Cost Analysis From a Randomized Comparison of Immediate Versus Delayed Angiography After Cardiac Arrest.

Background In patients with out-of-hospital cardiac arrest without ST-segment elevation, immediate coronary angiography did not improve clinical outcomes when compared with delayed angiography in the COACT (Coronary Angiography After Cardiac Arrest) trial. Whether 1 of the 2 strategies has benefits in terms of health care resource use and costs is currently unknown. We assess the health care resource use and costs in patients with out-of-hospital cardiac arrest. Methods and Results A total of 538 patients were randomly assigned to a strategy of either immediate or delayed coronary angiography. Detailed health care resource use and cost-prices were collected from the initial hospital episode. A generalized linear model and a gamma distribution were performed. Generic quality of life was measured with the RAND-36 and collected at 12-month follow-up. Overall total mean costs were similar between both groups (EUR 33 575±19 612 versus EUR 33 880±21 044; P=0.86). Generalized linear model: (ß, 0.991; 95% CI, 0.894-1.099; P=0.86). Mean procedural costs (coronary angiography and percutaneous coronary intervention, coronary artery bypass graft) were higher in the immediate angiography group (EUR 4384±3447 versus EUR 3028±4220; P<0.001). Costs concerning intensive care unit and ward stay did not show any significant difference. The RAND-36 questionnaire did not differ between both groups. Conclusions The mean total costs between patients with out-of-hospital cardiac arrest randomly assigned to an immediate angiography or a delayed invasive strategy were similar during the initial hospital stay. With respect to the higher invasive procedure costs in the immediate group, a strategy awaiting neurological recovery followed by coronary angiography and planned revascularization may be considered. Registration URL: https://trialregister.nl; Unique identifier: NL4857.

Long-term safety of intracoronary haemodynamic assessment for deferral of angioplasty in intermediate coronary stenoses: a 5-year follow-up.

BACKGROUND: Intracoronary flow and pressure measurements can be used for evaluating intermediate lesions. Studies focussing on short- and medium-term results demonstrated its safety. Long-term results are, however, not available. OBJECTIVE: The goal of this study was to assess the long-term safety and clinical implications of decision making for intermediate coronary stenosis based on intra-coronary haemodynamic measurements. METHODS AND RESULTS: In this prospective study, 61 patients with an intermediate coronary stenosis were included between January 1994 and December 1998. In these patients either coronary flow reserve or fractional flow reserve was measured. Death, target vessel revascularization, myocardial infarction, unstable angina and cerebrovascular accident were considered as major adverse cardiac events. The patients were followed during 5.5 (1.8) years for the occurrence of major adverse cardiac events (MACE). Although many patients presented with complaints, only 19.7% experienced a MACE in the follow-up period. CONCLUSION: Intracoronary measurements of CFR and FFR can be routinely used for objective clinical decision making in intermediate coronary stenoses. The low 5-year event rate supports conservative treatment strategy when cut-off values are implemented.

Clinical impact of vasomotor function assessment and the role of ACE-inhibitors and statins.

Impaired endothelial function is recognised as one of the earliest events of atherogenesis. Endothelium-dependent vasomotion has been the principal method to assess endothelial function. In this article, we will discuss the clinical value of the different techniques to evaluate endothelium-dependent vasomotion. To date, there seems not to be a simple and reliably endothelial function test to identify asymptomatic subjects at increased risk for cardiovascular disease in clinical practice. Recent studies indicate that pharmacological interventions, in particular with ACE-inhibitors and statins, might improve endothelial function. However, there is no solid evidence that improvement of endothelial function is a necessity for the observed reduction in cardiovascular events by these compounds. Overall, at this moment, there is no place in clinical practice for the use of endothelial function as a method for risk assessment or target of pharmacological interventions.