Rates of Intracoronary Imaging Optimization in Contemporary Percutaneous Coronary Intervention: A Report From the BMC2 Registry.

BACKGROUND: Intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) improves outcomes, yet hospital- and physician-level variabilities in ICI and its impact on ICI use in contemporary PCI remain unknown. This study was performed to evaluate hospital- and physician-level use of ICI to optimize PCI. METHODS: Using data from a large statewide registry, patients undergoing PCI between July 2019 and March 2021 were studied. The primary measure of interest was ICI (intravascular ultrasound or optical coherence tomography) optimization during PCI. A fitted hierarchical Bayesian model identified variables independently associated with ICI optimization. The performing hospital and physician were included as random effects in the model. RESULTS: Among 48 872 PCIs, ICI optimization was performed in 8094 (16.6%). Median [interquartile range] hospital- and physician-level frequencies of ICI were 8.8% [3.1%, 16.0%] and 6.1% [1.1%, 25.0%], respectively. Bayesian modeling identified left main PCI (adjusted odds ratio [aOR], 4.41; 95% credible interval [3.82, 5.10]), proximal left anterior descending artery PCI (aOR, 2.28 [2.00, 2.59]), PCI for in-stent restenosis (aOR, 1.55 [1.40, 1.72]), and surgical consult prior to PCI (aOR, 1.21 [1.07, 1.37]) as independent predictors of ICI optimization. The hospital-level median odds ratio, an estimate of the contribution of inter-hospital variability in odds of ICI use, was 3.48 (2.64, 5.04). Physician-level median odds ratio was 3.81 (3.33, 4.45). CONCLUSIONS: Substantial hospital- and physician-level variation in ICI was observed. Except for performance of left main PCI, the hospital and physician performing the PCI were more strongly associated with ICI optimization than any patient or procedural factors.

Trends and outcomes of percutaneous coronary intervention during the COVID-19 pandemic in Michigan.

BACKGROUND: The COVID-19 pandemic has severely impacted healthcare delivery and patient outcomes globally. AIMS: We aimed to evaluate the influence of the COVID-19 pandemic on the temporal trends and outcomes of patients undergoing percutaneous coronary intervention (PCI) in Michigan. METHODS: We compared all patients undergoing PCI in the BMC2 Registry between March and December 2020 ("pandemic cohort") with those undergoing PCI between March and December 2019 ("pre-pandemic cohort"). A risk-adjusted analysis of in-hospital outcomes was performed between the pre-pandemic and pandemic cohort. A subgroup analysis was performed comparing COVID-19 positive vs. negative patients during the pandemic. RESULTS: There was a 15.2% reduction in overall PCI volume from the pre-pandemic (n = 25,737) to the pandemic cohort (n = 21,822), which was more pronounced for stable angina and non-ST-elevation acute coronary syndromes (ACS) presentations, and between February and May 2020. Patients in the two cohorts had similar clinical and procedural characteristics. Monthly mortality rates for primary PCI were generally higher in the pandemic period. There were no significant system delays in care between the cohorts. Risk-adjusted mortality was higher in the pandemic cohort (aOR 1.26, 95% CI 1.07-1.47, p = 0.005), a finding that was only partially explained by worse outcomes in COVID-19 patients and was more pronounced in subjects with ACS. During the pandemic, COVID-19 positive patients suffered higher risk-adjusted mortality (aOR 5.69, 95% CI 2.54-12.74, p<0.001) compared with COVID negative patients. CONCLUSIONS: During the COVID-19 pandemic, we observed a reduction in PCI volumes and higher risk-adjusted mortality. COVID-19 positive patients experienced significantly worse outcomes.

Prevalence of coronary risk factors in contemporary practice among patients undergoing their first percutaneous coronary intervention: Implications for primary prevention.

BACKGROUND: Cigarette smoking, hypertension, dyslipidemia, diabetes, and obesity are conventional risk factors (RFs) for coronary artery disease (CAD). Population trends for these RFs have varied in recent decades. Consequently, the risk factor profile for patients presenting with a new diagnosis of CAD in contemporary practice remains unknown. OBJECTIVES: To examine the prevalence of RFs and their temporal trends among patients without a history of myocardial infarction or revascularization who underwent their first percutaneous coronary intervention (PCI). METHODS: We examined the prevalence and temporal trends of RFs among patients without a history of prior myocardial infarction, PCI, or coronary artery bypass graft surgery who underwent PCI at 47 non-federal hospitals in Michigan between 1/1/2010 and 3/31/2018. RESULTS: Of 69,571 men and 38,930 women in the study cohort, 95.5% of patients had 1 or more RFs and nearly half (55.2% of women and 48.7% of men) had ≥3 RFs. The gap in the mean age at the time of presentation between men and women narrowed as the number of RFs increased with a gap of 6 years among those with 2 RFs to <1 year among those with 5 RFs. Compared with patients without a current/recent history of smoking, those with a current/recent history of smoking presented a decade earlier (age 56.8 versus 66.9 years; p <0.0001). Compared with patients without obesity, patients with obesity presented 4.0 years earlier (age 61.4 years versus 65.4 years; p <0.0001). CONCLUSIONS: Modifiable RFs are widely prevalent among patients undergoing their first PCI. Smoking and obesity are associated with an earlier age of presentation. Population-level interventions aimed at preventing obesity and smoking could significantly delay the onset of CAD and the need for PCI.

Primary and Secondary Vascular Access Site Complications Associated With Percutaneous Coronary Intervention: Insights From the BMC2 Registry.

OBJECTIVES: This study sought to describe the association between trends in primary and secondary vascular access sites and vascular access site complications (VASCs) among patients who underwent percutaneous coronary intervention (PCI) in Michigan. BACKGROUND: The frequency of transradial PCI has increased. As a result, there is concern that operators may lose femoral-access proficiency resulting in a paradoxical increase in PCI complications. Anecdotally, an increase in secondary access use during PCI has also been observed. METHODS: Data from the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry was queried to evaluate the use of transradial and transfemoral PCI and their associated VASCs. RESULTS: From 2013 to 2017, transradial PCI increased from 25.9% to 45.2% and the overall use of secondary vascular access increased from 4.9% to 8.7% with minimal change in overall VASCs (1.2% to 1.4%). The use of secondary vascular access was associated with increased VASCs (odds ratio [OR]: 5.82; 95% confidence interval [CI]: 5.26 to 6.43). Although, patients treated by operators in the highest tertile of radial use were more likely to experience femoral VASCs (adjusted OR: 1.51; 95% CI: 1.08 to 2.13), treatment by these operators was associated with an overall reduction in all VASCs (adjusted OR: 0.62; 95% CI: 0.46 to 0.83). CONCLUSIONS: Despite increased use of transradial PCI, there has been no significant decrease in VASCs. This is in part attributable to an increased incidence of femoral VASCs and increasing use of secondary vascular access. An overall reduction in VASCs was observed in the highest radial use operators. Further strategies are needed to reduce VASCs in the transradial era.

Race and epicardial fat: the impact of anthropometric measurements, percent body fat and sex.

OBJECTIVE: Epicardial fat is known to be thicker in White men than in Black men. The impact of sex, % body fat, and other anthropometric measures on epicardial fat thickness has not been described. Therefore we sought to evaluate how the racial differences in epicardial fat thickness would differ by these factors. METHODS: We used two-dimensional transthoracic echocardiography to measure the epicardial fat thickness in 150 patients who were admitted to our clinical decision unit for chest pain. Standard anthropometric measurements were performed and body mass index (BMI) and % body fat were calculated. Data were analyzed using analysis of variance and multiple regression. RESULTS: Epicardial fat measured at the mid right ventricular wall was significantly greater in Whites than Blacks (4.9 +/- 2.1 mm vs 3.8 +/- 1.8 mm, for males, and 5.8 +/- 3.2 mm vs 3.7 +/- 1.7 mm, for females). The results from regression analysis showed that after controlling for age, sex, BMI and waist circumference, race remained a significant predictor of epicardial fat, with Whites having higher amounts of fat than Blacks. The difference by race remained even after controlling for % body fat, which was also a significant predictor. CONCLUSION: Anterior epicardial fat thickness is greater in White than Black men and women of the same race and is independent of anthropometric measurements and % body fat. Race may be an important consideration when analyzing the relationship between epicardial fat and cardiovascular risk.

Late stent thrombosis secondary to carbon monoxide poisoning.

Carbon monoxide poisoning has a variety of deleterious cardiac effects including arrhythmias, coronary spasm and myocardial infarction. The pro-thrombotic effect of carbon monoxide poisoning is one of the important postulated mechanisms of cardiac injury. There are multiple case reports of myocardial infarction secondary to carbon monoxide poisoning. However, there is no published case of carbon-monoxide-poisoning-induced stent thrombosis. We present a 50-year-old female with late stent thrombosis of a sirolimus-eluting stent secondary to acute carbon monoxide poisoning.

Myocardial infarction secondary to carbon monoxide poisoning: an uncommon presentation of a common condition. Case report and review of the literature.

Acute carbon monoxide poisoning is the most common cause of death from poisoning in the United States. It causes a spectrum of myocardial injury irrespective of carboxyhemoglobin levels and coronary anatomy. We present a 34-year-old woman with a non-ST-segment elevation myocardial infarction secondary to carbon monoxide poisoning who had normal coronary arteries by coronary angiography. A review of the literature is discussed.