Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention.

BACKGROUND: Radial artery access for coronary angiography and interventions has been promoted for reducing hemostasis time and vascular complications compared with femoral access, yet it can take longer to perform and is not always successful, leading to concerns about its cost. We report a cost-benefit analysis of radial catheterization based on results from a systematic review of published randomized controlled trials. METHODS AND RESULTS: The systematic review added 5 additional randomized controlled trials to a prior review, for a total of 14 studies. Meta-analyses, following Cochrane procedures, suggested that radial catheterization significantly increased catheterization failure (OR, 4.92; 95% CI, 2.69-8.98), but reduced major complications (OR, 0.32; 95% CI, 0.24-0.42), major bleeding (OR, 0.39; 95% CI, 0.27-0.57), and hematoma (OR, 0.36; 95% CI, 0.27-0.48) compared with femoral catheterization. It added approximately 1.4 minutes to procedure time (95% CI, -0.22 to 2.97) and reduced hemostasis time by approximately 13 minutes (95% CI, -2.30 to -23.90). There were no differences in procedure success rates or major adverse cardiovascular events. A stochastic simulation model of per-case costs took into account procedure and hemostasis time, costs of repeating the catheterization at the alternate site if the first catheterization failed, and the inpatient hospital costs associated with complications from the procedure. Using base-case estimates based on our meta-analysis results, we found the radial approach cost $275 (95% CI, -$374 to -$183) less per patient from the hospital perspective. Radial catheterization was favored over femoral catheterization under all conditions tested. CONCLUSIONS: Radial catheterization was favored over femoral catheterization in our cost-benefit analysis.

Recent Trends in Adherence to Secondary Prevention Guidelines for Patients Undergoing Coronary Revascularization in Washington State: An Analysis of the Clinical Outcomes Assessment Program (COAP) Registry.

BACKGROUND: Previous studies indicated that patients undergoing coronary artery bypass graft (CABG) surgery are less likely to receive guideline-based secondary prevention therapy than are those undergoing percutaneous coronary intervention (PCI) after an acute myocardial infarction. We aimed to evaluate whether these differences have persisted after the implementation of public reporting of hospital metrics. METHODS AND RESULTS: The Clinical Outcomes Assessment Program (COAP) database was analyzed retrospectively to evaluate adherence to secondary prevention guidelines at discharge in patients who underwent coronary revascularization after an acute ST-elevation myocardial infarction in Washington State. From 2004 to 2007, 9260 patients received PCI and 692 underwent CABG for this indication. Measures evaluated included prescription of aspirin, ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, or lipid-lowering medications; cardiac rehabilitation referral; and smoking-cessation counseling. Composite adherence was lower for CABG than for PCI patients during the period studied (79.6% versus 89.7%, P<0.01). Compared to patients who underwent CABG, patients who underwent PCI were more likely to receive each of the pharmacological therapies. There was no statistical difference in smoking-cessation counseling (91.7% versus 90.3%, P=0.63), and CABG patients were more likely to receive referral for cardiac rehabilitation (70.9% versus 48.3%, P<0.01). Adherence rates improved over time among both groups, with no significant difference in composite adherence in 2006 (85.6% versus 87.6%, P=0.36). CONCLUSIONS: Rates of guideline-based secondary prevention adherence in patients with ST-elevation myocardial infarction who underwent CABG surgery have been improving steadily in Washington State. The improvement possibly is associated with the implementation of public reporting of quality measures.

Trends in coronary revascularization in the United States from 2001 to 2009: recent declines in percutaneous coronary intervention volumes.

BACKGROUND: There is speculation that the volume of percutaneous coronary interventions (PCIs) has been decreasing over the past several years. Published studies of PCI volume have evaluated regional or hospital trends, but few have captured national data. This study describes the use of coronary angiography and revascularization methods in Medicare patients from 2001 to 2009. METHODS AND RESULTS: This retrospective study used data from the Centers for Medicare & Medicaid Services from 2001 to 2009. The annual number of coronary angiograms, PCI, intravascular ultrasound, fractional flow reserve, and coronary artery bypass graft (CABG) surgery procedures were determined from billing data and adjusted for the number of Medicare recipients. From 2001 to 2009, the average year-to-year increase for PCI was 1.3% per 1000 beneficiaries, whereas the mean annual decrease for CABG surgery was 5%. However, the increase in PCI volume occurred primarily from 2001 to 2004, as there was a mean annual rate of decline of 2.5% from 2004 to 2009; similar trends were seen with diagnostic angiography. The use of intravascular ultrasound and fractional flow reserve steadily increased over time. CONCLUSIONS: This study confirms recent speculation that PCI volume has begun to decrease. Although rates of CABG have waned for several decades, all forms of coronary revascularization have been declining since 2004.

Predictors of long-term mortality in patients with ischemic stroke referred for transesophageal echocardiography.

BACKGROUND AND PURPOSE: Findings on transesophageal echocardiography (TEE) after ischemic stroke predict recurrent embolic events and prompt therapy; however, the additive predictive power of TEE findings on long-term mortality is unknown. Our goal was to study the impact of TEE findings on all cause mortality in ischemic stroke patients referred for TEE. METHODS: We reviewed 245 consecutive patients who underwent TEE for ischemic stroke of undetermined origin (2000 to 2003). Long-term survival was assessed using the Social Security Death Index. RESULTS: In a mean follow-up period of 3.0 (1.4 to 4.8) years, death occurred in 19.2% of patients. TEE findings included patent foramen ovale (18.8%), left atrium/left ventricle thrombus (2.4%), spontaneous echo contrast (3.7%), atrial septal aneurysm (3.3%), valve vegetation/mass/tumor (7.8%), complex aortic atheroma ([CAA]; 14.7%), and the composite of any cardiac source of embolus (39.2%). A total atherosclerotic burden (TAB) score was also recorded. On Cox hazard regression analysis, measures of aortic atherosclerosis (CAA [hazard ratio (HR), 2.7; 95% CI, 1.4 to 5.3] or TAB score [HR, 1.4; 95% CI, 1.2 to 1.6]) were independent predictors of death, whereas other TEE findings were not. CONCLUSIONS: In patients with ischemic stroke of undetermined origin referred for TEE, measures of aortic atherosclerosis, including CAA, represent the only TEE findings that predict long-term mortality after all other clinical factors are considered. Further study is needed to determine whether treatments for CAA effect long-term survival in patients with ischemic stroke.