Percutaneous Coronary Interventions in Facilities Without Cardiac Surgery on Site

Prior to the widespread adoption of intracoronary stent implantation, potential complications of percutaneous coronary intervention (PCI) necessitated the presence of backup cardiac surgery. However, as stent implantation has become the predominant form of PCI, the incidence of emergent cardiac surgery has declined exponentially. Despite this, current guidelines recommend against the performance of elective PCI at hospitals without on-site cardiac surgery and recommend that primary PCI for ST-segment elevation myocardial infarction (STEMI) might be considered at hospitals without backup cardiac surgery. These recommendations are based predominantly on two principles: (1) hospital volume for PCI is strongly associated with clinical outcomes, and (2) results from a large registry study, in which the authors reported a substantial increase in mortality among patients undergoing non-primary/rescue PCI at hospitals without backup cardiac surgery. Since that time, evidence from multiple studies has suggested that performance of PCI at hospitals without backup cardiac surgery is feasible, safe, and both clinically and cost effective. Among STEMI patients, in particular, performance of primary PCI at hospitals without on-site cardiac surgery reduces time to reperfusion and subsequent adverse cardiovascular events as well as likely reducing infarct size. In this review, we will examine the evidence surrounding the performance of PCI for stable and unstable coronary disease at hospitals without on-site backup cardiac surgery.     

In hospital observation of patients with acute coronary syndrome without ST elevation and multivessels coronary artery disease treated with early invasive strategy. Comparison of results of percutaneous coronary intervention and coronary artery by-pass grafting

Acute coronary syndromes (ACS) without persistent ST-segment elevation are the main cause of hospitalization, morbidity and mortality. The objective of this study was to compare clinical and angiographic parameters as well as in-hospital results of treating 307 consecutive patients with ACS without persistent ST-segment elevation with either PCI or CABG. Inclusion criteria were: rest angina within the last 24 hours, ST-segment depression (> 0.5 mm), T-wave inversion (> 1 mm) in at least two leads, positive serum cardiac markers. PCI was performed in 75.9% of patients and 24.1% of patients underwent CABG. Both groups did not differ as to age, sex, history of diabetes, arterial hypertension, heart failure, smoking and ejection fraction. Positive troponin was significantly more frequent in the PCI group. 51% of PCI patients and 80% of CABG patients had complete revascularization (p = 0.00001). Independent predictors of in-hospital death in the CABG group were: inability to determine culprit vessel during coronary angiography due to lesions' severity (OR 13.65; 95% CI 9.40-15.20; p = 0.007) and heart failure (OR 15.58; 95% CI 12.29-18.01; p = 0.003). In the PCI group these independent predictors were: Braunwald's IIIC unstable angina (OR 5.48; 95% CI 3.10-7.17; p = 0.04) and diabetes (OR 2.22; 95% CI 1.07-3.90; p = 0.003). In-hospital mortality rate was significantly higher in the CABG group (8.1% vs 1.7% p < 0.01). Patients with multivessel coronary artery disease and ACS without ST-segment elevation treated with PCI have better in-hospital outcome than patients assigned to CABG, but the rate of complete revascularization is lower.     

In-hospital outcomes of primary percutaneous coronary interventions performed at hospitals with and without on-site coronary artery bypass graft surgery.

BACKGROUND: Primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) is performed in hospitals without on-site coronary artery bypass graft surgery in the ;real world'. However, data on the in-hospital outcomes of primary PCI performed at hospitals with and without on-site cardiac surgery are still lacking in Japan. METHODS AND RESULTS: In the present study, 2,230 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2005. Of these, 1,817 patients underwent primary PCI. Excluding patients without adequate data, we retrospectively compared clinical background, coronary risk factors, angiographic findings, acute results of primary PCI and in-hospital prognosis between patients undergoing primary PCI in hospitals without on-site cardiac surgery (without surgery group, n=792) and those in hospitals with (with surgery group, n=993). The without surgery group had higher prevalence of previous myocardial infarction, Killip class>or=3 at admission and multivessels as a culprit lesion than the with surgery group. The without surgery group was more likely to have lower frequency of stent usage and lower thrombolysis in myocardial infarction flow grade just after PCI, whereas it was more likely to have intra-aortic balloon pumping and temporary pacing during procedures. The overall in-hospital mortality did not differ between the 2 groups. On multivariate analysis, in AMI patients undergoing primary PCI, Killip class>or=3 at admission, multivessels or left main trunk (LMT) as culprit lesions, number of diseased vessels>or=2 or diseased LMT, and age were the independent predictors of the in-hospital mortality, but the presence of on-site cardiac surgery was not. CONCLUSIONS: These results suggest that in-hospital outcomes in AMI patients undergoing primary PCI at hospitals without on-site cardiac surgery are comparable to those at hospitals with on-site cardiac surgery in Japan.     

Prevalence, predictors, and outcomes of conservative medical management in non-ST-segment elevation acute coronary syndromes in Gulf RACE-2

We assessed the prevalence, predictors, and in-hospital and long-term outcomes of conservative medical management for patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) compared with percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This prospective study conducted from October 2008 to June 2009 in 65 hospitals from 6 Arabian Gulf countries included 30-day and 1-year mortality follow-up for 3661 patients. Compared with conservative management group (2859 patients; 78.1%), the PCI group (638; 17.4%) had significantly better unadjusted and adjusted in-hospital (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17-0.97), 30-day (OR: 0.44, 95% CI: 0.24-0.76) and 1-year (OR: 0.58, 95% CI: 0.40-0.87) mortality rates. Comparison with the CABG group (164; 4.5%) yielded similar results with inclusion of patients scheduled for CABG after hospital discharge. Independent predictors of conservative medical management were mainly country of residence and history of prior CABG.     

Elective and primary angioplasty at hospitals without on-site surgery versus with on-site surgery: results from a national registry

INTRODUCTION: Current European clinical guidelines do not restrict interventional cardiology at centers without on-site surgical backup, but disagreement still exists whether hospitals with cardiac catheterization laboratories, but without on-site cardiac surgery, should develop percutaneous coronary intervention (PCI) programs. Technical improvements in equipment and pharmacologic adjunctive therapy have increased the safety margins of diagnostic and therapeutic cardiac catheterization and more than half of the patients treated by PCI in Portugal are treated at hospitals without on-site cardiac surgery. OBJECTIVES: We set out to compare clinical outcomes of elective and primary PCI for ST-segment elevation myocardial infarction at centers without on-site cardiac surgery with those at centers with on-site cardiac surgery. METHODS: Based on the Portuguese Registry of Interventional Cardiology, we retrospectively reviewed a total of 13,235 PCI procedures performed from January 2002 to June 2006 and compared the results for 7,112 patients treated at hospitals without on-site cardiac surgery with 6,123 patients treated at hospitals with on-site cardiac surgery. RESULTS: Demographic data were similar, with a mean age of 64 (55-72) vs. 63 (54-71) years, 75% vs. 76% male and 25.0% vs. 24.2% with diabetes respectively at centers without and with on-site surgical backup. Hospital mortality at centers without and with on-site surgical backup respectively was: chronic angina: 0.3% vs. 0.3% (NS); acute coronary syndromes: 1.5% vs. 1.0% (NS); acute myocardial infarction with ST elevation and without cardiogenic shock: 4.0% vs. 5.0% (NS); cardiogenic shock: 50.9% vs. 53.4% (NS). CONCLUSIONS: Similar clinical outcomes for interventional cardiology were achieved at hospitals without on-site cardiac surgery and those with on-site cardiac surgery. In the era of coronary stents, adjunctive therapy and experienced operators, elective and primary PCI can safely be performed without on-site surgical backup.     

Comparability of quality-of-care indicators for emergency coronary angioplasty in patients with acute myocardial infarction regardless of on-site cardiac surgery (report from the National Registry of Myocardial Infarction)

Initial reports have suggested that primary percutaneous coronary intervention (PCI) can be performed safely in selected hospitals without on-site cardiac surgery; however, quality-of-care indicators for primary PCI in these institutions is unknown. Therefore, symptom onset-to-door intervals, door-to-balloon times, compliance with American College of Cardiology/American Heart Association (ACC/AHA) management guidelines, and in-hospital mortality were evaluated in 108,132 patients in 3 hospital settings in the National Registry of Myocardial Infarction: (1) diagnostic laboratories only (n = 47), (2) elective PCI only (n = 50), and (3) elective PCI and cardiac surgery (n = 562). Mean symptom onset-to-door intervals (127 minutes, 95% confidence interval 118 to135; 134 minutes, 95% confidence interval 125 to 142; and 140 minutes, 95% confidence intervals 138 to 141; p = 0.01) and door-to-balloon intervals (104 minutes, 95% confidence interval 101 to 108; 116 minutes, 95% confidence interval 112 to 119; and 119 minutes, 95% confidence interval 118 to 120; p <0.0001) were shorter in hospitals without cardiac surgery. Adherence to ACC/AHA guidelines for medications within the first 24 hours (aspirin, beta blockers, angiotensin-converting enzyme inhibitors) was greater in hospitals without cardiac surgery. There were comparable in-hospital mortality rates (3.2%, 4.2%, and 4.8%, respectively; p = 0.07) for patients with similar Thrombolysis In Myocardial Infarction risk scores; however, 4.7% of patients treated with primary PCI in hospitals without cardiac surgery were transferred to another institution. Thus, hospitals performing primary PCI without on-site cardiac surgery that participated in this registry have quality-of-care indicators and adherence to ACC/AHA management guidelines that are comparable to hospitals with on-site cardiac surgery. The lack of on-site cardiac surgery does not appear to adversely affect quality-of-care indicators in primary PCI.     

Association Between Hospital Cardiac Catheter Laboratory Status,Use of an Invasive Strategy,and Outcomes After NSTEMI

BackgroundIncreased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown.MethodsWe included 452,216 patients admitted with a diagnosis of non–ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes.ResultsA total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals.ConclusionsThis study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed.     

In-hospital outcome of primary PCI for patients with acute myocardial infarction and prior coronary artery bypass grafting

BackgroundThis study aims to analyze the in-hospital outcome of primary percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI) and prior coronary artery bypass grafting (CABG).MethodsThis was a retrospective study. From January 2011 to December 2018, the data of 78 consecutive patients (study group) with prior CABG, who received primary coronary angiography in the setting of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI), were screened. The study group was compared with another well-matched 78 patients without a history of CABG (control group). The information of the coronary angiograms and clinical data of both groups were analyzed. Multivariate conditional logistic regression models were constructed to test the association between PCI success rate and the prior CABG at age ≥65 and <65 years, respectively.ResultsThe results revealed that the primary PCI success rate in the study group was significantly lower than in the control group (67.9% vs. 92.3%, P<0.001) and in-hospital mortality was significantly higher than in control group (11.5% vs. 2.5%, P=0.03). The multivariate logistic regression analysis indicated that the primary PCI success rate was significantly associated with the history of prior CABG both in young patients [age <65 years; odds ratio (OR) =5.26, 95% confidence interval (CI): 1.69–16.47] and elderly (age ≥65 years; OR =13.76, 95% CI: 2.72–69.75).ConclusionsThe patients who receive primary PCI with AMI and prior CABG have poor in-hospital outcomes, with low PCI success rates and high mortality.     

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Stenosis

Background

The present study performed a meta-analysis of randomized and prospective trials to compare the outcomes of percutaneous coronary intervention (PCI) with stents versus coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (UPLM) stenosis.

中高危非ST段抬高急性冠状动脉综合征早期侵入与早期保守策略的评价

目的　了解早期侵入与早期保守策略对中高危非ST段抬高急性冠状动脉综合征(ACS)患者住院主要不良心脏事件(MACE)发生情况的影响。方法　根据入院后冠状动脉造影(CAG)与否和时间(≤48h与>48h)对910例中高危非ST段抬高ACS患者分为早期侵入策略组(n=237)和早期保守策略(n=673)两组,分析早期策略与血管重建方式对住院MACE(包括死亡、新发心肌梗死和靶血管再次血管重建)的关系。结果　早期侵入与早期保守组的住院病死率和靶血管血管重建率相当,早期侵入组的住院时间较短,住院MACE(6. 3%比2 .5%,OR0 .384, 95% CI0 188~0 .781,P=0 .006)与新发心肌梗死(4. 6%比0 .9%,OR0 .185, 95% CI0 068~0 .505,P=0.001)的发生率更高。早期侵入组MACE与新发心肌梗死的增加可能与其血管重建操作较多( 86 .9%比67. 5%,P<0 .001)有关。亚组分析显示,早期侵入组与早期保守组中接受经皮冠状动脉介入治疗(PCI)的患者新发心肌梗死、靶血管再次血管重建(TVR)和MACE发生率均相当,无1例死亡;而早期侵入组中接受冠状动脉旁路移植术(CABG)的患者新发心肌梗死的发生率高于早期保守组中接受CABG的患者(7 .5%比1 .8%,P=0 .027)。结论　中高危非ST段抬高ACS患者采取早期侵入策略不增加住院病死率,但有可能增加住院心肌梗死。早期PCI安全可行     

Early Outcomes of Percutaneous Coronary Intervention in Patients with Cancer: A Systematic Review and Meta-analysis

Chemotherapeutic regimens have cardiotoxic properties and thorax irradiation is associated with accelerated coronary artery disease (CAD). There is limited data regarding the influence of cancer on outcomes after percutaneous coronary intervention (PCI), as cancer patients were not routinely included in the PCI trials. We performed a systematic review and meta-analysis to compare the early outcomes of PCI between patients with active/historical cancer and patients without a cancer history. A systematic search was made in the PubMed, Medline, and Cochrane databases using the search terms “PCI” and “Cancer”. The major outcomes were in-hospital mortality, in-hospital cardiovascular mortality, 30-day mortality, and peri-procedural complications. We used random effects model to aggregate data and calculate pooled incidence and risk ratios with 95% confidence intervals (CIs). A total of 7 studies were included, out of which 4 studies reported in-hospital mortality. Compared to patients without cancer, patients with active/historical cancer undergoing PCI had higher rates of in-hospital mortality (relative risk [RR] 1.89; 95% CI 1.33-2.70; P = 0.0004), in-hospital cardiovascular mortality (RR 2.21; 95% CI 1.19-4.08; P = 0.01), 30-day mortality (RR 2.01; 95% CI 1.24-3.27; P = 0.005), and peri-procedural blood transfusion (RR 1.73; 95% CI 1.02-2.95; P = 0.04). There were no significant differences in peri-procedural myocardial re-infarction, new-onset heart failure, shock, and stroke between the two cohorts. In conclusion, Among patients undergoing PCI, active/historical cancer was associated with worse early mortality compared to patients without a history of cancer. Management of cancer patients undergoing PCI should be individualized and involve multi-specialist team discussion to narrow the mortality gap.     

Sex Differences in Clinical Outcomes Following Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery: A Systematic Review and Meta-Analysis

IntroductionPercutaneous coronary intervention (PCI) has emerged as a reasonable alternative to coronary artery bypass graft (CABG) surgery in well-selected patients with unprotected left main coronary disease (LMCD). We conducted a systematic review and meta-analysis with the aim of assessing the impact of sex on outcomes of PCI in patients with unprotected LMCD.MethodsA systematic search of PUBMED, EMBASE, Cochrane, and Google Scholar databases was performed to identify studies comparing the outcomes of men vs. women among patients undergoing PCI for unprotected LMCD. The primary outcome of interest was study defined major adverse cardiac events (MACE) and secondary outcomes were all-cause mortality, cardiac mortality, myocardial infarction (MI), target lesion revascularization (TLR), stent thrombosis and stroke. For all outcomes, pooled odds ratios (OR) with their corresponding 95% confidence intervals (CIs) were calculated using the DerSimonian-Laird random-effects model.ResultsSix studies with a total of 6515 individuals (4954 men, 1561women) with a mean follow up of 36 months were included in the analysis. MACE and MI were significantly higher in women with OR of 1.17 (95% CI 1.01–1.36; p = 0.03) and 1.42 (95% CI 1.07–1.87; p = 0.01) respectively. All-cause mortality, cardiac mortality, and TLR were similar among men and women.ConclusionOur meta-analysis suggests that women undergoing PCI for unprotected LMCD have higher rates of MACE and MI compared to men.     

Impact of COVID-19 on Outcomes of Patients Hospitalized With STEMI: A Nationwide Propensity-matched Analysis

Patients with ST-segment elevation myocardial infarction (STEMI) and concurrent coronavirus disease 2019 (COVID-19) have been reported to have poor outcomes. However, previous studies are small and limited. The National Inpatient Sample database for the year 2020 was queried to identify all adult hospitalizations with a primary diagnosis of STEMI, with and without concurrent COVID-19. A 1:1 propensity score matching was performed. A total of 159,890 hospitalizations with a primary diagnosis of STEMI were identified. Of these, 2210 (1.38%) had concurrent COVID-19. After propensity matching, STEMI patients with concurrent COVID-19 had a significantly higher mortality (17.8% vs 9.1%, OR 1.96, P< 0.001), lower likelihood to receive same-day percutaneous coronary intervention (PCI) (63.6% vs 70.6%, P = 0.019), with a trend towards lower overall PCI (74.9% vs 80.2%, P = 0.057) and significantly lower coronary artery bypass grafting) (3.0% vs 6.8%, P = 0.008) prior to discharge, compared with STEMI patients without COVID-19. The prevalence of cardiogenic shock, need for mechanical circulatory support, extracorporeal membrane oxygenation, cardiac arrest, acute kidney injury (AKI), dialysis, major bleeding and stroke were not significantly different between the groups. COVID-19-positive STEMI patients who received same-day PCI had significantly lower odds of in-hospital mortality (adjusted OR 0.42, 95% CI 0.20-0.85, P = 0.017). STEMI patients with concurrent COVID-19 infection had a significantly higher (almost 2 times) in-hospital mortality, and lower likelihood of receiving same-day PCI, overall (any-day) PCI, and CABG during their admission, compared with STEMI patients without COVID-19.     

Impact of prior revascularization on the outcomes of patients presenting with ST-elevation myocardial infarction and cardiogenic shock

BackgroundPatient presenting with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) have extremely high mortality rates.ObjectivesWe sought to assess the impact of prior revascularization by either coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) on the in-hospital and 12-month outcomes and compare them with revascularization-naïve patients.Methods and resultsBetween 1/2010 and 5/2017, a total of 241 consecutive patients were admitted to our institution with STEMI and CS as defined by New York State Percutaneous Coronary Interventions Reporting System (PCIRS) and underwent primary PCI. Baseline clinical, angiographic and procedural characteristics, as well as in-hospital outcomes were prospectively collected among all patients undergoing primary PCI as part of the New York State PCIRS data collection. Patients with a history of prior bypass graft surgery were older and had a history of heart failure, hypertension, dyslipidemia, and diabetes. The left anterior descending coronary artery was usually the culprit vessel in post PCI and revascularization naïve patients, whereas it was a vein graft in patients with a prior history of surgical bypass. In-hospital mortality rates were different in the three groups and there was no significant difference in major adverse cardiac and cerebrovascular events rates among the three groups (p = 0.87). Notably, revascularization-naïve patients had higher rates of major bleeding complications (p = 0.006). By multivariable analysis, only age (OR 1.03; CI = 1.0–1.06), a prior history of congestive heart failure (OR 4.36, CI = 1.04–18.38) and dyslipidemia (OR 0.32 CI = 0.15–0.64) were independent predictors of 12-month mortality. Prior revascularization had no impact on rates of stroke, death or MACCE.ConclusionsPatients with acute STEMI and CS had similar in-hospital and one year mortality, stroke or major adverse cardiac and cerebrovascular events rates irrespective of their prior revascularization status.     

Sustained ventricular tachycardia or fibrillation in the cardiac catheterization laboratory among patients receiving primary percutaneous coronary intervention: incidence, predictors, and outcomes

OBJECTIVES: We sought to evaluate the incidence, predictors, and outcomes of ventricular tachycardia and/or ventricular fibrillation (VT/VF) in the cardiac catheterization laboratory among patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND: Although VT/VF has been known to occur during primary PCI, the current data do not identify patients at risk for these arrhythmias or the outcomes of such patients. METHODS: We evaluated 3065 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) trials, who underwent primary PCI to evaluate the associations of VT/VF and the influence of these arrhythmias on in-hospital and one-year outcomes. RESULTS: In patients undergoing primary PCI, VT/VF occurred in 133 (4.3%). Multivariate analysis identified the following as independent correlates of VT/VF: smoking (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.26 to 3.02), lack of preprocedural beta-blockers (OR 2.34, 95% CI 1.35 to 4.07), time from symptom onset to emergency room of 相似文献   

Meta-analysis Comparing Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting for Non-ST Elevation Acute Coronary Syndrome in Patients With Multivessel or Left Main Disease

Outcomes of patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary disease (MVD) and/or unprotected left main coronary artery disease (CAD) revascularized with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is not well defined. MEDLINE/PubMed and EMBASE/Ovid were queried for studies that investigated PCI vs CABG in this disease subset. The primary outcome was major cardiac adverse events (MACE) at 30 days and long-term follow-up (3-5 years). The final analysis included 9 studies with a total of 9299 patients. No significant difference was observed between PCI and CABG in 30 days MACE (risk ratio [RR] 0.96; 95% confidence interval [CI] 0.38-2.39, all-cause mortality, myocardial infarction, and stroke. A meta-regression analysis revealed patients with a history of PCI had higher risk of MACE with PCI as compared with CABG. At long-term follow-up, PCI compared with CABG was associated with higher risk of MACE (RR 1.52; 95% CI 1.28-1.81), myocardial infarction, and repeat revascularization, while no difference was observed in the risk of stroke and all-cause mortality. In patients with NSTE-ACS and MVD or unprotected left main CAD, no differences were observed in the clinical outcomes between PCI and CABG at 30 days follow-up. With long-term follow-up, PCI was associated with a higher risk of MACE.     

Outcomes of Transradial PCI compared to Transfemoral PCI in veterans with anemia: Insight from the VA Clinical Assessment,Reporting and Tracking (CART) program

BackgroundPre-procedural anemia is associated with increased bleeding and mortality post-percutaneous coronary intervention (PCI). The effect of trans-radial PCI (TR-PCI) in improving outcomes compared to trans-femoral PCI (TF-PCI) in anemic patients is not known.ObjectiveThe aim of this study was to evaluate the association between arterial access site (radial versus femoral) and outcomes in anemic Veterans undergoing PCI.MethodsPatients with baseline anemia, undergoing PCI at Veterans Affairs (VA) facilities between 2009 and 2015, were divided into two groups based on primary radial or femoral access. The association between anemia and access site with in-hospital and one-year adverse outcomes was evaluated using multivariable analysis.Results7330 veterans were included in the analysis, with 1712 (23%) treated via radial access. Baseline anemia was independently associated with in-hospital major bleeding (OR 3.8, 95% CI 2.5–5.6 for moderate anemia, OR 18.6, 95% CI 11.6–29.7 for severe anemia), and in-hospital mortality (OR 3.2, 95% CI 1.8–5.8 for moderate anemia, OR 7.9, 95% CI 3.7–16.8 for severe anemia). Anemia was also associated with increased one-year MACE and mortality. PCI performed via radial access was not associated with different outcomes compared with femoral access in the presence of anemia. Comparable results were noted when analysis was restricted to only patients with acute coronary syndrome (ACS).ConclusionsModerate and severe anemia were strongly associated with increased in-hospital and one-year mortality in a large healthcare system, though there was no interaction between arterial access site for PCI and clinical outcomes among patients with moderate or severe anemia.     

Diabetes complications and adverse health outcomes after coronary revascularization

Aims

To examine effects of diabetes complications on health outcomes following coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), comparing outcomes for patients with diabetes complications to those without diabetes complications.

Methods

Retrospective analysis of discharge data for 61,566 patients with diabetes age 45 or older who had CABG or PCI in 2007 in United States community hospitals, using data from the Nationwide Inpatient Sample. Analysis included propensity score-adjusted logistic regression.

Results

Of all patients, 21.2% of the weighted sample had diabetes complications. Older patients, Blacks and Hispanics, and those with greater illness severity were more likely to have diabetes complications. Unadjusted rates of in-hospital mortality, postoperative stroke, and renal failure were higher for patients with diabetes complications (rate ratios 2.2, 1.8, and 9.8, respectively; all p < 0.0001). In adjusted results, having diabetes complications was associated with higher odds of in-hospital mortality (odds ratio, OR 1.62, 95% confidence interval, CI 1.37–1.91) and renal failure (OR 3.03, CI 1.71–5.39). Compared to CABG, PCI was associated with extra risk of postoperative renal failure for those with diabetes complications.

Conclusion

Among patients with diabetes having revascularization, those with diabetes complications have higher risks of in-hospital death and renal failure irrespective of having CABG or PCI.     

Public reporting and case selection for percutaneous coronary interventions: an analysis from two large multicenter percutaneous coronary intervention databases

OBJECTIVES: The purpose of this research was to determine the potential effect of public reporting on case selection for percutaneous coronary intervention (PCI). BACKGROUND: Previous studies have suggested that public reporting of coronary artery bypass graft surgery (CABG) mortality might result in case selection bias and in denial of care to or out migration of high-risk patients. The potential effect of public reporting on case selection for PCI is unknown. METHODS: We compared demographics, indications, and outcomes of 11,374 patients included in a multicenter (eight hospitals) PCI database in Michigan where no public reporting is present, with 69,048 patients in a statewide (34 hospitals) PCI database in New York, where public reporting is present. The primary end point was in-hospital mortality. RESULTS: Patients in Michigan more frequently underwent PCI for acute myocardial infarction (14.4% vs. 8.7%, p < 0.0001) and cardiogenic shock (2.56% vs. 0.38%, p < 0.0001) than those in New York. The Michigan cohort also had a higher prevalence of congestive heart failure and extracardiac vascular disease. The unadjusted in-hospital mortality rate was significantly lower in New York than in Michigan (0.83% vs. 1.54%, p < 0.0001; odds ratio [OR] 0.54, 95% confidence interval [CI] 0.45 to 0.63). However, after adjustment for comorbidities, there was no significant difference in mortality between the two groups (adjusted OR 1.05, 95% CI 0.84 to 1.31, p = 0.70, c-statistic 0.88). CONCLUSIONS: There are significant differences in case mix between patients undergoing PCI in Michigan and New York that result in marked differences in unadjusted mortality rates. A propensity in New York toward not intervening on higher-risk patients because of fear of public reporting of high mortality rates is a possible explanation for these differences.     

Optimal strategy of coronary revascularization in chronic kidney disease patients: A meta-analysis

BackgroundPatients with chronic kidney disease (CKD) have high risks of coronary artery disease (CAD). Coronary revascularization is beneficial for long-term survival, but the optimal strategy remains still controversial.MethodsWe searched studies that have compared percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for revascularization of the coronary arteries in CKD patients. Short-term (30 days or in-hospital) mortality, long-term (at least 12 months) all-cause mortality, cardiac mortality and the incidence of late myocardial infarction and recurrence of revascularization were estimated.Results28 studies with 38,740 patients were included. All were retrospective studies from 1977 to 2012. Meta-analysis showed that PCI group had lower short-term mortality (OR 0.55, 95% CI 0.41 to 0.73, P < 0.01), but had higher long-term all-cause mortality (OR 1.29, 95% CI 1.23 to 1.35, P < 0.01). Higher cardiac mortality (OR 1.08, 95% CI 1.01 to 1.15, P < 0.05), higher incidence of late myocardial infarction (OR 1.78, 95% CI 1.65 to 1.91, P < 0.01) and recurring revascularization rate (OR 2.94, 95%CI 2.15 to 4.01, P < 0.01) is found amongst PCI treated patients compared to CABG group.ConclusionsCKD patients with CAD received CABG had higher risk of short-term mortality but lower risks of long-term all-cause mortality, cardiac mortality and late myocardial infarction compared to PCI. This could be due to less probable repeated revascularization.