Management strategies and prognosis of patients ineligible for transcatheter mitral valve replacement.

BACKGROUND: Transcatheter mitral valve replacement (TMVR) faces anatomical challenges, currently limiting widespread adoption. OBJECTIVES: To describe the natural history and prognosis of patients ineligible for various TMVR devices. METHODS: During a 4-year period (2019-2023) 3 TMVR devices (SAPIEN M3, Intrepid and Alta Valve) became available at a single institution (The Christ Hospital, Cincinnati, OH) in the setting of pivotal clinical trials or early feasibility study. Consenting patients who were deemed ineligible ≥1 of these trials were prospectively studied to capture anatomical reasons for ineligibility, cross-over to alternative mitral valve therapies (surgery or high-risk mitral transcatheter edge to edge repair [M-TEER]), and clinical events. RESULTS: A total of 61 patients (out of 71 consenting patients or 85.9 %) were deemed ineligible for TMVR during the study period. The mean age was 79.2 ± 8.8 years, 65.6 % were female, with elevated surgical risk (median STS 4.3, IQR: 2.7-7.3). The 2 most common anatomical reasons for ineligibility were increased risk of left ventricular outflow tract obstruction (LVOTO) (n = 24, 39.3 %) and annular size (n = 29, 47.5 %). During follow-up (median 277 [162-555] days) there were 7 deaths (11.5 %) and 12 (19.7 %) hospitalizations for heart failure. Management strategies included high-risk M-TEER in 11 patients (1 death [9.0 %], 0 HF hospitalizations [0 %]), surgery in 9 patients (0 deaths, 1 HF hospitalizations [11.1 %]), and medical management in 41 patients (6 deaths [14.6 %], 11 HF hospitalizations [26.8 %]) (p = 0.715 for mortality and p = 0.093 for HF hospitalizations). Residual MR ≥ moderate was 0 %, 50 %, and 100 % for surgery, M-TEER and medical treatment, respectively (p < 0.001). CONCLUSIONS: One third of patients deemed ineligible for TMVR are candidates for high-risk M-TEER or surgery with acceptable morbidity and mortality. Our results have practical implications for patient management.

Transcatheter Treatment of Native Aortic Valve Regurgitation: The North American Experience With a Novel Device.

BACKGROUND: Transcatheter treatment of patients with native aortic valve regurgitation (AR) has been limited by anatomical factors. No transcatheter device has received U.S. regulatory approval for the treatment of patients with AR. OBJECTIVES: The aim of this study was to describe the compassionate-use experience in North America with a dedicated transcatheter device (J-Valve). METHODS: A multicenter, observational registry was assembled of compassionate-use cases of J-Valve implantation for the treatment of patients with severe symptomatic AR and elevated surgical risk in North America. The J-Valve consists of a self-expanding Nitinol frame, bovine pericardial leaflets, and a valve-locating feature. The available size matrix (5 sizes) can treat a wide range of anatomies (minimum and maximum annular perimeters 57-104 mm). RESULTS: A total of 27 patients (median age 81 years [IQR: 72-85 years], 81% at high surgical risk, 96% in NYHA functional class III or IV) with native valve AR were treated with the J-Valve during the study period (2018-2022). Procedural success (J-Valve delivered to the intended location without the need for surgical conversion or a second transcatheter heart valve) was 81% (22 of 27 cases) in the overall experience and 100% in the last 15 cases. Two cases required conversion to surgery in the early experience, leading to changes in valve design. At 30 days, there was 1 death, 1 stroke, and 3 new pacemakers (13%), and 88% of patients were in NYHA functional class I or II. No patient had residual AR of moderate or greater degree at 30 days. CONCLUSIONS: The J-Valve appears to provide a safe and effective alternative to surgery in patients with pure AR and elevated or prohibitive surgical risk.

Stress cardiac MR imaging compared with stress echocardiography in the early evaluation of patients who present to the emergency department with intermediate-risk chest pain.

PURPOSE: To compare the utility and efficacy of stress cardiac magnetic resonance (MR) imaging and stress echocardiography in an emergency setting in patients with acute chest pain (CP) and intermediate risk of coronary artery disease (CAD). MATERIALS AND METHODS: Written informed consent was obtained from all patients. This HIPAA-compliant study was approved by the institutional review board for research ethics. Sixty patients without history of CAD presented to the emergency department with intermediate-risk acute CP and were prospectively enrolled. Patients underwent both stress cardiac MR imaging and stress echocardiography in random order within 12 hours of presentation. Stress imaging results were interpreted clinically immediately (blinded interpretation was performed months later), and coronary angiography was performed if either result was abnormal. CAD was considered significant if it was identified at angiography (narrowing >50% ) or if a cardiac event (death or myocardial infarction) occurred during follow-up (mean, 14 months ± 5 [standard deviation]). McNemar test was used to compare the diagnostic accuracy of techniques. RESULTS: Stress cardiac MR imaging and stress echocardiography had similar specificity, accuracy, and positive and negative predictive values (92% vs 96%, 93% vs 88%, 67% vs 60%, and 100% vs 91%, respectively, for clinical interpretation; 90% vs 92%, 90% vs 88%, 58% vs 56%, and 98% vs 94%, respectively, for blinded interpretation). Stress cardiac MR imaging had higher sensitivity at clinical interpretation (100% vs 38%, P = .025), which did not reach significance at blinded interpretation (88% vs 63%, P = .31). However, multivariable logistic regression analysis showed stress cardiac MR imaging to be the strongest independent predictor of significant CAD (P = .002). CONCLUSION: In patients presenting to the emergency department with intermediate-risk CP, adenosine stress cardiac MR imaging performed within 12 hours of presentation is safe and potentially has improved performance characteristics compared with stress echocardiography. Online supplemental material is available for this article.

Clinical application of cine-MRI in the visual assessment of mitral regurgitation compared to echocardiography and cardiac catheterization.

BACKGROUND: Detecting and quantifying the severity of mitral regurgitation is essential for risk stratification and clinical decision-making regarding timing of surgery. Our objective was to assess specific visual parameters by cine-magnetic resonance imaging (MRI) in the determination of the severity of mitral regurgitation and to compare it to previously validated imaging modalities: echocardiography and cardiac ventriculography. METHODS: The study population consisted of 68 patients who underwent a cardiac MRI followed by an echocardiogram within a median time of 2.0 days and 49 of these patients who had a cardiac catheterization, median time of 2.0 days. The inter-rater agreement statistic (Kappa) was used to evaluate the agreement. RESULTS: There was moderate agreement between cine MRI and Doppler echocardiography in assessing mitral regurgitation severity, with a kappa value of 0.47, confidence interval (CI) 0.29-0.65. There was also fair agreement between cine MRI and cardiac catheterization with a kappa value of 0.36, CI of 0.17-0.55. CONCLUSION: Cine MRI offers a reasonable alternative to both Doppler echocardiography and, to a lesser extent, cardiac catheterization for visually assessing the severity of mitral regurgitation with specific visual parameters during routine clinical cardiac MRI.

Impact of early surgery on survival of patients with severe mitral regurgitation.

BACKGROUND: Optimal timing of surgery in degenerative mitral regurgitation (MR) remains a controversial topic. The impact of current ACC/AHA guideline recommendations about optimal timing of surgery on outcomes is untested and contemporary data are lacking. OBJECTIVE: To assess the association between the timing of surgery and long-term survival in patients with severe MR. METHODS: A cohort of 481 patients with severe, degenerative mitral regurgitation (1995-2007) from the Duke Cardiovascular Disease Databank who fulfilled at least one ACC/AHA guideline indication for surgery was identified. Exclusion criteria were rheumatic disease, congenital mitral valve (MV) disease, hypertrophic cardiomyopathy, coronary disease in more than one vessel, endocarditis, other severe valve disease, h/o valve repair/replacement. Patients were grouped into early surgery (in ≤ 2 months of presenting with surgical indications) and late surgery (>2 months) groups. An adjusted Cox regression model was constructed for time to death after 2 months with a time-dependent covariate term for late surgery. RESULTS: 168 patients had early surgery (median time to surgery 0.42 months) with 153 followed up after 2 months, 94 had late surgery (median time to surgery 8.75 months) and 219 medically managed. 127/168 in the early surgery group and 84/94 in the late surgery group received MV repair (p=0.02). Over 5.6 years' (median) follow-up there were 35 deaths (21%) in the early surgery group, with two occurring before 2 months and 20 (21%) in the late group. In the multivariable model, those undergoing early surgery had a lower hazard for death than those who underwent late surgery (HR=0.54 (95% CI 0.30 to 0.97), p=0.039). MV repair was independently associated with survival (HR=0.45 (95% CI 0.25 to 0.83), p=0.01). CONCLUSIONS: In patients with severe MR who presented with guideline indications for surgery, those selected for earlier surgery had improved survival. These data support the current guidelines for early referral to surgery in patients with severe MR for enlarged left ventricular dimensions, reduced ejection fraction and symptoms rather than delaying surgery. Larger randomised trials are needed to definitively answer the question of optimal timing of surgery in patients with severe degenerative MR.

Mitral gradients and frequency of recurrence of mitral regurgitation after ring annuloplasty for ischemic mitral regurgitation.

BACKGROUND: Undersized ring annuloplasty and surgical revascularization are commonly used to correct ischemic mitral regurgitation (MR), but published series have failed to demonstrate a benefit compared with revascularization alone. We hypothesized that surgical revascularization and annuloplasty lead to a durable repair, but may also lead to increased mitral gradients that could limit the benefit of the repair technique. METHODS: Data were collected for 222 consecutive patients who underwent combined revascularization and repair for ischemic MR between 1999 and 2006. The most recent transthoracic echocardiogram available for each patient (namely, the study that occurred at the latest date after surgery) was reviewed to define the fate of ischemic MR. When present, the mean gradient across the mitral valve was measured. Cox regression modeling was then performed to determine whether increasing gradients were associated with decreased long-term survival or increased hospitalization for heart failure. RESULTS: For the group of 222 patients, echocardiographic follow-up was available for 68% (149 patients). At follow-up, 1.3% had severe MR and 9.4% had moderate MR; 54% of patients (66 of 123) were found to have gradients of 5 mm or greater across the mitral valve, with 11% demonstrating gradients of 8 mm or more. Cox proportional hazards models failed to show adverse effects of increasing mitral gradient on outcomes analyzed: survival hazard ratio = 0.95 (95% confidence interval: 0.82 to 1.11, p = 0.527) and survival/heart failure hospitalization hazard ratio = 1.04 (95% confidence interval: 0.93 to 1.17, p = 0.488). CONCLUSIONS: Undersized ring annuloplasty and revascularization can provide a durable correction of ischemic mitral regurgitation. This technique frequently increases the gradient across the mitral valve, but increasing mitral gradient does not appear to adversely impact survival or heart failure hospitalization.

Certificate of Need (CON) for cardiac care: controversy over the contributions of CON.

OBJECTIVES: To test whether state Certificate of Need (CON) regulations influence procedural mortality or the provision of coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCI). DATA SOURCES: Medicare inpatient claims obtained for 1989-2002 for patients age 65+ who received CABG or PCI. STUDY DESIGN: We used differences-in-differences regression analysis to compare states that dropped CON during the sample period with states that kept the regulations. We examined procedural mortality, the number of hospitals in the state performing CABG or PCI, mean hospital volume, and statewide procedure volume for CABG and PCI. PRINCIPAL FINDINGS: States that dropped CON experienced lower CABG mortality rates relative to states that kept CON, although the differential is not permanent. No such mortality difference is found for PCI. Dropping CON is associated with more providers statewide and lower mean hospital volume for both CABG and PCI. However, statewide procedure counts remain the same. CONCLUSIONS: We find no evidence that CON regulations are associated with higher quality CABG or PCI. Future research should examine whether the greater number of hospitals performing revascularization after CON removal raises expenditures due to the building of more facilities, or lowers expenditures due to enhanced price competition.

Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial.

OBJECTIVES: The purpose of this study was to evaluate the diagnostic accuracy of electrocardiographically gated 64-multidetector row coronary computed tomographic angiography (CCTA) in individuals without known coronary artery disease (CAD). BACKGROUND: CCTA is a promising method for detection and exclusion of obstructive coronary artery stenosis. To date, no prospective multicenter trial has evaluated the diagnostic accuracy of 64-multidetector row CCTA in populations with intermediate prevalence of CAD. METHODS: We prospectively evaluated subjects with chest pain at 16 sites who were clinically referred for invasive coronary angiography (ICA). CCTAs were scored by consensus of 3 independent blinded readers. The ICAs were evaluated for coronary stenosis based on quantitative coronary angiography (QCA). No subjects were excluded for baseline coronary artery calcium score or body mass index. RESULTS: A total of 230 subjects underwent both CCTA and ICA (59.1% male; mean age: 57 +/- 10 years). On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect > or =50% or > or =70% stenosis were 95%, 83%, 64%, and 99%, respectively, and 94%, 83%, 48%, 99%, respectively. No differences in sensitivity and specificity were noted for nonobese compared with obese subjects or for heart rates < or =65 beats/min compared with >65 beats/min, whereas calcium scores >400 reduced specificity significantly. CONCLUSIONS: In this prospective multicenter trial of chest pain patients without known CAD, 64-multidetector row CCTA possesses high diagnostic accuracy for detection of obstructive coronary stenosis at both thresholds of 50% and 70% stenosis. Importantly, the 99% negative predictive value at the patient and vessel level establishes CCTA as an effective noninvasive alternative to ICA to rule out obstructive coronary artery stenosis. (A Study of Computed Tomography [CT] for Evaluation of Coronary Artery Blockages in Typical or Atypical Chest Pain; NCT00348569).

Impact of heart failure on patients undergoing major noncardiac surgery.

BACKGROUND: Changes in the demographics and epidemiology of patients with cardiovascular comorbidities who undergo major noncardiac surgery require an updated assessment of which patients are at greater risk of mortality or readmission. The authors evaluated short-term outcomes among patients with heart failure, coronary artery disease (CAD), or neither who underwent major noncardiac surgery. METHODS: Patients were aged 65 and older, had Medicare fee-for-service coverage, and underwent 1 of 13 major noncardiac procedures from 2000 through 2004, excluding patients with end-stage renal disease and patients who did not have at least 1 yr of Medicare fee-for-service eligibility before surgery. Main outcome measures were operative mortality and 30-day all-cause readmission. RESULTS: Of 159,327 procedures, 18% were performed in patients with heart failure and 34% were performed in patients with CAD. Adjusted hazard ratios of mortality and readmission for patients with heart failure, compared with patients with neither heart failure nor CAD, were 1.63 (95% confidence interval, 1.52-1.74) and 1.51 (95% confidence interval, 1.45-1.58), respectively. Adjusted hazard ratios of mortality and readmission for patients with CAD, compared with patients with neither heart failure nor CAD, were 1.08 (95% confidence interval, 1.01-1.16) and 1.16 (95% confidence interval, 1.12-1.20), respectively. These effects were statistically significant. Patients with heart failure were at significantly higher risk for both outcomes compared with patients with CAD. CONCLUSIONS: Elderly patients with heart failure who undergo major surgical procedures have substantially higher risks of operative mortality and hospital readmission than other patients, including those with coronary disease, admitted for the same procedures. Improvements in perioperative care are needed for the growing population of patients with heart failure undergoing major noncardiac surgery.

Pannus-related prosthetic valve dysfunction and life-threatening aortic regurgitation.

Prosthetic valve dysfunction is a rare but life-threatening condition. A 66-year-old woman presented with shock 15 years after aortic valve replacement with a tilting-disc valve. Imaging demonstrated severe aortic insufficiency and a fixed-open prosthetic valve. Reoperation revealed pannus ingrowth from the aortic aspect, resulting in immobility of the occluder. A bioprosthetic valve was installed and the patient recovered uneventfully. The diagnosis and surgical management of this problem are discussed.

Deterioration of regional wall motion immediately after coronary artery bypass graft surgery is associated with long-term major adverse cardiac events.

BACKGROUND: Patients undergoing coronary artery bypass graft (CABG) surgery frequently develop wall motion abnormalities diagnosed by intraoperative transesophageal echocardiography. However, the relation between deterioration in wall motion and postoperative morbidity or mortality is unclear. Therefore, the authors hypothesized that deterioration in intraoperative left ventricular regional wall motion immediately after CABG surgery is associated with a higher risk of adverse cardiac events. METHODS: With institutional review board approval, data were gathered from 1,412 CABG surgery patients. Echocardiographic wall motion score (WMS) was derived using a 16-segment model. Outcomes data were gathered for up to 2 yr after surgery. The primary outcome, major adverse cardiac event, was a composite index of myocardial infarction, need for subsequent coronary revascularization, or all-cause mortality during the follow-up period. RESULTS: Two hundred twenty-one patients (16%) had 254 primary outcome events during follow-up. Postbypass WMS did not change in 812 patients (58%), deteriorated in 219 patients (16%), and improved in 368 patients (26%). Kaplan-Meier analysis showed that patients with deterioration in WMS after CABG experienced significantly lower major adverse cardiac event-free survival than patients with either no change or improvement in WMS (P = 0.004). Cox proportional hazards regression modeling revealed a significant association between deterioration in WMS and the composite adverse outcome (hazard ratio, 1.47 [1.06-2.03]; P = 0.02). CONCLUSIONS: The authors confirmed their hypothesis that deterioration in wall motion detected by intraoperative echocardiography after CABG surgery is associated with increased risk of long-term adverse cardiac morbidity. Worsening wall motion after CABG surgery should be considered a prognostic indicator of adverse cardiovascular outcome.

Temporal trends in target vessel revascularization in clinical practice: long-term outcomes following coronary stenting from the Duke Database for Cardiovascular Disease.

OBJECTIVE: We examined outcomes of clinical restenosis and temporal trends in repeat target vessel revascularization (TVR) among a broad, unselected patient population undergoing percutaneous coronary revascularization. BACKGROUND: The extent to which clinical trials involving protocol-specified follow-up angiography reflect real-world practice where interventions are driven by clinical restenosis is not completely understood. Whether clinical outcomes have varied over a long-term period that has paralleled substantial advances in stent design, balloon delivery catheter and adjunctive pharmacologic therapies is uncertain. METHODS: To characterize the effectiveness of coronary stenting in routine practice, we examined 1-year clinical outcomes of death and repeat TVR among 5,765 patients enrolled in the Duke Database for Cardiovascular Disease who underwent stent placement between 1994 and 2002. To assess for temporal trends in outcomes, patients were further divided into tertiles according to the year of initial revascularization. RESULTS: Overall, the 1-year occurrence of TVR and death was 11.4% and 4.9%, respectively. Rates of repeat TVR increased at 3-month intervals, with most events occurring prior to 9 months. In an adjusted analysis over an 8-year period, 1-year survival did not significantly differ across patient tertiles (p = 0.95), although rates of recurrent TVR significantly decreased (1994-1996, 11.1%; 1997-1999, 11.5%; 2000-2002, 9.3%; p = 0.003). CONCLUSIONS: In a broad patient population in whom repeat angiography is not protocol-specified, most events occur within the initial months following revascularization, yet late clinical restenosis continues. Although survival has not improved since the introduction of coronary stents, overall rates of repeat revascularization have modestly, but significantly, declined.

Comparison of long-term (seven year) outcomes among patients undergoing percutaneous coronary revascularization with versus without stenting.

Coronary stents have markedly improved the short- and intermediate-term safety and efficacy of percutaneous coronary intervention by improving acute gains in luminal dimensions, decreasing abrupt vessel occlusion, and decreasing restenosis, yet the long-term benefit of coronary stenting remains uncertain. We examined long-term clinical outcomes of death, myocardial infarction, and repeat target vessel revascularization (TVR) among patients enrolled in the Duke Database for Cardiovascular Disease who underwent revascularization with percutaneous transluminal coronary angioplasty alone or stent placement from 1990 to 2002. Among 6,956 patients who underwent percutaneous revascularization, propensity modeling was applied to identify 1,288 matched patients with a similar likelihood to receive coronary stents according to clinical, angiographic, and demographic characteristics. Significant (p <0.05) predictors of stent placement included multivessel disease, diabetes, hypertension, recent myocardial infarction, decreased ejection fraction, and year of study entry. At a median follow-up of 7 years, although treatment with coronary stenting was associated with a significant and sustained decrease in repeat TVR (18.0% vs 28.1%, p = 0.0002) and the occurrence of death, myocardial infarction or TVR (39.2% vs 45.8%, p = 0.004), long-term survival did not significantly differ between treatment groups (19.9% vs 20.5%, p = 0.72). Outcomes of death and myocardial infarction did not significantly differ between patients who did and did not undergo repeat TVR. In conclusion, compared with angioplasty alone, revascularization with coronary stents provides a significant early and sustained decrease in the need for repeat revascularization, but stents do not influence long-term survival.

Dollars and stents: the economics of drug-eluting stents.

By averting restenoses, drug-eluting stents (DES) reduce the need for repeat revascularization procedures and improve quality of life. Large, randomized clinical trials including the Sirolimus-Eluting Balloon Expandable Stent in Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) suggest that DES may be cost-effective to the Medicare system over time. However, the high cost of DES and the loss of revenues from revascularization procedures coupled with inadequate Medicare reimbursement are likely to have adverse effects on hospitals, making it hard to meet their bottom line. Key contributors to this problem include the unequal distribution of Medicare reimbursement based on diagnosis-related groups or diagnosis-related group calculations and the lack of price competition for DES. The economic burden of restenoses, the efficacy of DES in averting restenoses, the cost-effectiveness of DES, and the interaction of Medicare, DES manufacturers, and hospitals are reviewed. Using specific cost-containment strategies, hospitals can better maneuver the financial barriers to optimize DES utilization.

Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes.

An analysis of smokers admitted with acute coronary syndrome who received transdermal nicotine therapy and those who did not was performed. Propensity analysis was used to match patients. Transdermal nicotine therapy appears safe and does not have an effect on the mortality of patients with acute coronary syndromes.

Outcomes in heart failure patients after major noncardiac surgery.

OBJECTIVES: The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery. BACKGROUND: There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample of Medicare beneficiaries, we identified patients with HF who underwent major noncardiac surgery. A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery. Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups. RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery. There were 44,512 patients in the Control group with major noncardiac surgery. After accounting for demographic characteristics, type of surgery, and comorbid conditions, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control 6.2% (HF vs. CAD, p < 0.001; CAD vs. Control, p = 0.518). The risk-adjusted 30-day readmission rate was HF 20.0%, CAD 14.2%, and Control 11.0% (p < 0.001). CONCLUSIONS: In patients 65 years of age and older, HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care, whereas patients with CAD without HF have similar mortality compared with a more general population.

The prognostic importance of comorbidity for mortality in patients with stable coronary artery disease.

OBJECTIVES: To identify the prevalent and prognostically important coexisting illnesses among single coronary artery disease (CAD) patients. BACKGROUND: As the population ages, physicians are increasingly required to make decisions concerning patients with multiple co-existing illnesses (comorbidity). Many trials of CAD therapy have excluded patients with significant comorbidity, such that there are limited data to guide the management of those patients. METHODS: To consider the long-term prognostic importance of comorbid illness, we examined a cohort of 1471 patients with CAD who underwent cardiac catheterization between 1985 and 1989 and were followed up through 2000 in the Duke Databank for Cardiovascular Diseases. Weights were assigned to individual diseases according to their prognostic significance in Cox proportional hazards models, thus creating a new CAD-specific index. The new index was compared with the widely used Charlson index, according to prevalence of conditions, individual and overall associations with survival, and agreement. RESULTS: The Charlson index and the CAD-specific index were highly associated with long-term survival and almost equivalent to left ventricular ejection fraction. When considering the components of the Charlson index, diabetes, renal insufficiency, chronic obstructive pulmonary disease, and peripheral vascular disease had greater prognostic significance among CAD patients, whereas peptic ulcer disease, connective tissue disease, and lymphoma were less significant. Hemiplegia, leukemia, lymphoma, severe liver disease, and acquired immunodeficiency syndrome were rarely identified among patients undergoing coronary angiography. CONCLUSIONS: Comorbid disease is strongly associated with long-term survival in patients with CAD. These data suggest co-existing illnesses should be measured and considered in clinical trials, disease registries, quality comparisons, and counseling of individual patients.

Medication errors in hospitalized cardiovascular patients.

BACKGROUND: The Institute of Medicine's report To Err Is Human: Building a Safer Health System recommends pharmacist participation in patient rounds as an immediate approach to reducing medical errors. In the same report and in prior publications, cardiovascular drugs have been commonly associated with severe adverse drug events. METHODS: We systematically reviewed the experience of a clinical pharmacist on the cardiology wards between September 1, 1995, and February 18, 2000. We classified medication errors according to the type of error, medications involved, personnel involved, stages of drug administration involved, and time of year most frequently associated with errors. RESULTS: Among 14983 pharmacist interventions, 4768 were related to medication errors, or 24 medication errors per 100 admissions. The most common errors involved the wrong drug (36.0%) or wrong dose (35.3%), and cardiovascular medications were involved in 41.2% of the errors. Prescribers were associated with most of the errors, and the transition from outpatient to inpatient was the most common point in the system for the occurrence of these medication errors. Higher numbers of errors were also identified during the transition period of house staff, and the total number of errors increased during the study period. CONCLUSIONS: Through the clinical pharmacist's identification and correction of medication errors, 2 areas of improvement that may reduce medication errors were identified. The first is ensuring accurate knowledge of a patient's outpatient medication regimen. The second involves improving the education and support of new interns during their initial months of training. This work exemplifies the approach recommended by the Institute of Medicine to reduce medical errors through systematic analyses rather than ascribing fault to individuals.