Hospital and Physician Variability in Revascularization Decisions and Outcomes for Patients With 3-Vessel and Left Main Coronary Artery Disease: A Population-Based Cohort Study.

BACKGROUND: Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. METHODS AND RESULTS: From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization. CONCLUSIONS: Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

Presentation, care, coronary intervention and outcomes of patients with NSTEMI according to age: insights from the international prospective ACVC-EAPCI EORP NSTEMI registry.

BACKGROUND: Older people less frequently receive invasive coronary angiography (ICA) for NSTEMI than younger patients. We describe care, ICA data, and in-hospital and 30-day outcomes of NSTEMI by age in a contemporary and geographically diverse cohort. METHODS: Prospective cohort study including 2947 patients with NSTEMI from 287 centres in 59 countries, stratified by age (≥75 years, n = 761). Quality of care was evaluated based on 12 guideline-recommended care interventions, and data collected on ICA. Outcomes included in hospital acute heart failure, cardiogenic shock, repeat myocardial infarction, stroke/transient ischaemic attack, BARC Type ≥3 bleeding and death, as well as 30-day mortality. RESULTS: Patients aged ≥75 years, compared with younger patients, at presentation had a higher prevalence of comorbidities and oral anticoagulation prescription (22.4% vs 7.6%, p < 0.001). Older patients less frequently received ICA than younger patients (78.6% vs 90.6%, p < 0.001) with the recorded reason more often being advanced age, comorbidities or frailty. Of those who underwent ICA, older patients more frequently demonstrated 3-vessel, 4-vessel and/or left main stem coronary artery disease compared to younger patients (49.7% vs 34.1%, p < 0.001) but less frequently received revascularisation (63.6% vs 76.9%, p < 0.001). Older patients experienced higher rates of in-hospital acute heart failure (15.0% vs 8.4%, p < 0.001) and bleeding (2.8% vs 1.3%, p = 0.006), as well as in-hospital and 30-day mortality (3.4% vs 1.3%, p < 0.001; 4.8% vs 1.7%, p < 0.001; respectively), than younger patients. CONCLUSIONS: Patients aged ≥75 years with NSTEMI, compared with younger patients, less frequently received ICA and guideline-recommended care, and had worse short-term outcomes.

Treatment Adherence Rates and Long-Term Mortality in a Quaternary Multidisciplinary Heart Team: An Observational Cohort.

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.

Impact of Chronic Kidney Disease on the Processes of Care and Long-Term Mortality of Non-ST-Segment-Elevation Myocardial Infarction: A Nationwide Cohort Study and Long-Term Follow-Up.

BACKGROUND: A growing population of patients with chronic kidney disease (CKD) presents with non-ST-segment-elevation myocardial infarction, although little is known about their longer-term mortality. METHODS AND RESULTS: Using the MINAP (Myocardial Ischaemia National Audit Project) registry, linked to Office for National Statistics mortality data, we analyzed 363 559 UK patients with non-ST-segment-elevation myocardial infarction, with or without CKD. Cox regression models were fitted, adjusting for baseline demographics. Compared with patients without CKD, patients with CKD were less frequently prescribed P2Y12 inhibitors (89% versus 86%, P<0.001) less likely to undergo invasive angiography (67% versus 41%, P<0.001) or percutaneous coronary intervention (41% versus 25%, P<0.001), and were less often referred to cardiac rehabilitation (80% versus 66%, P<0.001). Following non-ST-segment-elevation myocardial infarction, patients with CKD had higher risk of 30-day (adjusted hazard ratio [HR], 1.24 [95% CI, 1.20-1.29], 1-year 1.47 [95% CI, 1.44-1.51]) and 5-year mortality 1.55 (95% CI, 1.53-1.58) than patients without CKD (all P<0.001). Risk of mortality over the entire study period was highest in CKD Stage 5 (HR, 2.98 [95% CI, 2.87-3.10]), even after excluding mortality ≤30 days (HR, 3.03 [95% CI, 2.90-3.17]) (P<0.001). There was no significant difference in proportion of deaths attributable to cardiovascular disease at 30 days (CKD; 76% versus no CKD; 76%), or 1 -year (CKD; 62% versus no CKD; 62%). CONCLUSIONS: Patients with CKD were significantly less likely to receive invasive investigation or undergo percutaneous coronary intervention and had significantly higher risk of short- and longer-term mortality. Risk of mortality increased with reducing CKD stage. Cardiovascular disease was the main cause of mortality in patients with CKD, but at comparable rates to the general population with non-ST-segment-elevation myocardial infarction.

Effect of COVID-19 Pandemic Lockdown on Emergency Medical Service Utilisation, and Percutaneous Coronary Intervention Volume-An Australian Perspective.

BACKGROUND: Acute coronary syndrome (ACS) admissions and percutaneous coronary intervention (PCI) volume declined during periods of COVID-19 lockdown internationally in 2020. The effect of lockdown on emergency medical service (EMS) utilisation, and PCI volume during the initial phase of the pandemic in Australia has not been well described. METHOD: We analysed data from the Victorian Cardiac Outcomes Registry (VCOR), a state-wide PCI registry, linked with the Ambulance Victoria EMS registry. PCI volume, 30-day major adverse cardiovascular and cerebrovascular events (MACCE; composite of mortality, myocardial infarction, stent thrombosis, unplanned revascularisation, and stroke), and EMS utilisation were compared over four time periods: lockdown (26 Mar 2020-12 May 2020); pre-lockdown (26 Feb 2020-25 Mar 2020); post-lockdown (13 May 2020-10 Jul 2020); and the year prior (26 Mar 2019-12 May 2019). Interrupted time series analysis was performed to assess PCI trends within and between consecutive periods. RESULTS: The EMS utilisation for ACS during lockdown was higher compared with other periods: lockdown 39.4% vs pre-lockdown 29.7%; vs post-lockdown 33.6%; vs year prior 27.1%; all p<0.01. Median daily PCI cases were similar: 31 (IQR 10, 38) during lockdown; 39 (15, 49) pre-lockdown; 39.5 (11, 44) post-lockdown; and, 42 (10, 49) the year prior; all p>0.05. Median door-to-procedure time for ACS indication during lockdown was shorter at 3 hours (1.2, 20.6) vs pre-lockdown 3.9 (1.7, 21); vs post-lockdown 3.5 (1.5, 21.26); and, the year prior 3.5 (1.5, 23.7); all p<0.05. Lockdown period was associated with lower odds for 30-day MACCE compared to pre-lockdown (odds ratio [OR] 0.55 [0.33-0.93]; p=0.026); post-lockdown (OR 0.66; [0.40-1.06]; p=0.087); and the year prior (OR 0.55 [0.33-0.93]; p=0.026). CONCLUSIONS: Contrary to international trends, EMS utilisation for ACS increased during lockdown but PCI volumes remained similar throughout the initial stages of the pandemic in Victoria, with no observed adverse effect on 30-day MACCE during lockdown. These data suggest that the public health response in Victoria was not associated with poorer quality cardiovascular care in patients receiving PCI.

Temporal trends and prognostic impact of reperfusion modalities in Tunisian patients presenting with ST-elevation myocardial infarction: A 20-year analysis.

INTRODUCTION: With the advent of reperfusion therapies, management of patients presenting with ST-elevation myocardial infarction (STEMI) has witnessed significant changes during the last decades. AIM: We sought to analyze temporal trends in reperfusion modalities and their prognostic impact over a 20-year period in patients presenting with STEMI the Monastir region (Tunisia). METHODS: Patients from Monastir region presenting for STEMI were included in a 20-year (1998-2017) single center registry. Reperfusion modalities, early and long-term outcomes were studied according to five four-year periods. RESULTS: Out of 1734 patients with STEMI, 1370 (79%) were male and mean age was 60.3 ± 12.7 years. From 1998 to 2017, primary percutaneous coronary intervention (PCI) use significantly increased from 12.5% to 48.3% while fibrinolysis use significantly decreased from 47.6% to 31.7% (p<0.001 for both). Reperfusion delays for either fibrinolysis or primary PCI significantly decreased during the study period. In-hospital mortality significantly decreased from 13.7% during Period 1 (1998-2001) to 5.4% during Period 5 (2014-2017), (p=0.03). Long-term mortality rate (mean follow-up 49.4 ± 30.7 months) significantly decreased from 25.3% to 13% (p<0.001). In multivariate analysis, age, female gender, anemia on-presentation, akinesia/dyskinesia of the infarcted area and use of plain old balloon angioplasty were independent predictors of death at long-term follow-up whereas primary PCI use and preinfaction angina were predictors of long-term survival. CONCLUSIONS: In this long-term follow-up study of Tunisian patients presenting for STEMI, reperfusion delays decreased concomitantly to an increase in primary PCI use. In-hospital and long-term mortality rates significantly decreased from 1998 to 2017.

Patterns of 12-Month Post-Myocardial Infarction Medication Use According to Revascularisation Strategy: Analysis of 15,339 Admissions in Victoria, Australia.

AIM: Clinical guidelines recommend secondary prevention medications following myocardial infarction (MI) regardless of revascularisation strategy. Studies suggest that there is variation in post-MI medication use following percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG). We investigated initial dispensing and 12-month patterns of medication use according to revascularisation strategy following non-ST-elevation MI (NSTEMI). METHOD: We included all public and private hospital admissions for NSTEMI for patients aged ≥30 years in Victoria, Australia, between July 2012 and June 2017. We investigated initial dispensing of P2Y12 inhibitors (P2Y12i), statins (total and high intensity), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), and beta blockers within 60 days after discharge. Twelve-month post-MI medication use was estimated as the proportion of days covered (PDC) over a 12-month period from the date of hospital discharge. Analyses were performed using adjusted regression models, stratified by revascularisation strategy. RESULTS: There were 15,399 admissions for NSTEMI: 11,754 with PCI and 3,645 with CABG. Following adjustments, predicted probability of initial dispensing in the PCI and CABG groups, respectively, was 0.94 (95% confidence interval 0.93-0.95) vs 0.17 (0.13-0.21) for P2Y12i; 0.69 (0.66-0.71) vs 0.42 (0.37-0.48) for ACEi/ARB; 0.59 (0.57-0.62) vs 0.69 (0.64-0.74) for beta blockers; 0.89 (0.87-0.91) vs 0.89 (0.85-0.92) for statins; and 0.60 (0.57-0.62) vs 0.69 (0.63-0.73) for high intensity statins. The 12-month PDC in the PCI and CABG groups, respectively, was 0.82 (0.80-0.83) vs 0.12 (0.09-0.15) for P2Y12i; 0.62 (0.60-0.65) vs 0.43 (0.39-0.48) for ACEi/ARB; 0.53 (0.51-0.55) vs 0.632 (0.58-0.66) for beta blockers; 0.79 (0.78-0.81) vs 0.78 (0.74-0.81) for statins; and 0.49 (0.47-0.51) vs 0.55 (0.50-0.59) for high intensity statins. CONCLUSIONS: Post-discharge dispensing of secondary prevention medications differed with respect to revascularisation strategy from 2012 to 2017, despite clear evidence of benefit during this period. Interventions may be needed to address possible clinician and patient uncertainty about the benefits of secondary prevention medications, regardless of revascularisation strategy.

Structural Inequities In The Adoption Of Percutaneous Coronary Intervention Services By US Hospitals, 2000-20.

Percutaneous coronary intervention (PCI) is a procedure that opens blocked arteries and restores blood flow to the heart. Timely access to hospitals offering PCI services can be a matter of life or death for patients experiencing a heart attack; however, hospitals' adoption of PCI services may vary between communities, posing potential barriers to critical care. Our cohort study of US general acute hospitals during the period 2000-20 examined PCI service adoption across communities stratified by race, ethnicity, income, and rurality and further classified as segregated or integrated. Of 5,260 hospitals, 1,621 offered PCI services in 2020 or before, 630 added PCI services between 2001 and 2010, and 225 added PCI services between 2011 and 2020. Hospitals serving Black, racially segregated communities were 48 percent less likely to adopt PCI services compared with hospitals serving non-Black, racially segregated communities, and hospitals serving Hispanic, ethnically segregated communities were 41 percent less likely to do so than those serving non-Hispanic, ethnically segregated communities. Hospitals in high-income, economically integrated communities were 1.8 times more likely to adopt PCI services than those in high-income, economically segregated communities, and rural hospitals were less likely to do so than urban hospitals. Understanding where services are expanding in relation to community need may aid in successful policy interventions.

Impact of the SARS-CoV-2 pandemic on acute coronary syndrome patients admitted to an urban academic hospital in Soweto, South Africa.

Introduction: recent worldwide data has shown a concerning decline in the number of acute coronary syndrome (ACS) related admissions and percutaneous coronary intervention (PCI) procedures during the coronavirus disease 2019 (COVID-19) pandemic. We suspected a similar trend at Chris Hani Baragwanath Hospital (CHBAH). Methods: a retrospective descriptive study was conducted to evaluate and compare all ACS-related admissions to the cardiac care unit (CCU) at CHBAH in the pre-COVID-19 (November 2019 to March 2020) and during COVID-19 periods (April 2020 to August 2020). Results: the study comprised 182 patients with a mean age of 57.9 ±10.9 years (22.5% females). Of these, 108 (59.32%) patients were admitted in the pre-COVID-19 period and 74 (40.66%) during COVID-19 (p=0.0109). During the pre-COVID-19 period, 42.9% of patients had ST-segment-elevation myocardial infarction (STEMI), 39.2% with non-ST-segment -elevation myocardial infarction (NSTEMI) and unstable angina (UA) was noted in 18.52%. In contrast, STEMI was noted in 50%, NSTEMI in 43.24% and UA in 6.76% of patients during the COVID-19 period. A statistically significant difference in STEMI and NSTEMI-related admissions was not noted, however, there was a greater number of admissions for UA during the pre-COVID-19 period (18.52% vs 6.76%, P =0.013). Only a third of the patients with STEMI received thrombolysis during the pre-and COVID-19 periods (30.4% vs 37.8%, P=0.47). No difference in the number of PCI procedures was noted between the pre-and during the COVID-19 periods (78.7% vs 72.9%, P=0.37). Conclusion: there was a difference in overall ACS admissions to the CCU between pre-and during COVID-19 periods, however no difference between STEMI and NSTEMI in both periods. A higher number of UA admissions was noted during the pre-COVID-19 period. During both periods, the use of thrombolysis was low for STEMI and no difference in PCI was noted.

Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation.

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited. METHODS: The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI. RESULTS: After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07). CONCLUSIONS: In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.

The Impact of Centralized Procurement on Treatment Patterns for Myocardial Infarction and More Principled Utilization of Coronary Stents.

Reducing the price of expensive medical products through centralized procurement is generally considered an effective way to save public medical resources. Against this background, this paper presents an analysis of the impact of centralized procurement in China by comparing the treatment costs and patterns for acute myocardial infarction (AMI) patients before and after the introduction of this method of purchasing, with specific reference to the use of coronary stents. We found that, after the implementation of centralized procurement for coronary stents, the total expenditure of AMI cases receiving percutaneous coronary interventions with stent implantation (PCI with stents) dropped by 23.4%. The use rate of PCI with stents decreased by 32.5%, with the most significant decrease being evident in cases in which two stents were used simultaneously (32.9%). Meanwhile, percutaneous coronary interventions with balloon implantation (PCI with balloons) increased by 31.5% and coronary artery bypass grafting (CABG) increased by 80.3%. Based on these patterns, it can be observed that the use of centralized procurement significantly reduced the profits of the relevant medical manufacturers, forcing them to decrease their marketing investments, weakening their influence on providers, and ultimately resulting in a more principled use of coronary stents. We therefore conclude that, with reference to the data cited, the centralized procurement program led not only to a reduction in procurement prices but also to decreased overuse of these expensive medical products.

Sex disparity of DAPT noncompliance in patients with left main stem PCI with DES.

This retrospective study aims to explore the sex disparity in dual antiplatelet therapy (DAPT) noncompliance among left main stem percutaneous coronary intervention (PCI) patients with drug-eluting stent (DES) and identify predictors associated with non-adherence. Data were collected from the medical records of 1585 patients, including 1104 males and 481 females, who underwent left main stem PCI with DES. Baseline characteristics, angiographic features, and DAPT compliance rates at 1 month and 12 months were analyzed. Univariate logistic regression was used to identify predictors of DAPT noncompliance. The overall DAPT noncompliance rate at 1 month was 8.5%, increasing to 15.5% at 12 months. Females exhibited slightly higher noncompliance rates than males at both 1 month (15.6% vs 14.5%) and 12 months (28.1% vs 19.0%), although the difference was not statistically significant. Smoking status showed a modest impact on non-adherence, with current smokers exhibiting a lower noncompliance rate (14.9% at 1 month). Prior coronary artery disease history was associated with increased noncompliance at 12 months (18.9%). Angiographic characteristics, including lesion location and Syntax score, had no consistent association with DAPT noncompliance. This study highlights sex disparity in DAPT noncompliance among patients undergoing left main stem PCI with DES. Comorbidities, socioeconomic status, smoking status, and prior coronary artery disease history were identified as predictors of non-adherence.

10-Year Mortality After ST-Segment Elevation Myocardial Infarction Compared to the General Population.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) is associated with high early mortality. However, it remains unclear if patients surviving the early phase have long-term excess mortality. OBJECTIVES: This study aims to assess excess mortality in STEMI patients treated with primary percutaneous coronary intervention (PCI) compared with an age- and- sex-matched general population at landmark periods 0 to 30 days, 31 to 90 days, and 91 days to 10 years. METHODS: Using the Western Denmark Heart Registry, we identified first-time PCI-treated patients who had primary PCI for STEMI from January 2003 to October 2018. Each patient was matched by age and sex to 5 individuals from the general population. RESULTS: We included 18,818 patients with first-time STEMI and 94,090 individuals from the general population. Baseline comorbidity burden was similar in STEMI patients and matched individuals. Compared with the matched individuals, STEMI was associated with a 5.9% excess mortality from 0 to 30 days (6.0% vs 0.2%; HR: 36.44; 95% CI: 30.86-43.04). An excess mortality remained present from 31 to 90 days (0.9% vs 0.4%; HR: 2.43; 95% CI: 2.02-2.93). However, in 90-day STEMI survivors, the absolute excess mortality was only 2.1 percentage points at 10-year follow-up (26.5% vs 24.5%; HR: 1.04; 95% CI: 1.01-1.08). Use of secondary preventive medications such as statins, antiplatelet therapy, and beta-blockers was very high in STEMI patients throughout 10-year follow-up. CONCLUSIONS: In primary PCI-treated STEMI patients with high use of guideline-recommended therapy, patients surviving the first 90 days had 10-year mortality that was only 2% higher than that of a matched general population.

Trends in Regional Disparities in Cardiovascular Surgery and Mortality in Korea: A National Cross-sectional Study.

OBJECTIVES: Regional disparities in cardiovascular care in Korea have led to uneven patient outcomes. Despite the growing need for and access to procedures, few studies have linked regional service availability to mortality rates. This study analyzed regional variation in the utilization of major cardiovascular procedures and their associations with short-term mortality to provide better evidence regarding the relationship between healthcare resource distribution and patient survival. METHODS: A cross-sectional study was conducted using nationwide claims data for patients who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), stent insertion, or aortic aneurysm resection in 2022. Regional variation was assessed by the relevance index (RI). The associations between the regional RI and 30-day mortality were analyzed. RESULTS: The RI was lowest for aortic aneurysm resection (mean, 26.2; standard deviation, 26.1), indicating the most uneven regional distribution among the surgical procedures. Patients undergoing this procedure in regions with higher RIs showed significantly lower 30-day mortality (adjusted odds ratio [aOR], 0.73; 95% confidence interval, 0.55 to 0.96; p=0.026) versus those with lower RIs. This suggests that cardiovascular surgery regional availability, as measured by RI, has an impact on mortality rates for certain complex surgical procedures. The RI was not associated with significant mortality differences for more widely available procedures like CABG (aOR, 0.96), PCI (aOR, 1.00), or stent insertion (aOR, 0.91). CONCLUSIONS: Significant regional variation and underutilization of cardiovascular surgery were found, with reduced access linked to worse mortality for complex procedures. Disparities should be addressed through collaboration among hospitals and policy efforts to improve outcomes.

Racial Disparities in Outcomes of Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction Secondary to Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare cause of ST-segment elevation myocardial infarction (STEMI), predominantly affecting women. Because primary percutaneous coronary intervention (PPCI) is reserved for a select group of patients, vulnerable and minority patients may experience delays in appropriate management and adverse outcomes. We examined the racial differences in the outcomes for patients with SCAD who underwent PPCI for STEMI. Records of patients aged ≥18 years who underwent PPCI for SCAD-related STEMI between 2016 and 2020 were identified from the National Inpatient Sample database. Clinical, socioeconomic, and hospital characteristics were compared between non-White and White patients. Weighted multivariate analysis assessed the association of race with inpatient mortality, length of stay (LOS), and hospitalization costs. The total weighted estimate of patients with SCAD-STEMI who underwent PPCI was 4,945, constituting 25% non-White patients. Non-White patients were younger (56 vs 60.7 years, p <0.001); had a higher prevalence of diabetes, acute renal failure, and obesity; and were more likely to be uninsured and be in the lowest income group. Inpatient mortality (7.7% vs 8.4%, p = 0.74) and hospitalization costs ($34,213 vs $31,858, p = 0.27) were similar for non-White and White patients, and the adjusted analysis did not show any association between the patients' race and inpatient mortality (odds ratio 0.60, 95% confidence interval [CI] 0.32 to 1.13, p = 0.11) or hospitalization costs (ß [ß coefficient]: 215, 95% CI -4,193 to 4,623, p >0.90). Similarly, there was no association between the patients' race and LOS (incident rate ratio 1.20, 95% CI 1.00 to 1.45, p = 0.054). The weighted multivariate analysis showed that age; clinical co-morbidities such as diabetes, acute renal failure, valvular dysfunction, and obesity; low-income status; and hospitalization in the western region were associated with adverse outcomes. In conclusion, our study does not show any differences in inpatient mortality, LOS, and hospitalization costs between non-White and White patients who underwent PPCI for SCAD-related STEMI.

Influence of Organisational-Level Factors on Delayed Door-to-Balloon Time among Patients with ST-Elevation Myocardial Infarction.

Objectives: This study aimed to estimate the door-to-balloon (DTB) time and determine the organisational-level factors that influence delayed DTB times among patients with ST-elevation myocardial infarction in Oman. Methods: A cross-sectional retrospective study was conducted on all patients who presented to the emergency department at Sultan Qaboos University Hospital and Royal Hospital, Muscat, Oman, and underwent primary percutaneous coronary interventions during 2018-2019. Results: The sample included 426 patients and the median DTB time was 142 minutes. The result of the bivariate logistic regression showed that patients who presented to the emergency department with atypical symptoms were 3 times more likely to have a delayed DTB time, when compared to patients who presented with typical symptoms (odds ratio [OR] = 3.003, 95% confidence interval [CI]: 1.409-6.400; P = 0.004). In addition, patients who presented during off-hours were 2 times more likely to have a delayed DTB time, when compared to patients who presented during regular working hours (OR = 2.291, 95% CI: 1.284-4.087; P = 0.005). Conclusion: To meet the DTB time recommendation, it is important to ensure adequate staffing during both regular and irregular working hours. Results from this study can be used as a baseline for future studies and inform strategies for improving the quality of care.

The association of bariatric surgery with myocardial infarction and coronary revascularization: a propensity score match analysis of National Inpatient Sample.

BACKGROUND: Metabolic bariatric surgery (MBS) not only leads to a durable weight loss but also lowers mortality, and reduces cardiovascular risks. OBJECTIVES: The current study aims to investigate the association of bariatric metabolic surgery (BMS) with admissions for acute myocardial infarction (AMI), including ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), as well as, coronary revascularization procedures, including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and thrombolysis. SETTING: The National Inpatient Sample (NIS) database. METHODS: The NIS data from 2016 to 2020 were analyzed. A propensity score matching in a 1:1 ratio was performed to match patients with history of MBS with non-MBS group. RESULTS: Two hundred thirty-three thousand seven hundred twenty-nine patients from the non-MBS group were matched with 233,729 patients with history of MBS. The MBS group had about 52% reduced odds of admission for AMI compared to the non-MBS group (adjusted odd ratio: .477, 95% confidence interval: .454-.502, P value <.001). In addition, the odds of STEMI and NSEMI were significantly lower in the MBS group in comparison to the non-MBS group. Also, the MBS group had significantly lower odds of CABG, PCI, and thrombolysis compared to the non-MBS group. In addition, in patients with AMI, MBS was associated with lower in-hospital mortality (adjusted odd ratio: .627, 95% confidence interval: .469-.839, P value = .004), length of hospital stays, and total charges. CONCLUSIONS: History of MBS is significantly associated with reduced risk of admission for AMI including STEMI and NSTEMI, as well as the, need for coronary revascularization such as PCI and CABG.

Partial-Cost Analysis and Economic Impact of Ambulatory Coronary Angioplasty in a Private Hospital in the Caribbean: Análisis Parcial de Costos e Impacto Económico de la Angioplastia Coronaria Ambulatoria en un Hospital Privado del Caribe.

OBJECTIVES: This study aimed to assess direct costs of percutaneous coronary intervention (PCI) without hospital admission versus PCI with hospital admission longer than 24 hours in a private hospital-institutional perspective in the Dominican Republic in 2022. METHODS: This study has a comparative approach based on a prospective cross-sectional partial-cost analysis. We evaluated the direct costs of 10 patients from PCI without hospital admission approach and 10 patients from a hospital admission longer than 24 hours as a control group. We used a "first-come-first-served" approach from December 2021 to March 2022. The analysis used the electronic invoice generated for each patient. RESULTS: PCI without hospital admission approach represents $472.56 in patient savings, equivalent to a cost reduction of 12.5%. The subcosts analysis showed the pharmacy section as the main driver of the overall cost difference. CONCLUSIONS: PCI without hospital admission was economically cost-saving compared with the control approach in direct costs in the Dominican perspective. The economic benefit is substantial and compliments the ease of use. This analysis may lead to improvements in institutional management of resources and can potentially be adapted to other health systems in the region.

Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV: A Systematic Review and Meta-Analysis.

Importance: Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. Objective: To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Data Sources: Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Study Selection: Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data Extraction and Synthesis: Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. Main Outcome and Measures: The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. Results: A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and ß-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). Conclusions and Relevance: These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

Geospatial epidemiology of coronary artery disease treated with percutaneous coronary intervention in Crete, Greece

Coronary artery disease (CAD) constitutes a leading cause of morbidity and mortality worldwide. Percutaneous coronary intervention (PCI) is indicated in a significant proportion of CAD patients, either to improve prognosis or to relieve symptoms not responding to optimal medical therapy. Thus the annual number of patients undergoing PCI in a given geographical area could serve as a surrogate marker of the total CAD burden there. The aim of this study was to analyze the potential, spatial patterns of PCItreated CAD patients in Crete. We evaluated data from all patients subjected to PCI at the island's sole reference centre for cardiac catheterization within a 4-year study period (2013-2016). The analysis focused on regional variations of yearly PCI rates, as well as on the effect of several clinical parameters on the severity of the coronary artery stenosis treated with PCI across Crete. A spatial database within the ArcGIS environment was created and an analysis carried out based on global and local regression using ordinary least squares (OLS) and geographically weighted regression (GWR), respectively. The results revealed significant inter-municipality variation in PCI rates and thus potentially CAD burden, while the degree and direction of correlation between key clinical factors to coronary stenosis severity demonstrated specific geographical patterns. These preliminary results could set the basis for future research, with the ultimate aim to facilitate efficient healthcare strategies planning.