RESUMEN
BACKGROUND: A multidisciplinary heart team (HT) approach to patients with complex coronary artery disease has a class IB recommendation, yet there are limited data on adherence to HT treatment recommendations and long-term clinical follow-up. The objective of this study was to assess adherence rates to HT recommendations and assess long-term mortality rates among patients with complex CAD. METHODS AND RESULTS: Six hundred eighty-four sequential HT cases for complex coronary artery disease from January 2015 to May 2017 were reviewed. After excluding cases with significant comorbid valve disease, baseline characteristics were compared based on HT treatment recommendations: optimal medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. Adherence rates were manually extracted, and 5-year mortality rates were obtained from the Michigan Death Registry. Seventy-two percent of 405 included patients were men (mean age 66±11 years), with high rates of medical comorbidities. Estimated surgical risk scores were lowest in the coronary artery bypass grafting group. Optimal medical therapy was recommended in 138 patients (34%), percutaneous coronary intervention in 95 (23%), and coronary artery bypass grafting in 172 (42%). Adherence to HT recommendations across groups was high (96%) and did not differ between treatment groups. Over 5 years of follow-up, there were 119 deaths, resulting in a cumulative mortality rate of 29%. CONCLUSIONS: In the largest HT cohort in the United States to date, high rates of adherence to HT recommendations were observed among high-risk patients with coronary artery disease. High rates of adherence to HT recommendations were observed irrespective of treatment group recommendation, suggesting that HT recommendations were individualized and acceptable to both patients and physicians alike.
Asunto(s)
Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Grupo de Atención al Paciente , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Anciano , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/terapia , Persona de Mediana Edad , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/estadística & datos numéricos , Factores de Tiempo , Estudios Retrospectivos , Sistema de Registros , Michigan/epidemiología , Adhesión a Directriz , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Atrial fibrillation (AF) increases stroke and mortality in patients with hypertrophic cardiomyopathy (HCM). Cardiac MRI (CMR) is increasingly used to detect late gadolinium enhancement (LGE) as a reliable indicator of left ventricular fibrosis, a potential predisposing factor of AF. Our research explored the correlation between left ventricular LGE and AF prevalence in HCM. METHODS: This retrospective study involved 351 HCM patients who underwent CMR. LGE percentages (0%, 1-5%, 6-14%, ≥15%) on CMR were compared with AF prevalence in HCM patients. Demographic, comorbidity, and imaging data were analyzed using appropriate univariate and multivariate analyses assessing for significant differences in AF prevalence. The predetermined significance level was p < 0.05. RESULTS: CMR demonstrated increased LGE in those with AF (p = 0.004). Increased LGE correlated with increased AF rates: 27.6% (0% LGE), 38.5% (1-5% LGE), 44.4% (6-14% LGE), and 54.7% (≥15% LGE) (p = 0.101, p = 0.043, p = 0.002, respectively, vs. 0% LGE). Adjusted for age, differences persisted and were most evident for LGE >15% (p = 0.001). Multivariate analysis, factoring age, gender, BMI, RVSP, and LVEF, supported LGE (odds ratio of 1.20, p = 0.036) and LAVI (odds ratio 1.05, 1.02-1.07, p < 0.001) as predictive markers for AF prevalence. CONCLUSIONS: Our study suggests a correlation between ventricular LGE and AF in patients with HCM. LGE exceeding 15% was associated with a significant increase in AF prevalence. These patients may require more frequent AF monitoring.
Asunto(s)
Fibrilación Atrial , Cardiomiopatía Hipertrófica , Medios de Contraste , Gadolinio , Imagen por Resonancia Cinemagnética , Valor Predictivo de las Pruebas , Humanos , Fibrilación Atrial/diagnóstico por imagen , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Cardiomiopatía Hipertrófica/complicaciones , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Imagen por Resonancia Cinemagnética/métodos , Adulto , Anciano , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Ventrículos Cardíacos/patologíaRESUMEN
BACKGROUND: General practice is well situated to promote physical activity (PA) among middle-aged and older adults, but often those who are most likely to benefit from interventions tend to be the least likely recruited to participate in research. This study aimed to systematically review the published literature pertaining to PA interventions in general practice settings, in order to investigate approaches to recruitment and study populations profiles. METHODS: Seven databases were searched, including: PubMed, CINAHL, the Cochrane Library Register of Controlled Trials, Embase, Scopus, PsycINFO and Web of Science. Only randomised control trials RCTs involving adults 45 years old or older recruited through primary care, were included. The PRIMSA framework for systematic review was followed, which involved two researchers independently conducting title, abstract and full article screening. Tools for data extraction and synthesis were adapted from previous work on inclusivity in recruitment. RESULTS: The searches retrieved 3491 studies, of which 12 were included for review. Sample size of the studies ranged from 31 to 1366 and a total of 6085 participants were included. Studies recorded characteristics of harder to reach populations. Participants tended to be urban based, white females with at least one pre-existing condition. Reporting of studies demonstrated a lack of ethnic minorities and lower numbers of males. Only one practice out of 139 was rural. Recruitment quality and efficiency was inconsistently reported. CONCLUSION: Certain participants, including rural-based populations, are under-represented. RCT study design, recruitment and reporting must be improved to increase study sample representativeness so that those most in need of PA interventions are targeted and successfully recruited.
Asunto(s)
Ejercicio Físico , Medicina General , Masculino , Femenino , Persona de Mediana Edad , Humanos , Anciano , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: General practice is well situated to promote physical activity (PA), but with PA levels declining after 45 years of age, often those who are most likely to benefit from interventions tend to be the least likely recruited to participate in research. AIMS AND RATIONALE: The aim of this study was to investigate recruitment and reporting of participant demographics in PA trials for adults aged 45 years and above. Specific objectives were: (i) to examine the reporting of demographics of participants; (ii) to investigate the strategies used to recruit these participants; and, (iii) to examine the efficiency of recruitment strategies. METHODS: Seven databases were searched, including: PubMed, CINAHL, the Cochrane Library Register of Controlled Trials, Embase, Scopus, PsycINFO, and Web of Science. Only randomized control trials involving adults 45 years old or older recruited through primary care were included. The PRISMA framework for systematic review was followed, which involved 2 researchers independently conducting title, abstract, and full article screening. Tools for data extraction and synthesis were adapted from previous work on inclusivity in recruitment. RESULTS: The searches retrieved 3,491 studies of which 12 were included for review. Sample size of the studies ranged from 31 to 1,366, with a total of 6,042 participants of which 57% were female. Of 101 participating practices, 1 was reported as rural. Reporting of recruitment lacked detail-only 6 studies outlined how practices were recruited. 11/12 studies involved a database or chart review to identify participants that met the inclusion criteria, followed by a letter of invitation sent to those people. The studies with higher recruitment efficiency ratios each employed more than 1 recruitment strategy, e.g. opportunistic invitations and telephone calls. CONCLUSION: This systematic review has presented deficits in the reporting of both demographics and recruitment. Future research should aim for a standardized approach to reporting.
Asunto(s)
Ejercicio Físico , Medicina General , Humanos , Adulto , Femenino , Persona de Mediana Edad , MasculinoRESUMEN
[Figure: see text].
Asunto(s)
Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/metabolismo , Metabolismo de los Lípidos , Intervención Coronaria Percutánea/instrumentación , Placa Aterosclerótica , Espectroscopía Infrarroja Corta , Stents , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/metabolismo , Enfermedad de la Arteria Coronaria/mortalidad , Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Insuficiencia del Tratamiento , Ultrasonografía IntervencionalRESUMEN
Background: Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts. Objective: To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments. Design: Prospective cohort study. (ClinicalTrials.gov: NCT01755052). Setting: 94 hospitals throughout the United States. Participants: 3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive. Measurements: Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality. Results: Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment. Limitation: The model was not externally validated. Conclusion: A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge. Primary Funding Source: National Heart, Lung, and Blood Institute of the National Institutes of Health.
Asunto(s)
Infarto del Miocardio/mortalidad , Actividades Cotidianas , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Infarto del Miocardio/diagnóstico , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
Cardiac amyloidosis is an elusive condition that is notorious for mimicking various cardiovascular conditions that present with left ventricular hypertrophy (LVH). The hypertrophy in amyloidosis is typically diffuse; however, rare reports of echocardiographic resemblances with hypertrophic cardiomyopathy (HCM) exist, such as asymmetric septal hypertrophy and left ventricular outflow tract obstruction. Cardiac MRI can help differentiate amyloidosis from hypertrophic cardiomyopathy in unclear situations. This differentiation from HCM and other forms of cardiomyopathy has important treatment implications. Here we present the case of a 76-year-old man with cardiomyopathy who had echocardiographic features of asymmetric hypertrophic cardiomyopathy but was correctly diagnosed with amyloidosis with the help of cardiac MRI and ECG.
RESUMEN
Hypertrophic cardiomyopathy (HCM) is characterized by increased left ventricular wall thickness in the absence of any other identifiable cause of thickness. It predisposes the patient to increased risk of sudden cardiac death (SCD) due to fatal arrhythmias. Approximately 2% of the HCM patients have left ventricular apical aneurysm. CMR imaging is better in identifying this apical aneurysm as compared to echocardiogram. This apical aneurysm, which can be akinetic or dyskinetic, increases the risk of disease-related adverse events as compared to general HCM. These adverse disease-related events include SCD, thromboembolism, and symptoms of heart failure. We report a rare case of hypertrophic cardiomyopathy in association with Williams-Beuren Syndrome. On CMR imaging, patient was found to have a large apical aneurysm and mid-ventricular obstruction with underlying thrombus. He was started on oral anticoagulation, and ICD was recommended.
RESUMEN
AIMS: The present study explores the feasibility of telestenting, wherein a physician operator performs stenting on a patient in a separate physical location using a combination of robotics and telecommunications. METHODS AND RESULTS: Patients undergoing robotic stenting were eligible for inclusion. All manipulations of guidewires, balloons, and stents were performed robotically by a physician operator located in an isolated separate room outside the procedure room housing the patient. Communication between the operating physician and laboratory personnel was via telecommunication devices providing real-time audio and video connectivity. Among 20 patients who consented to participate, technical success, defined as successful advancement and retraction of guidewires, balloons, and stents by the robotic system without conversion to manual operation, was achieved in 19 of 22 lesions (86.4%). Procedural success, defined as <30% residual stenosis upon completion of the procedure in the absence of death or repeat revascularisation prior to hospital discharge, was achieved in 19 of 20 patients (95.0%). There were no deaths or repeat revascularisations prior to hospital discharge. CONCLUSIONS: To the best of our knowledge, the present study is the first to explore the feasibility of telestenting. Additional studies are required to determine if future advancements in robotics will facilitate telestenting over greater geographic distances.
Asunto(s)
Angioplastia Coronaria con Balón , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea , Robótica , Telecomunicaciones , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/instrumentación , Angiografía Coronaria/métodos , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: In a previous exploratory analysis, intracoronary near-infrared spectroscopy (NIRS) found the majority of culprit lesions in ST-segment-elevation myocardial infarction (STEMI) to contain a maximum lipid core burden index in 4 mm (maxLCBI4mm) of >400. This initial study was limited by a small sample size, enrollment at a single center, and post hoc selection of the maxLCBI4mm ≥400 threshold. This study was designed a priori to substantiate the ability of NIRS to discriminate STEMI culprit from nonculprit segments and to confirm the performance of the maxLCBI4mm ≥400 threshold. APPROACH AND RESULTS: At 2 centers in the United States and Sweden, 75 STEMI patients underwent intracoronary NIRS imaging after establishing thrombolysis in myocardial infarction 3 flow, but before stenting. Blinded core laboratory analysis defined the culprit segment as the 10-mm segment distal to the proximal angiographic culprit margin. The remaining vessel was divided into contiguous 10-mm nonculprit segments. The maxLCBI4mm of culprit segments (median [interquartile range]: 543 [273-756]) was 4.4-fold greater than nonculprit segments (median [interquartile range]: 123 [0-307]; P<0.001). Receiver-operating characteristic analysis demonstrated that maxLCBI4mm differentiated culprit from nonculprit segments with high accuracy (c-statistic=0.83; P<0.001). A threshold maxLCBI4mm ≥400 identified STEMI culprit segments with a sensitivity of 64% and specificity of 85%. CONCLUSIONS: This study substantiates the ability of NIRS to accurately differentiate STEMI culprit from nonculprit segments and confirms that a threshold maxLCBI4mm ≥400 is detected by NIRS in the majority of STEMI culprits.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Lípidos/análisis , Placa Aterosclerótica , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Espectroscopía Infrarroja Corta , Anciano , Área Bajo la Curva , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/metabolismo , Enfermedad de la Arteria Coronaria/patología , Vasos Coronarios/metabolismo , Vasos Coronarios/patología , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Michigan , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Reproducibilidad de los Resultados , Infarto del Miocardio con Elevación del ST/metabolismo , Infarto del Miocardio con Elevación del ST/patología , Suecia , Ultrasonografía IntervencionalRESUMEN
AIMS: A recent study demonstrated that intracoronary near-infrared spectroscopy (NIRS) findings in non-target vessels are associated with major adverse cardiovascular and cerebrovascular events (MACCE). It is unknown whether NIRS findings at non-stented sites in target vessels are similarly associated with future MACCE. This study evaluated the association between large lipid-rich plaques (LRP) detected by NIRS at non-stented sites in a target artery and subsequent MACCE. METHODS AND RESULTS: This study evaluated 121 consecutive registry patients undergoing NIRS imaging in a target artery. After excluding stented segments, target arteries were evaluated for a large LRP, defined as a maximum lipid core burden index in 4 mm (maxLCBI4âmm) ≥400. Excluding events in stented segments, Cox regression analysis was performed to evaluate for an association between a maxLCBI4âmm ≥400 and future MACCE, defined as all-cause mortality, non-fatal acute coronary syndrome, and cerebrovascular events. NIRS detected a maxLCBI4âmm ≥400 in a non-stented segment of the target artery in 17.4% of patients. The only baseline clinical variable marginally associated with MACCE was ejection fraction (HR 0.96, 95% CI 0.93-1.00, P = 0.054). A maxLCBI4âmm ≥400 in a non-stented segment at baseline was significantly associated with MACCE during follow-up (HR 10.2, 95% CI 3.4-30.6, P < 0.001). CONCLUSION: Detection of large LRP by NIRS at non-stented sites in a target artery was associated with an increased risk of future MACCE. These findings support ongoing prospective studies to further evaluate the ability of NIRS to identify vulnerable patients.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Placa Aterosclerótica/diagnóstico por imagen , Espectroscopía Infrarroja Corta/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios ProspectivosRESUMEN
Takotsubo cardiomyopathy is generally considered to have a favorable prognosis. However, several major problems may complicate the clinical course. We present a patient with four simultaneous complications of shock, left ventricular thrombus, left ventricular outflow obstruction, and severe mitral regurgitation. Despite this dramatic presentation, the patient had a complete recovery with resolution of all four complications within weeks.
RESUMEN
Myocardial bridging is commonly observed in hypertrophic cardiomyopathy, usually confined to the left anterior descending (LAD), and correlates to the hypertrophic septum. We present a patient with unique spiral hypertrophic cardiomyopathy (HCM) and compression of all three coronary arteries corresponding to this hypertrophy pattern.
RESUMEN
Ventricular arrhythmias in young people most commonly occur due to the presence of hypertrophic cardiomyopathy, long QT syndrome or Wolff-Parkinson-White syndrome. We present a case in which the patient had exercise induced syncopal spells and was found to have ventricular tachycardia (VT) during both exercise stress testing and an electrophysiology study. Further genetic studies showed a previously unseen desmosomal gene mutation confirming the presence of Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC).
RESUMEN
Contrast-induced acute kidney injury (CI-AKI) is a common complication of percutaneous coronary intervention (PCI). Current guidelines support the use of iodixanol (Visipaque®, GE Healthcare, Princeton, New Jersey) in patients at high risk for CI-AKI. Recent trials and meta-analyses have shown no difference in CI-AKI when iodixanol is compared to low-osmolar contrast media (LOCM). We evaluated the incidence of CI-AKI, in-hospital dialysis and in-hospital death in 58,957 patients who underwent PCI in 2007 and 2008 in a large regional consortium of 31 hospitals and who were treated with iodixanol (n = 17,814) or LOCM (n = 41,143). Propensity-matched analysis was performed to adjust for differences in baseline variables. Patients treated with iodixanol compared to those treated with LOCM were slightly older, had more medical comorbidities and a higher baseline creatinine (1.35 ± 1.07 mg/dL versus 1.10 ± 0.85 mg/dL; p < 0.0001). In propensity-matched, risk-adjusted models, there was no significant difference between iodixanol and LOCM in the risk of CIAKI (4.54% vs. 4.14%; p = 0.14), need for dialysis (0.37% vs. 0.43%; p = 0.35) or death (1.46% vs. 1.39%; p = 0.18). Among patients undergoing PCI, the use of iodixanol was more frequent in older patients with more comorbidities and worse baseline renal function. There was no difference in the adjusted risk of CI-AKI among patients treated with iodixanol compared with those treated with LOCM.
Asunto(s)
Lesión Renal Aguda/inducido químicamente , Angioplastia Coronaria con Balón , Medios de Contraste , Ácidos Triyodobenzoicos , Lesión Renal Aguda/prevención & control , Medios de Contraste/efectos adversos , Femenino , Humanos , Masculino , Concentración Osmolar , Factores de Riesgo , Ácidos Triyodobenzoicos/efectos adversosRESUMEN
OBJECTIVES: This study sought to evaluate the prevalence, risk factors, outcomes, and predictors of mortality of retroperitoneal hematoma (RPH) following percutaneous coronary intervention. BACKGROUND: Retroperitoneal hematoma is a serious complication of invasive cardiovascular procedures. METHODS: The study sample included 112,340 consecutive patients undergoing percutaneous coronary intervention in a large, multicenter registry between October 2002 and December 2007. End points evaluated included the development of RPH and mortality. RESULTS: Retroperitoneal hematoma occurred in 482 (0.4%) patients. Of these, 92.3% were treated medically and 7.7% underwent surgical repair. Female sex, body surface area <1.8 m(2), emergency procedure, history of chronic obstructive pulmonary disease, cardiogenic shock, pre-procedural IV heparin, pre-procedural glycoprotein IIb/IIIa inhibitors, adoption of sheath size >or=8-F, and use of vascular closure devices were independent predictors of RPH, whereas the use of bivalirudin was associated with a lower risk. The development of RPH was associated with a higher frequency of post-procedure myocardial infarction (5.81% vs. 1.67%, p < 0.0001), infection and/or sepsis (17.43% vs. 3.00%, p < 0.0001), and heart failure (8.00% vs. 1.63%, p < 0.0001). In-hospital mortality was significantly higher in patients who developed RPH than in patients who did not (6.64% vs. 1.07%, p < 0.0001). Among patients with RPH, independent predictors of death were history of myocardial infarction, cardiogenic shock, pre-procedural creatinine >or=1.5 mg/dl, and left ventricular ejection fraction <50%. CONCLUSIONS: Retroperitoneal hematoma is an uncommon complication of contemporary percutaneous coronary intervention associated with high morbidity and mortality. The identification of risk factors for the development of RPH could lead to modification of procedure strategies aimed toward reducing its incidence.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Hematoma/mortalidad , Hematoma/terapia , Evaluación de Procesos y Resultados en Atención de Salud , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/mortalidad , Planes de Seguros y Protección Cruz Azul , Femenino , Hematoma/etiología , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Michigan , Persona de Mediana Edad , Oportunidad Relativa , Evaluación de Procesos y Resultados en Atención de Salud/estadística & datos numéricos , Prevalencia , Sistema de Registros , Espacio Retroperitoneal , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Prior studies have shown a relationship between female gender and adverse outcomes after percutaneous coronary interventions (PCIs). Whether this relationship still exists with contemporary PCI remains to be determined. METHODS: We evaluated gender differences in clinical outcomes in a large registry of contemporary PCI. Data were prospectively collected from 22,725 consecutive PCIs in a multicenter regional consortium (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) between January 2002 and December 2003. The primary end point was in-hospital all-cause mortality; other clinical outcomes evaluated included in-hospital death, vascular complications, transfusion, postprocedure myocardial infarction, stroke, and a combined major cardiovascular adverse event (MACE) end point including myocardial infarction, death, stroke, emergency coronary artery bypass grafting, and repeated PCI at the same site. Independent predictors of adverse outcomes were identified using multivariate logistic regression analysis. RESULTS: Compared with men, women were older, had a higher prevalence of comorbidities, and had a significantly higher frequency of adverse outcomes after PCI. After adjustment for baseline demographics, comorbidities, clinical presentation, and lesion characteristics, female gender was associated with an increased risk of in-hospital death, vascular complication, blood transfusion, stroke, and MACE. The relationship between female gender and increased risk of death and MACE was no longer present after further adjustment for kidney function and low body surface area. CONCLUSIONS: Differences in mortality rates between men and women no longer exist after PCI. However, our data suggest that technological advancements have not completely offset the relationship between gender and adverse outcomes after PCI.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Michigan , Persona de Mediana Edad , Sistema de Registros , Factores Sexuales , Resultado del TratamientoRESUMEN
BACKGROUND: We sought to examine the temporal variations in the rate of both bare-metal stent (BMS) and drug-eluting stent (DES) use for off-label indications after the reports of an increased risk of very late stent thrombosis in patients with DES at the 2006 meeting of the European Society of Cardiology (ESC). HYPOTHESIS: To determine whether the decrease in use of DES has affected both on and off-label indications. METHODS: The study cohort included patients undergoing coronary intervention in a large regional registry, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Patient demographic and clinical characteristics for patients with DES in the third quarter of 2006 (pre-ESC) were compared to those from the fourth quarter of 2008 (post-guideline changes). Use of DES for off-label indications, such as ST-segment elevation myocardial infarction (STEMI), in-stent restenosis (ISR), and saphenous vein graft (SVG) interventions, were evaluated. RESULTS: The overall deployment of DES fell sharply from 83% pre-ESC to a plateau of 58% in the first quarter of 2008. This corresponded to a rise in BMS use, while angioplasty procedures stayed the same. The STEMI subgroup showed the most dramatic change, from 78% to only 36%. Off-label use in SVGs showed a similar trend, from 74% to 43%. Drug-eluting stent deployment for ISR was less affected, though it also fell 25% (from 79%-56%). CONCLUSIONS: The use of DES has fallen dramatically from June 2006 to December 2008, particularly for nonapproved indications. Our study provides a real-world assessment of contemporary change in DES use in response to the presentation of negative observational studies.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Angioplastia Coronaria con Balón/tendencias , Stents Liberadores de Fármacos/tendencias , Cardiopatías/terapia , Uso Fuera de lo Indicado , Pautas de la Práctica en Medicina/tendencias , Etiquetado de Productos/tendencias , Stents/tendencias , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/estadística & datos numéricos , Stents Liberadores de Fármacos/estadística & datos numéricos , Femenino , Adhesión a Directriz , Humanos , Estudios Longitudinales , Masculino , Metales , Guías de Práctica Clínica como Asunto , Diseño de Prótesis , Sistema de Registros , Stents/estadística & datos numéricos , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVES: We evaluated the association between guiding catheter size and complications of percutaneous coronary intervention (PCI). BACKGROUND: The association between guiding catheter size and complications of PCI in contemporary practice remains controversial. METHODS: Procedure and outcome variables from 103,070 consecutive patients that underwent PCI with 6-F (n = 64,335), 7-F (n = 32,676), and 8-F (n = 6,059) guide catheters were compared. RESULTS: Compared with 6-F guides, PCIs performed with 7- and 8-F guides were associated with incrementally more contrast agent use, and more post-PCI complications including contrast-induced nephropathy, vascular access site complications, bleeding, transfusion, major adverse cardiac event, and death. After multivariate analysis, the use of larger guides were associated with a higher risk of contrast-induced nephropathy (7-F odds ratio [OR]: 1.18, p = 0.0004; 8-F OR: 1.44, p < 0.0001), vascular complications (7-F OR: 1.19, p = 0.0002, 8-F OR: 1.68, p < 0.0001), decline in hemoglobin >3 g/dl (7-F OR: 1.12, p < 0.0001, 8-F OR: 1.72, p < 0.0001), and post-procedure blood transfusion (7-F OR: 1.08, p = 0.03; 8-F OR: 1.80, p < 0.0001), whereas major adverse cardiac events (7-F OR: 1.06, p = 0.13; 8-F OR: 1.37, p < 0.0001) and in-hospital mortality (7-F OR: 1.11, p = 0.13; 8-F OR: 1.34, p = 0.03) were increased with 8-F but not 7-F guides. CONCLUSIONS: Compared with 6-F guides, PCIs performed with 7- and 8-F guides were associated with more contrast medium use, renal complications, bleeding, vascular access site complications, greater need for post-procedure transfusion, and 8-F guides with increased nephropathy requiring dialysis, in-hospital major adverse cardiac events, and mortality. These data suggest that selection of smaller guide catheters may result in improved clinical outcome in patients undergoing contemporary PCI.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/instrumentación , Anciano , Angioplastia Coronaria con Balón/mortalidad , Transfusión Sanguínea , Medios de Contraste/efectos adversos , Diseño de Equipo , Femenino , Cardiopatías/etiología , Hemorragia/etiología , Hemorragia/terapia , Mortalidad Hospitalaria , Humanos , Enfermedades Renales/inducido químicamente , Enfermedades Renales/terapia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Sistema de Registros , Diálisis Renal , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI). METHODS AND RESULTS: Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10,287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case (P<0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points (all P<0.05). CONCLUSIONS: Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a "causal" or a "casual" relationship.