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.

Patient preference regarding assessment of clinical follow-up after percutaneous coronary intervention: the PAPAYA study.

AIMS: To keep patients in long-term clinical follow-up programmes after percutaneous coronary intervention (PCI), knowledge of the patient-preferred mode for follow-up assessment is crucial. We systematically assessed patient preference, and explored potential relationships with age and gender. METHODS AND RESULTS: In the prospective, observational PAPAYA study (ClinicalTrials.gov: NCT02189070), 2,566 patients, treated by PCI between June 2008 and May 2012, were invited to participate in a postal survey on the patient-preferred mode (postal questionnaire, telephone or e-mail consultation) and frequency of follow-up assessment. A total of 1,797 (70.0%) patients responded. The vast majority preferred completing postal questionnaires (1,248 [69.9%]) as compared to telephone (240 [13.4%]) or e-mail-based approaches (227 [12.7%]) (p<0.001). With increasing age, there was a gradual decline in preference for e-mail (p<0.001); the youngest patients (≤60 years) preferred e-mail-based follow-up more often than the oldest (21.1% vs. 3.1%). Nevertheless, 79.9% of the youngest preferred to be approached in ways other than by e-mail. Women more often preferred approaches other than e-mail (94.1% vs. 87.3%, p<0.001). CONCLUSIONS: Patients showed a distinct preference for completing postal questionnaires rather than being approached by telephone or e-mail. Younger patients accepted e-mail-based follow-up more often, but the majority of the youngest patients still preferred approaches other than by e-mail.

Assessment of the relation between initial culprit vessel patency in acute ST-elevation myocardial infarction and endothelial function.

AIMS: To assess whether better endothelial function increases the likelihood of patients with acute ST-elevation myocardial infarction (STEMI) having initially patent culprit vessels. Clinical data on the relation between endothelial function and culprit vessel patency in STEMI patients are scarce. METHODS AND RESULTS: In this prospective cohort study in 71 patients with STEMI, endothelial function was non-invasively assessed by use of the reactive hyperaemia peripheral artery tonometry (RH-PAT) method at four to six weeks after the primary percutaneous coronary intervention (PPCI). The RH-PAT index measured on average 1.90±0.58. In patients with patent culprit vessels before PPCI (n=33, 46.5%), endothelial function was significantly better than in patients with occluded vessels (n=38, 53.5%) (RH-PAT index 2.08±0.34 vs. 1.75±0.35; p<0.007). Compared to patients with normal endothelial function, the patients with severe endothelial dysfunction had a fivefold higher risk of presenting with an occluded culprit vessel (OR 5.1, 95% CI: 1.8-14.2). Logistic regression analysis revealed that this relation between endothelial function and vessel patency became even stronger after adjustment for potential confounders (adjusted OR 7.1, 95% CI: 2.1-23.6). CONCLUSIONS: In this series of patients with acute STEMI, better endothelial function was independently associated with a higher likelihood of presenting with an initially patent culprit vessel.

Magnetic resonance imaging versus Doppler guide wire in the assessment of coronary flow reserve in patients with coronary artery disease.

BACKGROUND: Coronary flow velocity reserve (CFVR), defined as the ratio of maximal hyperaemic to baseline flow velocity, has been validated as a marker of physiological significance of a coronary lesion. Clinically, this parameter is measured invasively during X-ray angiography using the Doppler guide wire. With magnetic resonance (MR) imaging it is possible to quantify CFVR non-invasively. DESIGN: The purpose of the study was to compare CFVR, acquired with MR imaging and the Doppler guide wire in patients with coronary artery disease. METHODS: Twenty-two patients suffering from one- or two-vessel coronary artery disease as derived from diagnostic X-ray coronary angiography were included. Coronary flow velocity reserve was measured at baseline and during maximal hyperaemia, obtained by intravenous administration of adenosine using MR phase contrast velocity quantification. Within 2 weeks CFVR was measured invasively with a Doppler guide wire. RESULTS: In 26 coronary arteries CFVR was acquired with both techniques. Mean CFVR in the stenosed and healthy reference arteries was 1.5 +/- 0.7 and 2.7 +/- 1.0 (P < 0.01) respectively for MR measurements and 1.9 +/- 0.7 and 3.1 +/- 0.6 (P < 0.01) respectively for Doppler measurements. Bland-Altman analysis revealed a non-significant mean difference between the two techniques of 0.4 +/- 1.2. CONCLUSION: In a selected group of stable patients with coronary artery disease MR flow velocity quantification provides non-invasive data equivalent to the invasive Doppler guide wire data. Variability in both the MR and Doppler ultrasound measurement resulted in a significant scatter of data without systematic difference.