Effect of Clinical Decision Support With Audit and Feedback on Prevention of Acute Kidney Injury in Patients Undergoing Coronary Angiography: A Randomized Clinical Trial.

Importance: Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes. Objective: To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI. Design, Setting, and Participants: A stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020. Interventions: During the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention. Main Outcomes and Measures: The primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models. Results: Of the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 [SD, 10.7] years; 1384 were women [32.0%]) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 [SD, 10.8] years; 1151 were women [33.0%]). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, -2.3% [95% CI, -0.6% to -4.1%]; odds ratio [OR], 0.72 [95% CI, 0.56 to 0.93]; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, -12.0% [95% CI, -14.4% to -9.4%]; OR, 0.77 [95% CI, 0.65 to 0.90]; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, -15.8% [95% CI, -19.7% to -12.0%]; OR, 0.68 [95% CI, 0.53 to 0.87]; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events. Conclusions and Relevance: Among cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation. Trial Registration: ClinicalTrials.gov Identifier: NCT03453996.

Change Management Accompanying Implementation of Decision Support for Prevention of Acute Kidney Injury in Cardiac Catheterization Units: Program Report.

Purpose of program: Different models exist to guide successful implementation of electronic health tools into clinical practice. The Contrast Reducing Injury Sustained by Kidneys (Contrast RISK) initiative introduced an electronic decision support tool with physician audit and feedback into all of the cardiac catheterization facilities in Alberta, Canada, with the goal of preventing contrast-associated acute kidney injury (CA-AKI) following coronary angiography and intervention. This report describes the change management approaches used by the initiative and end-user's feedback on these processes. Sources of information and methods: The Canada Health Infoway Change Management model was used to address 6 activities relevant to project implementation: governance and leadership, stakeholder engagement, communications, workflow analysis and integration, training and education, and monitoring and evaluation. Health care providers and invasive cardiologists from all sites completed preimplementation, usability, and postimplementation surveys to assess integration and change success. Key findings: Prior to implementation, 67% of health providers were less than satisfied with processes to determine appropriate contrast dye volumes, 47% were less than satisfied with processes for administering adequate intravenous fluids, and 68% were less than satisfied with processes to ensure follow-up of high-risk patients. 48% of invasive cardiologists were less than satisfied with preprocedural identification of patients at risk of acute kidney injury (AKI). Following implementation, there were significant increases among health providers in the odds of satisfaction with processes for identifying those at high risk of AKI (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.36-6.66, P = .007), quantifying the appropriate level of contrast dye for each patient (OR 6.98, 95% CI 3.06-15.91, P < .001), determining the optimal amount of IV fluid for each patient (OR 1.86, 95% CI 0.88-3.91, P = .102), and following up of kidney function of high risk patients (OR 5.49, 95%CI 2.45-12.30, P < .001). There were also significant increases among physicians in the odds of satisfaction with processes for identifying those at high risk of AKI (OR 19.53, 95% CI 3.21-118.76, P = .001), quantifying the appropriate level of contrast dye for each patient (OR 26.35, 95% CI 4.28-162.27, P < .001), and for following-up kidney function of high-risk patients (OR 7.72, 95% CI 1.62-36.84.30, P = .010). Eighty-nine percent of staff perceived the initiative as being successful in changing clinical practices to reduce the risk of CA-AKI. Physicians uniformly agreed that the system was well-integrated into existing workflows, while 42% of health providers also agreed. Implications: The Canada Health Infoway Change Management model was an effective framework for guiding implementation of an electronic decision support tool and audit and feedback intervention to improve processes for AKI prevention within cardiac catheterization units.

Objectif du program: Il existe différents modèles pour guider la mise en œuvre efficace d'outils électroniques dans la pratique clinique. L'initiative Contrast RISK (Contrast Reducing Injury Sustained by Kidneys) a permis d'introduire un outil électronique d'aide à la décision avec surveillance par le médecin et rétroaction dans tous les établissements de l'Alberta (Canada) pratiquant le cathétérisme cardiaque, dans le but de prévenir les insuffisances rénales aiguës associées aux produits de contraste (IRA-PC) après une coronarographie et une intervention. Le présent rapport décrit les approches de gestion du changement utilisées dans le cadre de l'initiative, ainsi que les commentaires des utilisateurs sur ces processus. Sources de l'information et méthodologie: Le modèle de gestion du changement d'Inforoute Santé du Canada a été employé pour aborder six activités pertinentes pour la mise en œuvre de projets: gouvernance et leadership, engagement des intervenants, communications, analyze du flux de travail et intégration, formation et éducation, surveillance et évaluation. Les prestataires de soins et les cardiologues spécialisés en interventions invasives de tous les sites ont répondu à un sondage avant, pendant et après la mise en œuvre afin d'évaluer le succès de l'intégration et du changement. Principaux résultats: Avant la mise en œuvre, 67% des prestataires de soins étaient insatisfaits des processus pour déterminer les volumes appropriés des produits de contraste, 47% étaient insatisfaits des processus pour administrer l'hydratation intraveineuse et 68% étaient insatisfaits des processus de surveillance des patients présentant un risque élevé. Près de la moitié (48%) des cardiologues spécialisés en interventions invasives étaient insatisfaits du processus d'identification préalable des patients présentant un risque élevé d'IRA. Après la mise en œuvre, on a observé une augmentation significative de la satisfaction des prestataires de soins à l'égard des processus pour identifier les patients présentant un risque élevé d'IRA (rapport de cote [RC]: 3,01; IC 95%: 1,36-6,66; P = .007), quantifier le niveau approprié de produit de contraste pour chaque patient (RC: 6,98; IC 95%: 3,06-15,91; P < .001), déterminer le volume optimal d'hydratation IV pour chaque patient (RC: 1,86, IC 95%: 0,88-3,91; P = .102) et surveiller la fonction rénale chez les patients présentant un risque élevé (RC: 5,49 IC 95%: 2,45-12,30; P < .001). On a également observé une augmentation significative de la satisfaction des médecins à l'égard des processus pour identifier les patients présentant un risque élevé d'IRA (RC: 19,53; IC 95%: 3,21-118,76; P = .001), quantifier le niveau approprié de produit de contraste pour chaque patient (RC: 26,35; IC 95%: 4,28-162,27; P < .001) et surveiller la fonction rénale des patients présentant un risque élevé (RC: 7,72; IC 95%: 1,62-36,84,30; P = .010). Une grande majorité du personnel (89%) était d'avis que l'initiative avait permis de changer les pratiques cliniques visant à réduire le risque d'IRA-PC. L'ensemble des médecins s'entendait pour dire que le système était bien intégré dans les flux de travail existants; 42% des prestataires de soins étaient également de cet avis. Conclusion: Le modèle de gestion du changement d'Inforoute Santé du Canada s'est avéré un cadre efficace pour guider la mise en œuvre d'un outil électronique d'aide à la décision et d'une intervention de surveillance et de rétroaction visant à améliorer les processus de prévention de l'IRA dans les unités de cathétérisme cardiaque.

Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program.

BACKGROUND: Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS: By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION: In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.

Development and Evaluation of an Audit and Feedback Process for Prevention of Acute Kidney Injury During Coronary Angiography and Intervention.

Background: Contrast-associated acute kidney injury (CA-AKI) is a potentially preventable complication of coronary angiography and intervention. Relatively little research has been done to determine how knowledge on CA-AKI prevention can be translated into clinical practice. Methods: We developed, implemented, and surveyed end-users about the usability, acceptability, and utility of an audit and feedback process for CA-AKI prevention in Alberta, Canada. The audit and feedback reported on amount of radiocontrast dye used, hemodynamic optimization of intravenous fluids, and CA-AKI incidence for each cardiologist practicing coronary angiography or percutaneous coronary intervention, compared with peers at their site and across the province. Reports were developed through an iterative process involving interventional cardiologists throughout the design process and usability testing. Results: Cardiologists participating in usability testing indicated a preference for the visual displays of data and summarizing indicators on the front page, and endorsed the value of peer-to-peer comparisons of performance measures. Of 31 eligible cardiologists from across Alberta, 17 responded to a survey evaluating the audit and feedback process. Fifteen respondents (88.2%) agreed that the data presented in the audit and feedback report were understandable; 17 respondents (100%) agreed or strongly agreed that the presentation of the report helped them better understand their performance compared with that of their peers; and 14 (82.4%) agreed that the audit and feedback process helped them identify ways to reduce the risk of AKI for their patients. Conclusions: Conducting an audit and providing feedback was an understandable and acceptable intervention to help cardiologists identify ways to improve prevention of CA-AKI during coronary angiography or intervention.

Contexte: L'insuffisance rénale aiguë provoquée par un produit de contraste (IRA-PC) est une complication possiblement évitable de la coronarographie et de l'intervention coronarienne. Relativement peu de travaux de recherche ont été menés pour déterminer comment les connaissances sur la prévention de l'IRA-PC peuvent se traduire dans la pratique clinique. Méthodologie: Nous avons élaboré et réalisé un sondage auprès d'utilisateurs finaux sur l'utilisabilité, l'acceptabilité et l'utilité d'un processus de vérification et de rétroaction pour la prévention de l'IRA-PC en Alberta, au Canada. Ce processus visait à rendre compte des données sur la quantité de substances de contraste utilisées, de l'optimisation hémodynamique des liquides intraveineux et de la fréquence de l'IRA-PC pour chaque cardiologue pratiquant des coronarographies ou des interventions coronariennes percutanées, comparativement à leurs confères du même centre et à ceux d'ailleurs dans la province. Les rapports ont été élaborés à l'aide d'un processus itératif auquel ont participé des cardiologues interventionnels tout au long du processus de conception et des tests d'utilisabilité. Résultats: Les cardiologues participant aux tests d'utilisabilité ont indiqué une préférence pour les affichages visuels des données et des indicateurs récapitulatifs sur la première page, et approuvé la valeur des comparaisons des mesures de rendement entre pairs. Sur les 31 cardiologues admissibles de partout en Alberta, 17 ont répondu au sondage évaluant le processus de vérification et de rétroaction. Quinze répondants (88,2 %) ont convenu que les données présentées dans le rapport de vérification et de rétroaction étaient compréhensibles; 17 répondants (100 %) étaient d'accord ou fortement d'accord que la présentation du rapport les avait aidés à mieux comprendre leur rendement comparativement à celui de leurs pairs; et 14 (82,4 %) ont convenu que le processus de vérification et de rétroaction les avait aidés à trouver des façons de réduire le risque d'IRA chez leurs patients. Conclusions: Procéder à une vérification et fournir une rétroaction s'est avérée une intervention compréhensible et acceptable pour aider les cardiologues à trouver des façons d'améliorer la prévention de l'IRA-PC pendant une coronarographie ou une intervention coronaire.

Patient Experience After Risk Stratification and Follow-up for Acute Kidney Injury After Cardiac Catheterization: Patient Survey.

BACKGROUND: Acute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization. METHODS: We implemented an initiative across 3 cardiac catheterization units in Alberta, Canada to provide standardized assessment, followed by guidance for patients at risk of AKI. This was accompanied by communication to primary care providers to improve continuity of care when patients transition from the hospital to the community. A structured survey from a sample of 100 participants at increased risk of AKI determined their perceptions of information provided and experiences with follow-up steps after the initiative was implemented in each cardiac catheterization unit in Alberta. RESULTS: The mean age of participants was 72.4 (SD 10.4) years, 37% were female, and the mean risk of AKI was 8.8%. Most (63%) participants were able to recall the information provided to them about their risk of kidney injury, 68% recalled the education provided on strategies to reduce risk, and 65% believed their primary care practitioner had received enough information to conduct appropriate follow-up care. Eighty-six percent of patients were satisfied with their transition to the community, and 53% were reassured by the information and follow-up care they received. CONCLUSIONS: These findings suggest that communicating risk information to patients, in combination with education and collaboration for follow-up with primary care providers, is associated with positive patient experiences and satisfaction with care.

CONTEXTE: L'insuffisance rénale aiguë (IRA) après un cathétérisme cardiaque est associée à de mauvais résultats en matière de santé. Nous avons voulu décrire l'expérience des patients après qu'on leur ait transmis de l'information standardisée concernant le risque d'IRA et des directives pour les soins de suivi après un cathétérisme cardiaque. MÉTHODOLOGIE: Nous avons mis en place une initiative dans trois unités de cathétérisme cardiaque en Alberta, au Canada, afin de permettre une évaluation standardisée, puis d'offrir des directives concernant les patients à risque d'IRA. Notre initiative comprenait également des communications aux fournisseurs de soins primaires en vue d'améliorer la continuité des soins prodigués aux patients quittant l'hôpital pour retourner en milieu communautaire. Un sondage structuré mené auprès de 100 participants présentant un risque accru d'IRA a permis de connaître leurs perceptions quant à l'information reçue et à leur expérience à l'égard du suivi après la mise en place de l'initiative dans chacune des unités de cathétérisme cardiaque en Alberta. RÉSULTATS: L'âge moyen des participants était de 72,4 ans (écart type : 10,4), 37 % étaient des femmes, et le risque moyen d'IRA était de 8,8 %. La plupart des participants (63 %) étaient en mesure de se souvenir de l'information qui leur avait été transmise au sujet de leur risque d'insuffisance rénale, 68 % se rappelaient la formation reçue concernant les stratégies pour réduire leur risque, et 65 % estimaient que leur médecin de soins primaires avait recueilli suffisamment d'information pour effectuer un suivi adéquat. Quatre-vingt-six pour cent (86 %) des patients étaient satisfaits de leur transition en milieu communautaire, et 53 % étaient rassurés par l'information reçue et le suivi dont ils faisaient l'objet. CONCLUSIONS: Ces résultats suggèrent que le fait de transmettre aux patients de l'information au sujet des risques, en plus de les éduquer et de leur permettre de collaborer avec leur fournisseur de soins primaires pour le suivi est associé à une expérience positive pour le patient et à la satisfaction à l'égard des soins reçus.

Percutaneous Left Ventricular Assist Device in Cardiogenic Shock: A Five-Year Single Canadian Center Initial Experience.

BACKGROUND: Mechanical circulatory support in cardiogenic shock (CS) with percutaneous left ventricular assist devices (PVADs) has expanded rapidly, but there is a paucity of Canadian data. Conflicting observational reports have emerged regarding the benefit of PVADs in CS. We describe a 5-year experience with Impella CP for CS at a single Canadian tertiary care centre. METHODS: Consecutive adult patients with CS supported with Impella CP were included. Comprehensive clinical data and outcomes were retrospectively assessed. We evaluated patient characteristics, patterns of care, in-hospital outcomes, 6-month survival, and predictors of survival. RESULTS: Thirty-four patients were supported with Impella CP for CS over 5 years. A majority had acute myocardial infarction (94%) with advanced CS (68% Society for Cardiovascular Angiography and Intervention [SCAI] stage D or E). Survival to discharge was 58%. In patients who survived to discharge, 6-month survival was 100% with excellent functional status. SCAI CS stage and initial serum lactate showed significant associations with survival. There was also a trend towards improved survival with shorter door-to-PVAD time. Clinically significant bleeding was common (26%), and 3 patients had device-related vascular complications. CONCLUSION: Impella CP may have a role in carefully selected patients with CS. The SCAI shock classification and serum lactate may facilitate patient selection, and minimizing door-to-support time as well as bleeding complications are important considerations. Further clinical investigations, particularly in a Canadian setting, will be necessary to establish the role of this new technology in CS.

CONTEXTE: L'assistance circulatoire mécanique en cas de choc cardiogénique (CC) avec des dispositifs d'assistance ventriculaire gauche percutanée s'est rapidement développée, mais les données canadiennes restent rares. Des rapports d'observation contradictoires ont émergé concernant les avantages des dispositifs d'assistance ventriculaire gauche percutanée en cas de CC. Nous décrivons une expérience de cinq ans avec l'Impella CP pour les CC dans un seul centre de soins tertiaires canadien. MÉTHODES: Des patients adultes assistés par l'Impella CP, consécutivement à un CC, ont été inclus. Les données et les conclusions cliniques détaillées ont été évaluées rétrospectivement. Nous avons évalué les caractéristiques des patients, les modèles de soins, les bilans en milieu hospitalier, la survie à six mois et les indicateurs de survie. RÉSULTATS: Trente-quatre patients ont été pris en charge avec l'Impella CP pour un CC sur une période de cinq ans. Une majorité d'entre eux ont subi un infarctus aigu du myocarde (94 %) avec un CC avancé (68 % au stade D ou E sur l'échelle de la Society for Cardiovascular Angiography and Intervention [SCAI]). La survie jusqu'au congé hospitalier était de 58 %. Chez les patients qui ont survécu jusqu'à leur congé de l'hôpital, la survie à six mois était de 100 % avec un excellent état fonctionnel. Le stade de leur CC selon la SCAI et le lactate sérique initial ont montré des associations significatives avec le taux de survie. On a également constaté une tendance à l'amélioration de la survie avec un temps de porte à dispositifs d'assistance ventriculaire gauche percutanée raccourci. Des hémorragies importantes étaient fréquentes (26 %) et trois patients présentaient des complications vasculaires liées au dispositif. CONCLUSION: L'Impella CP pourrait avoir un rôle chez des patients atteints de CC soigneusement sélectionnés. La classification du choc selon la SCAI et le niveau de lactate sérique peuvent faciliter la sélection des patients, et la réduction du temps de « porte à assistance ¼ ainsi que les complications hémorragiques constituent des considérations d'importance. D'autres investigations cliniques, en particulier dans un contexte canadien, seront nécessaires pour établir le rôle de cette nouvelle technologie dans le CC.

Prognosis and Natural History of Conduction System Disease in Patients Undergoing Coronary Angiography.

BACKGROUND: Infranodal conduction abnormalities, including right or left bundle branch block bifascicular block, and nonspecific intraventricular conduction block are common electrocardiogram (ECG) abnormalities with uncertain persistence and prognostic significance. We evaluated their trajectory and prognostic significance in patients undergoing coronary angiography. METHODS: We linked an institutional ECG repository with the provincial coronary angiography registry and administrative databases. We included patients without severe left ventricular dysfunction who had an ECG within 180 days of angiography. Multivariable Cox models were used to assess associations between conduction abnormalities and a composite outcome, including all-cause mortality, heart failure hospitalizations, placement of a permanent pacemaker, and placement of an implantable cardiac defibrillator or cardiac resynchronization therapy defibrillator. Serial ECGs were used to model conduction disease as a time-dependent repeated measure. RESULTS: We included 10,786 patients (mean age, 62.3 ± 12.4 years; 70.3% were male), of whom 2530 (23.4%) had baseline conduction abnormality. During a median follow-up of 3.5 years, conduction normalized in 885 patients (34.9%) and the composite outcome occurred in 1541 patients (14.3%). After multivariable adjustment, intraventricular conduction block (adjusted hazard ratio, 1.42; P = 0.001) and bifascicular block (adjusted hazard ratio, 1.59; P = 0.003) were associated with increased risk of the composite outcome. Left bundle branch block was not associated with the composite outcome. CONCLUSIONS: Regression of conduction abnormalities was frequent among patients undergoing coronary angiography, primarily for suspected acute coronary syndrome. After adjustment for important confounders including extent of coronary artery disease, infranodal conduction abnormalities were associated with a modest increase in cardiovascular risk.

Predictive value of repeated versus single N-terminal pro B-type natriuretic peptide measurements early after-myocardial infarction.

BACKGROUND: A single, markedly elevated B-type natriuretic peptide (BNP) serum concentration predicts an increased risk of death after myocardial infarction (MI), though its sensitivity and predictive accuracy are low. We compared the predictive value of a modestly and persistently elevated, versus a single, markedly elevated measurement of N terminal pro-BNP (NT-BNP) early after MI. METHODS AND RESULTS: NT-BNP was measured 2-4, 6-10, and 14-18 weeks after MI. The median age of the 100 patients was 61 years, median left ventricular ejection fraction (LVEF) was 0.40, and 88% were males. Over a median follow-up of 39 months, 10 patients died. The initial median NT-BNP was 802 pg/mL and declined over time (P = 0.002). An initial NT-BNP > or =2,300 pg/mL (upper quintile) was observed in 19 patients and predicted a 3.4-fold higher independent risk of death (P = 0.05), with modest sensitivity (30%) and positive predictive accuracy (16%). A NT-BNP consistently > or =1,200 pg/mL (upper tertile) was observed in 19 patients, and was associated with a 5.7-fold higher independent risk of death (P = 0.01), with a higher sensitivity (50%) and positive predictive accuracy (26%) than a single, markedly elevated NT-BNP measurement. CONCLUSIONS: A moderately and persistently elevated NT-BNP in the early post-MI period was associated with a 5.7-fold higher risk of death, independent of age, LVEF, and functional class. Compared with a single measurement, serial NT-BNP measurements early after MI were more accurate predictors of risk of death.

Clinical Decision Support to Reduce Contrast-Induced Kidney Injury During Cardiac Catheterization: Design of a Randomized Stepped-Wedge Trial.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes of care and clinical outcomes. METHODS: The Contrast-Reducing Injury Sustained by Kidneys (Contrast RISK) study will implement an evidence-based multifaceted intervention designed to reduce the incidence of CI-AKI, encompassing automated identification of patients at increased risk for CI-AKI, point-of-care information on safe contrast volume targets, personalized recommendations for hemodynamic optimization of intravenous fluids, and follow-up information for patients at risk. Implementation will use cardiologist academic detailing, computerized clinical decision support, and audit and feedback. All 31 physicians practicing in all 3 of Alberta's cardiac catheterization laboratories will participate using a cluster-randomized stepped-wedge design. The order in which they are introduced to this intervention will be randomized within 8 clusters. The primary outcome is CI-AKI incidence, with secondary outcomes of CI-AKI avoidance strategies and downstream adverse major kidney and cardiovascular events. An economic evaluation will accompany the main trial. CONCLUSIONS: The Contrast RISK study leverages information technology systems to identify patient risk combined with evidence-based protocols, audit, and feedback to reduce CI-AKI in cardiac catheterization laboratories across Alberta. If effective, this intervention can be broadly scaled and sustained to improve the safety of cardiac catheterization.

Comparative Performance of Prediction Models for Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention.

BACKGROUND: Identifying patients at increased risk of contrast-associated acute kidney injury (CA-AKI) can help target risk mitigation strategies toward these individuals during percutaneous coronary intervention. Illuminating which risk models best stratify risk is an important foundation for such quality improvement efforts. METHODS AND RESULTS: Seven previously published risk prediction models for CA-AKI and 3 models for kidney injury requiring dialysis were validated using 2 definitions for CA-AKI (the Kidney Disease: Improving Global Outcomes definition of ≥0.3 mg/dL within 48 hours or ≥50% increase in serum creatinine from baseline within 7 days and the historical definition of ≥0.5 mg/dL or ≥25% increase in serum creatinine from baseline within 48 hours), and AKI requiring dialysis within 30 days of percutaneous coronary intervention. Model performance was compared based on discrimination, calibration, and categorical net reclassification index before and after model recalibration. Among 7888 patients who underwent percutaneous coronary intervention in Alberta Canada, CA-AKI occurred in 330 patients (4.2%) when CA-AKI was defined using the Kidney Disease: Improving Global Outcomes definition and 571 (7.3%) when using the historical definition. CA-AKI requiring dialysis occurred in 42 (0.6%) patients. When validated using the Kidney Disease: Improving Global Outcomes definition for CA-AKI, the 2 most recently published models for CA-AKI showed better discrimination (C statistics, 0.75-0.76) than older models (C statistics, 0.61-0.68). C statistics of models for kidney injury requiring dialysis ranged from 0.70 to 0.86. The calibration of all models for CA-AKI deviated from ideal, and the proportion of patients classified into different risk categories for CA-AKI differed substantially for the 2 most recent models. Recalibration significantly improved risk stratification of patients into clinical risk categories for some models. CONCLUSIONS: Recent prediction models for CA-AKI show better discrimination compared with older models; however, model recalibration should be examined in external cohorts to improve the accuracy of predictions, particularly if predicted risk strata are used to guide management approaches.

Kidney Function, ACE-Inhibitor/Angiotensin Receptor Blocker Use, and Survival Following Hospitalization for Heart Failure: A Cohort Study.

BACKGROUND: Angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACE-I/ARB) improve outcomes in patients with heart failure and reduced left-ventricular (LV) systolic function. However, these medications can cause a rise in serum creatinine and their benefits in patients with HF accompanied by kidney disease are less certain. OBJECTIVE: To characterize associations between estimated glomerular filtration rate (eGFR), patterns of ACE-Is and ARBs use, and 1-year survival following hospitalization for heart failure (HF). DESIGN: We formed a retrospective cohort study of patients admitted with HF and followed HF medication prescriptions using the pharmaceutical information network, stratified by discharge eGFR. SETTING: Cardiology services in 3 centers in Southern Alberta, Canada. PATIENTS: The study cohort included patients admitted to hospital with a clinical diagnosis of HF. MEASUREMENTS: eGFR was determined from inpatient laboratory data prior to discharge. Outpatient prescription data prior to and following the index hospitalization was obtained using the Pharmaceutical Information Network of Alberta and survival was determined from provincial vital statistics. METHODS: Characteristics of the HF cohort were obtained from the Admissions Module of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Multivariable Cox proportional hazards models were used to evaluate the association between time-varying ACE-I/ARB use, and mortality, and to test whether eGFR modified this association. RESULTS: Totally, 1404 patients were included. Within the first 3 months following discharge, ACE-I/ARBs were used in 71%, 67%, 62%, and 52% for those with eGFR > 90, 45-89, 30-44, and < 30 mL/min/1.73 m2, respectively, with differences in use persisting after 1 year of follow-up. Patients with eGFR < 45 mL/min/1.73 m2 had significantly lower rates of ACE-I/ARB use following hospitalization. In adjusted models, ACE-I/ARB use following discharge was associated with 25% lower risk of mortality (Hazard Ratio [HR]: 0.75, 95% confidence interval [CI]: 0.61-0.92; P < 0.01), without evidence that this association differed by eGFR (P = 0.75). LIMITATIONS: LV function measurements were not available for the cohort. Due to the observation design of the study, treatment-selection bias may be present. CONCLUSION: Patients with HF and reduced eGFR at time of hospital discharge were less likely to receive ACE-I/ARB despite these medications being associated with lower mortality independent of eGFR. These findings demonstrate the need for further research on strategies for safe use of ACE-I and ARB in patients with HF and kidney disease.

CONTEXTE: Les inhibiteurs de l'enzyme de conversion de l'angiotensine (IECA) et les antagonistes des récepteurs de l'angiotensine (ARA) améliorent les résultats des patients atteints d'insuffisance cardiaque (IC) et d'une fonction systolique réduite du ventricule gauche. Ces médicaments peuvent cependant provoquer une hausse de la créatinine sérique et leurs bienfaits pour les patients atteints d'IC et de néphropathie sont plus incertains. OBJECTIF: L'étude visait à caractériser l'association entre le débit de filtration glomérulaire estimé (DFGe), les schémas d'utilisation des IECA/ARA, et la survie sur un an à la suite d'une hospitalisation pour IC. CONCEPTION DE L'ÉTUDE: Nous avons procédé à une étude de cohorte rétrospective à partir des données du réseau d'information pharmaceutique. La cohorte était constituée de patients admis pour IC et ayant suivi un traitement pour cette affection. La cohorte a été stratifiée sur la base du DFGe des patients à leur sortie de l'hôpital. CADRE: Le département de cardiologie de trois centres hospitaliers du sud de l'Alberta (Canada). SUJETS: La cohorte était constituée de patients admis à la suite d'un diagnostic d'IC. MESURES: Le DFGe a été déterminé en consultant les résultats de laboratoire des patients hospitalisés avant leur départ. L'information sur les prescriptions avant et après l'hospitalisation a été obtenue grâce au réseau d'information pharmaceutique de l'Alberta, et le taux de survie a été déterminé à l'aide des statistiques de vie de la province. MÉTHODOLOGIE: Les caractéristiques des patients ont été obtenues grâce au module d'admission de la base de données APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease). Des modèles multivariés des risques proportionnels de Cox ont été employés pour évaluer l'association entre l'utilisation variable des IECA/ARA dans le temps et le taux de mortalité; de même que pour vérifier si le DFGe avait une incidence sur cette association. RÉSULTATS: Au total, 1404 patients ont été inclus à l'étude. Dans les trois mois suivant l'hospitalisation, les taux de prescriptions des IECA/ARA variaient entre les différentes strates de DFGe de la cohorte et s'établissaient à 71% (DFGe > 90 mL/min/1.73 m2), 67% (DFGe entre 45 et 89 mL/min/1.73 m2), 62% (DFGe entre 30 et 44 mL/min/1.73 m2), et 52% (DFGe < 30 mL/min/1.73 m2); et ces différences ont persisté après un an de suivi. Les patients dont le DFGe était inférieur à 45 mL/min/1.73 m2 présentaient des taux d'utilisation des IECA/ARA significativement inférieurs après leur séjour à l'hôpital. Dans les modèles ajustés, l'utilisation des IECA/ARA à la sortie de l'hôpital a été associée à un risque inférieur de 25% de la mortalité (RR: 0.75; IC 95%: 0.61-0.92; P < .01), sans preuve que cette association diffère selon le DFGe (P = .75). LIMITES: Les mesures de la fonction ventriculaire gauche n'étaient pas disponibles pour la cohorte. De plus, en raison de sa nature observationnelle, l'étude pourrait comporter des biais relatifs au choix du traitement. CONCLUSION: Les patients atteints d'IC et dont le DFGe était faible au moment du congé étaient moins susceptibles de se voir prescrire des IECA/ARA, bien que ces médicaments soient associés à de plus faibles taux de mortalité indépendamment de la valeur du DFGe. Ces résultats démontrent la nécessité de poursuivre la recherche de stratégies permettant une utilisation sûre des IECA/ARA chez les patients atteints de néphropathie et d'insuffisance cardiaque.