Outcomes of Patients Undergoing Cardiac Catheterization After a Three-Day Holiday Weekend Versus a Two-Day Weekend.

OBJECTIVES: The study aim is to determine whether invasive cardiac procedures following a 3-day (holiday) weekend have worse outcomes compared with procedures following a 2-day (normal) weekend. BACKGROUND: Catheterization laboratory schedules after 3-day holiday weekends tend to be overloaded with urgent procedures for patients who have waited up to 3 days. We hypothesized that this would be reflected by more procedural complications in patients undergoing procedures after a 3-day weekend. METHODS: Invasive cardiac procedures that occurred after a weekend at Geisinger Medical Center from July 2012 to December 2019 were included. Baseline characteristics, presentation, periprocedural variables, adverse events, and clinical outcomes were compared between catheterizations on the day following a 2-day weekend and catheterizations following a 3-day weekend. Independent correlates of adverse events were identified by logistic regression analysis. RESULTS: We identified 13,704 invasive cardiac procedures performed after a weekend, of which 722 occurred after a 3-day (holiday) weekend. Baseline demographics, presentation, and case volumes were similar between the 2 groups. Procedures after a 3-day weekend were not associated with any differences in in-hospital mortality, myocardial infarction, or stroke compared with those after a standard 2-day weekend. By univariate analysis, procedural complications were more frequent after a 3-day weekend (15.1% vs 12.3%; P=.03), but this difference was not significant on multivariate analysis (odds ratio, 1.22; P=.30). CONCLUSIONS: Cardiac catheterization procedures performed after a 3-day weekend were not associated with differences in in-patient mortality, myocardial infarction, stroke, or procedural complications.

Prognostic implications of prior contrast reaction in patients with emergency premedication before undergoing percutaneous coronary intervention.

BACKGROUND: Patients with iodinated contrast material (ICM) adverse reactions are at increased risk for breakthrough reactions. Previous studies suggest that the severity of a prior ICM adverse reaction corresponds to the severity of a repeat reaction. OBJECTIVE: We investigated whether the severity of prior ICM adverse reactions in patients receiving emergency premedication therapy prior to PCI predicts outcomes. METHODS: A retrospective observational study of percutaneous coronary intervention (PCI) encounters between January 1, 2005, and May 30, 2018, was conducted at Geisinger Medical Center. Patients with ICM adverse reactions premedicated with an emergency premedication regimen prior to PCI were included in the study. PCIs were stratified based on the severity of the index ICM adverse reactions; PCIs with a prior severe reaction were compared to PCIs with a prior mild-moderate reaction. RESULTS: We evaluated 604 PCI, of these, 144 (23.8%) had prior severe reactions and 460 (76.2%) had mild-to-moderate reactions. Nine patients had breakthrough reactions, of which seven were of the same or decreased severity in comparison to the index reactions. The overall breakthrough reactions occurred in 1 of 144 patients (0.7%) with an initial severe reaction and in 8 of 460 (1.7%) with an initial mild/moderate reaction (p = 0.69). Outcomes including length of hospital stay and 30-day mortality were similar for PCI with or without severe index ICM reactions. CONCLUSION: Frequency and severity of breakthrough reaction and clinical outcomes in patients treated with emergency premedication regimen prior to PCI were independent of the severity of index ICM reactions.

Coronary and Structural Heart Disease Interventions During COVID-19 Pandemic: A Road Map for Clinicians and Health Care Delivery Systems.

BACKGROUND: Because of the COVID-19 pandemic, cath labs have had to modify their workflow for elective and urgent patients. METHODS: We surveyed 16 physicians across 3 hospitals in our healthcare system to address COVID-19 related concerns in the management of interventional and structural heart disease patients, and to formulate system wide criteria for deferring cases till after the pandemic. RESULTS: Our survey yielded common concerns centered on the need to protect patients, cath lab staff and physicians from unnecessary exposure to COVID-19; for COVID-19 testing prior to arrival to the cath lab; for clear communication between the referring physician and the interventionalist; but there was initial uncertainty among physicians regarding the optimal management of ST elevation myocardial infarction (STEMI; percutaneous coronary intervention versus thrombolytics). Patients with stable angina and hemodynamically stable acute coronary syndromes were deemed suitable for initial medical management, except when they had large ischemic burden. Most transcatheter aortic valve implantations (TAVI) were felt appropriate for postponement except in symptomatic patients with aortic valve area <0.5 cm2 or recent hospitalization for heart failure (HF). Most percutaneous mitral valve repair (pMVR) procedures were felt appropriate for postponement except in patients with HF. All left atrial appendage closure (LAAC) and patent foramen ovale (PFO)/atrial septal defect (ASD) closure procedures were felt appropriate for postponement. CONCLUSION: Our survey of an experienced team of clinicians yielded concise guidelines to direct the management of CAD and structural heart disease patients during the initial phases of the COVID-19 pandemic.

Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality?

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) model for publicly reporting national 30-day-risk-adjusted mortality rates for patients admitted with heart failure fails to include clinical variables known to impact total mortality or take into consideration the culture of end-of-life care. We sought to determine if those variables were related to the 30-day mortality of heart failure patients at Geisinger Medical Center. METHODS: Electronic records were searched for patients with a diagnosis of heart failure who died from any cause during hospitalization or within 30 days of admission. RESULTS: There were 646 heart-failure-related admissions among 530 patients (1.2 admissions/patient). Sixty-seven of the 530 (13%) patients died: 35 (52%) died during their hospitalization and 32 (48%) died after discharge but within 30 days of admission; of these, 27 (40%) had been transferred in for higher-acuity care. Fifty-one (76%) died from heart failure, and 16 (24%) from other causes. Fifty-five (82%) patients were classified as American Heart Association Stage D, 58 (87%) as New York Heart Association Class IV, and 30 (45%) had right-ventricular systolic dysfunction. None of the 32 patients who died after discharge met recommendations for beta-blockers. Criteria for prescribing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor blockers were not met by 33 of the 34 patients (97%) with heart failure with reduced ejection fraction not on one of those drugs. Fifty-seven patients (85%) had a do-not-resuscitate (DNR) status. CONCLUSION: A majority of heart failure-related mortality was among patients who opted for a DNR status with end-stage heart failure, limiting the appropriateness of administering evidence-based therapies. No care gaps were identified that contributed to mortality at our institution. The CMS 30-day model fails to take important variables into consideration.

Primary Purulent Pericarditis with Cardiac Tamponade due to Oropharyngeal Polymicrobial Infection: A Case Report and Literature Review.

Cardiac tamponade due to purulent pericarditis with a characteristic greenish fluid is rare in this antibiotic era. It is highly fatal despite early diagnosis and advanced treatment. Gram-positive cocci are the leading cause of purulent pericarditis, which usually results from a direct or hematogenous spread of organisms to the pericardium from the primary foci of infection. We describe an index case of rapidly developing pericardial tamponade caused by oropharyngeal polymicrobial infection in the absence of a primary source of infection in a 62-year-old man, who was successfully managed with emergency large-volume pericardiocentesis followed by pericardiectomy.

Readmission in the 30 days after percutaneous coronary intervention.

OBJECTIVES: This study sought to identify the frequency and etiology of readmission within 30 days of percutaneous coronary intervention (PCI) in a large integrated healthcare system. BACKGROUND: One-fifth of Medicare patients are readmitted within 30 days of hospitalization. Identifying the causes of readmission may help identify strategies to prevent readmission. METHODS: All patients undergoing PCI (elective, urgent, and emergent) at our center between January 1, 2007, and April 12, 2010, were prospectively entered into the American College of Cardiology National Cardiovascular Data Registry. Patients readmitted to any hospital within 30 days of the index procedure were identified using an administrative database and telephone follow-up. Individual charts were reviewed independently by 2 investigators; disagreements regarding the cause for readmission were resolved by a third investigator. RESULTS: During the study period, 3,255 PCI were performed, and 262 patients (8.0%) were readmitted within 30 days. Of these, 261 (99.6%) had medical records available for review. Reasons for readmission included: complications related to the PCI (n = 31, 11.9%); non-PCI cardiac causes related to index admission (n = 93, 35.6%); noncardiac causes related to index admission (n = 34, 13%); causes unrelated to the index admission (n = 103, 39.5%). Multivariable logistic regression modeling revealed that female sex, advanced age, peripheral arterial disease, prior valvular surgery, and PCI complications during the index procedure were associated with 30-day readmission. CONCLUSIONS: Readmissions within 30 days due to complications related to PCI performed on index admission are rare (0.9% of all PCI) and are an infrequent cause of readmission (<12% of readmissions). Thirty-day readmission after PCI should not be used as a quality metric of PCI performance.

Monitoring and Reversal of Anticoagulation and Antiplatelets.

Since percutaneous transluminal coronary angioplasty was first described and the breakthrough studies of the role of stents were reported, the evolution in anticoagulation and antiplatelet therapy used during percutaneous coronary intervention (PCI) has reduced periprocedural ischemic events and stent thrombosis. Although greater combinations and doses of anticoagulation with antiplatelets seem to provide the best protection against thrombogenic and embolic events, there is a significant trade-off with a higher risk of major and minor bleeding episodes. This review article expands on each of the commonly used antiplatelet and anticoagulants used at time of PCI, focusing on drug monitoring and reversal.