"Major" Depressive Disorder, coronary heart disease, and the DSM-IV threshold problem.

Seventy-seven patients with documented coronary heart disease (CHD) were evaluated for demographic/risk factor characteristics, Major Depressive Disorder (MDD) according to the Patient's Health Questionnaire (PHQ - Diagnostic and Statistical Manual IV criteria), and emotional distress by the Symptom Checklist 90-Revised (SCL-90-R). Early age at initial diagnosis for coronary heart disease (AAID) was used as a proxy for disease malignancy because early AAID is a known predictor of early mortality. MDD was unrelated to early AAID despite being strongly associated with all the scales of the SCL-90-R. Several of the SCL-90-R scales were significantly associated with early AAID in the sample as a whole (Depression, Interpersonal Sensitivity, Anxiety, Paranoia, and Psychoticism) and after removal of the patients meeting criteria for MDD (residual N = 54). Our results suggest a new criterion for determining whether depression, or any mental disorder, is "major": onset or aggravation of serious medical illness.

Familial transmissability of early age at initial diagnosis in coronary heart disease (CHD): males only, and mediated by psychosocial/emotional distress?

In equal sized samples, a strong association between a positive Family History of Early Coronary Heart Disease (FamHx) and early Age at Initial Diagnosis (AAID) was found only for males, and thus all further analyses were restricted to males. All three scales of the self-report version of the Ketterer Stress Symptom Frequency Checklist--Revised (KSSFCR)--"AIAI" (or aggravation, irritation, anger, and impatience), Depression, and Anxiety--were associated with both a positive FamHx and early AAID. A series of regression models was used to demonstrate that the KSSFCR scales may plausibly account for 22-32% of the variance in the relationship between a positive FamHx and early AAID. Because of previously documented denial in males, the analyses were repeated in a subgroup of males for whom Spouse/Friend KSSFCRs were obtained. Spouse/Friend-reported AIAI was related to both early FamHx and early AAID, and could account for 68% of the common variance.

Frequency and prognosis of emergency coronary artery bypass grafting after percutaneous coronary intervention for acute myocardial infarction.

We evaluated the frequency and prognosis of emergency coronary artery bypass grafting (CABG) after percutaneous coronary intervention (PCI) for acute myocardial infarction in a large, multicenter registry of contemporary PCI. In this study, emergency CABG occurred in 2% of cases, and was associated with high in-hospital mortality (20%) and with a high incidence of stroke (8%), renal failure requiring dialysis (8.3%), and bleeding (63.3%).

The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions.

The past decade has been characterized by increased scrutiny of outcomes of surgical and percutaneous coronary interventions (PCIs). This increased scrutiny has led to the development of regional, state, and national databases for outcome assessment and for public reporting. This report describes the initial development of a regional, collaborative, cardiovascular consortium and the progress made so far by this collaborative group. In 1997, a group of hospitals in the state Michigan agreed to create a regional collaborative consortium for the development of a quality improvement program in interventional cardiology. The project included the creation of a comprehensive database of PCIs to be used for risk assessment, feedback on absolute and risk-adjusted outcomes, and sharing of information. To date, information from nearly 20,000 PCIs have been collected. A risk prediction tool for death in the hospital and additional risk prediction tools for other outcomes have been developed from the data collected, and are currently used by the participating centers for risk assessment and for quality improvement. As the project enters into year 5, the participating centers are deeply engaged in the quality improvement phase, and expansion to a total of 17 hospitals with active PCI programs is in process. In conclusion, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium is an example of a regional collaborative effort to assess and improve quality of care and outcomes that overcome the barriers of traditional market and academic competition.

Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.

This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets. Univariate predictors were identified and a multivariate logistic regression model was developed. The MRCD was calculated for each patient as: MRCD = 5 ml x body weight (kilograms)/serum creatinine (milligrams per deciliter). Predictive accuracy was assessed by receiver-operating characteristic curve analysis. In the development set, 41 patients (0.44%) developed NRD with a subsequent in-hospital mortality rate of 39.0%. NRD increased with worsening baseline renal dysfunction. Other risk factors included peripheral vascular disease, diabetes mellitus, congestive heart failure, and cardiogenic shock. There was a direct relation between the number of risk factors and NRD. After adjustment for baseline risk factors, MRCD was the strongest independent predictor of NRD (adjusted odds ratio 6.2, 95% confidence interval 3.0 to 12.8). NRD and in-hospital mortality were both significantly higher in patients who exceeded the MRCD compared with patients who did not (p <0.001). In conclusion, NRD following PCI is a rare complication with a poor prognosis. Baseline clinical characteristics identify patients at greatest risk for NRD. Optimization of procedural variables such as timing of the intervention relative to the diagnostic catheterization, staging coronary procedures, or dosing within the MRCD may help reduce the risk of this complication in high-risk patients. A risk prediction tool for NRD with guidelines for prevention is presented.

Spontaneous closure of a perforation-induced coronary artery pseudoaneurysm.

We describe an unusual case of a coronary perforation presenting as a large pseudoaneurysm. An elderly woman who had undergone percutaneous coronary intervention several months earlier presented with shortness of breath. Cardiac catheterization revealed a large pseudoaneurysm arising from the proximal circumflex artery. At follow-up angiography a few days later, the pseudoaneurysm had spontaneously closed. In the discussion, we describe the incidence and treatment of this rare complication.

The big mush: psychometric measures are confounded and non-independent in their association with age at initial diagnosis of Ischaemic Coronary Heart Disease.

The present study uses early diagnosis of ischaemic coronary heart disease (ICHD) as a proxy for disease malignancy in testing the statistical strength of association, and uniqueness/confounding, of several psychometric scales that have previously been found to prospectively predict death in cardiac samples (Beck Depression Inventory, Crown-Crisp Phobic Anxiety Scale, Type D Scale & Ketterer Stress Symptom Frequency Checklist). Eighty-three patients (no. of females = 35) with documented ICHD were assessed for traditional and psychometric risk factors. The psychometric risk factors were moderately to strongly intercorrelated, and strongly confounded in their relationship to age at initial diagnosis. In a stepwise multiple regression, only the AIAI (aggravation, irritation, anger and impatience) scale of the Ketterer Stress Symptom Frequency Checklist (KSSFC) survived as a predictor of age at initial diagnosis (P = 0.016). In a subgroup of the sample for whom the Spouse/Friend Version of the KSSFC was received (n = 58, or 70%), spouse/friend reported AIAI survived as the only predictor (P = 0.010). While present results need replication in a prospective study of diagnosed ICHD patients for all important clinical outcomes, only one psychometric screening instrument may be necessary to identify patients in need of treatment.