Rates of Elective Percutaneous Coronary Intervention in England and Wales: Impact of COURAGE and ORBITA Trials.

Background There are limited data about how COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trials have impacted percutaneous coronary intervention (PCI) practices at regional or national level. We evaluated temporal trends in elective PCI rates for stable angina and, specifically, examined the impact of the COURAGE and ORBITA trials on PCI practices in England and Wales. Methods and Results We used national PCI data comprising >1.2 million patients undergoing PCI between January 2006 and December 2019. Patient demographics, procedural details, and clinical outcomes were analyzed, and temporal trends in PCI rates for stable angina were compared before and after the publication of the COURAGE and ORBITA trials. Of 1 245 802 PCI procedures, 430 248 (34.5%) were performed for stable angina. Over the study period, the number of elective PCI procedures per year (30 823 in 2006 to 34 103 in 2019) and per 100 000 population estimates (50.7 in 2006 to 58.4 in 2019) remained stable. The proportion of patients undergoing elective PCI without angina symptoms almost doubled from 5.1% to 9.7%. The incidence rate of elective PCI volume after the COURAGE trial, published in 2007, was not different from before the trial was published (incidence rate ratio, 1.06 [95% CI, 0.69-1.62]). It also remained stable after the publication of the ORBITA trial in 2017 (incidence rate ratio, 0.96 [95% CI, 0.74-1.23]). Conclusions In this nationwide analysis, rates of elective PCI for stable angina remained stable over 14 years. Publication of the COURAGE and ORBITA trials had no impact on elective PCI activity.

Differential Impact of Type 1 and Type 2 Diabetes Mellitus on Outcomes Among 1.4 Million US Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: The aim was to determine the impact of diabetes mellitus (DM) on outcomes after percutaneous coronary intervention (PCI). There is limited data on the impact of DM and its subtypes among patients who underwent PCI during hospitalization. METHODS: All PCI hospitalizations from the National Inpatient Sample (October 2015-December 2018) were stratified by the presence and subtype of DM. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in type 1 DM (T1DM) and type 2 DM (T2DM) compared to no-DM. RESULTS: Out of 1,363,800 individuals undergoing PCI, 12,640 (0.9%) had T1DM and 539,690 (39.6%) had T2DM. T1DM patients had increased aOR of major adverse cardiovascular and cerebrovascular events (MACCE) (1.26, 95%CI 1.17-1.35), mortality (1.56, 95%CI 1.41-1.72), major bleeding (1.63, 95%CI 1.45-1.84), and stroke (1.75, 95%CI 1.51-2.02), while T2DM patients had only increased aOR of MACCE (1.02, 95%CI 1.01-1.04), mortality (1.10, 95%CI 1.08-1.13) and stroke (1.22, 95%CI 1.18-1.27), compared to no-DM patients. However, both T1DM and T2DM had lower aOR of cardiac complications (0.87, 95%CI 0.77-0.97 and 0.87, 95%CI 0.85-0.89, respectively), in comparison to no-DM patients. When accounting for the indication, both DM subgroups had higher aOR of MACCE, mortality, and stroke compared to no-DM patients in the acute coronary syndrome setting (p < 0.001, for all), while only increased aOR of stroke (1.59, 95%CI 1.17-2.15 for T1DM and 1.12, 95%CI 1.05-1.20 for T2DM) persisted in the elective setting. CONCLUSIONS: Patients with DM who have undergone PCI during hospitalization are more likely to experience adverse in-hospital outcomes, and T1DM patients are a particularly high-risk cohort.

Trends of Sex Differences in Clinical Outcomes After Myocardial Infarction in the United States.

BACKGROUND: Female patients have been shown to experience worse clinical outcomes after acute myocardial infarction (AMI) compared with male patients. However, it is unclear what trend these differences followed over time. METHODS: Data from patients hospitalized with AMI between 2004 and 2015 in the National Inpatient Sample were retrospectively analyzed, stratified according to sex. Multivariable logistic regression analyses were performed to examine the adjusted odds ratios (aORs) of invasive management and in-hospital outcomes according to sex. The Mantel-Haenszel extension of the χ2 test was performed to examine the trend of management and in-hospital outcomes over the study period. RESULTS: Of 7,026,432 AMI hospitalizations, 39.7% (n = 2,789,494) were women. Overall, women were older (median: 77 vs 70 years), with a higher prevalence of risk factors such as diabetes, hypertension, and depression. Women were less likely to receive coronary angiography (aOR, 0.92; 95% confidence interval [CI], 0.91-0.93) and percutaneous coronary intervention (aOR, 0.82; 95% CI, 0.81-0.83) compared with men. Odds of all-cause mortality were higher in women (aOR, 1.03; 95% CI, 1.02-1.04; P < 0.001) and these rates have not narrowed over time (2004 vs 2015: aOR, 1.07 [95% CI, 1.04-1.09] vs 1.11 [95% CI, 1.07-1.15), with similar observations recorded for major adverse cardiovascular and cerebrovascular events. CONCLUSIONS: In this temporal analysis of AMI hospitalizations over 12 years, we showed lower receipt of invasive therapies and higher mortality rates in women, with no change in temporal trends. There needs to be a systematic and consistent effort toward exploring these disparities to identify strategies to mitigate them.

CONTEXTE: Il a été démontré que les femmes présentent de moins bons résultats cliniques après un infarctus aigu du myocarde (IAM) que les hommes. Cependant, la tendance de ces différences dans le temps n'est pas claire. MÉTHODOLOGIE: Les données de la National Inpatient Sample sur les patients hospitalisés pour un IAM entre 2004 et 2015 ont été analysées rétrospectivement, stratifiées selon le sexe. Des analyses de régression logistique multidimensionnelles ont été effectuées pour examiner les rapports de cotes ajustés (RCA) de la prise en charge par un traitement invasif et des résultats obtenus en milieu hospitalier en fonction du sexe. Le test du χ2 étendu de Mantel-Haenszel a été effectué pour examiner la tendance de la prise en charge et des résultats en milieu hospitalier au cours de la période d'étude. RÉSULTATS: Sur 7 026 432 patients hospitalisés pour un IAM, 39,7 % (n = 2 789 494) étaient des femmes. Dans l'ensemble, les femmes étaient plus âgées (âge médian : 77 vs 70 ans), avec une plus forte prévalence de facteurs de risque comme le diabète, l'hypertension et la dépression. Les femmes étaient moins susceptibles que les hommes de subir une coronarographie (RCA : 0,92; intervalle de confiance [IC] à 95 % : 0,91-0,93) et une intervention coronarienne percutanée (RCA : 0,82; IC à 95 % : 0,81-0,83). Les probabilités de mortalité toutes causes confondues étaient plus élevées chez les femmes (RCA : 1,03; IC à 95 % : 1,02-1,04; p < 0,001), et ces taux n'ont pas diminué avec le temps (2004 vs 2015 : RCA : 1,07 [IC à 95 % : 1,04-1,09] vs 1,11 [IC à 95 % : 1,07-1,15), des observations similaires étant consignées pour les événements cardiovasculaires et vasculaires cérébraux majeurs. CONCLUSIONS: Dans cette analyse temporelle des hospitalisations pour IAM sur 12 ans, nous avons montré que les femmes subissaient moins de traitements invasifs et présentaient des taux de mortalité plus élevés, sans changement dans les tendances temporelles. Il faut un effort systématique et cohérent pour explorer ces disparités afin de cibler des stratégies pour les atténuer.

Sex Disparities in the Choice of Cardiac Resynchronization Therapy Device: An Analysis of Trends, Predictors, and Outcomes.

BACKGROUND: There is limited evidence on the influence of sex on the decision to implant a cardiac resynchronization therapy device with pacemaker (CRT-P) or defibrillator (CRT-D) and the existence of sex-dependent differences in complications that may affect this decision. METHODS: All patients undergoing de novo CRT implantation (2004-2014) in the United States National Inpatient Sample were included and stratified by device type (CRT-P and CRT-D). Multivariable logistic regression models were conducted to assess the association of female sex with receipt of CRT-D and periprocedural complications. RESULTS: Out of 400,823 weighted CRT procedural records, the overall percentages of women undergoing CRT-P and CRT-D implantations were 41.5% and 27.8%, respectively, and these percentages increased compared with men over the study period. Women were less likely to receive CRT-D (odds ratio 0.66, 95% confidence interval 0.64-0.67), and this trend remained stable throughout the study period (P = 0.06). Furthermore, compared with men, women were associated with increased odds of procedure-related complications (bleeding, thoracic, and cardiac) in the CRT-D group but not in the CRT-P group. Factors such as atrial fibrillation, malignancies, renal failure, advanced age (> 60 years), and admission to nonurban/small hospitals favoured the receipt of CRT-P over CRT-D, whereas history of ischemic heart disease, cardiac arrest ,or ventricular arrhythmias favoured the receipt of CRT-D over CRT-P. CONCLUSIONS: Women were associated with persistently reduced odds of receipt of CRT-D compared with men over an 11-year period. This study identifies important factors that predict the choice of CRT device offered to patients in the United States.

Trends of Sex Differences in Outcomes of Cardiac Electronic Device Implantations in the United States.

BACKGROUND: The disparity in outcomes of cardiac electronic device implantations between sexes has been previously demonstrated in device-specific cohorts (eg, implantable cardioverter-defibrillators [ICDs]). However, it is unclear whether sex differences are present with all types of cardiac implantable electronic devices (CIEDs) and, if so, what the trends of such differences have been in recent years. METHODS: With the use of the National Inpatient Sample, all hospitalizations from 2004 to 2014 for de novo implantation of permanent pacemakers, cardiac resynchronization therapy with or without a defibrillator, and ICDs were analyzed to examine the association between sex and in-hospital acute complications of CIED implantation. RESULTS: Out of 2,815,613 hospitalizations for de novo CIED implantation, 41.9% were performed on women. Women were associated with increased adjusted odds (95% confidence interval) of adverse procedural complications (major adverse cardiovascular complications: 1.17 [1.16-1.19]; bleeding: 1.13 [1.12-1.15],-thoracic: 1.42 [1.40-1.44]; cardiac: 1.44 [1.38-1.50]), whereas the adjusted odds of in-hospital all-cause mortality compared with men was 0.96 (0.94-1.00). The odds of adverse complications in the overall CIED cohort were persistently raised in women throughout the study period, whereas similar odds of all-cause mortality across the sexes were observed throughout the study period. CONCLUSION: In a national cohort of CIED implantations we demonstrate that women are at an overall higher risk of procedure-related adverse events compared with men, but not at increased risk of all-cause mortality. Further studies are required to identify procedural techniques that would improve outcomes among women undergoing such procedures.

Acute Myocardial Infarction in Severe Mental Illness: Prevalence, Clinical Outcomes, and Process of Care in U.S. Hospitalizations.

BACKGROUND: Severe mental illness (SMI) is associated with increased cardiovascular mortality. We sought to examine the prevalence, clinical outcomes, and management strategy of patients with SMI presenting with acute myocardial infarction (AMI). METHODS: All AMI hospitalizations from the National Inpatient Sample were included, stratified by mental health status into 5 groups: no SMI, schizophrenia, other non-organic psychoses (ONOP), bipolar disorder, and major depression. Regression analyses were performed to assess the association (adjusted odds ratios [ORs], P ≤ 0.001 for all outcomes) between SMI subtypes and clinical outcomes. RESULTS: Of 6,968,777 AMI hospitalizations between 2004 and 2014, 439,544 patients (6.5%) had an SMI diagnosis. Although patients with schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared with those without SMI, only schizophrenic patients were at increased odds of mortality (OR, 1.10; 95% confidence interval [CI], 1.04-1.16), whereas ONOP was the only group at increased odds of stroke (OR, 1.53; 95% CI, 1.42-1.65) after multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared with those without SMI (OR, 1.11; 95% CI, 1.04-1.17). All those with SMI subtypes were less likely to receive coronary angiography and percutaneous coronary intervention, with the schizophrenia group being at least odds of either procedure (OR, 0.46; 95% CI, 0.45-0.48 and OR, 0.57; 95% CI, 0.55-0.59, respectively). CONCLUSION: Schizophrenia and ONOP are the only SMI subtypes associated with adverse clinical outcomes after AMI. However, all patients with SMI were less likely to receive invasive management for AMI, with female gender and schizophrenia diagnosis being the strongest predictors of conservative management. A multidisciplinary approach between psychiatrists and cardiologists could improve the outcomes of this high-risk population.

Effect of Concomitant Atrial Fibrillation on In-Hospital Outcomes of Non-ST-Elevation-Acute Coronary Syndrome-Related Hospitalizations in the United States.

Atrial fibrillation (AF) is the most common arrhythmia in patients presenting with acute coronary syndrome (ACS). The present study examined the rates and trends of clinical outcomes and management strategies of non-ST-elevation ACS (NSTE-ACS) related hospitalizations in the United States, in patients with concomitant AF compared with those in sinus rhythm (SR). We analyzed the "Nationwide Inpatient Sample" database (2004 to 2014) for patients with a primary discharge diagnosis of NSTE-ACS, and further stratified the cohort on the basis of diagnoses into SR and AF groups. Multivariate analysis was performed to examine the association between AF and major adverse cardiovascular and cerebrovascular events (composite of mortality, stroke, and cardiac complications) and its components. Of 4,668,737 NSTE-ACS hospitalizations, the proportions of SR and AF groups were 82.4% (3,848,202) and 17.6% (820,535), respectively. The incidence of AF increased significantly over time from 16.5% (2004) to 19.3% (2014). The AF group was at a greater risk of adverse outcomes with higher rates and adjusted relative risk (RR) of major adverse cardiovascular and cerebrovascular events (12.9% vs 5.3%; RR 1.74 [1.72, 1.75]), mortality (6.5% vs 3.3%; RR 1.12 [1.11, 1.13]), stroke (2.7% vs 1.5%; RR 1.32 [1.30, 1.34]), and bleeding (14.7% vs 8.8%; RR 1.42 [1.41, 1.43]). Furthermore, the AF group was less likely to receive coronary angiography (47.1% vs 58%) and percutaneous coronary intervention (18.7% vs 32.6%) in comparison to SR (p <0.001 for all outcomes). In conclusion, patients with concomitant AF and NSTE-ACS are less likely to be offered an invasive management strategy for their ACS and are associated with worse complications and higher mortality.

Successful treatment of a radial artery pseudoaneurysm in an octogenarian.

The transradial approach for coronary catheterisation has gained rising popularity owing to its fewer access site complications compared with the transfemoral approach. A rare but recognisable complication of the procedure is radial artery pseudoaneurysm (PSA). We report a case of radial PSA occurring 2 h following percutaneous coronary intervention in an 85-year-old woman, which was successfully treated by ultrasound-guided thrombin injection. This non-surgical technique has recently gained rising popularity as a relatively novel modality of managing radial PSA.

Renal cell carcinoma presenting as an upper gastrointestinal bleeding.

An 80-year-old man presented with melaena and anaemia of 1 week duration. This was associated with shortness of breath and an indigestion-type pain for the preceding 8 weeks. General physical examination revealed epigastric tenderness, but an otherwise soft abdomen with no organomegaly. The patient had a gastroscopy, showing a polypoidal lesion in the second part of duodenum (D2) as the bleeding point, which was managed with epinephrine injection and endoclips. This was followed by CT of the abdomen, revealing a lobulated 8 cm mass arising from the lower pole of the right kidney and invading the duodenum. The case report aims to acknowledge the possibility of direct duodenal involvement in renal cell carcinoma, which is a rare occurrence.