope at 539 CathPCI Registry hospitals with ≥70% stenosis in at least 1 coronary artery, excluding those with ST-segment elevation myocardial infarction (MI), cardiogenic shock, left main disease, and coronary artery bypass grafting. In a propensity-matched population, we compared short-term (90-day) all-cause readmission risk and long-term (3-year) risks of readmission for syncope and MI, as well as mortality in those receiving PCI versus medical management. RESULTS: Among 14,674 syncope patients, 9,549 (65%) had at least 1-vessel obstructive CAD. After exclusions, 3,196 of 7,338 patients (44%) underwent PCI. In the propensity-matched cohort, there was no significant difference in 90-day all-cause readmission risk (28.2% vs 30.3%, adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or long-term risks of readmission for syncope (7.0% vs 6.1%, adjusted HR 1.06, 95% CI 0.83-1.35). PCI-treated patients had significantly higher risk of readmission for MI (5.6% vs 4.0%, adjusted HR 1.56, 95% CI 1.18-2.06) but lower risk of long-term mortality (27.0% vs 30.3%, adjusted HR 0.86, 95% CI 0.77-0.97) than medically managed patients. CONCLUSIONS: In patients presenting with syncope and obstructive CAD, PCI was not associated with significant improvements in the risk of readmission but was associated with lower long-term mortality compared with medical therapy, suggesting the need to more definitively assess the benefit of PCI among elderly syncope patients.

Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry.

BACKGROUND: For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging. METHODS AND RESULTS: We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002). CONCLUSIONS: Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.

Remote Stab Wound Resulting in AV Fistula and High-Output Heart Failure.

A 54-year-old African American male with no medical history presented to an urgent care clinic with signs and symptoms of new-onset congestive heart failure. There was an initial concern for congestive heart failure secondary to an ischemic etiology as an echocardiogram revealed a depressed ejection fraction. However, a left heart cardiac catheterization did not demonstrate any significant coronary disease. As a loud bruit was auscultated over the right base of the patient's neck, he underwent a carotid duplex ultrasound revealing a fistula between the right common carotid artery (CCA) and the right internal jugular vein (IJV). A diagnosis of high-output heart failure secondary to a large arteriovenous (AV) fistula was made, and the patient underwent ligation and repair of the fistula with resolution of symptoms of congestive heart failure.