Contemporary Predictors of Major Adverse Cardiovascular Events Following Percutaneous Coronary Intervention: A Nationally Representative US Sample.

Background: Patient outcomes after percutaneous coronary intervention (PCI) have improved over the last 30 years due to better techniques, therapies, and care processes. This study evaluated contemporary predictors of post-PCI major adverse cardiovascular events (MACE) and summarized risk in a parsimonious risk prediction model. Methods: The Cardiovascular Patient-Level Analytical Platform (CLiPPeR) is an observational dataset of baseline variables and longitudinal outcomes from the American College of Cardiology's CathPCI Registry® and national claims data. Cox regression was used to evaluate 2-6 years of patient follow-up (mean: 2.56 years), ending in December 2017, after index PCI between 2012 and 2015 (N = 1,450,787), to examine clinical and procedural predictors of MACE (first myocardial infarction, stroke, repeat PCI, coronary artery bypass grafting, and mortality). Cox analyses of post-PCI MACE were landmarked 28 days after index PCI. Results: Overall, 12.4% (n = 179,849) experienced MACE. All variables predicted MACE, with cardiogenic shock, cardiac arrest, four diseased coronary vessels, and chronic kidney disease having hazard ratios (HRs) ≥ 1.50. Other major predictors of MACE were in-hospital stroke, three-vessel disease, anemia, heart failure, and STEMI presentation. The index revascularization and discharge prescription of aspirin, P2Y12 inhibitor, and lipid-lowering medication had HR ≤ 0.67. The primary Cox model had c-statistic c = 0.761 for MACE versus c = 0.701 for the parsimonious model and c = 0.752 for the parsimonious model plus treatment variables. Conclusions: In a nationally representative US sample of post-PCI patients, predictors of longitudinal MACE risk were identified, and a parsimonious model efficiently encapsulated them. These findings may aid in assessing care processes to further improve care post-PCI outcomes.

Association of type 2 diabetes with coronary risk factors, clinical presentation, angiography, coronary interventions and follow-up outcomes: A single centre prospective registry.

BACKGROUND & AIMS: To determine variations in coronary artery disease (CAD) clinical presentation, interventions, and outcomes in patients with diabetes vs without, a prospective study was performed. METHODS: Successive patients with predominantly acute coronary syndromes who underwent percutaneous coronary intervention (PCI) were enrolled from January 2018 to March 2021. Patients with diabetes were compared to those without diabetes to determine differences in clinical and angiographic features and outcomes. In-person and telephonic follow-up were performed. Primary outcome was cardiovascular death and co-primary were major adverse cardiovascular events (cardiovascular death, myocardial infarction, revascularization, stroke). Cox-proportional hazard ratios (HR) and 95% confidence intervals (CI) were calculated. RESULTS: 5181 patients (men 4139,women 1042) were enrolled. Acute coronary syndrome(ACS) was in 4917 (94.9%) and diabetes in 1987 (38.4%). Patients with diabetes were older (61.1 ± 9.6 vs 59.7 ± 11.5years), with more hypertension (71.1 vs 45.5%), chronic kidney disease (3.0 vs 1.7%), previous PCI (13.5 vs 11.0%), past coronary artery bypass graft surgery (4.9 vs 2.4%), non ST-elevation myocardial infarction (59.6 vs 51.6%) and triple vessel disease (20.3 vs 17.2%) (p < 0.01). Duration of hospitalization was more in diabetes (4.2 ± 2.6 vs 4.0 ± 2.1 days, p = 0.023) with no difference in in-hospital deaths (1.4 vs 1.0%, p = 0.197). Follow up was performed in 1202 patients (diabetes 499,41.5%) enrolled from April 2020 to March 2021 (median 16.4 months). In diabetes there were more cardiovascular deaths (multivariate adjusted HR 2.38, CI 1.13-5.02) and all-cause deaths (HR 1.85, CI 1.06-3.22). CONCLUSIONS: CAD patients with diabetes undergoing PCI have more hypertension, chronic kidney disease, non ST-elevation myocardial infarction and triple vessel disease. At medium-term follow-up the incidence of cardiovascular and all-cause deaths is significantly more in these patients.

Troponin Levels at Presentation Before Coronary Angiogram and Their Association With Cost, Mortality, and Readmission.

Background and objective In patients undergoing coronary angiogram, the degree of cardiac enzyme elevation at presentation has been thought of as a strong and independent predictor of in-hospital mortality and readmission. Recent studies, however, have suggested a lack of clarity regarding this speculation, particularly with regard to troponin elevations. Additionally, the impact of troponin levels (TnI) at presentations on cost is poorly understood. In this study, we aimed to evaluate the association of Tnl at initial presentation with 30-day all-cause readmission and all-cause mortality as well as admission costs. Methods This study was a retrospective analysis of 7,388 patients who underwent coronary angiogram at our facility from 2015 to 2017. Patients were identified from a local CathPCI Registry® registry, and a subsequent chart review was performed for readmission and mortality data. Cost data were provided by our in-facility finance department. We excluded patients with incomplete records and those who required coronary artery bypass grafting (CABG). After the exclusion of patients deemed ineligible, the final sample size eligible for analysis was 1,163. Patients were divided into two groups based on Tnl at presentation with a cut-off value of 0.04 ng/ml. Adjusted regression and multivariate analysis were used for clinical outcomes. Primary outcomes were 30-day readmission and mortality. The secondary outcome was the admission cost. Results Within our cohort, the average participant age was 64.6 years (SD: 12.7), and the majority of them were male (70.7%). Of these patients, 207 had lower TnI (<0.04 ng/ml), while 956 had higher TnI at presentation. The high TnI (≥0.04 ng/ml) group had a significantly higher number of patients with a family history of coronary artery disease (CAD) (13.8% vs. 7.7%: p=0.017) and those on dialysis (3.2% vs. 0.5%: p=0.028) compared to the low Tnl group. Additionally, we did not find any significant difference in 30-day mortality or readmission between the two groups in our cohort. On average, each patient in the high TnI group spent $936 more for hospital admissions compared to patients in the low Tnl group. However, this difference was not statistically significant. Conclusions Tnl at admission did not reveal a significant impact on 30-day mortality or readmission, which is consistent with the findings of previous studies. A high Tnl at admission increased the cost of admission; however, the difference was not statistically significant in our cohort.

Enhanced mortality risk prediction with a focus on high-risk percutaneous coronary intervention: results from 1,208,137 procedures in the NCDR (National Cardiovascular Data Registry).

OBJECTIVES: This study sought to update and validate a contemporary model for inpatient mortality following percutaneous coronary intervention (PCI), including variables indicating high clinical risk. BACKGROUND: Recently, new variables were added to the CathPCI Registry data collection form. This modification allowed us to better characterize the risk of death, including recent cardiac arrest and duration of cardiogenic shock. METHODS: Data from 1,208,137 PCI procedures performed between July 2009 and June 2011 at 1,252 CathPCI Registry sites were used to develop both a "full" and pre-catheterization PCI in-hospital mortality risk model using logistic regression. To support prospective implementation, a simplified bedside risk score was derived from the pre-catheterization risk model. Model performance was assessed by discrimination and calibration metrics in a separate split sample. RESULTS: In-hospital mortality was 1.4%, ranging from 0.2% among elective cases (45.1% of total cases) to 65.9% among patients with shock and recent cardiac arrest (0.2% of total cases). Cardiogenic shock and procedure urgency were the most predictive of inpatient mortality, whereas the presence of a chronic total occlusion, subacute stent thrombosis, and left main lesion location were significant angiographic predictors. The full, pre-catheterization, and bedside risk prediction models performed well in the overall validation sample (C-indexes 0.930, 0.928, 0.925, respectively) and among pre-specified patient subgroups. The model was well calibrated across the risk spectrum, although slightly overestimating risk in the highest risk patients. CONCLUSIONS: Clinical acuity is a strong predictor of PCI procedural mortality. With inclusion of variables that further characterize clinical stability, the updated CathPCI Registry mortality models remain well-calibrated across the spectrum of PCI risk.