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The field of interventional cardiology (IC) has evolved dramatically over the past 40 years. Training and certification in IC have kept pace, with the development of accredited IC fellowship training programs, training statements, and subspecialty board certification. The application process, however, remained fragmented with lack of a universal process or time frame. In recent years, growing competition among training programs for the strongest candidates resulted in time-limited offers and high-pressure situations that disadvantaged candidates. A grassroots effort was recently undertaken by a Society for Cardiovascular Angiography & Interventions task force, to create equity in the system by establishing a national Match for IC fellowship. This manuscript explores the rationale, process, and implications of this endeavor.
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BACKGROUND: Percutaneous coronary intervention (PCI) without surgical backup is becoming increasingly common in the United States. Additionally, a recent SCAI expert consensus document has liberalized recommendations for performing PCI without cardiac surgery on site (SOS). AIMS: The current study sought to understand practice patterns and operator preferences with regard to performing PCI without SOS. METHODS: Two internet-based surveys were distributed to interventional cardiologists worldwide. Survey items asked about operator demographics, procedural preferences when performing PCI without SOS, self-judged personality traits, and history of malpractice. RESULTS: Between March 2021 and May 2021, 517 interventional cardiologists completed the survey; 341 of whom perform elective PCI without SOS (no-SOS operators), and 176 who perform elective PCI with surgical backup (SOS operators). Most operators were male 473 (91.5%). There was a greater proportion of SOS operators in academic practice (86 vs. 75, p < 0.001) and greater proportion of no-SOS operators in hospital-owned practices (158 vs. 56, p < 0.001). Lesion characteristics (left main, chronic total occlusions, and need for atherectomy) were the most important procedural attributes for no-SOS operators, and international operators reported higher comfort levels with PCI on high-risk lesions. Cumulative personality profile scores were similar between SOS and no-SOS operators. SOS operators expressed more concern with legal ramifications of performing PCI without SOS (2.57 vs. 2.34, p = 0.049). CONCLUSIONS: In the absence of surgical backup, lesion characteristics were the most important consideration for PCI patient selection for operators worldwide. Compared to the United States, international operators were more confident in performing high-risk PCI without surgical backup.
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Cardiólogos , Intervención Coronaria Percutánea , Humanos , Masculino , Estados Unidos , Femenino , Intervención Coronaria Percutánea/efectos adversos , Resultado del Tratamiento , Encuestas y Cuestionarios , HospitalesRESUMEN
Background: Multidisciplinary rounds (MDR) consisting of social workers, dietitians, pharmacists, physical therapists, nurses, and physicians have been implemented at many healthcare institutions to address the complex components of inpatient care. However, little is known on the association of MDR on clinical outcomes across cardiovascular pathologies. This study aimed to investigate the impact of MDR on cardiovascular patients. Methods: Hospital admissions to inpatient cardiology were evaluated prior to (November 2017 to November 2018) and after implementation of MDR (December 2018 to August 2020) at a metropolitan academic medical center. The following outcomes were evaluated: clinical complications (incidence of stroke, gastrointestinal bleed, myocardial infarction, or systemic infection during hospitalization), Length of Stay (LOS), 30-day readmissions and all-cause in-hospital mortality. Secondary outcomes included utilization of physical therapy and dietary services. Results: Admissions were evaluated prior to (N = 1054) and after (N = 1659) MDR implementation. All-cause in-hospital mortality after MDR implementation decreased significantly from 2.8 to 1.6% (P = 0.03). Although the number of complications and LOS decreased, these differences were not statistically significant. No significant change was observed in 30-day readmissions. Significant increase in the utilization of physical therapy (34.2 to 53.5%; P < 0.01) and dietary services (7.2 to 19.3%; P < 0.01) were observed. Conclusion: Multidisciplinary rounds implementation was associated with significantly decreased mortality and positively impacted resource utilization with increased consultations for ancillary services. MDR is a high impact intervention that utilizes existing resources to improve mortality and should be implemented especially for cardiovascular patients. Further investigation into the benefit of MDR across different patient populations and care settings is warranted.
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A subset of patients with severe aortic stenosis (AS) who are who underwent transcatheter aortic valve implantation (TAVI) also has mitral regurgitation (MR). Clinical outcomes in these patients with combined MR and AS have varied. The purpose of this study was to assess clinical outcomes and echocardiographic outcomes after TAVI in patients with preprocedural MR. A retrospective chart review from March 2018 to June 2020 identified all TAVI patients. Patients were assigned an MR class of mild, moderate, or severe based upon pre-TAVI transthoracic echocardiogram (TTE). Patients were excluded if they were discharged from the hospital and did not have a 6-month follow-up after TAVI. Clinical outcomes at 6 months included all-cause mortality, major adverse cardiovascular events, clinically significant bleeding, changes in ejection fraction (EF) category, and changes in MR severity. Of 118 included patients (age 76 ± 10 years, 79% male, 46% White), 33% had MR, with 26% being mild and 7% moderate MR. Before TAVI, AS + MR patients were more likely to have a reduced EF (<50%) by category compared with those with AS only (33.3% vs 8.8%, p = 0.01) but were more likely to show an increase in EF by category after TAVI (19.4% vs 5.5%, p = 0.039). No significant differences were observed between the 2 groups in terms of all-cause mortality (12.8 vs 5.1%, p = 0.14), major adverse cardiovascular events (17.9 vs 8.9%, p = 0.15), or clinically significant bleeding (10.3 vs 6.3%, p = 0.45). Patients with AS and co-existing MR experienced similar clinical outcomes at 6 months to those with AS only after TAVI. They were more likely to show increases in EF category 6 months after valve implantation. Our results support the conclusion that in addition to treating the aortic valve, TAVI also potentially benefits left ventricular function in the setting of mild or moderate MR.
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Estenosis de la Válvula Aórtica , Insuficiencia de la Válvula Mitral , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/cirugía , Cateterismo Cardíaco/métodos , Femenino , Humanos , Masculino , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/cirugía , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del TratamientoRESUMEN
PURPOSE: Stable angina is ischemic chest pain on exertion or with emotional stress. Despite guideline-directed therapy, up to 30% of patients have suboptimal pain relief. The aims of this study were to: (1) determine the feasibility and acceptability of a randomized controlled trial (RCT) of acupuncture; and (2) evaluate preliminary efficacy of acupuncture with respect to reduction of pain and increased functional status and health-related quality of life (HRQoL). METHODS: Participants with stable angina for ⩾1 month received either a standardized acupuncture protocol, twice per week for 5 weeks, or an attention control protocol. Measures included the McGill Pain Questionnaire (average pain intensity (API), pain now) and the Seattle Angina Questionnaire-7 (functional status, symptoms, and HRQoL). Feasibility was defined as ⩾80% recruitment, ⩾75% retention following enrollment, and ⩾80% completion. Descriptive statistics and mixed-effects linear regression were used for analysis. RESULTS: The sample (n = 24) had a mean age of 59 ± 12 years, was predominantly female (63%), and represented minority groups (8% White, 52% Black, 33% Hispanic, and 8% Other). Feasibility was supported by 79% retention and 89% completion rates. The recruitment rate (68%) was slightly lower than expected. Acceptability scores were 87.9% for the acupuncture group and 51.7% for the control group. Outcomes were significantly better for the acupuncture versus control groups (API, b = -2.1 (1.1), p = 0.047; functional status, b = 27.6 (7.2), p < 0.001; and HRQoL, b = 38.8 (11.9), p = 0.001). CONCLUSIONS AND IMPLICATIONS: Acupuncture was feasible and acceptable in our diverse sample. We were slightly under the recruitment target of 80%, but participants who started the study had a high likelihood of completing it. Acupuncture shows promise for stable angina, but its effectiveness needs to be confirmed by a larger, adequately powered RCT. TRIAL REGISTRATION NUMBER: NCT02914834 (ClinicalTrials.gov).
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Terapia por Acupuntura , Terapia por Acupuntura/métodos , Anciano , Estudios de Factibilidad , Femenino , Humanos , Persona de Mediana Edad , Dimensión del Dolor , Calidad de Vida , Resultado del TratamientoRESUMEN
BACKGROUND: Transradial (TR) percutaneous coronary intervention (PCI) is a preferable PCI route. The complication difference between TR and TF approaches is controversial. METHODS: PubMed, Embase, and the Cochrane databases were queried for PCI outcomes of TR TF in STEMI for major cardiac and cerebrovascular events (MACCE), major bleeding, and mortality. The odds ratio (OR) was calculated using the random-effect model. RESULTS: We included 56 studies comprising of 68,733 patients (TR, n = 26,179; TF, n = 42,537). TR-PCI was associated with statistically significant lower odds of MACCE (OR = 0.66, 95% CI: 0.49-0.88, p-value = 0.005), major bleeding (OR = 0.47, 95% CI 0.32-0.68, p-value<0.001), mortality (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001) at in hospital follow-up. TR-PCI was associated with statistically significant lower MACCE (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001), major bleeding (OR = 0.58, 95% CI 0.49-0.68, p-value<0.001), and mortality (OR = 0.61, 95% CI 0.44-0.86, p-value = 0.005) at 30-day follow-up. The same difference was seen at 1-year. CONCLUSION: TR-PCI was associated with lower odds of MACCE, major bleeding, and mortality during short- and long-term follow-up.
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Intervención Coronaria Percutánea/métodos , Infarto del Miocardio con Elevación del ST/terapia , Arteria Femoral , Hemorragia/etiología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Arteria Radial , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/mortalidad , Resultado del TratamientoRESUMEN
AIMS: To evaluate safety and efficacy of distal right radial access (DRRA) compared to right radial access (RRA), for coronary procedures, in patients with smaller diameter radial arteries (SDRA) (radial artery diameter (RAD) < 2.1 mm). METHODS AND RESULTS: This is a retrospective analysis of safety and efficacy of DRRA Vs. RRA in patients undergoing coronary procedures at our cardiac catheterization laboratories over a 10- month period between September 2017 and June, 2018 (first 5 calendar months with RRA-first; next 5 calendar months with DRRA-first). All patients underwent pre-procedure ultrasound of arm arteries. All patients had RAD<2.1 mm (mean RAD 1.63 ± 0.27 mm; RAD≤1.6 mm in 73.5%). Baseline characteristics were similar between groups. Primary end-point of puncture success was significantly lower in DRRA vs RRA group [79.5% vs 98.5%, p < 0.0001]. Puncture success was also lower in the subgroup of patients with RAD <1.6 mm Vs. ≥ 1.6 mm in the DRRA group (p < 0.0001). The secondary end-point of puncture time was significantly higher (2.1 ± 1.4 min vs. 1.0 ± 0.45 min, p < 0.00001) in the DRRA Vs. RRA group. The occurrence of vascular access site complications (including access site hematomas), radial artery occlusion (RAO) and distal RAO at day 1 and day 30 were similar between RRA and DRRA groups.Non-vascular access-site complication was seen only in the DRRA group. CONCLUSION: DRRA is a safe and effective access for coronary procedures; though technically challenging in patients with SDRA (RAD<2.1 mm; mean RAD 1.63 ± 0.27 mm), with lower puncture success and higher puncture time compared to RRA.
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Cateterismo Cardíaco/métodos , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Arteria Radial/diagnóstico por imagen , Ultrasonografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVE: This study evaluated the safety and efficacy of orbital atherectomy (OA) for the treatment of severely calcified coronary artery bifurcation lesions. BACKGROUND: Percutaneous coronary intervention (PCI) of severely calcified coronary artery lesions is associated with lower procedural success and higher rates of target lesion failure compared to non-calcified lesions. OA is an effective treatment for calcified coronary artery lesions prior to stent implantation. However, there is little data regarding the safety and efficacy of OA in patients with coronary artery bifurcation lesions. METHODS: Data were obtained from analysis of patients with severe coronary artery calcification who underwent OA and coronary stent implantation at ten high-volume institutions. Data were pooled and analyzed to assess peri-procedural outcomes and 30-day major adverse cardiac events (MACE). RESULTS: A total of 1156 patients were treated with OA and PCI. 363 lesions were at a coronary artery bifurcation. There were no statistically significant differences in baseline characteristics between the bifurcation and non-bifurcation groups. In the bifurcation group, treatment involved the left anterior descending artery and its branches more frequently and right coronary artery less frequently. After propensity score matching, the 30-day freedom from MACE was not statistically significant between the two groups. CONCLUSION: In this multicenter cohort analysis, patients with severely calcified coronary bifurcation lesions had low rates of MACE and target vessel revascularization at 30 days at rates comparable to non-bifurcation lesions. This analysis demonstrates that OA is safe and effective for complex coronary lesions at both bifurcation and non-bifurcation locations.
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Aterectomía Coronaria , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Calcificación Vascular , Aterectomía , Aterectomía Coronaria/efectos adversos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Humanos , Intervención Coronaria Percutánea/efectos adversos , Estudios Prospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/cirugíaRESUMEN
BACKGROUND: To evaluate the trends in complication rates following transcatheter aortic valve replacement (TAVR) procedures according to the type of vascular approach (endovascular vs. transapical) in a large US population sample. METHODS: The National Inpatient Sample (NIS) was queried for all patients diagnosed with aortic stenosis who underwent a TAVR procedure in the United States during the years 2012-2016. Outcomes assessed were peri-procedural mortality, cardiac, and non-cardiac complications. Hospitalization outcomes were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. RESULTS: There were 97,320 endovascular-TAVR patients and 11,140 transapical-TAVR patients. The mean age was 80.8 years (standard error of the mean: ± 0.1). Most patients were males (53.7%) and Caucasian (87.1%). On multivariate analysis, after adjusting for age, gender, comorbidities, as well as hospital factors, patients with the transapical approach had a higher risk for mortality and adverse outcomes. Among the endovascular-TAVR group, national trends showed a diminishing incidence of procedural mortality (incidence rate ratio [IRR] 0.77; 95% CI: 0.72-0.84, p < 0.001), stroke (IRR 0.80; 95% CI: 0.73-0.87, p < 0.001), and all secondary outcomes, but no significant change in myocardial infarction. In contrast, most transapical-TAVR related procedural complications remained unchanged over time, except for a significant decrease in stroke, acute respiratory failure and need for pacemaker insertion. CONCLUSION: National trends show a steady increase in the number of endovascular-TAVR procedures with a concurrent decrease in procedural complications.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Procedimientos Endovasculares/tendencias , Evaluación de Procesos y Resultados en Atención de Salud/tendencias , Reemplazo de la Válvula Aórtica Transcatéter/tendencias , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/mortalidad , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Pacientes Internos , Masculino , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: A lifesaving treatment for myocardial infarction is the placement of a stent in a closed or obstructed coronary artery. The largest modifiable risk factor after receiving a stent is medication adherence to Dual AntiPlatelet Therapy, a combination of P2Y12 inhibitors and aspirin. OBJECTIVE: This study aimed to determine the acceptability of a protocol and an intervention using the My Interventional Drug-Eluting Stent Educational App (MyIDEA) and to evaluate medication adherence using the proportion of days covered (PDC) and platelet activation tests in a multisite randomized controlled trial. METHODS: Potential participants who received a post percutaneous coronary intervention (PCI) procedure with a drug-eluting stent were approached. All patients older than 50 years and who spoke English were recruited. Participants were recruited, baseline demographics were collected, and the Hospital Anxiety and Depression Scale (HADS), Rapid Estimate of Adult Literacy in Medicine-Short Form, Burden-Benefit questionnaire, 36-Item Short Form Health Survey, and PCI knowledge questionnaire were administered. Block randomization was used to randomize participants to either usual care or MyIDEA supplementation. MyIDEA is a personalized educational intervention based on the Kolb experiential learning theory using patient narratives for education. During the visits, participants' blood was collected to measure platelet suppression from medication. During the second and third encounters, the Morisky medication adherence score and cardiology outcomes were measured. The study was conducted at the University of Illinois Hospital and John H Stroger Jr Cook County Hospital with appropriate ethical approvals. Platelet suppression was measured through aspirin reactive units and P2Y12 reactive units. Medication adherence was measured using the PDC. The analysis team was blinded to the participants' group membership. The primary outcome was a feasibility analysis of recruitment and retention. RESULTS: The mean age of participants was 60.4 years (SD 7.1); the majority of patients were black and non-Hispanic. The majority of patients' reading levels were seventh grade or above, and they were not very familiar with other electronic devices for information and communication. The number of control subjects was 21, and the number of participants in the interventional arm was 24. The interventional group was able to use MyIDEA in both the hospital and outpatient setting. However, there was no significant difference in platelet suppression or medication adherence between groups. There were also differences between the groups in terms of depression and anxiety, initially, as measured by HADS. No documented adverse event associated with the intervention was found. CONCLUSIONS: Elderly patients are willing to use tablet devices to be educated about health conditions. Additional studies are required to measure the effectiveness and determine the most suitable timing and location for patient education. TRIAL REGISTRATION: ClinicalTrials.gov NCT04439864; https://clinicaltrials.gov/ct2/show/NCT04439864.
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Stents Liberadores de Fármacos , Aplicaciones Móviles , Intervención Coronaria Percutánea , Adulto , Anciano , Estudios de Factibilidad , Humanos , Cumplimiento de la Medicación , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/uso terapéuticoRESUMEN
INTRODUCTION: The VA Mission Act of 2018 sought to increase access to local care facilities for Veterans meeting certain eligibility criteria including a drive time of >60 min from a VA facility. As part of an ongoing review of our VA program's same day discharge (SDD) program following elective percutaneous coronary intervention (PCI), we investigated whether the distance criteria of the VA Mission Act had any impact on overall safety outcomes. METHODS: We performed a single center, retrospective study in patients who underwent outpatient PCI between 2013 and 2019. We stratified patients into an overnight observation (ON) and SDD group. We used Google Maps in order to calculate patient home distance to the Jesse Brown Veterans Affairs Hospital (JBVA). Primary endpoints included all-cause death andmajor adverse cardiac events (MACE; cardiovascular death, myocardial infarction, stroke, and/or target vessel revascularization). Secondary outcomes included total unplanned interactions with the healthcare system. Outcomes were analyzed at 30 days after PCI. RESULTS: There were 76 patients in the SDD group. The SDD group had a median drive time of 80 min from the JBVA. Regarding primary outcomes, there were no cases of MACE in either group and there was no statistically significant difference in terms of all-cause mortality (ON: 1.3%, SDD: 0%, p = .5) 30 days following PCI. All secondary outcomes at 30 days did not demonstrate a statistically significant difference between either group. CONCLUSION: Same day discharge following successful PCI procedures appears safe. In response to the VA Mission Act, drive time and distance travelled did not appear to impact outcomes. SUMMARY: Same day discharge in select patients at our VA hospital was both safe and feasible. Neither drive time nor distance travelled affected overall outcomes in response to the 2018 VA MISSION Act. As such, shared decision making between patients and physicians remains essential to ensure Veterans continue to receive high quality care that is in their best medical interest.
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Intervención Coronaria Percutánea , Toma de Decisiones Conjunta , Hospitales , Humanos , Tiempo de Internación , Pacientes Ambulatorios , Alta del Paciente , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: For low-risk patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) the recommended optimal discharge timing is inconsistent in guidelines. The European Society of Cardiology guidelines recommend early discharge within 48-72 h, while the American College of Cardiology guidelines do not recommend a specific discharge strategy. In this systematic review and meta-analysis we compared outcomes with early discharge (≤3 days) versus late discharge (>3 days). METHODS: Randomized controlled trials (RCTs) and observational studies were selected after searching MEDLINE and EMBASE database. Meta-analysis was stratified according to study design. Outcomes were reported as random effects risk ratios (RR) with 95% confidence intervals. RESULTS: Seven RCTs comprising 1780 patients and 4 observational studies comprising 39,288 patients were selected. The RCT-restricted analysis did not demonstrate significant differences in terms of all-cause mortality (RR, 0.97 [0.23-4.05]) and major adverse cardiac events (MACE) (RR, 0.84 [0.56-1.26]). Conversely, observational study restricted analysis showed that early vs late discharge strategy was associated with a reduction in all-cause mortality (RR, 0.40 [0.23-0.71]) and MACE (RR, 0.45 [0.26-0.78]). There were no significant differences in hospital readmissions between early vs late discharge in both RCT or observational study analyses. CONCLUSIONS: Early discharge strategy in appropriately selected low-risk patients with STEMI undergoing PCI is safe and it has the potential to improve cost of care.
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Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Estudios Observacionales como Asunto , Alta del Paciente , Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Current risk prediction models in acute coronary syndrome (ACS) patients undergoing PCI are mathematically complex. This study was undertaken to assess the accuracy of a modified CHA2DS2-VASc score, comprised of easily accessible clinical factors in predicting adverse events. METHODS: The National Inpatient Sample (NIS) was queried for ACS patients who underwent PCI between 2010 and 2014. We developed a modified CHA2DS2-VASc score for risk prediction in ACS patients. Multivariate mixed effect logistic regression was utilized to study the adjusted risk for adverse outcomes based on the score. The primary outcome evaluated was in-hospital mortality. Secondary outcomes assessed were stroke, respiratory failure, acute kidney injury, all-cause bleeding, pacemaker insertion, vascular complications, length of stay and cost. RESULTS: There were 252,443 patients admitted with ACS included. Mean age was 62 ± 12 years. The mean CH3A2DS-VASc score was 1.6 ± 1.6. The in-hospital mortality rate was 2.5%. CH3A2DS-VASc score was highly correlated with increased rate of mortality and all secondary outcomes. ROC curve analysis for association of CH3A2DS-VASc score with mortality demonstrates that area under the curve (AUC) = 0.83 (95%C: 0.82-0.84). Stepwise increases in CH3A2DS-VASc score correlated with incremental risk, and total score was an independent predictor of mortality (adjusted OR: 1.99 (95%CI: 1.96-2.03) p < 0.001) and all secondary outcomes. CONCLUSION: This study supports the applicability of the CH3A2DS-VASc score as an accurate risk prediction model for ACS patients undergoing PCI and could supplant more complicated models for quality assurance.
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OBJECTIVES: This study sought to define contemporary rates of drug eluting stent (DES) usage in patients with chronic kidney disease (CKD). BACKGROUND: Among patients with CKD undergoing percutaneous coronary interventions (PCIs), outcomes are superior for those who receive DES compared to those who receive bare metal stents (BMSs). However, perceived barriers may limit the use of DES in this population. METHODS: All adult PCI cases from the NCDR CathPCI Registry involving coronary stent placement between July 1, 2009 and December 31, 2015 were analyzed. The rate of DES usage was then compared among four groups, stratified by CKD stage (I/II, III, IV, and V). Subgroup analysis was conducted based on PCI status and indication. Cases were linked to Medicare claims data to assess 1-year mortality. RESULTS: A total of 3,650,333 PCI cases met criteria for analysis. DES usage significantly declined as renal function worsened (83.0%, 79.9%, 75.6%, and 75.6%, respectively, in the four CKD stages; p < .001). DES usage was universally lower across the four groups in the setting of ST-Elevation Myocardial Infarction (STEMI) (70.6%, 66.5%, 58.7%, 58.0%; p < .001) and higher in the setting of elective PCI (87.6%, 84.9%, 82.3%, 77.9%; p < .0001). DES was associated with improved 1-year survival, and usage increased over time across each group. CONCLUSIONS: DESs are underutilized in patients with advanced renal dysfunction. Although DES usage has increased over time, variation still exists between patients with normal renal function and those with CKD.
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Isquemia Miocárdica/terapia , Intervención Coronaria Percutánea/instrumentación , Insuficiencia Renal Crónica/complicaciones , Stents , Anciano , Anciano de 80 o más Años , Toma de Decisiones Clínicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Diseño de Prótesis , Sistema de Registros , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
Transradial angiography and intervention continues to become increasingly common as an access site for coronary procedures. Since the first "Best Practices" paper in 2013, ongoing trials have shed further light onto the safest and most efficient methods to perform these procedures. Specifically, this document comments on the use of ultrasound to facilitate radial access, the role of ulnar artery access, the utility of non-invasive testing of collateral flow, strategies to prevent radial artery occlusion, radial access for primary PCI and topics that require further study.
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Cateterismo Cardíaco/normas , Cateterismo Periférico/normas , Angiografía Coronaria/normas , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/normas , Arteria Radial/diagnóstico por imagen , Ultrasonografía Intervencional/normas , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/prevención & control , Benchmarking , Cateterismo Cardíaco/efectos adversos , Cateterismo Periférico/efectos adversos , Consenso , Angiografía Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/fisiopatología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las Pruebas , Arteria Radial/fisiopatología , Factores de Riesgo , Resultado del Tratamiento , Arteria Cubital/diagnóstico por imagen , Ultrasonografía Intervencional/efectos adversos , Grado de Desobstrucción Vascular , VasoconstricciónRESUMEN
Acute coronary syndrome (ACS) admissions are common and costly. The association between comprehensive ACS care pathways, outcomes, and costs are lacking. From 434,172 low-risk, uncomplicated ACS patients eligible for early discharge (STEMI 35%, UA/NSTEMI 65%) from the Premier database, we identified ACS care pathways, by stratifying low-risk, uncomplicated STEMI and UA/NSTEMI patients by access site for PCI (trans-radial intervention [TRI] vs transfemoral intervention [TFI]) and by length of stay (LOS). Associations with costs and outcomes (death, bleeding, acute kidney injury, and myocardial infarction at 1-year) were tested using hierarchical, mixed-effects regression, and projections of cost savings with change in care pathways were obtained using modeling. In low-risk uncomplicated STEMI patients, compared with TFI and LOS ≥3 days, a strategy of TRI with LOS <3 days and TFI with LOS <3 days were associated with cost savings of $6,206 and $4,802, respectively. Corresponding cost savings for UA/NSTEMI patients were $7,475 and $6,169, respectively. These care-pathways did not show an excess risk of adverse outcomes. We estimated that >$300 million could be saved if prevalence of the TRI with LOS <3 days and TFI with LOS <3 days strategies are modestly increased to 20% and 70%, respectively. In conclusion, we demonstrate the potential opportunity of cost savings by repositioning ACS care pathways in low-risk and uncomplicated ACS patients, toward transradial access and a shorter LOS without an increased risk of adverse outcomes.
Asunto(s)
Síndrome Coronario Agudo/economía , Predicción , Costos de la Atención en Salud/tendencias , Intervención Coronaria Percutánea , Mejoramiento de la Calidad/economía , Sistema de Registros , Síndrome Coronario Agudo/cirugía , Costos y Análisis de Costo , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30â¯days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (Pâ¯<â¯.001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, Pâ¯=â¯.24; mortality: 0% vs. 0.07%, Pâ¯=â¯.99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.