RESUMO
INTRODUCTION: Multiple risk models are used to predict the presence of obstructive coronary artery disease (CAD) in patients with chest pain. We aimed to compare the performance of these models to an experienced cardiologist's assessment utilizing coronary angiography (CA) as a reference. MATERIALS AND METHODS: We prospectively enrolled patients without known CAD referred for elective CA. We assessed pretest probability of CAD using the following risk models: Diamond-Forrester (original and updated), Duke Clinical score, ACC/AHA, CAD consortium (basic and clinical) and PROMISE minimal risk tool. All patients completed self-administrative Rose angina questionnaire. Independently, an experienced cardiologist assessed the patients to provide a binary prediction of obstructive CAD prior to CA. Obstructive CAD was defined as >80% stenosis in epicardial coronary arteries by visual assessment, or fractional flow reserve <0.80 in intermediate lesions (30-80%). RESULTS: A total of 150 patients were recruited (100 women, 50 men). Mean age was 58 (32-78) years. Obstructive CAD was found in 31 patients (21%). The area under the curve (AUC) for all the clinical risk prediction models (except the Duke Clinical Score, AUC 0.73, P = 0.07) was significantly lower compared with the clinician's assessment (AUC 0.51-0.65 vs. 0.81, respectively, P < 0.01). The clinician's assessment had sensitivity comparable to the Duke Clinical score, which was higher than all other clinical models. There was no difference in prediction performance on the basis of sex in this predominantly female population. DISCUSSION/CONCLUSION: In stable patients with chest pain and suspected CAD, current clinical risk models which are universally based upon the characteristics of the chest pain, show suboptimal performance in predicting obstructive CAD. These findings have important clinical implications, as current appropriateness criteria for recommending CA are on the basis of these risk models.
Assuntos
Doença da Artéria Coronariana , Reserva Fracionada de Fluxo Miocárdico , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: The healthcare burden posed by the coronavirus disease 2019 (COVID-19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training. METHODS: We conducted a web-based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows. RESULTS: Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID-19 related duties. More than two-thirds of PDs believed that the COVID-19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one-fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one-third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship. CONCLUSIONS: The COVID-19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.
Assuntos
COVID-19/epidemiologia , Cateterismo Cardíaco , Cardiologia/educação , Educação de Pós-Graduação em Medicina/organização & administração , Bolsas de Estudo/organização & administração , Intervenção Coronária Percutânea/educação , Acreditação , Humanos , New Jersey , Cidade de Nova Iorque , Diretores Médicos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Various risk assessment scores were proposed in the last decade for prediction of in-hospital mortality in patients undergoing percutaneous coronary intervention (PCI). We sought to apply two validated scores, the Mayo Clinic Risk Score (MCRS) and the New York Risk Score (NYRS) to a contemporary cohort treated at a single institution and to simplify the NYRS, such that the parameters used in both scores are similar. METHODS AND RESULTS: Patients undergoing PCI in 2005-2007 were included. MCRS and NYRS were calculated for each patient. A simplified NYRS, similar to MCRS, was constructed by deleting two variables (gender and left main coronary stenosis). Model discrimination was assessed by the C statistic and goodness-of-fit (calibration) was measured with the Hosmer-Lemeshow test. There were 3,165 procedures. The in-hospital mortality was 0.56% (95% CI 0.31-0.83%). Mean MCRS was 2.7 +/- 2.4 (predicted mortality 0.3%). The C-statistic for MCRS was 0.82 (0.71-0.94) and the model was well calibrated (P = 0.79). Mean NYRS was 5.1 +/- 3.3, (predicted mortality 0.23%). The C-statistic for NYRS was 0.83 (0.74-0.95), not different from MCRS (P = 0.62) and the model was well calibrated (P = 0.29). The mean simplified NYRS was 4.6 +/- 3.1 among survivors and 10.9 +/- 5.8 among those who died, P < 0.001. The score had a C-statistic of 0.83 (0.71-0.95), not different from MCRS (P = 0.84) or NYRS (P = 0.27) and was well calibrated (P = 0.71). CONCLUSION: PCI risk scores utilizing easily collected variables are useful in discriminating risk and predicting death. NYRS might be simplified by removing the gender and left main coronary stenosis variables from its algorithm.
Assuntos
Angioplastia Coronária com Balão/mortalidade , Doença da Artéria Coronariana/terapia , Estenose Coronária/terapia , Indicadores Básicos de Saúde , Mortalidade Hospitalar , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Angioplastia Coronária com Balão/efeitos adversos , Estudos de Coortes , Doença da Artéria Coronariana/mortalidade , Estenose Coronária/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sistema de Registros , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: We sought to compare 3-year outcomes of percutaneous coronary intervention (PCI) according to recently published appropriateness criteria for PCI. BACKGROUND: The choice of revascularization between PCI and coronary artery bypass grafting (CABG) remains uncertain in many patients despite numerous randomized clinical trials and meta-analyses. METHODS: Consecutive patients undergoing a first PCI at a single, large-volume institution were included if they did not have prior CABG and did not need emergency PCI. Patients were classified according to PCI indication into the following groups: Appropriate (A) - 1- or 2-vessel coronary artery disease (CAD), Uncertain (U) - 3-vessel CAD and Inappropriate (I) - left main coronary artery stenosis. Survival was assessed with the Social Security Death Index. RESULTS: A total of 2,134 patients fulfilled the study criteria: 1,706 (80%) with "appropriate" PCI, 414 (19.4%) with "uncertain" PCI and only 14 (0.6%) with "inappropriate" PCI. In-hospital outcomes were very favorable, with 99.3%, 98.6% and 100% of the three groups, respectively, experiencing no complications (p = 0.31). The estimated survival in the three categories at 900 days was 92.6% (95% confidence interval 91-94%) for Group A, 91.3% (88-4%) for Group U and 66.9% (33-87%) for Group I; p = 0.014. The only predictors of mortality were advanced age and comorbidities, but not "appropriateness level" (p = 0.26). CONCLUSION: The majority of PCIs performed would were classified as "appropriate." The patients classified as "uncertain" had similarly favorable outcomes, as those considered "appropriate" both during initial hospitalization and during the 3-year follow up. If confirmed, these data suggest that anatomically-based appropriateness criteria are not sufficient to inform choice of revascularization method.