Complete revascularization in stable multivessel coronary artery disease: A real world analysis from the British Columbia Cardiac Registry.

BACKGROUND: More than half of patients undergoing percutaneous coronary intervention (PCI) have multivessel disease (MVD). The prognostic significance of PCI in stable patients has recently been debated, but little data exists about the potential benefit of complete revascularization (CR) in stable MVD. We investigated the prognostic benefit of CR in patients undergoing PCI for stable disease. METHODS: We compared CR versus incomplete revascularization (IR) in 8,436 patients with MVD. The primary outcome was all-cause mortality at 5 years. RESULTS: A total of 1,399 patients (17%) underwent CR during the index PCI procedure for stable disease. CR was associated with lower mortality (6.2 vs. 10.7%, p < .001) and lower repeat revascularization at 5 years (12.7 vs. 18.4%, p < .001). Multivariable-adjusted analyses indicated that CR was associated with lower mortality (HR = 0.73, 95% CI: 0.58-0.91, p = .005) and repeat revascularization at 5 years (HR = 0.78, 95% CI: 0.66-0.93, p = .005). These findings were also confirmed in propensity-matched cohorts. Subgroup analyses indicated that CR conferred survival in older patients, male patients, absence of renal disease, greater angina (CCS Class III-IV) and heart failure (NYHA Class III-IV) symptoms, and greater burden of coronary disease. In sensitivity analyses where patients with subsequent repeat revascularization events were excluded, CR remained a strong predictor for lower mortality (HR = 0.69, 95% CI: 0.54-0.89, p = .004). CONCLUSIONS: In this study of stable patients with MVD, CR was an independent predictor of long-term survival. This benefit was specifically seen in higher risk patient groups and indicates that CR may benefit selected stable patients with MVD.

Coronary Angiography and Revascularization Following Coronary Artery Bypass Grafting in British Columbia: Incidence, Predictors and Longer-term Outcomes.

BACKGROUND: Coronary artery bypass grafting (CABG) is established treatment for subsets of coronary artery disease (CAD). Observational data have characterised significant progression of native coronary as well as graft vessel disease during longer-term follow-up, potentially reducing the benefit of CABG. We sought to assess longer-term outcomes following CABG by determining rates of repeat coronary angiography, revascularization procedures, and survival. METHODS: Data for all patients undergoing isolated CABG in British Columbia between 2001 and 2009 inclusive, and with follow-up until the end of 2013, were retrieved from the British Columbia Cardiac Registry. Cox proportional hazard regression and competing risk regression were performed for survival and subsequent cardiac procedures (coronary angiography, percutaneous coronary intervention [PCI] or repeat CABG). RESULTS: Data were available from 17,316 patients with a mean age at index CABG of 65.7 ± 9.8 years. At a median follow-up of 8.5 (range 4.0 to 12.9) years, 3185 patients (18.4%) had died, 3135 (18.1%) underwent repeat coronary angiography with or without PCI or repeat CABG, and 11,557 (66.7%) had survived without additional procedures. Of those who underwent angiography, 1459 patients (46.5%) underwent further revascularization. In multivariate analysis, the strongest predictors of long-term mortality were dialysis dependency and age >75, whereas left internal mammary artery utilization and aspirin therapy were protective. Repeat revascularization predicted survival (adjusted hazard ratio 0.76; 95% confidence interval, 0.63-0.92; P = 0.004), whereas angiography alone did not. CONCLUSIONS: Following CABG, patients frequently undergo repeat coronary angiography. Although only a minority of patients receive further revascularization, this appears to be associated with longer-term survival.

The prognostic impact of revascularization strategy in acute myocardial infarction and cardiogenic shock: Insights from the British Columbia Cardiac Registry.

BACKGROUND: In patients with acute myocardial infarction (AMI) and cardiogenic shock (CS), percutaneous coronary intervention (PCI) of the culprit vessel is associated with improved outcomes. A large majority of these patients have multivessel disease (MVD). Whether or not PCI of non-culprit disease in the acute setting improves outcomes continues to be debated. We evaluated the prognostic impact of revascularization strategy for patients presenting with AMI and CS. METHODS: We compared culprit vessel intervention (CVI) versus multivessel intervention in 649 patients with AMI, CS, and MVD enrolled in the British Columbia Cardiac Registry. We evaluated mortality at 30 days and 1 year. RESULTS: CVI was associated with lower mortality at 30 days (23.7% vs. 34.5%, P = 0.004) and 1 year (32.6% vs. 44.3%, P = 0.003). CVI was an independent predictor for survival at 30 days (HR = 0.63, 95% CI: 0.45-0.88, P = 0.009) and 1 year (HR = 0.72, 95% CI: 0.54-0.96, P = 0.027). These findings were confirmed in propensity-matched cohorts. Subgroup analyses indicated that CVI was associated with lower mortality in patients aged <80 years; non-diabetics; and those presenting with ST-elevation MI. When analyzing non-culprit anatomy, PCI of non-culprit LAD disease was associated with higher 1-year mortality (HR = 1.51, 95% CI: 1.13-2.01, P = 0.006), primarily with non-culprit proximal LAD disease (HR = 1.82, 95% CI: 1.20-2.76, P = 0.005). However, PCI of non-culprit non-proximal LAD, LCx, and RCA disease was not associated with mortality. CONCLUSIONS: In patients with AMI and CS, a strategy of CVI appears to be associated with lower mortality. These findings are consistent with recently published randomized-controlled trial data.

Radial artery pseudoaneurysms after transradial cardiac catheterisation.

BACKGROUND: Although uncommon, radial artery access site complications are likely to become more frequent with the increased adoption of transradial cardiac catheterisation. There is a lack of data regarding the incidence and clinical features of radial artery pseudoaneuryms. We aimed to describe the incidence, clinical features and management of radial artery pseudoaneurysms in a high-volume transradial cardiac catheterisation centre. PATIENTS AND METHODS: We performed a search of the Vancouver Island Health Authority medical imaging database from 1st Jan 2008 to April 2012 looking for all radial and femoral artery pseudoaneuryms occurring after cardiac catheterisation. Hospital charts were reviewed to determine patient and procedural characteristics as well as management and outcome. RESULTS: There were a total of 14,968 coronary procedures performed over the four year search period, of which 13,216 (88%) were trans-radial. The incidence of radial artery pseudoaneurysm after cardiac catheterisation was 0.08%, and did not differ between transradial diagnostic angiography and PCI (0.07% vs 0.08%; P = 0.90). In contrast, the incidence of femoral artery pseudoaneurysm was higher, at 1.4% (P < 0.0001). Patients with radial pseudoaneurysms were generally elderly, with a median age of 77 years, and there were no gender differences. Only one patient had received a glycoprotein IIb/IIIa inhibitor, whilst two received warfarin post-procedure. The majority of cases (80%) were treated with surgical repair. CONCLUSIONS: We have demonstrated that radial artery pseudoaneuryms are a rare but important complication of transradial cardiac catheterisation, with patients generally requiring surgical repair. Most patients were elderly, but surprisingly only a minority were anti-coagulated with warfarin.

Non-red blood cell transfusion as a risk factor for mortality following percutaneous coronary intervention.

BACKGROUND: Bleeding following percutaneous coronary intervention (PCI) is common and may lead to transfusion and death. Although previous work has examined the effect of red blood cell (RBC) transfusion in patients with coronary disease, no study had investigated whether transfusion of non-RBC components was associated with mortality following PCI. METHODS: All subjects transfused in the 10 days following PCI were identified using the British Columbia Cardiac and Central Transfusion Registries. Patients undergoing cardiac surgery following PCI were excluded as transfusion was assumed to be due to surgical related bleeding. Transfusion products were categorised as RBC and non-RBC comprising platelets, plasma and cryoprecipitate. Blood product use was compared according to thirty day mortality using multivariate regression and propensity adjustment for confounding variables. RESULTS: From a total of 32,580 patients who underwent PCI, 952 patients received at least 1 blood product within 10 days of PCI. Non-RBC transfusion occurred more commonly in the cohort of transfused patients dying within 30 days (p<0.001). After adjustment for baseline risk, transfusion of plasma/cryoprecipitate (HR 5.17; 95% C.I. 2.87-9.32, p<0.001) and platelets (HR 2.13; 95% C.I. 1.10-4.13, p=0.03) was associated with increased 30 day mortality. In a propensity risk adjusted model, transfusion of plasma/cryoprecipitate and RBC transfusion volume remained as significant predictors of 30-day mortality (p<0.001). CONCLUSIONS: Transfusion following PCI appears to be associated with an increased risk of death within 30 days. We now report that transfusion with plasma rich non-RBC products may confer an additional mortality risk to patients undergoing PCI.

Chronic kidney injury in patients after cardiac catheterisation or percutaneous coronary intervention: a comparison of radial and femoral approaches (from the British Columbia Cardiac and Renal Registries).

BACKGROUND: Acute kidney injury (AKI) is a well-recognised complication of cardiac catheterisation and percutaneous coronary intervention (PCI). However, the incidence of chronic kidney disease (CKD) after catheterisation and PCI has not been fully evaluated. A number of risk factors have been implicated in the development of AKI following cardiac catheterisation. Transradial access could lead to a lower incidence of CKD after catheterisation or PCI because of less catheter contact with aortic atheroma, and reduced potential for atheroembolism. OBJECTIVE: To determine the incidence of CKD onset and its association with arterial access in patients after cardiac catheterisation or PCI. METHODS AND RESULTS: Linkages between the British Columbia (BC) Cardiac Registry (N=69 214) patients who underwent catheterisation or PCI between 1999 and 2005 and the BC Renal Database were determined. Within 6 months after the cardiac procedure 0.4% of patients developed dialysis dependency, 0.2% in the transradial versus 0.4% in the transfemoral group (p<0.0001); 0.3% of patients developed stage 4 or 5 CKD, 0.1% in the transradial versus 0.4% in the transfemoral group (p<0.0001); 0.9% of patients developed new CKD, 0.2% in the transradial versus 1.2% in the transfemoral group (p<0.0001). After adjusting for baseline characteristics the femoral access site had an OR of 4.36 (95% CI 2.48 to 7.66) for the development of the composite end point of new dialysis, new stage 4 or 5 CKD or new CKD. CONCLUSIONS: In this large database of current practice coronary catheterisation and PCI, the incidence of CKD onset within 6 months of the procedure was 0.9%. The transradial access site is associated with less CKD than the femoral approach.

Red blood cell storage duration and mortality in patients undergoing percutaneous coronary intervention.

BACKGROUND: Blood transfusion has been associated with an increased mortality in patients undergoing percutaneous coronary intervention (PCI). Although the reasons for this remain unclear, it may be related to the structural and functional changes occurring within red blood cells (RBCs) during storage. We investigated whether RBC storage duration was associated with mortality in patients requiring transfusion after PCI. METHODS: We collected data on all RBC transfusions occurring within 10 days of PCI (excluding those related to cardiac surgery) using the British Columbia Cardiac Registry and Central Transfusion Registry. Transfusion details were analyzed according to 30-day survival. RESULTS: From a total of 32,580 patients undergoing PCI, 909 (2.8%) patients received RBCs with a mean storage duration of 25 +/- 10 days. In these 909 patients, mean transfusion volumes were lower in survivors (2.8 +/- 2.1 vs 3.8 +/- 2.9 U, P = .002) than those who died within 30 days. In a multivariate analysis to adjust for baseline risk, mean RBC storage age (HR 1.02 [95% CI 1.01-1.04], P = .002) and transfusion volume (HR 1.26 [95% CI 1.18-1.34], P < .001) both predicted 30-day mortality. Transfused patients who received only older blood (RBC min age >28 days) appeared to be at greater risk of death (HR 2.49 [95% CI 1.45-4.25], P = .001). CONCLUSION: Red blood cell transfusion is associated with increased 30-day mortality in patients undergoing PCI. Although current transfusion practice permits RBC storage for up to 42 days, the use of older red cells may pose an additional hazard to this patient group.

Body mass index, periprocedural bleeding, and outcome following percutaneous coronary intervention (from the British Columbia Cardiac Registry).

The incidence of obesity is increasing throughout the industrialized world and is a major public health concern. Some studies have shown a paradoxical protective effect of moderate obesity on outcome after percutaneous coronary intervention (PCI). The association between bleeding, body mass, and outcome is not well established and formed the basis for the present study, which examined major bleeding rates and mortality after PCI in British Columbia during a 6-year period. We identified 38,346 consecutive patients from the British Columbia Cardiac Registry who underwent PCI from 1999 to 2005. Data were cross-referenced to determine outcomes at 30 days and 1 year. Information about bleeding after PCI was obtained by cross-referencing the British Columbia Cardiac Registry with the Central Transfusion Registry. Baseline patient characteristics were compared among body mass index (BMI) categories. A clear bimodal (U-shaped) relation was seen between BMI and mortality. BMI was a potent independent predictor of mortality, particularly evident in the underweight (BMI <18.5 kg/m(2); odds ratio [OR] 1.98, 95% confidence interval [CI] 1.6 to 2.5, p <0.0001) and morbidly obese (> or =40 kg/m(2); OR 1.61, 95% CI 1.28 to 2.08, p <0.0001) groups. Periprocedural transfusion was also associated with adverse outcome (OR 2.86, 95% CI 2.52 to 3.25, p <0.0001). Transfusion adopted the same bimodal distribution across the entire cohort. Emergent PCI and femoral access were procedural factors associated with outcome. In conclusion, major bleeding conferred an adverse long-term prognosis after PCI. Identifying demographic and procedural factors that increase risk will facilitate more accurate risk scoring of patients undergoing PCI and allow targeted bleeding-avoidance strategies. Body mass and female gender identified subgroups at much higher risk of bleeding after PCI, an observation that merits further study.

Magnesium sulphate during transradial cardiac catheterization: a new use for an old drug?

OBJECTIVE: To assess the effect of intra-arterial magnesium on the radial artery during transradial cardiac catheterization. BACKGROUND: Transradial coronary angiography has become popular in the last decade and offers several advantages over transfemoral angiography. Radial artery spasm is a major limitation of this approach, and a vasodilatory cocktail is usually given. The aim of this study was to examine the effect of magnesium sulphate on the radial artery during cardiac catheterization. METHODS: This was a prospective, double-blind, randomized trial of 86 patients undergoing radial catheterization. Patients were randomized to receive magnesium sulphate (150 mg) or verapamil (1 mg) into the radial sheath. Radial dimensions were assessed using Doppler ultrasound. The primary endpoint of the study was a change in radial artery diameter following administration. Secondary endpoints included operator-defined radial artery spasm and patient pain. RESULTS: Following administration of the study drug, there was an increase in radial artery diameter in both groups (p < 0.01), although the increase seen was greater in the group receiving magnesium (magnesium 0.36 +/- 0.03 mm; verapamil 0.27 +/- 0.03 mm; p < 0.05). Administration of verapamil resulted in a fall in mean arterial pressure (MAP) (change in MAP -6.6 +/- 1.4 mmHg; p < 0.01), whereas magnesium did not have a hemodynamic effect. Severe arm pain (pain score > 5) was observed in 14 (30%) patients receiving verapamil and 9 (27%) receiving magnesium (p = NS). CONCLUSION: This study demonstrates that magnesium is a more effective vasodilator when compared to verapamil, with a reduced hemodynamic effect, and is equally effective at preventing radial artery spasm. As such, the use of this agent offers distinct advantages over verapamil during radial catheterization.

Safety of same day discharge radial PCI in patients under and over 75 years of age.

To check the safety of same day discharge radial PCI in patients under or over 75 years of age. A total of 943 patients who had same day discharge radial PCI between April 1998 and March 2001 were contacted. Patient health status, entry site complications, and repeat interventions during the first month after the procedure were compared in patients under 75 years of age (< 75) with those 75 or over (> or = 75). Responses were received from 811 patients (694 aged < 75 and 117 aged > or = 75 years). Two hundred and thirty-eight patients (34.3%) aged < 75 years and 36 patients (30.7%) aged > or = 75years reported one or more access site complications during the first 24 hours postdischarge, and 105 (15.1%) and 12 patients (10.3%), respectively, during the first month, (P > 0.05). However, all complications in both groups were minor and none of the patients required admission to the hospital. During the first 24 hours postdischarge only one patient (0.1%) aged < 75 years had a repeat angiogram showing a normal patent vessel, while during the first month 4 patients (0.6%) aged < 75 years and none aged > or = 75 years had target vessel closure. Out of the 132 patients who did not respond to our questionnaire, 1 patient aged < 75 and 1 patient aged > or = 75 years had subacute stent thrombosis within a month and died. There were no major entry site complications, and target vessel closure (0.6% versus 0.7%) was similar in patients aged < 75 and > or = 75 years. Thus, same day discharge radial PCI is safe in patients 75 years old or over.

Day procedure intervention is safe and complication free in higher risk patients undergoing transradial angioplasty and stenting. The discharge study.

OBJECTIVES: To assess the timeframe of postprocedural complications following transradial percutaneous intervention in selected nonlow-risk risk patients as a feasibility study for same day discharge. BACKGROUND: Percutaneous coronary intervention (PCI) is traditionally performed as an inpatient procedure. Transradial access with its lower complication rate facilitates safe and same day discharge. We hypothesize that with current standards of pharmacotherapy and intervention, complications post transradial percutaneous coronary angioplasty even in a nonlow-risk patient cohort will be evident within 6 hr or occur more than 24 hr post procedure. Under these circumstances, overnight stay results in no improvement in patient safety. METHODS: 2,189 patients underwent transradial PCI at our institution between January 2005 and June 2006. Of these 1,174 were assessed as intermediate or high risk and admitted postprocedure. The remaining 1,015 were assessed as low risk and discharged the day of procedure. All 1,174 inpatients were entered into our study database. Information was collected on patient demographics, angiographic characteristics, post procedural complications, and timing of post procedural events. RESULTS: 1,543 ACC type B2 or C lesions were treated in 1,174 patients. All post-procedural complications were identified within 6 hr of the intervention or occurred more than 24 hr later when patients would have been discharged according to overnight admission protocols. CONCLUSIONS: Day case transradial percutaneous intervention with a 6-hr period of post procedure observation is a safe and feasible practice. The presence of higher-risk features should not be considered an absolute indication for overnight admission in patients considered clinically appropriate for discharge.

Vascular communications of the hand in patients being considered for transradial coronary angiography: is the Allen's test accurate?

OBJECTIVES: The purpose of this study was to assess the accuracy of the Allen's test (AT) in predicting hand ischemia in patients undergoing transradial coronary angiography. BACKGROUND: Patients with poor vascular communications between the radial artery (RA) and ulnar artery (UA), as indicated by an abnormal AT, are usually excluded from transradial coronary angiography to avoid ischemic hand complications. METHODS: Over a four-month period, patients undergoing coronary angiography were screened for AT time. Circulation in the RA, UA, principal artery of the thumb (PAT), and thumb capillary lactate were measured before and after 30 min of RA occlusion. RESULTS: Fifty-five patients were studied (20 normal, 15 intermediate, 20 abnormal). Three patients with an abnormal AT were excluded, owing to absence of detectible flow in the distal UA. Patients with an abnormal AT were all men, had a larger RA (3.4 vs. 2.8 mm; p <0.001), and smaller UA (1.9 vs. 2.5 mm; p <0.001), compared with patients with a normal AT. After 30 min of RA occlusion in patients with abnormal AT, blood flow to the PAT improved (3.2 to 7.7 cm/s; p <0.001) yet remained reduced relative to patients with normal AT (7.7 vs. 21.4 cm/s; p <0.001. Thumb capillary lactate was elevated in patients with an abnormal AT (2.0 vs. 1.5 mmol/l; p = 0.019). CONCLUSIONS: After 30 min of RA occlusion, patients with an abnormal AT showed significantly reduced blood flow to the thumb and increased thumb capillary lactate (compared with patients with a normal AT) suggestive of ischemia. Transradial cardiac catheterization should not be performed in patients with an abnormal AT.

A comparison of the radial and the femoral approach in vein graft PCI. A retrospective study.

BACKGROUND: Transradial PCI is a safe and effective method of percutaneous revascularization. However, there is limited data on the efficacy of the transradial approach for saphenous vein graft (SVG) PCI. METHODS: We studied 334 patients who underwent SVG PCI between January 2000 and December 2003, and compared the radial (132 patients) and the femoral (202 patients) approach. RESULTS: Mean EF (55.6+/-18.6% radial versus 58.1+/-16.8% femoral), lesion location (proximal, mid, distal: 22.6/50.6/26.7% versus 22.6/44.5/32.9% respectively) and lesion type (B1/B2/C: 3.4/4.1/92.5% versus 0.4/3.1/96.5%) were similar in both groups (P>0.05). Five patients had a failed radial attempt (3.8%) and were switched to the femoral approach. Mean fluoroscopy time (20.4+/-12.2 versus 18.4+/-10.2 min), procedural time (60.0+/-27.2 versus 61.6+/-24.9 min) and the use of contrast (223+/-91 versus 234+/-91 ml) IIB/IIIA inhibitors (27.2 versus 33.2%), and stenting (81.5 versus 81.3%) were similar in both groups, whereas 5 or 6 French sheaths were used more often in the radial group (83.4 versus 64.9%, P<0.01). Angiographic success (93.9 versus 92.9%), in hospital MACE (radial:5 MI (3.8%) versus femoral: 1 death (0.5%) and 7 MI (3.5%) and major vascular complications (0.7 versus 0.5%) were also similar. CONCLUSIONS: The radial approach in SVG PCI is as fast and successful as the femoral.

Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions.

This study was designed to evaluate safety and effectiveness of the 0.9 mm excimer laser coronary catheter with increased laser parameters. We report a prospective trial of 100 calcified and/or balloon-resistant lesions where a new 0.9 mm excimer laser catheter was used at standard or higher energy level to facilitate angioplasty. Standard in-hospital clinical and angiographic parameters were collected and measured. Laser technical success was obtained in 87 lesions (92%), procedural success was reached in 88 lesions (93%), and clinical success in 82 lesions (86%). Increased laser parameters were used for 29 resistant lesions. This new 0.9 mm excimer laser coronary catheter using higher energy parameters seems to be safe and effective for management of calcified and nondilatable lesions.