Impact of public health emergency response to COVID-19 on management and outcome for NSTEMI patients in Beijing: A single-center historic control.

BACKGROUND: During coronavirus disease 2019 (COVID-19) epidemic, reducing the number of invasive procedure and choosing conservative medication strategy for patients with non-ST-segment elevation myocardial infarction (NSTEMI) is unavoidable. Whether this relatively conservative strategy will impact in-hospital outcome for NSTEMI patients remains unclear. METHODS AND RESULTS: The current study included all consecutive NSTEMI patients who visited the emergency department in Fuwai Hospital from February 1 to March 31, 2020 and all the NSTEMI patients in the same period of 2019 as a historical control. Very-high-risk patients were defined as clinical presentation of heart failure, cardiac shock, cardiac arrest, recurrent chest pain, and life-threatening arrhythmias. The primary outcome was in-hospital major adverse cardiac events (MACE), defined as a composite of all-cause death, recurrent myocardial infarction, or heart failure. A total of 115 NSTEMI patients were enrolled since the outbreak of COVID-19, and a total of 145 patients were included in the control group. There was a tendency toward higher MACE risk in 2020 compared with 2019 (18.3% vs. 11.7%, p = .14). Among very-high-risk patients, early percutaneous coronary intervention (PCI) strategy in 2019 was associated with reduced MACE risk compared with delayed PCI in 2020 (60.6% [20/33] in 2020 vs. 27.9% [12/43] in 2019, p = .01). CONCLUSIONS: COVID-19 pandemic results in a significant reduction in immediate/early PCI and a trend toward higher adverse event rate during hospitalization, particular in very-high-risk patients.

Lombardy regional urgent reorganization for congenital cardiac patients following the Covid-19 pandemic.

OBJECTIVE: By the end of February 2020, the COVID-19 pandemic infection had spread in Northern Italy, with thousands of patients infected. In Lombardy, the most affected area, the majority of public and private hospitals were dedicated to caring for COVID-19 patients and were organized following the 'Hub-and-Spoke' model for other medical specialties, like cardiac surgery and interventional procedures for congenital cardiac disease (CHD). Here, we report how the congenital cardiac care system was modified in Lombardy and the first results of this organization. METHODS: We describe a modified 'Hub-and-Spoke' model - that involves 59 birthplaces and three specialized Congenital Cardiac Centers -- and how the hub center organized his activity. We also reported the data of the consecutive cases hospitalized during this period. RESULTS: From 9 March to 15 April, we performed: a total of 21 cardiac surgeries, 4 diagnostic catheterizations, 3 CT scans, and 2 CMR. In three cases with prenatal diagnosis, the birth was scheduled. The spoke centers referred to our center six congenital cardiac cases. The postop ExtraCorporeal Membrane Oxygenation support was required in two cases; one case died. None of these patients nor their parents or accompanying person was found to be COVID-19-positive; 2 pediatric intensivists were found to be COVID-19-positive, and needed hospitalization without mechanical ventilation; 13 nurses had positive COVID swabs (4 with symptoms), and were managed and isolated at home. CONCLUSION: Our preliminary data suggest that the model adopted met the immediate needs with a good outcome without increased mortality, nor COVID-19 exposure for the patients who underwent procedures.

Physician and Hospital Utilization of P2Y12 Inhibitors in ST-Segment-Elevation Myocardial Infarction in the United States: A Study From the National Cardiovascular Data Registry's Research to Practice Initiative.

Background Ticagrelor and prasugrel are potent P2Y12 inhibitors with superior efficacy compared with clopidogrel among patients with ST-segment-elevation myocardial infarction (STEMI), though use in recent practice is not well described. In this retrospective study, we assessed trends, predictors, and variation in use of P2Y12 inhibitors in patients with STEMI in the United States. Methods and Results We identified 169 505 STEMI patients in the Chest Pain-Myocardial Infarction Registry from October 2013 through March 2017. We determined national utilization rates of P2Y12 inhibitors at discharge, patient predictors for each medication, and variation in use between hospitals. In a subset of 9655 Medicare patients ≥65 years old, we compared 1-year adjusted risks of death, myocardial infarction, stroke, and bleeding based on hospital quartile of potent P2Y12 inhibitor use. Rates of ticagrelor use increased from 18.0% to 44.0%, while rates of prasugrel and clopidogrel use decreased from 24.6% to 13.5% and 57.4% to 42.6%, respectively. Prior percutaneous coronary intervention was the strongest clinical predictor for use of ticagrelor (adjusted odds ratio, 1.13 [95% CI, 1.09-1.18]) and prasugrel (adjusted odds ratio, 1.27 [95% CI, 1.21-1.34]) compared with clopidogrel. Predictors of clopidogrel use included no insurance, insurance with Medicare or Medicaid, and features associated with higher bleeding risk. The median hospital usage rate for newer P2Y12 inhibitors was 51.3% (interquartile range, 35.0%-65.9%), with substantial variation between hospitals (adjusted median odds ratio, 2.92 [95% CI, 2.77-3.10]). Among patients ≥65 years old, there were no differences in adjusted 1-year risks of adverse outcomes across hospital quartiles of potent P2Y12 inhibitor use. Conclusions Almost one-half of STEMI patients by 2017 were discharged on ticagrelor while far fewer received prasugrel. Patient characteristics are associated with P2Y12 inhibitor selection, though substantial hospital variation exists. Identifying barriers to use of more potent P2Y12 inhibitors may improve patient-centered decision-making for STEMI patients.

Outcomes of cardiac implantable electronic device transvenous lead extractions performed in centers without onsite cardiac surgery.

BACKGROUND: While major complications associated with CIED lead extractions are uncommon, they carry a significant risk of morbidity and mortality in the absence of surgical intervention. However, there is limited data on the differences in outcomes of these procedures between centers with and without on-site CS support. The present study examined outcomes of transvenous cardiac implantable electronic device (CIED) lead extractions according to admitting hospitals' cardiac surgery (CS) facilities. METHODS: We analyzed the National Inpatient Sample for CIED lead extraction procedures, stratified by hospitals' CS facilities into two groups; on-site and off-site CS. Logistic regression analyses were performed to estimate the adjusted odds (aOR) of procedure-related complications in off-site CS centers. RESULTS: In 221,606 procedures over an 11-year-period, CIED lead extractions were increasingly undertaken in on-site as opposed to off-site CS centers (Onsite CS 2004 vs. 2014: 78.2% vs. 90.4%, p < 0.001) during the study period. In comparison to on-site CS group, patients admitted to off-site CS group were older, less comorbid, and experienced lower adjusted odds of major adverse cardiovascular events (0.72 [0.67, 0.77]), mortality (0.60 [0.52, 0.69]), procedure-related bleeding (0.48 [0.44, 0.54]) and complications (thoracic: 0.81 [0.75, 0.88]; cardiac: 0.45 [0.38, 0.54]) (p < 0.001 for all). CONCLUSIONS: Our national analysis demonstrates that transvenous CIED lead extractions are being increasingly undertaken in centers with on-site CS surgery, in compliance with international guideline recommendations. Patients managed with lead extractions in on-site CS centers are more comorbid and critically ill compared to those admitted to off-site CS centers, and remain at a higher risk of procedure-related complications.

Trends in Performance and Opportunities for Improvement on a Composite Measure of Acute Myocardial Infarction Care.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P<0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P<0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P<0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P<0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P<0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

Center experience does not influence long-term outcome and peri-procedural complications after cryoballoon ablation of paroxysmal atrial fibrillation: Data on 860 patients from the real-world multicenter observational project.

BACKGROUND: The aim of this research was to evaluate whether the procedural data, the incidence of complications, and the long-term freedom from atrial fibrillation (AF) recurrences are influenced by center experience in a paroxysmal AF (PAF) population performing a first-time pulmonary vein isolation (PVI) by cryoballoon ablation (CBA). METHODS: A total of 860 patients underwent PVI by CBA. Center experience groups were predefined according to the quartiles of the distribution regarding the amount of performed procedures: 3.1%, 10.6%, 22.7% and 63.6% of patients were respectively followed in each group from 1st (less experienced) to 4th (more experienced) quartile of experience. RESULTS: In the entire population, median procedure and fluoroscopy time were 105 and 25 min, respectively. The median procedure time significantly decreased from 130 to 90 min (P < 0.001) as the center's experience increased. In 47 (5.5%) patients, a peri-procedural complication occurred. As the experience of centers increased, the acute intraprocedural PVI success rate increased (from 94.3% to 98.9%, P = 0.007), whereas there was a tendency towards a decreased incidence of peri-procedure complications (from 7.4% to 4.6%, P = 0.998). The mean 1-year freedom from AF recurrence probability was 78.3%, and the 18-month mean was 68.9% with no difference among the groups with different levels of experience. CONCLUSION: CBA is a safe and effective treatment for patients with PAF. Peri-procedural complications and procedural times were low in all the analyzed sub-groups, showing a decreasing trend in function of center expertise. The long-term freedom from AF recurrence was not influenced by the level of experience. (clinicaltrials.gov: NCT01007474).

Comparison of patients with multivessel disease treated at centers with and without on-site cardiac surgery.

BACKGROUND: The regional needs and consolidation of cardiac surgery services (CSS) result in an increased number of stand-alone interventional cardiology units. We aimed to explore the impact of a heart team on the decision making and outcomes of patients with multivessel coronary artery disease referred for coronary revascularization in stand-alone interventional cardiology units. METHODS: This prospective study included 1063 consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and percutaneous coronary intervention (PCI), with or without on-site CSS. RESULTS: Of the 1063 patients, 487 (46%) underwent coronary artery bypass grafting (CABG) and 576 (54%) underwent PCI. A higher proportion of patients underwent PCI in hospitals without on-site CSS compared with those with on-site CSS (65% vs 46%; P < .001). Furthermore, patients referred to CABG from hospitals without on-site CSS had a significantly higher mean SYNTAX score compared with those who underwent CABG in centers with on-site CSS (29 vs 26; P = .018). Multivariate logistic regression analysis consistently showed that the absence of on-site cardiac surgery and a heart team was independently associated with a 2.5-fold increased likelihood for predicting the referral of PCI rather than CABG (odds ratio, 2.54; 95% confidence interval, 1.8-3.6). CONCLUSIONS: Patients with multivessel coronary artery disease treated in centers without on-site cardiac surgery services receive a lower rate of appropriate guideline-based intervention with CABG. These findings suggest that a heart team approach should be mandatory even in centers with stand-alone interventional cardiology units.

Current management and treatment of patients with stable coronary artery diseases presenting to cardiologists in different clinical contexts: A prospective, observational, nationwide study.

Background Stable coronary artery disease (CAD) is a leading cause of mortality worldwide. Few studies document the complete sequence of investigation of the overall stable CAD population during outpatient visits or hospitalisation. Aim To obtain accurate and up-to-date information on current management of patients with stable CAD. Methods START (STable coronary Artery diseases RegisTry) was a prospective, observational, nationwide study aimed at evaluating the presentation, management, treatment and quality of life of stable CAD patients presenting to cardiologists during outpatient visits or discharged from cardiology wards. Results Over a 3-month period, 5070 consecutive patients were enrolled in 183 participating centres: 72% managed by a cardiologist during outpatient or day hospital visits and 28% discharged from cardiology wards. The vast majority of patients (87%) received a coronary angiography (86% of patients managed during outpatient visits and 90% during hospitalisation; p < 0.0001). Outpatients more frequently received optimal medical therapy (OMT; i.e. aspirin or thienopyridine, ß-blockers and statins) compared to hospitalised patients (70.2% vs 67.1%; p = 0.03). A personalised diet was prescribed in 58% (60.5% in outpatients and 52.9% in those admitted to hospitals; p < 0.0001), physical activity programmes were suggested in 65% (69.4% and 54.3%; p < 0.0001) and smoking cessation was recommended in 71% of currently smoking patients (73.2% and 65.2%; p = 0.02). Conclusions In this large, contemporary registry, patients with stable CAD discharged from cardiology wards more commonly underwent diagnostic imaging procedures and less frequently received OMT or lifestyle modification programmes compared to patients manged by cardiologists during outpatient visits.

Temporal Trends of Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging in Patients With Coronary Artery Disease: A 22-Year Experience From a Tertiary Academic Medical Center.

BACKGROUND: There has been a gradual decline in the prevalence of abnormal stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging studies among patients without history of coronary artery disease (CAD). The trends of SPECT studies among patients with known CAD have not been evaluated previously. METHODS AND RESULTS: We assessed the Mayo Clinic nuclear cardiology database for all stress SPECT tests performed between January 1991 and December 2012 in patients with history of CAD defined as having previous myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting. The study cohort was divided into 5 time periods: 1991 to 1995, 1996 to 2000, 2001 to 2005, 2006 to 2010, and 2011 to 2012. There were 19 373 patients with a history of CAD who underwent SPECT between 1991 and 2012 (mean age, 66.2±10.9 years; 75.4% men). Annual utilization of SPECT in these patients increased from an average of 495 tests per year in 1991 to 1995 to 1425 in 2003 and then decreased to 552 tests in 2012 without evidence for substitution with other stress modalities. Asymptomatic patients initially increased until 2006 and then decreased. Patients with typical angina decreased, whereas patients with dyspnea and atypical angina increased. High-risk SPECT tests significantly decreased, and the percentage of low-risk SPECT tests increased despite decreased SPECT utilization between 2003 and 2012. Almost 80% of all tests performed in 2012 had a low-risk summed stress score compared with 29% in 1991 (P<0.001). CONCLUSIONS: In Mayo Clinic, Rochester, annual SPECT utilization in patients with previous CAD increased between 1992 and 2003, but then decreased after 2003. High-risk SPECT tests declined, whereas low-risk tests increased markedly. Our results suggest that among patients with a history of CAD, SPECT was being increasingly utilized in patients with milder CAD. This trend parallels reduced utilization of other stress modalities, coronary angiography, reduced smoking, and greater utilization of optimal medical therapy for prevention and treatment of CAD.

Comparing medication adherence tools scores and number of controlled diseases among low literacy patients discharged from a Brazilian cardiology ward.

Background Adherence to prescribed drug therapy is associated with lower rates of cardiovascular causes of death. In view of the relevance for public health, it is important to understand the relation between medication adherence tools' scores, especially in low literacy patients discharged from a cardiology ward. Objectives We aimed to assess: (a) the association between number of controlled clinical conditions and adherence tools scores, and (b) the correlation between the scores of three instruments to assess adherence. Methods We conducted a prospective study and included patients discharged from a specialized cardiovascular ward in Brazil. The results of the Beliefs about Medicines questionnaire (BMQ), the Adherence to Refills and Medication Scale (ARMS) and the MedTake test were compared. Results Of 53 included patients, most of them were elderly, and did not complete primary school. On average, there were six health conditions per patient, where two of them were not controlled. ARMS was the only tool that was associated with number of controlled health conditions (r = -0.312, p < 0.05). Moreover, ARMS (average score 15.6 ± 3.4) had significant correlation with MEDTAKE (r = 0.535, p < 0.01) and BMQ (r = 0.38, p < 0.01). BMQ and MEDTAKE were also positively correlated (r = 0.311, p < 0.05). Conclusions Clinically, higher ARMS scores (>12) suggest assumed non-adherence. It is also negatively correlated with the number of controlled clinical conditions in low literacy elderlies with cardiovascular diseases.

Guideline-Appropriate Care and In-Hospital Outcomes in Patients With Heart Failure in Teaching and Nonteaching Hospitals: Findings From Get With The Guidelines-Heart Failure.

BACKGROUND: Despite increasing awareness regarding evidence-based guidelines, considerable gaps exist for heart failure (HF) quality of care at teaching hospitals (TH) and nonteaching hospitals (NTH). We analyzed data from Get With The Guidelines (GWTG)-HF to compare the rates and trends of guideline-recommended care at TH and NTH for patients with HF. METHOD AND RESULTS: Baseline patient characteristics, performance measures, and in-hospital outcomes were compared between 197 187 HF patients admitted to TH and 106 924 patients admitted to NTH between 2005 and 2014. Patients treated in TH were younger and were more likely to be black and uninsured. Defect-free care (defined as 100% compliance with performance measures) was similar in both group of hospitals (crude rates: 88% at TH versus 86% at NTH, adjusted odds ratio 0.99, 95% confidence interval 0.73-1.34) as were individual performance measures: discharge instruction, documentation of ejection fraction, use of angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists, use of ß-blocker, and smoking cessation counseling. During the study period, there was improvement in adherence with performance measures over time, with no significant difference at TH (adjusted odds ratio 1.20, 95% confidence interval 1.11-1.30; P<0.01) and NTH (adjusted odds ratio 1.09, 95% confidence interval 1.02-1.17; P=0.01; interaction P value 0.07). CONCLUSIONS: Data from the GWTG-HF program suggest that there was improving and comparable adherence with HF performance measures and use of guideline-recommended therapies irrespective of hospital teaching status.

Prevalence of aortic valve dystrophy and insufficiency in a cohort of 255 HIV-positive patients followed-up in a cardiology department between 2012 and 2014.

OBJECTIVES: To study valve appearance and the presence of valve disease in a cohort of people living with HIV (PLHIV). DESIGN: A prospective study of PLHIV examined at the cardiology department of the Clermont Ferrand university hospital group (CHU) between January 1, 2012, and December 31, 2014. Were excluded those with a history of infection associated with a possible endocarditis. METHODS: Demographic, medical characteristics and cardiovascular disease risk factors at time of cardiovascular examination and Doppler-echocardiography were recorded and analyzed. RESULTS: In total, 903 PLHIV were examined in the infectious diseases department, 255 of whom were included. These consisted of 67 women (26.3%) and 188 men, of a mean age of 51.2±9.7years, in whom coronary artery disease was diagnosed in 18 patients (7.0%), two women and 16 men, representing a prevalence of 3.0% in females and 8.5% in males. The appearance of the aortic cusps was considered dystrophic in 14.1% of cases (36/255), dysplastic in two cases (0.8%), exhibiting a bicuspid deformity in one case. The prevalence of aortic valve abnormality was therefore 6.0% in the women (4/67) and 17.0% in the men (32/188). On facing off this data with the Kora Monica study findings, an increase in prevalence appears only to truly manifest after 50years of age. We registered 35 aortic insufficiency cases (13.7%), representing a higher incidence than that of the Framingham cohort, with age and masculine gender being the determining factors. CONCLUSION: Valve disease, along with coronary artery disease, should be closely monitored in PLHIV.

Nationwide Survey of the Transfer of Adults With Congenital Heart Disease From Pediatric Cardiology Departments to Adult Congenital Heart Disease Centers in Japan.

BACKGROUND: Current Japanese transfer practices for adult congenital heart disease (ACHD) patients in pediatric departments are elucidated in this study. The focus was on 149 facilities (from the Japanese Society of Pediatric Cardiology and Cardiac Surgery Subspecialty Board and the Japanese Association of Children's Hospitals and Related Institutions). One hundred and thirteen facilities were surveyed and the response rate was 75.8%. METHODS AND RESULTS: Twenty-six facilities (23.0%) treated ≥200 outpatients annually; 48 facilities (42.9%) treated <50 outpatients. Only eight facilities admitted ≥50 inpatients; 61 facilities (54.0%) admitted <10 inpatients. Nine facilities fulfilled international regional ACHD center criteria. The estimated median number of patients receiving outpatient pediatric department follow up was 33,806. Sixty facilities (53.6%) treated patients in pediatric departments after they reached adulthood. Of 49 facilities that transferred patients, the transfer was most commonly to another department in the same facility (20 facilities; 40.8%), typically the adult cardiology department (29 facilities; 59.2%). In future, 55 facilities (48.7%) desired the transfer of patients to regional ACHD centers, while 34 facilities (30.1%) preferred to continue treating patients in the pediatric department. CONCLUSIONS: The number of regional ACHD centers offering sufficient outpatient and inpatient care is limited; transfer from pediatric departments is not standard in Japan. Role division clarification between regional ACHD centers and other facilities and cooperative network establishment including transitional care programs is necessary. (Circ J 2016; 80: 1242-1250).

Variation of ventilation practices with center volume after pediatric heart surgery.

BACKGROUND: This study was designed to evaluate the odds of mechanical ventilation and duration of mechanical ventilation after pediatric cardiac surgery across centers of varying center volume using the Virtual PICU Systems database. HYPOTHESIS: Children receiving cardiac surgery at high-volume centers will be associated with lower odds of mechanical ventilation and shorter duration of mechanical ventilation, compared with low-volume centers. METHODS: Patients age <18 years undergoing operations (with or without cardiopulmonary bypass) for congenital heart disease at one of the participating intensive care units in the Virtual PICU Systems database were included (2009-2013). Logistic regression models and Cox proportional hazards models were fitted for the probability of conventional mechanical ventilation and duration of mechanical ventilation, respectively, to investigate the difference in the outcomes between different center volume groups with/without adjustment for other risk factors. RESULTS: A total of 10 378 patients from 43 centers qualified for inclusion. Of these, 7648 (74%) patients received conventional mechanical ventilation after cardiac surgery. Higher center volume was significantly associated with lower odds of mechanical ventilation after cardiac surgery (odds ratio: 2.68, 95% confidence interval: 2.15-3.35). However, patients receiving mechanical ventilation in these centers were associated with longer duration of mechanical ventilation, compared with lower-volume centers (hazard ratio: 1.26, 95% confidence interval: 1.16-1.37). This association was most prominent in the lower surgical-risk categories. CONCLUSIONS: Large clinical practice variations were demonstrated for mechanical ventilation following pediatric cardiac surgery among intensive care units of varied center volumes.

Expansion of invasive cardiac services in the United States.

BACKGROUND: The number of hospitals offering invasive cardiac services (diagnostic angiography, percutaneous coronary intervention, and coronary artery bypass grafting) has expanded, yet national patterns of service diffusion and their effect on geographic access to care are unknown. METHODS AND RESULTS: This is a retrospective cohort study of all hospitals in fee-for-service Medicare, 1996 to 2008. Logistic regression identified the relationship between cardiac service adoption and the proportion of neighboring hospitals within 40 miles already offering the service. From 1996 to 2008, 397 hospitals began offering diagnostic angiography, 387 percutaneous coronary intervention, and 298 coronary artery bypass grafting (increasing the proportion with services by 3%, 11%, and 4%, respectively). This capacity increase led to little new geographic access to care; the population increase in geographic access to diagnostic angiography was 1 percentage point; percutaneous coronary intervention 5 percentage points, and coronary artery bypass grafting 4 percentage points. Controlling for hospital and market characteristics, a 10 percentage point increase in the proportion of nearby hospitals already offering the service increased the odds by 10% that a hospital would add diagnostic angiography (odds ratio, 1.102; 95% confidence interval, 1.018-1.193), increased the odds by 79% that it would add percutaneous coronary intervention (odds ratio, 1.794; 95% confidence interval, 1.288-2.498), and had no significant effect on adding coronary artery bypass grafting (odds ratio, 0.929; 95% confidence interval, 0.608-1.420). CONCLUSIONS: Hospitals are most likely to introduce new invasive cardiac services when neighboring hospitals already offer such services. Increases in the number of hospitals offering invasive cardiac services have not led to corresponding increases in geographic access.

Indicação e acessibilidade à reabilitação cardiovascular em um hospital público do Distrito Federal / Indication and accessibility to cardiovascular rehabilitation at a public hospital in Federal District

A reabilitação cardiovascular (RCV) raramente tem sido considerada obrigatória; o encaminhamento de cardiopatas para tal programa é baixo e estima-se que apenas 25% dos pacientes aptos tenham acesso a tal terapêutica. Este trabalho teve como objetivo verificar se os cardiologistas de um hospital público do Distrito Federal reconhecem a RCV como tratamento não farmacológico e indicam pacientes para a RCV, bem como identificar se estes pacientes recebem orientação, indicação ou encaminhamento e/ou participam ou participaram do programa. Estudo descritivo prospectivo realizado no segundo semestre de 2008, por meio da aplicação de questionários estruturados elaborados pelos pesquisadores, sendo um questionário para os médicos cardiologistas e outro para os pacientes internados no Pronto Socorro da cardiologia. Foram entrevistados 15 cardiologistas com média de idade de 47,8 ± 7,69 anos e tempo de profissão médio de 21,33 ± 6,20 anos. Todos afirmam orientar atividade física a seus pacientes, 60% conhecem serviços de RCV em Brasília e 33,33% dizem ter encaminhado/indicado pacientes do estabelecimento para tal programa. Os 58 pacientes tinham média de idade de 58,10 ± 12,76 anos, 41,38% referem ter recebido orientação para a prática de atividade física, 1,72% afirma ter recebido orientação/indicação médica para RCV e nenhum participa ou participou de tal programa. Poucos médicos indicam e/ou orientam RCV aos cardiopatas, uma minoria dos pacientes aptos à associação do tratamento clínico e medicamentoso com a reabilitação recebeu indicação para a terapêutica e nenhum deles chegou a ser encaminhado e a participar de tal programa.