Review of subacute stent thrombosis following percutaneous coronary intervention at a low-volume catheterization laboratory.

BACKGROUND: The frequency of coronary stent subacute thrombosis (SAT) following percutaneous coronary intervention (PCI) with uncoated stents in recent studies is 0.5%-0.9%. Prior studies have indicated that complication rates are significantly higher when performed in low-volume centers. We sought to determine the incidence and outcomes of SAT following PCI with stent placement at a low-volume catheterization laboratory. METHODS: We reviewed the Brooke Army Medical Center Interventional Database for all consecutive PCIs with stent implantation performed from January 1998 to December 2002. Clinical outcomes were obtained primarily through hospitalization records and clinic follow-up visits. RESULTS: There were 789 interventions with stenting on 750 patients over the specified time period, for an average of 158 procedures on 150 patients per year. There were seven cases of SAT, representing a rate of 0.89%. There was no difference in the clinical characteristics, procedural technique, or postprocedural antithrombotic therapy of the subjects with and without SAT. Of those with SAT, there were no subjects requiring surgical revascularization during index hospitalization, and all survived to index hospital discharge. Six of these seven subjects with SAT (85.7%) were alive at one year, with the single death noncardiovascular related. CONCLUSIONS: The incidence of thrombosis occurring within 30 days of intracoronary stent implantation is similar in low- and high-volume catheterization laboratories. In our low-volume laboratory experience, these events were not associated with significantly increased adverse outcomes.

Glycoprotein IIb/IIIa inhibitor-associated thrombocytopenia: clinical predictors and effect on outcome.

Glycoprotein IIb/IIIa inhibitors are used as an adjunct to antiplatelet therapy in percutaneous coronary intervention to reduce postprocedural enzyme elevations. Previous studies have shown a risk for thrombocytopenia that is associated with these agents. We sought to evaluate the incidence and outcomes of glycoprotein IIb/IIIa inhibitor-associated thrombocytopenia in an unselected series of patients undergoing percutaneous coronary intervention. We reviewed 984 interventions performed on 908 subjects over a specific time period. Glycoprotein IIb/IIIa inhibitors were used in 58.8% of cases. Their use increased from 38 to 82% during the study period (p < 0.0001). The incidence of glycoprotein IIb/IIIa inhibitor-associated thrombocytopenia was 5.4%. The occurrence of thrombocytopenia was not associated with higher age, gender or ethnicity. The preprocedural platelet count was not associated with induced thrombocytopenia (237 +/- 76 vs. 209 +/- 68 x 10(3), p > 0.05). The occurrence of thrombocytopenia was not associated with increased in-hospital mortality, 1-year mortality, myocardial infarction or revascularization, but was associated with a hospital stay twice as long as in those patients without thrombocytopenia (5.6 +/- 11.3 vs. 2.1 +/- 2.2 days, p < 0.001). Of the 5.4% of patients who developed thrombocytopenia, only 2 patients (7.1%) required platelet or blood cell transfusion.

Guidelines for appropriate in-hospital emergency team time management: the Brooke Army Medical Center approach.

UNLABELLED: Successful outcome following cardiac arrest have been reported in the range of 13-59%. It is well established that the time from the onset of a ventricular arrhythmia to successful defibrillation predicts outcome. Recent out of hospital arrest protocols minimizing time to defibrillation have reported significant improvement in outcomes. The Bethesda conference and American Heart Association (AHA) both set standards for defibrillation time for in hospital codes but do not set standards for other interventions. In February 2000, the Brooke Army Medical Center (BAMC) cardiopulmonary resuscitation committee published time guidelines for the initiation of CPR, emergency team arrival, first defibrillation and first medication. We sought to evaluate resuscitation outcomes before and after this intervention. METHODS: Data on each response time was prospectively collected as was etiology for the event, emergency location, patient age, gender, and emergency outcome for the 7 months prior to the guideline introduction and 15 months afterwards. RESULTS: The mean response times (in minutes) for initiation of CPR (1.3 vs. 0.4), emergency team arrival (1.6 vs. 1.2), first defibrillation (7.8 vs. 6.6) and first medication (4.1 vs. 3.8) demonstrated trends toward improvement. Compliance with the time standards also increased (67-91, 85-95, 67-71 and 93-86%, respectively). Emergency survival trended toward improvement (47 vs. 57%) while discharge survival significantly increased from 3 to 24% (P=0.017). CONCLUSIONS: Setting time guidelines for Advanced Cardiac Life Support (ACLS) improved initiation of CPR, emergency team arrival, first defibrillation, and first medication administration. These time reductions were accompanied by improved event survival and a statistically improved survival to discharge.

Percutaneous coronary intervention in the elderly: procedural success and 1-year outcomes.

Clinical trials have found increased morbidity in elderly persons presenting for percutaneous coronary intervention for chronic stable angina. Long-term follow-up is limited for the elderly following percutaneous coronary intervention. The authors reviewed all coronary interventions performed from January 1998 to August 2001. One year following the procedure, subjects were screened for death, need for revascularization, and myocardial infarction. There were 401 subjects aged >/=65 years (mean 73.4+/-6.0 years) and 479 subjects aged <65 years (mean 55.6+/-6.7 years). Although there was no difference in 1-year rate of subsequent myocardial infarction or in revascularization, the elderly were more likely to die during hospitalization (4.7% vs. 1.0%, p<0.01), and at 1 year (10.2% vs. 4.0%, p<0.01). When controlled for ejection fraction, age was no longer significant in either predischarge mortality or in 1-year mortality. Excess postpercutaneous coronary intervention mortality in the elderly may be due to underlying comorbidities and not due to subsequent myocardial infarction or revascularization.