Management of cardiovascular emergencies during the COVID-19 pandemic.

BACKGROUND: It has been reported that patients attending the emergency department with other pathologies may not have received optimal medical care due to the lockdown measures in the early phase of the COVID-19 pandemic. METHODS: This was a retrospective study of patients presenting with cardiovascular emergencies to four tertiary regional emergency departments in western India during the government implementation of complete lockdown. RESULTS: 25.0% of patients during the lockdown period and 17.4% of patients during the pre-lockdown period presented outside the window period (presentation after 12 hours of symptom onset) compared with only 6% during the pre-COVID period. In the pre-COVID period, 46.9% of patients with ST elevation myocardial infarction underwent emergent catheterisation, while in the pre-lockdown and lockdown periods, these values were 26.1% and 18.8%, respectively. The proportion of patients treated with intravenous thrombolytic therapy increased from 18.4% in the pre-COVID period to 32.3% in the post-lockdown period. Inhospital mortality for acute coronary syndrome (ACS) increased from 2.69% in the pre-COVID period to 7.27% in the post-lockdown period. There was also a significant decline in emergency admissions for non-ACS conditions, such as acute decompensated heart failure and high degree or complete atrioventricular block. CONCLUSION: The COVID-19 pandemic has led to delays in patients seeking care for cardiac problems and also affected the use of optimum therapy in our institutions.

Can Patients Select the Best Hospital for Carotid Revascularization?

BACKGROUND: Public reporting of cardiac surgery outcomes has been available for many years in the USA. Whether public information regarding carotid endarterectomy or stenting outcomes is available has not been studied previously. METHODS: The Medicare Hospital Compare website was analyzed for carotid endarterectomy and stenting volume and complications data. RESULTS: Within a large metropolitan area, endarterectomy volume data was provided in less than half of hospitals, with no information provided on morbidity or mortality. No information was available on carotid stenting. CONCLUSIONS: The quality of information available to patients in the USA contemplating a carotid revascularization procedure is suboptimal. Considering the volume of these procedures, greater transparency with regard to outcomes is desirable. Adoption of carotid procedure reporting practices as used in the UK should be considered.

Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction.

CONTEXT: Public reporting of patient outcomes is an important tool to improve quality of care, but some observers worry that such efforts will lead clinicians to avoid high-risk patients. OBJECTIVE: To determine whether public reporting for percutaneous coronary intervention (PCI) is associated with lower rates of PCI for patients with acute myocardial infarction (MI) or with higher mortality rates in this population. DESIGN, SETTING, AND PATIENTS: Retrospective observational study conducted using data from fee-for-service Medicare patients (49,660 from reporting states and 48,142 from nonreporting states) admitted with acute MI to US acute care hospitals between 2002 and 2010. Logistic regression was used to compare PCI and mortality rates between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware). Changes in PCI rates over time in Massachusetts compared with nonreporting states were also examined. MAIN OUTCOME MEASURES: Risk-adjusted PCI and mortality rates. RESULTS: In 2010, patients with acute MI were less likely to receive PCI in public reporting states than in nonreporting states (unadjusted rates, 37.7% vs 42.7%, respectively; risk-adjusted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]; P = .003). Differences were greatest among the 6708 patients with ST-segment elevation MI (61.8% vs 68.0%; OR, 0.73 [95% CI, 0.59-0.89]; P = .002) and the 2194 patients with cardiogenic shock or cardiac arrest (41.5% vs 46.7%; OR, 0.79 [95% CI, 0.64-0.98]; P = .03). There were no differences in overall mortality among patients with acute MI in reporting vs nonreporting states. In Massachusetts, odds of PCI for acute MI were comparable with odds in nonreporting states prior to public reporting (40.6% vs 41.8%; OR, 1.00 [95% CI, 0.71-1.41]). However, after implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% vs 45.6%; OR, 0.81 [95% CI, 0.47-1.38]; P = .03 for difference in differences). Differences were most pronounced for the 6081 patients with cardiogenic shock or cardiac arrest (prereporting: 44.2% vs 36.6%; OR, 1.40 [95% CI, 0.85-2.32]; postreporting: 43.9% vs 44.8%; OR, 0.92 [95% CI, 0.38-2.22]; P = .03 for difference in differences). CONCLUSIONS: Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute MI mortality between states with and without public reporting.

The European Society for Vascular Surgery guidelines for carotid intervention: an updated independent assessment and literature review.

BACKGROUND AND PURPOSE: Many medical societies now recommend carotid stenting as an alternative to endarterectomy which raises the question of whether the ESVS guidelines are still valid. This review addresses the validity of the ESVS guidelines that refer to carotid stenting based on the evidence available today. METHODS: We conducted a review and meta-analysis based on the original ESVS guidelines paper and articles published over the past 2 years. RESULTS: For symptomatic patients, surgery remains the best option, since stenting is associated with a 61% relative risk increase of periprocedural stroke or death compared to endarterectomy. However, centres of excellence in carotid stenting may achieve comparable results. In asymptomatic patients, there is still no good evidence for any intervention because the stroke risk from an asymptomatic stenosis is very low, especially with the best modern medical treatment. CREST and CAVATAS have verified that mid-term stroke prevention after successful stenting is similar to endarterectomy. EVA-3S, SPACE, ICSS and CREST have provided additional evidence regarding the role of age in choosing therapeutic modality. The role of the cerebral protection devices is challenged by the imaging findings of small randomised trials but supported by large systematic reviews. CONCLUSIONS: The ESVS guidelines that refer to carotid stenting not only remain valid but also have been further strengthened by the latest available clinical data. An update of these guidelines including all of the recent evidence is needed to provide an objective and up-to-date interpretation of the data.

Cost implications of more widespread carotid artery stenting consistent with the American College of Cardiology/American Heart Association guideline.

The recent American College of Cardiology/American Heart Association guideline recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients. This and the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) form the basis for seeking more liberalized indications and reimbursement for CAS. For the years 2005-2007, >130,000 carotid interventions/year were performed, 88.6% of which were CEAs and 11.4% were CAS. For the same years, each CAS procedure had on average $12,000-$13,500 more expensive mean total hospital charges than each CEA. If the percentages of CAS and CEA had been equal (ie, 50% CAS and 50% CEA), this would translate into an additional $2,000,000,000 in charges for these 3 years. It seems unreasonable to approve enhanced reimbursement for CAS at this time, especially since the large incremental costs would go to support CAS procedures that are inferior in most symptomatic patients and possibly unnecessary in most asymptomatic patients.

Lost in translation: health resource variability in the achievement of optimal performance and clinical outcome.

BACKGROUND- An evidence-practice gap in acute coronary syndromes (ACS) is commonly recognized. System, provider, and patient factors can influence guideline adherence. Through using guideline facilitators in the clinical setting, the uptake of evidence-based recommendations may be increased. We hypothesized that facilitators of guideline recommendations (systems, tools, and workforce) in acute cardiac care were associated with increased guideline adherence and decreased adverse outcome. METHODS AND RESULTS- A cross-sectional evaluation of guideline facilitators was conducted in Australian hospitals. The population was derived from the Acute Coronary Syndrome Prospective Audit (ACACIA) and assessed performance, death, and recurrent myocardial infarction (death/re-MI) at 30 days and 12 months. Thirty-five hospitals and 2392 patients participated. Significant associations with decreased death/re-MI were observed with hospital strategies to facilitate primary percutaneous coronary intervention for ST-elevation MI patients (38/428 [8.9%] versus 30/154 [19.5%], P<0.001) and after adjustment (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.24 to 0.90], P<0.023), electronic discharge checklists (none: 233/1956 [11.9%], integrated; 43/251[17.1%], P=0.069, electronic; 6/124 [4.8%], P<0.001) and after adjustment (integrated versus none: OR, 1.66 [95% CI, 0.98 to 2.80], P=0.057 and electronic versus none: OR, 0.49 [95% CI, 0.35 to 0.68], P<0.001), and intensive cardiac care unit (ICCU) staff-to-patient ratios (neither: 200/1257 (15.9%), CCU: 135/1051 (12.8%), ICCU: 8/84 (9.5%), P=0.049 and after adjustment (CCU versus neither: OR, 0.74 [95% CI, 0.47 to 1.14], P=0.172 and ICCU versus neither: OR, 0.55; [95% CI, 0.38 to 0.81] P=0.003). CONCLUSIONS- Facilitating uptake of evidence in clinical practice may need to consider quality improvement systems, tools and workforce to achieve optimal ACS outcomes.

Is mechanical clot removal or disruption a cost-effective treatment for acute stroke?

BACKGROUND AND PURPOSE: It is unclear whether the costs and risks of mechanical therapies make them cost-effective. We examined whether interventions such as mechanical clot removal or disruption with angioplasty are cost-effective for acute ischemic stroke compared with best medical therapy. MATERIALS AND METHODS: We performed a cost-utility analysis of patients with acute stroke due to large intracranial artery occlusion presenting beyond the 3-hour window for IV tPA. Model inputs for the mechanical arm were derived from Multi MERCI trial data and a recent meta-analysis. For best medical therapy, we used rates of spontaneous recanalization, ICH, and functional outcomes based on a systematic literature review. Discounted QALYs were determined by using the Markov modeling for 65-year-old patients with acute ischemic stroke. RESULTS: On the basis of a systematic literature review, we modeled an 84% rate of recanalization with mechanical intervention and a 6.3% rate of symptomatic ICH. For best medical therapy, we modeled a spontaneous recanalization rate of 24% with a 2% rate of symptomatic ICH. Mechanical therapies were associated with a $7718 net cost and a gain of a 0.82 QALYs for each use, thus yielding a net of $9386/QALY gained. In sensitivity analyses, results were dependent on the rates of recanalization, symptomatic ICH rates, and costs of treatment. CONCLUSIONS: On the basis of available data, mechanical therapies in qualified patients with acute stroke beyond the window for IV tPA appear to be cost-effective. However, the inputs are not derived from randomized trials, and results are sensitive to several assumptions.

Capturing the essence of developing endovascular expertise for the construction of a global assessment instrument.

OBJECTIVES: To explore what characterises the development of endovascular expertise and to construct a novel global assessment instrument. DESIGN: Literature review and an experimental study. MATERIALS AND METHODS: The literature was searched for information regarding available global rating scales (GRSs); scientific societies' official statements on endovascular competence; and task analyses of endovascular procedures. In the experimental study, clinicians performed a video-recorded simulated iliac-artery stenting procedure. Subsequently, by using the method of retrospective verbalisation, the clinicians were interviewed while watching their performance on video commenting on key issues of the construct. Data from all sources were analysed, categorised and synthesised into a novel rating scale. RESULTS: Available GRSs primarily included technical aspects of performance, whereas the competence statements, task analyses and clinicians' perceptions added a range of non-technical aspects. The novel rating scale SAVE (Structured Assessment of endoVascular Expertise) differs from prior scales by including issues of pre-planning; prediction of challenges; preparation of tools; management of imaging presentation; distinction of technical skills into external and internal control according to operator focus of visual attention; adaptation of strategy; clinical decision making; use of assistant; complications; inter-personal skills; and post-procedural planning. CONCLUSIONS: The essence of developing endovascular expertise goes far beyond mere technical aspects.

Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis.

BACKGROUND AND PURPOSE: Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT: This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of Neurolnterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebro-vascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSION: In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.

Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis.

BACKGROUND AND PURPOSE: Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT: This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSION: In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.

Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis.

BACKGROUND AND PURPOSE: Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT: This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSIONS: In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.

Practice variability in the management of subrenal arterial stenoses in seven Belgian hospitals.

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating subrenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate patency analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5,300 Euros, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 days), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway, could increase both the quality and the cost-effectiveness of the care.

Advances in interventional radiology. The search for less invasive management sparks new approaches.

Many new, minimally invasive interventional radiology procedures are now viable alternatives to traditional invasive therapy. The radiology procedures can often be performed in the outpatient setting, and although expensive technology may be required, the overall cost to the patient may be lower in the long run. Endovascular repair of abdominal aortic aneurysms with stent grafts and radiofrequency tumor ablation are examples of rapidly expanding technologies in interventional radiology. Patient enthusiasm and interest are the primary forces driving these advances in management. Familiarity with these procedures is vital as medicine moves into the new millennium.

Carotid angioplasty-stent: clinical experience and role for clinical trials.

Carotid angioplasty-stenting (CAS) is a relatively new endovascular procedure that has been used increasingly in recent years. Its popularity is due to, at least in part, the perceived advantages of a less invasive treatment for extracranial carotid occlusive disease. However, valid data that contrast the efficacy of CAS and carotid endarterectomy (CEA), the gold standard for the treatment of symptomatic carotid stenosis, are not available. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) will contrast the relative efficacy of CAS with CEA in the prevention of stroke, myocardial infarction, or death during a 30-day periprocedural period or an ipsilateral stroke thereafter during a follow-up period extending up to 4 years. Stroke events will be verified by an adjudication committee masked to the assigned treatment. Secondary outcomes will (1) describe differential efficacy of CAS and CEA in men and women, (2) contrast periprocedural (30-day) morbidity and postprocedural (after 30-days) morbidity and mortality rates, (3) estimate and contrast the restenosis rates of the two procedures, (4) evaluate the differences in measures of health-related quality of life and cost effectiveness, and (5) identify subgroups of participants at differential risk for CAS and CEA. The primary eligibility criterion is a >50% stenosis of the carotid artery in patients with ipsilateral amaurosis fugax (transient monocular blindness), transient ischemic attack, or nondisabling stroke. Men and women will be eligible for the trial, but patients with medical conditions likely to limit their participation during the follow-up or to interfere with outcome evaluation will be excluded. After a credentialing and training phase, 2500 patients will be randomized to the treatments. Statistical analysis of the primary outcome will use standard survival methods.

Long-term outcome of patients with very long stents for treatment of diffuse coronary disease.

OBJECTIVES: The study sought to determine the 6-month clinical outcome of patients who underwent implantation of very long coronary stents to treat diffuse disease and/or long dissections and to compare the findings with those reported in the literature for patients who underwent implantation of multiple short coronary stents. BACKGROUND: New designs of flexible stents enable the implantation of long stents rather than multiple short, older design stents. The initial experience is very promising but the long-term outcome has not been described yet. METHODS: Fifty-seven consecutive patients in whom 67 long stents (>/=30 mm) were successfully deployed were included in this study. Six-month clinical and angiographic follow-up was prospectively collected. Patients with recurrent angina underwent coronary angiography without further testing. Patients who remained asymptomatic at the 6-month follow-up visit underwent positron emission tomographic imaging, and those with results suggestive of ischemia underwent coronary angiography. A combined study end point was defined as death, myocardial infarction, and the need for target vessel revascularization. RESULTS: Only 1 patient (2%) reached a study end point at hospital discharge. An additional 20 patients (total 21 patients [37%]) reached an end point by 6 months. The outcome was not influenced by the clinical presentation (stable or unstable angina) or by the indication for stenting (elective or emergency). Predictors for adverse outcome were multiple stents per narrowing (63% vs 29%, P <. 04), and stents smaller than 3.5 mm (49% vs 22%). Narrowing and stent length were not predictive of a study end point in narrowings that were successfully treated by a single long stent. CONCLUSIONS: Elective stenting provides an effective solution for patients with diffuse coronary disease provided that a single long stent (usually <40 mm) can cover the full length of the narrowing. The results are better when vessels larger than 3 mm are treated. Compared with multiple short stents, implantation of a single long stent is probably at least as effective, and the procedure is quicker and cheaper and thus should be the preferred approach.