Effect of insurance type on adverse cardiac events after percutaneous coronary intervention

Previous studies have documented disparities in both access to invasive cardiovascular procedures and outcomes in patients with Medicaid, Medicare, or no insurance. Outcomes by insurance have yet not been examined in a percutaneous coronary intervention (PCI) population. Data from patients undergoing PCI from June 2000 to June 2009 were retrospectively analyzed. Insurance was categorized as private, Medicare, Medicaid, and uninsured, according to the primary insurance at discharge. The outcome variable of interest was major adverse cardiac events (a composite of death, Q-wave myocardial infarction, and target vessel revascularization) at 1 year. Multivariable Cox regression analysis was stratified according to age <65 and ≥65 years. Of the 13,573 patients who had undergone PCI, 6,653 (49.0%) had private insurance, 6,150 (45.3%) had Medicare, 486 (3.6%) had Medicaid, and 284 (2.1%) were uninsured. Of the patients <65 years old, Medicaid (hazard ratio [HR] 1.59, 95% confidence interval [CI] 1.04 to 2.43), Medicare (HR 2.18, 95% CI 1.58 to 2.99), and no insurance (HR 2.41, 95% CI 1.36 to 4.27) were associated with greater rates of adjusted major adverse cardiac events at 1 year compared with private insurance. Of the patients ≥65 years old, only Medicaid (HR 3.07, 95% CI 1.09 to 8.61) was associated with a greater rate of adjusted major adverse cardiac events at 1 year. In conclusion, patients with government-sponsored insurance and no insurance have worse cardiovascular outcomes than patients with private insurance after PCI at 1 year. This implies that the provision of health insurance alone might not have a dramatic effect on cardiovascular outcomes after PCI.     

Incidence of periprocedural myocardial infarction and cardiac biomarker testing after percutaneous coronary intervention in Japan: results from a multicenter registry

Periprocedural myocardial infarction (pMI) is an important complication associated with percutaneous coronary intervention (PCI). However, data on the frequency of biomarker testing and the incidence of pMI remain unclear. Using the multicenter Japan Cardiovascular Database, we identified 2182 patients who underwent PCI without preprocedural cardiac biomarker elevation (silent ischemia, stable angina, or unstable angina without biomarker elevation) from September 2008 to August 2011. Of these, 550 patients (25.2 %) underwent cardiac biomarker testing within 6–24 h after PCI. The incidence of pMI was 2.7 % among all identified patients and 7.5 % among those who underwent cardiac marker testing. Of note, cardiac biomarker testing was performed more frequently than no testing in patients with a higher risk profile such as unstable angina (32.7 vs 24.7 %, P < 0.001), higher symptom scaling (28.2 vs 22.5 %, P = 0.008), urgent or emergent procedures (19.3 vs 15.0 %, P = 0.022 or 4.2 vs 1.0 %, P < 0.001, respectively), and type C lesion (31.3 vs 25.2 %, P = 0.006). Presentation with silent ischemia (odds ratio = 1.51, 95 % confidence interval (CI) 1.16–1.97) and nonemergent PCIs (odds ratio = 3.45, 95 % CI 1.79–6.67) were associated with no postprocedural cardiac biomarker testing. The real-world multicenter PCI registry in Japan revealed an incidence of 2.7 % for pMI; however, cardiac biomarkers were assessed in only 25.2 % of patients after PCI. The results suggest an underuse of postprocedural biomarker testing and room for procedural quality improvement, particularly in cases of silent ischemia and nonemergent cases.     

Relationship between operator volume and adverse outcome in contemporary percutaneous coronary intervention practice: an analysis of a quality-controlled multicenter percutaneous coronary intervention clinical database

OBJECTIVES: The aim of our study was to evaluate the volume-outcome relationship in a large, quality-controlled, contemporary percutaneous coronary interventions (PCI) database. BACKGROUND: Whether the relationship between physician volume of PCI and outcomes still exists in the era of coronary stents is unclear. METHODS: Data on 18,504 consecutive PCIs performed by 165 operators in calendar year 2002 were prospectively collected in a regional consortium. Operators' volume was divided into quintiles (1 to 33, 34 to 89, 90 to 139, 140 to 206, and 207 to 582 procedures/year). The primary end point was a composite of major adverse cardiovascular events (MACE) including death, coronary artery bypass grafting, stroke or transient ischemic attack, myocardial infarction, and repeat PCI at the same site during the index hospital stay. RESULTS: The unadjusted MACE rate was significantly higher in quintiles one and two of operator volume when compared with quintile five (7.38% and 6.13% vs. 4.15%, p = 0.002 and p = 0.0001, respectively). A similar trend was observed for in-hospital death. After adjustment for comorbidities, patients treated by low volume operators had a 63% increased odds of MACE (adjusted odds ratio [OR] 1.63, 95% confidence interval [CI] 1.29 to 2.06, p < 0.0001 for quintile [Q]1; adjusted OR 1.63, 95% CI 1.34 to 1.90, p < 0.0001 for Q2 vs. Q5), but not of in-hospital death. Overall, high volume operators had better outcomes than low volume operators in low-risk and high-risk patients. CONCLUSIONS: Although the relationship between operator volume and in-hospital mortality is no longer significant, the relationship between volume and any adverse outcome is still present. Technological advancements have not yet completely offset the influence of procedural volume on proficiency of PCIs.     

急性ST段抬高型心肌梗死经皮冠状动脉介入治疗患者预后与平均血小板体积相关性研究

目的探讨术前平均血小板体积(MPV)与急性ST段抬高型心肌梗死(STEMI)行急诊经皮冠脉介入治疗(PCI)患者预后的关系。方法选择STEMI行急诊PCI患者335例,根据入院时MPV水平分为A组(≤9.9 fl,123例)和B组(MPV>9.9 fl,212例)。对患者进行随访1年,观察主要心脏不良事件(MACE)发生率。根据MACE的发生,分为MACE(+)组和MACE(-)组,对两组数据进行分析。并对各因素采用Logistic回归分析。结果 MACE发生率B组[53例(25.0%)]高于A组[16例(13.0%)](χ2=6.844,P=0.01),主要表现在再发心绞痛[37例(17.4%)比9例(7.3%),χ2=6.751,P<0.01]和再次住院[40例(18.7%)比12例(9.7%),χ2=4.928,P=0.03]。MACE(+)组中MPV>9.9 fl病例比例高于MACE(-)组[54例(78.2%)比165例(62%),χ2=6.376,P=0.02]。多因素Logistic回归分析示MPV>9.9 fl(OR:2.05,P=0.03),提示MPV>9.9 fl与STEMI行急诊PCI患者1年预后相关。结论术前MPV>9.9 fl是预测STEMI行急诊PCI患者1年MACE的独立危险因素。     

Heparin after percutaneous intervention (HAPI): a prospective multicenter randomized trial of three heparin regimens after successful coronary intervention.

OBJECTIVES: The purpose of this study was to determine the incidence of bleeding, vascular, and ischemic complications using three different heparin regimens after successful intervention. BACKGROUND: The ideal dose and duration of heparin infusion after successful coronary intervention is unknown. METHODS: Patients were randomized to one of three heparin strategies after coronary intervention: Group 1 (n = 157 patients) received prolonged (12 to 24 h) heparin infusion followed by sheath removal; Group 2 (n = 120 patients) underwent early removal of sheaths, followed by reinstitution of heparin infusion for 12 to 18 h; Group 3 (n = 137 patients) did not receive any further heparin after intervention with early sheath removal. The primary end point of the study was the combined incidence of in-hospital bleeding and vascular events. Secondary end points included in-hospital ischemic events, length of stay, cost and one-month outcome. RESULTS: After successful coronary intervention, 414 patients were randomized. Unstable angina or postinfarction angina was present in 83% of patients before intervention. The combined incidence of bleeding and vascular events was 21% in Group 1, 14% in Group 2 and 8% in Group 3 (p = 0.01). The overall incidence of in-hospital ischemic complications was 2.2%; there were no differences between groups. Length of hospital stay was shorter (p = 0.033) and adjusted hospital cost was lower (p < 0.001) for Group 3. At 30 days, the incidence of delayed cardiac and vascular events was similar for all three groups. CONCLUSIONS: Heparin infusion after successful coronary intervention is associated with more minor bleeding and vascular injury, prolonged length of stay and increased cost. In-hospital and one-month ischemic events rarely occur after successful intervention, irrespective of heparin use. Routine postprocedure heparin is not recommended, even in patients who present with unstable ischemic syndromes.     

Determination of platelet aggregation inhibition during percutaneous coronary intervention with the platelet function analyzer PFA-100

Background A simple device to rapidly evaluate platelet function may aid in optimizing glycoprotein IIb/IIIa inhibition during percutaneous coronary intervention (PCI). We prospectively studied platelet function in 250 patients receiving abciximab or eptifibatide during PCI. Methods and Results The platelet function analyzer PFA-100 (Dade-Behring, Deerfield, Ill) measures platelet function by determining the time to occlusion of an aperture in a biochemically active membrane as whole blood flows under high shear conditions. Platelet aggregation causes aperture occlusion, and results are reported as a closure time (CT). All patients received either abciximab or eptifibatide, along with aspirin and heparin; patients undergoing stent implantation received aspirin and a thienopyridine postprocedure. The CT was measured at baseline and 10 minutes, 4 hours, 12 hours (abciximab-only), and 24 hours after the bolus. Profound inhibition was exhibited in most patients shortly after the platelet inhibitor bolus and during the course of therapy. We observed recovery of platelet function 12 hours after discontinuation of abciximab, with a high degree of interpatient variability, and ongoing profound platelet inhibition 4 to 6 hours after the discontinuation of eptifibatide. Among patients treated with abciximab, patients who were obese recovered from platelet inhibition sooner than patients who were not obese, whereas patients who were elderly had delayed recovery compared with patients who were not elderly. Failure to achieve maximal platelet inhibition (nonclosure) at 10 minutes indicated a possible association with adverse clinical events at the 6-month follow-up examination (60% vs 20%). Conclusions PFA-100 is a rapid simple assay used as a means of assessing inhibition of platelet aggregation during PCI performed with glycoprotein IIb/IIIa inhibition. Failure to achieve nonclosure early after the initiation of abciximab therapy warrants further investigation because there may be an association with adverse cardiac events at 6-month follow-up. (Am Heart J 2002;144:151-8.)     

急性冠脉综合征行PCI患者残粒脂蛋白-胆固醇水平与主要不良心血管事件的相关性研究

目的 研究急性冠脉综合征(ACS)行急诊经皮冠状动脉介入治疗(PCI)患者残粒脂蛋白-胆固醇(RLP-C)水平与主要不良心血管事件(MACE)的关系.方法 选择在江苏省苏北人民医院心脏科住院的ACS并行急诊PCI患者143例为研究对象,入院时检测其RLP-C水平,依据RLP-C定标值将患者分为高水平组(n=42)及低水...     

冠心病介入治疗术后服用氯吡格雷患者的CYP2C19基因型与血小板抑制率的关系研究

目的探讨服用氯吡格雷的冠心病介入术后患者的CYP2C19基因型与二磷酸腺苷(ADP)诱导的血小板抑制率之间的关系。方法选取冠心病介入治疗术后服用氯吡格雷的患者500例,根据CYP2C19基因型分为氯吡格雷快、中、慢代谢3组,通过血栓弹力图测定ADP诱导的血小板抑制率;分析3组CYP2C19基因型与血小板抑制率之间的相关性;对患者进行术后6个月的随访,观察心血管不良事件发生率。结果 (1)500例患者中,氯吡格雷快、中、慢代谢3组的人群分布为42.0%、44.8%和13.2%。(2)氯吡格雷快代谢组的血小板抑制率在0~20%、20%~50%、50%~75%和75%~100%的人群分布为1.90%、14.29%、30.00%和53.81%;中代谢组的人群分布为3.57%、17.86%、22.32%和56.25%;慢代谢组的人群分布为7.58%、21.21%、30.30%和40.91%;3组之间ADP诱导的血小板抑制率差异无统计学意义(P>0.05)。(3)随访6个月,氯吡格雷快、中、慢代谢3组发生心血管缺血事件分别有9、13和4例,3组之间的缺血性心血管事件差异无统计学意义(P>0.05)。结论在本组人群中,CYP2C19基因型与氯吡格雷血小板抑制率之间无明显相关性,推测仅通过CYP2C19基因型不能准确预测氯吡格雷抵抗。     

Quantification of abciximab-induced platelet inhibition is assay dependent: a comparative study in patients undergoing percutaneous coronary intervention

Background The best method for measuring the degree of platelet inhibition with glycoprotein (GP) IIb-IIIa antagonists during percutaneous coronary intervention (PCI) and the optimal degree of periprocedural inhibition is uncertain. Low molecular weight heparins have been reported to cause less platelet activation than unfractionated heparin. Therefore, compared with unfractionated heparin (UHF), a low molecular weight heparin could enhance measured platelet inhibition. In this study, we compared 3 methods of measuring platelet inhibition and investigated the effects of half doses of abciximab in combination with either UFH or the low molecular weight heparin dalteparin in patients undergoing PCI with planned abciximab administration. Methods Abciximab-induced platelet inhibition was measured serially by means of 3 assays: 1) GP IIb-IIIa receptor occupancy, 2) binding of the activated GP IIb—IIIa-specific monoclonal antibody PAC1, and 3) agglutination of platelets with fibrinogen-coated beads (RPFA). Forty patients were randomly allocated to receive either UFH (70 U/kg) or dalteparin (60 IU/kg), followed by a half dose of abciximab (0.125 mg/kg) administered twice at 10-minute intervals. Assays were obtained 10 minutes after each half dose of abciximab and 8 to 10 and 24 hours after abciximab administration. Results No differences between UFH and dalteparin were observed. At each time-point measured, the mean percent platelet inhibition as determined by means of the receptor occupancy assay and PAC1 binding assay was less than the degree of inhibition determined by means of the RPFA. Conclusions The results of targeted levels of platelet inhibition cannot be extrapolated between different clinical trials of GP IIb-IIIa antagonists unless the same assay is used. Dalteparin, compared with UFH, does not enhance platelet inhibition or receptor occupancy by abciximab, as demonstrated by means of 3 separate assays. (Am Heart J 2003;145:e6.)     

心脏康复运动对经皮冠状动脉介入术后不稳定型心绞痛患者危险因素的影响

目的探讨心脏康复运动对经皮冠状动脉介入治疗(PCI)术后不稳定型心绞痛患者心血管危险因素的影响。方法选取2015年1月至2016年6月于鄂尔多斯市中心医院心内科首次行冠状动脉造影的不稳定型心绞痛患者120例,按随机数字表法分为常规治疗组和康复运动组各60例。两组均给予常规药物治疗和冠心病知识教育,康复运动组还给予为期6个月的不同阶段、不同强度的康复锻炼。对两组患者的血压、血脂和空腹血糖进行术后1、3和6个月的随访观察和比较。结果入选和术后1个月时,两组患者的血压、血脂和空腹血糖比较,差异均无统计学意义(均为P>0.05)。术后1个月时,康复运动组与入选时比较,总胆固醇(TC)、三酰甘油(TG)和空腹血糖(FPG)均显著下降(均为P<0.05)。术后3个月时,康复运动组的TC、TG和FPG低于常规治疗组,差异有统计学意义(均为P<0.05),康复运动组与入选时比较,收缩压、舒张压、TC、TG、FPG和低密度脂蛋白胆固醇均显著下降(均为P<0.05)。术后6个月时,康复运动组与常规治疗组比较,除高密度脂蛋白胆固醇外,其他危险因素差异均有统计学意义(均为P<0.05),康复运动组与入选时比较,各危险因素差异均有统计学意义(均为P<0.05),常规治疗组与入选时比较,TC和低密度脂蛋白胆固醇显著下降(均为P<0.05)。结论心脏康复运动可使PCI术后不稳定型心绞痛患者的血压、血脂和血糖得到良好控制,长期规范化的心脏康复运动可能会给患者带来更多益处。     

Diabetes mellitus associated with an increased risk of percutaneous coronary intervention long-term adverse outcomes in Taiwan: A nationwide population-based cohort study

AimsThis study compared the incidence rates of patients with diabetes mellitus (DM) and patients without DM with percutaneous coronary intervention (PCI) in a national population-based cohort to determine if the patients with DM have an increased risk of adverse outcomes.MethodsWe performed a retrospective cohort study among 92,624 patients with and without DM, who underwent PCI for the first time in 2000–2008. The patients were identified from National Health Insurance Program Database through propensity score matching. Endpoints were the occurrence of PCI adverse outcomes, including myocardial infarction (MI), need for target vessel revascularization by either bypass surgery or repeat PCI, all-cause mortality or 2011/12/31. Incidence rate was calculated and hazard ratios of PCI adverse events were estimated using Cox's proportional hazard regression model.ResultsDuring the mean six-year follow up, the rates of MI (incidence rate 20.96 vs. 15.59 per 1000 person-years), bypass surgery (incidence rate 8.15 vs. 5.15 per 1000 person-years), all-cause mortality (incidence rate 6.20 vs. 4.72 per 1000 person-years), and the composite measure of MI, repeat PCI, bypass surgery, all-cause mortality (incidence rate 37.31 vs. 28.14 per 1000 person-years) were higher in patients with DM. The corresponding hazard ratios (HRs) and their 95% confidence intervals (CIs) were 1.34 (95% CI: 1.29, 1.39), 1.46 (1.38, 1.56), 1.34 (1.25, 1.44), and 1.31 (1.27, 1.35). However, the repeat PCI rate (incidence rate 2.65 vs. 2.70 per 1000 person-years); with an adjusted HR of 0.97 (0.88, 1.07) was not statistically different.ConclusionsThis nationwide retrospective cohort study determined a positive correlation between PCI adverse events and DM. As the prevalence of DM and PCI continues to increase, novel treatments and intensified surveillance coronary angiography for high risk patients are needed.