Frequency of coronary angiography and revascularization among men and women with myocardial infarction and their relationship to mortality at one year: an analysis of the Geisinger myocardial infarction cohort.

OBJECTIVES: To determine sex bias in the selection of strategies to evaluate patients with acute myocardial infarction (AMI), and determine if the choice of strategy influences survival. BACKGROUND: Controversy exists regarding the role of female sex in the use of invasive evaluation for AMI and its possible effect on adverse outcomes. METHODS: Electronic health record data from the Geisinger Acute Myocardial Infarction Cohort (GAMIC) was analyzed which included 1,968 men and 1,047 women admitted to the Geisinger Medical Center between January 2001 and December 2006 with acute myocardial infarction (AMI).Multivariate logistic regression analyses were used to determine independent correlates of an invasive evaluation. Multivariate logistic regression modeling stratified on sex was used to determine when invasive evaluation was done and whether there was a correlation with mortality. RESULTS: In unadjusted analyses, male sex was a significant predictor for the use of invasive evaluation (odds ratio = 1.71, 95% CI = [1.46, 2.00]). Adjusted for baseline differences (like age, renal function, co-morbid conditions) multivariate analyses found no significant relationship between male sex and invasive evaluation (OR = 1.02, 95% CI = [0.82, 1.23]). Females in the STEMI group were found to be less revascularized. No difference was observed in the one-year mortality between women and men regardless of invasive evaluation or revascularization. CONCLUSIONS: Sex was not independently associated with the occurrence of an invasive evaluation of a MI. Females in the STEMI group were less revascularized. There was no strong gender effect on survival irrespective of the performance on an invasive evaluation or revascularization.

Comparative study of same sitting hybrid coronary artery revascularization versus off-pump coronary artery bypass in multivessel coronary artery disease.

OBJECTIVE: We compared the outcomes of same sitting robotic-assisted hybrid coronary artery revascularization (HCR) with off-pump coronary artery bypass grafting (OPCABG) in similar patients with multivessel coronary artery disease. BACKGROUND: HCR is a novel procedure in selected patients with multivessel coronary artery disease (CAD). Although there are some data on staged HCR, the data on same sitting HCR are limited. METHODS: We conducted a prospective study comparing same sitting robotic-assisted HCR patients (n = 25) to a group of consecutive low to moderate risk OPCABG patients (n = 27) during the study period. HCR patients underwent robotic internal mammary artery takedown followed by OPCABG via minithoracotomy. After confirming graft patency, immediate percutaneous coronary intervention on the nonbypass arteries was performed. Comparative analyses were performed on in-hospital and 30 day outcomes. RESULTS: The baseline characteristics were similar for both groups including the severity of CAD (Syntax score 33.5+/-8.2 vs. 34.9+/-8.2, P = 0.556). Overall MACE was similar between both groups; however, the HCR group showed improved hospital outcomes with lower need for postoperative transfusions (12% vs. 67%, P < 0.001), and shorter length of hospital stay (5.1+/-2.8 vs. 8.2+/-5.4 days, P < 0.01). Despite lower postoperative costs, the HCR group had higher overall hospital costs due to higher procedural costs ($33,984 +/-$4,806 vs. $27,816+/-$11,172, P < 0.0001). Propensity model analysis showed similar findings. The HCR group showed improved quality of life measures with shorter time to return to work (5.3+/-3.0 vs. 8.2+/- 4.6 weeks, P = 0.01). CONCLUSIONS: Same sitting HCR appears to be feasible and may offer superior outcomes to standard OPCABG, further studies are warranted.

Impact of Switching From Prasugrel to Clopidogrel Shortly After a Percutaneous Coronary Intervention Without a Loading Dose of Clopidogrel.

OBJECTIVE: To determine the safety and efficacy of administering prasugrel at the time of percutaneous coronary intervention (PCI), and switching to clopidogrel, without reloading. BACKGROUND: Prasugrel has faster onset of action and appears to be of greater benefit than clopidogrel, particularly early after PCI. However, long-term prasugrel increases bleeding. Many physicians at Geisinger Medical Center (GMC) administer prasugrel before PCI and switch to clopidogrel afterward. The safety and efficacy of this strategy has not been studied. METHODS: We performed a retrospective study using electronic medical records and identified patients at GMC who underwent PCI between February 1, 2009 and January 31, 2012 and received a loading dose of prasugrel with a subsequent switch to clopidogrel, without reloading. The primary endpoint was major adverse cardiovascular event (MACE), defined as death, myocardial infarction (MI), stroke, or stent thrombosis, 7 days after the first dose of clopidogrel. Secondary endpoints included MACE at 30 days, individual MACE components at 7 and 30 days post procedure, and bleeding as defined by the Bleeding Academic Research Consortium (BARC) at 1 day and 30 days. RESULTS: A total of 151 patients met inclusion criteria. One patient suffered a MACE on day 7 (0.7%; 95% confidence interval, 0.03%-3.33%). One patient had an MI between 8-30 days. Two patients had BARC bleeding (type 2 and type 3b) 30 days post PCI. CONCLUSIONS: In this small, retrospective analysis, the results of loading patients with prasugrel for PCI and switching them to clopidogrel without a loading dose appear to be encouraging.

Cardiac troponin release following hybrid coronary revascularization versus off-pump coronary artery bypass surgery.

OBJECTIVES: Cardiac ischaemic marker release is associated with adverse clinical outcomes after cardiac surgery. We sought to compare the release of cardiac troponin I (cTnI) after hybrid coronary revascularization (HCR) with off-pump coronary artery bypass surgery (OPCAB). METHODS: Using data from a prospective single-centre registry, we compared cTnI measured at postoperative day 1 following one-stage HCR and OPCAB among patients with normal baseline cTnI. Multivariable linear regression analysis was used to adjust for variables that may have influenced cardiac marker release other than the used revascularization strategy. RESULTS: Sixty-five consecutive patients underwent elective HCR (n = 33) or OPCAB (n = 32). Overall, no differences were seen in comorbidities, CABG risk scores and the lesion-specific SYNTAX score. Procedural complications were lower (15.2 vs 34.4%, P = 0.072), but 30-day and 1-year clinical outcomes (death, myocardial infarction, and repeat revascularization) were similar between the two groups (3.0 vs 3.1% and 9.1 vs 6.2%, respectively). Post-procedural cTnI release measured at 24 h after surgery was significantly lower following HCR compared with OPCAB [ratio of upper reference level URL: median: 3.5, interquartile range (IQR): 0.8-9.1 vs 12.8, IQR: 6.9-21.8, P = 0.001]. After adjusting for potential confounders, HCR was associated, on average, with cTnI less than half (46%) compared with CABG (P <0.0001). CONCLUSIONS: HCR is associated with lower postoperative cTn release, compared with OPCAB. Further research into the clinical implications of this finding is warranted.