Underuse of Catheter Ablation as First-Line Therapy for Supraventricular Tachycardia.

Background Catheter ablation (CA) is a safe, effective, cost-effective technique and may be considered a first-line strategy for the treatment of symptomatic supraventricular tachycardias (SVT). Despite the high prospect of cure and the recommendations of international guidelines in considering CA as a first-line treatment strategy, the average time between diagnosis and the procedure may be long. The present study aims to evaluate predictors related to non-referral for CA as first-line treatment in patients with SVT. Methods and Results The model was derived from a retrospective cohort of patients with SVT or ventricular pre-excitation referred for CA in a tertiary center. Clinical and demographical features were used as independent variables and non-referral for CA as first-line treatment the dependent variable in a stepwise logistic regression analysis. Among 20 clinical-demographic variables from 350 patients, 10 were included in initial logistic regression analysis: age, women, presence of pre-excitation on ECG, palpitation, dyspnea and chest discomfort, number of antiarrhythmic drugs before ablation, number of concomitant symptoms, symptoms' duration and evaluations in the emergency room due to SVT. After multivariable adjusted analysis, age (odds ratio [OR], 1.2; 95% CI 1.01-1.32; P=0.04), chest discomfort during supraventricular tachycardia (OR, 2.7; CI 1.6-4.7; P<0.001) and number of antiarrhythmic drugs before ablation (OR, 1.8; CI 1.4-2.3; P<0.001) showed a positive independent association for non-referral for CA as SVT first-line treatment. Conclusions The independent predictors of non-referral for CA as first-line treatment in our logistic regression analysis indicate the existence of biases in the decision-making process in the referral process of patients who would benefit the most from catheter ablation. They very likely suggest a skewed medical decision-making process leading to catheter ablation underuse.

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score.

BACKGROUND: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. OBJECTIVE: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. METHODS: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. RESULTS: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). CONCLUSION: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

Option for the radial versus femoral access in coronary intervention in acute coronary syndromes: a risk-treatment paradox / Opção para o acesso radial versus femoral na intervenção coronária em síndromes coronárias agudas: um paradoxo de tratamento de risco

Background: In coronary procedures, although the radial approach protects patients from hemorrhagic complications, it is technically more complex than the femoral approach. Objectives: To test the hypothesis that the radial approach is the procedure of choice in ACS patients due to the high risk of bleeding; and to identify independent predictors of the choice for radial access. Methods: Patients admitted for ACS who underwent invasive coronary procedure were included. We registered the type of access (femoral or radial) chosen by the physician for the first angiography; the investigators did not interfere with this choosing process. Student's t-test was used for comparisons between the CRUSADE and ACUITY scores. Predictors of radial access were compared between the groups. Statistical significance was defined by p < 0,05.Results: Radial access was chosen in 67% of 347 consecutive patients. Patients who underwent radial approach had lower risk of bleeding determined by CRUSADE (30 ± 14 vs. 37 ± 15; p < 0.001) as compared with femoral access. In multivariate analysis, four variables were identified as independent predictors negatively associated with radial access ­ age (OR = 0.98; 95%CI = 0.96 ­ 0.99), creatinine (OR = 0.54; 95%CI = 0.3 ­ 0.98), signs of left ventricular failure (OR = 0.45; 95% CI = 0.22 ­ 0.92) and previous CABG (OR = 0.022; 95%CI = 0.003 ­ 0.166). Conclusion: The propensity to choose radial over femoral access in coronary intervention was not primarily influenced by patients' bleeding risk. Predictors of this decision, identified in the study, indicated less complex patients, suggesting that the difficulty in performing the technique was a stronger determinant than its potential antihemorrhagic effect

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score / Valor Prognóstico Incremental da Incorporação de Dados Clínicos à Anatomia Coronária em Síndromes Coronarianas Agudas: Escore SYNTAX-GRACE

Abstract Background: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. Objective: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. Methods: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. Results: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). Conclusion: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

Resumo Fundamento: Uma vez realizada a coronariografia em pacientes com síndrome coronariana aguda (SCA), a extensão anatômica da doença coronária prevalece no raciocínio prognóstico. Não está estabelecido se dados clínicos devem também ser contabilizados na estimativa de risco, uma vez que se tenha conhecimento da anatomia coronária. Objetivo: Testar a hipótese de que dados clínicos incrementam o valor prognóstico da avaliação anatômica em pacientes com SCA. Métodos: Indivíduos admitidos com critérios objetivos de SCA e que realizaram coronariografia durante o internamento foram incluídos no estudo. Desfecho primário foi definido como óbito cardiovascular hospitalar, sendo comparado o valor prognóstico do Escore SYNTAX (anatomia) com o do escore SYNTAX-GRACE, resultante da incorporação do Escore GRACE ao Escore SYNTAX. O cálculo do Integrated Discrimination Improvement (IDI) foi realizado para avaliar a capacidade do modelo SYNTAX-GRACE para reclassificar corretamente a informação do modelo SYNTAX tradicional. Resultados: Foram estudados 365 pacientes, idade 64±14 anos, 58% masculinos. A mortalidade cardiovascular durante hospitalização foi de 4,4% e o Escore SYNTAX foi preditor desse desfecho com estatística-C de 0,81 (IC 95% = 0,70 - 0,92; p < 0,001). O Escore GRACE mostrou-se preditor de óbito cardiovascular intra-hospitalar, independente do Escore SYNTAX (p < 0,001 por regressão logística). Ao ser incorporado ao modelo preditor, o Escore GRACE incrementou a capacidade discriminatória do SYNTAX de 0,81 para 0,92 (IC 95% = 0,87 - 0,96; p = 0,04). Conclusão: Em pacientes com SCA, dados clínicos complementam o valor prognóstico da anatomia coronária, devendo a estratificação de risco ser baseada no paradigma clínico-anatômico e não apenas em dados angiográficos.