Quality metrics in cardiac catheterization for congenital heart disease: Utility of 30‐day mortality

Objectives: To characterize the frequency and attributability of death among patients who died within 30 days of their cardiac catheterization (30‐day mortality). Background: 30‐day postprocedure mortality is commonly used as a quality outcome metric in national cardiac catheterization registries. It is unclear if this parameter is sufficiently specific to meaningfully capture mortality attributable to cardiac catheterization in patients with congenital heart disease (CHD). Methods: Multicenter cohort study with 3 participating centers. Records were retrospectively reviewed for patients who died within 30 days of catheterization (06/2007‐06/2012). Attributability of death was assigned to each case. Results: A total of 14,707 cardiac catheterization procedures were performed during the study period. Death occurred within 30 days in 279/14,707 (1.9%) of cases. Among the patients who died, 53% of cases were emergent or urgent cases. The median age was 4 mos (1 day–45 years). Death was attributable to the catheterization procedure in 29/279 (10%) of cases. Death was attributable to cardiac surgery in 14%, precatheterization clinical status in 34%, postcatheterization clinical status in 22%, and noncardiac comorbidity in 19%. In 1%, death attributability could not be established. Conclusions: While valuable in adult settings, 30‐day mortality is inadequate as a quality metric among patients with CHD undergoing cardiac catheterization. To derive the optimal benefit from catheterization registry data, more robust methodologies to capture procedure‐related mortality are needed. © 2014 Wiley Periodicals, Inc.     

Prognostic value of different laboratory measures of renal function for long-term mortality after contrast media-associated renal impairment

Background: Contrast media‐induced nephropathy (CIN) is associated with markedly increased morbidity and mortality. Although creatinine is at present routinely used to characterize renal function, many studies and guidelines recommend using the estimated glomerular filtration rate (eGFR) since it was found to be much more accurate. Hypothesis: To assess whether the eGFR or creatinine alone provided a better predictive value for long‐term mortality after contrast media‐associated renal impairment. Methods: From a prospective trial with 412 patients undergoing heart catheterization, creatinine and eGFR before and after 24 h, 48–72 h, and 30 d after contrast‐media exposure were assessed as well as long‐term mortality. Results: Univariate Cox regression models identified increases in creatinine after 48 h (hazard rate ratio [HRR] 1.754, 95% confidence interval [CI] 1.134–2.712) and 30 d (HRR 3.157, 95% CI 1.968–5.064) as well as decreases in eGFR after 30 d (HRR 0.962, 95% CI 0.939–0.986) to be significant predictors of long‐term mortality. However, by multivariable Cox regression, only increases in creatinine after 48 h (HRR 1.608, 95% CI 1.002–2.581) and after 30 d (HRR 2.685, 95% CI 1.598–4.511) turned out to be significant and independent predictors of mortality. With regard to a possibly critical threshold of creatinine increase, our data confirmed the historically grown increase in creatinine of 0.5 mg/dl or more during the first 48 h as being associated with increased mortality (p = 0.016, log rank test). Conclusions: Serum creatinine, but not eGFR, was predictive for long‐term mortality, with a threshold of 0.5 mg/dl or more indicating worse prognosis. Copyright © 2010 Wiley Periodicals, Inc. Supported by an unrestricted research grant from Schering AG, Berlin, Germany.     

Characteristics and clinical outcomes of patients with cardiogenic shock complicating acute myocardial infarction treated by emergent coronary angioplasty

BACKGROUND: Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines. AIM: To evaluate the in‐hospital and 30‐day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS. METHODS AND RESULTS: Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co‐morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In‐hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non‐cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48?hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age ?75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0–1.24, P = 0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95–1.0, P = 0.05), were independent predictors of all cause mortality at 30 days. CONCLUSION: Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.     

Percutaneous left main coronary disease treatment without on‐site surgery back‐up in patients with acute coronary syndromes

Background : Best revascularization strategy in patients with acute coronary syndromes (ACS) and unprotected left main (ULM) coronary disease is still debate reflecting lack of convincing data. Objectives : To assess clinical feasibility and efficacy of ULM percutaneous coronary intervention (PCI) in patients with ACS and describe the practice of a center without on‐site surgical back‐up over a 7‐year period. Methods : Data on high‐risk patients with ACSs undergoing percutaneous ULM treatment were prospectively collected in an independent registry. Primary end‐points of this study were immediate and long‐term outcomes expressed as target lesion failure (TLF, composite of cardiac death, myocardial infarction (MI), and target lesion revascularization). Results : Between January 2003 and January 2010, 200 consecutive patients were included in this study. Angiographic success was obtained in 95% of patients but procedural success was 87% primarily affected by an 11% of in‐hospital cardiac mortality. At median follow‐up of 26 months (IQ 10–47), the overall TLF rate was 28.5%, with 16.0% of cardiac death, 7.0% of MI, and 10.5% of clinically driven target lesion revascularization rates. Cumulative definite/probable stent thrombosis was 3.5%. Elevated EuroSCORE value and pre‐procedural hemodynamic instability were the strongest predictors of TLF. Temporal trend analysis showed progressive but not significant improvement for both immediate (P = 0.110) and long‐term (P = 0.073) outcomes over the study period. Conclusions : This single‐center study based on current clinical practice in patient with ULM disease and ACS confirmed PCI as feasible revascularization strategy in absence of on‐site cardio‐thoracic support. Nevertheless, the outcome of these high‐risk patients is still hampered by a sensible in‐hospital mortality rate. © 2011 Wiley Periodicals, Inc.     

Percutaneous coronary intervention and 30‐day mortality: The British Columbia PCI risk score

Objectives : To construct a calculator to assess the risk of 30‐day mortality following PCI. Background : Predictors of 30‐day mortality are commonly used to aid management decisions for cardiac surgical patients. There is a need for an equivalent risk‐score for 30‐day mortality for percutaneous coronary intervention (PCI) as many patients are suitable for both procedures. Methods : The British Columbia Cardiac Registry (BCCR) is a population‐based registry that collects information on all PCI procedures performed in British Columbia (BC). We used data from the BCCR to identify risk factors for mortality in PCI patients and construct a calculator that predicts 30‐day mortality. Results : Patients (total n = 32,899) were divided into a training set (n = 26,350, PCI between 2000 and 2004) and validation set (n = 6,549, PCI in 2005). Univariate predictors of mortality were identified. Multivariable logistic regression analysis was performed on the training set to develop a statistical model for prediction of 30‐day mortality. This model was tested in the validation set. Variables that were objective and available before PCI were included in the final risk score calculator. The 30‐day mortality for the overall population was 1.5% (n = 500). Area under the ROC curve was 90.2% for the training set and 91.1% for the validation set indicating that the model also performed well in this group. Conclusions : We describe a large, contemporary cohort of patients undergoing PCI with complete follow‐up for 30‐day mortality. A robust, validated model of 30‐day mortality after PCI was used to construct a risk calculator, the BC‐PCI risk score, which can be accessed at www.bcpci.org . © 2009 Wiley‐Liss, Inc.     

Favorable Long‐Term Survival in Patients Undergoing Multivessel‐PCI Compared to Predicted Prognosis of CABG Estimated by EuroSCORE: Procedural and Clinical Determinants of Long‐Term Outcome

Aims/Methods: Treatment of patients with multivessel coronary artery disease (CAD) has been an ongoing focus of recent clinical studies, questioning the ideal treatment. Randomized trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have so far only included a minority of screened patients. Therefore, we analyzed data from 679 consecutive “all‐comer” patients, who underwent PCI in at least two main vessels. Expected in‐hospital mortality for CABG was calculated using the EuroSCORE and compared to the observed mortality rate during in‐hospital as well as long‐term follow‐up. Results: The patients were suffering from 2.5 ± 0.6 diseased vessels, and 2.8 ± 1.0 lesions were stented (32% of patients received at least one drug‐eluting stent [DES]; 20% of lesions were treated with DES). Forty‐seven percent of patients were treated for acute coronary syndrome (ACS) ( N = 176 ST‐elevation myocardial infarction [STEMI]; N = 140 non‐ST‐elevation myocardial infarction [NSTEMI]). The EuroSCORE was significantly higher in ACS patients compared to stable patients (logistic: STEMI 16.3 ± 17.2; NSTEMI 13.6 ± 13.0; stable CAD 3.9 ± 4.2). The observed in‐hospital mortality (STEMI 13.0%; NSTEMI 2.9%; stable CAD 1.7%, P < 0.001) was far lower than the estimated 30‐day mortality. Cox regression analysis identified an elevated logistic EuroSCORE (HR per quartile 2.7, P = 0.003), severely reduced left ventricular ejection fraction (HR 2.7, P < 0.001), elevated C‐reactive protein (HR 1.8, P = 0.012), and chronic renal failure (HR 2.8, P = 0.001) as independent predictors of long‐term mortality. Conclusions: The EuroSCORE, which is routinely used to estimate the perioperative risk of patients undergoing CABG, also predicts short‐ and long‐term prognosis of patients undergoing MV‐PCI. The observed mortality of patients undergoing MV‐PCI seems to be much lower than the estimated mortality of CABG.     

Prognostic Significance of Electrocardiographic Abnormalities in Diphtheritic Myocarditis After Hospital Discharge: A Long‐Term Follow‐Up Study

Objective: We aimed to investigate the long‐term cardiac mortality and the relationship between cardiac mortality and electrocardiographic abnormalities in patients with diphtheritic myocarditis who survived after hospital discharge. Materials and Methods: Between 1991 and 1996, 32 patients (all males, mean age 21.00 ± 3.77 years) surviving diphtheritic myocarditis were included in the study and they were followed up for an average of 16.3 months (range 10.3–26.8 months) after hospital discharge. Clinical evaluation, ECG, and echocardiography were performed on admission, daily while in hospital and at the time of discharge. ECG changes were permanent during the follow‐up period. The causes of death of the patients during follow‐up period were inferred from the death records of the patients and talking to the people witnessing cardiac arrest. Results: We observed that the patients with left bundle branch block (LBBB) and T wave inversion at hospital discharge had lower survival rates than that of the patients without these ECG changes in the long term. Although univariate Cox regression analysis identified LBBB (P = 0.001) and T wave inversion (P = 0.014) as the predictors of survival, only LBBB was an independent predictor of survival in multivariate Cox regression analysis. Adjusted hazard ratio was calculated as 13.67 for LBBB (P = 0.001; CI = 2.81–66.28). Conclusion: Diphtheritic myocarditis does not only demonstrate a malignant clinical course during acute phase of the disease, but also during the long‐term follow‐up period, especially in patients with LBBB and T wave inversion. Besides, T wave inversion and LBBB can help us to predict survival rate of the patients in long term. Moreover, LBBB is an independent predictor of long‐term survival in diphtheritic myocarditis.     

Temporal variations in hematocrit values in patients with left ventricular dysfunction: Relationship with cause-specific mortality and morbidity and optimal monitoring--further insights from SOLVD

BACKGROUND

Anemia is associated with an increased risk of death in heart failure (HF) patients. Currently, the relationship between temporal variations in hematocrit and specific causes of mortality and morbidity, as well as the most appropriate way to monitor changes in hematocrit, is unknown.

OBJECTIVE

To evaluate the prognostic value of changes in hematocrit during follow-up on specific causes of mortality and morbidity in the Studies Of Left Ventricular Dysfunction (SOLVD).

METHODS

A retrospective analysis of the SOLVD trials was conducted. Changes in hematocrit were evaluated in two ways: hematocrit as an absolute value at baseline and at each visit, and relative hematocrit variations compared with baseline.

RESULTS

Low absolute hematocrit values during follow-up were associated with cardiovascular (CV), non-CV and HF mortality, HF and non-CV hospitalizations, and cardiac ischemic events (P<0.05 for all end points). Decreases in hematocrit during follow-up compared with baseline were associated with HF hospitalizations (P<0.05) and non-CV death in patients receiving placebo (P=0.01 for interaction).

CONCLUSIONS

Hematocrit values during follow-up provide independent prognostic information in patients with HF for both CV and non-CV events. Absolute values of hematocrit are more closely related with outcomes and are therefore more clinically relevant to monitor than relative variations.     

Comparison of the predictive value of EuroSCORE,SYNTAX score,and clinical SYNTAX score for outcomes of patients undergoing percutaneous coronary intervention for unprotected left main coronary artery disease

Objectives : We aimed to assess the prognostic values of the EuroSCORE, SYNTAX score, and the novel Clinical SYNTAX score (CSS) for 30‐day and 1‐year outcomes in patients undergoing left main (LM) percutaneous coronary intervention (PCI). Background : PCI has become an alternative treatment for LM coronary artery disease, and risk scoring system might be beneficial for pre‐PCI risk stratification. Methods and Results : We enrolled 198 consecutive patients with unprotected LM disease undergoing PCI (mean age 71.5 ± 10.7 years). The CSS was calculated by multiplying the SYNTAX Score to (age/left ventricular ejection fraction +1 for each 10 mL the estimated glomerular filtration rate <60 mL/min per 1.73 m²). The endpoints were 30‐day, and 1‐year all‐cause death and major adverse cardiovascular events (MACE), which were defined as all‐cause death, nonfatal MI, and clinical‐driven target vessel revascularization. Comparing with the SYNTAX score, the predictive accuracy of CSS for 30‐day and 1‐year all‐cause death and MACE were significantly higher (c‐statistics, CSS versus SYNTAX score: P < 0.01 for 30‐day and 1‐year all‐cause death; P < 0.05 for 30‐day and 1‐year MACE, respectively). Furthermore, in the multivariate Cox regression analysis, both EuroSCORE and CSS were identified as the independent predictors of 30‐day and 1‐year all‐cause death and MACE, but the SYNTAX score was not. Conclusions : In the general practice among a high‐risk population undergoing LM PCI, EuroSCORE and CSS might be independent predictors for 30‐day and 1‐year all‐cause death and MACE. Furthermore, the CSS had a superior discriminatory ability in predicting the 30‐day and 1‐year clinical outcomes comparing with the SYNTAX score. © 2012 Wiley Periodicals, Inc.     

First human experience of thermal arterial closure

Objectives: This study was designed to evaluate the efficacy and safety of the CardioDex arterial closure device, which is a novel femoral artery closure device used following percutaneous cardiac catheterization. Background: Current devices utilized to achieve hemostasis of the femoral artery following percutaneous cardiac catheterization include collagen plug and suture mediated devices, but are associated with significant vascular complications. The CardioDex closure device utilizes thermal energy to cause collagen shrinking and swelling and thereby, achieve hemostasis. Methods: The device was evaluated in a prospective nonrandomized single‐center trial with patients undergoing 6F invasive cardiac procedures. Femoral artery puncture closure was performed immediately at completion of the procedure, followed by 3–4 minutes of manual compression. Time to hemostasis (TTH), time to ambulation (TTA), and short‐term clinical follow‐up data were collected. Results: A total of 34 patients including 21 diagnostic and 13 interventional cases were evaluated. The median TTH was 3 min in diagnostic and 4 min in interventional cases. TTH was independent of activated clotting time (ACT). The median TTA was 2.75 hr and 3.37 hr in diagnostic and interventional groups, respectively. There were no major adverse events identified at 1 week and 30 day follow up. Conclusions: This first in human clinical experience with the CardioDex closure device demonstrates that in the small cohort studied, it is safe and effective in diagnostic cardiac catheterization and also in interventional cases on mild anticoagulation (mean ACT = 188 sec). It has the advantage of leaving no foreign material in the body following use. © 2013 Wiley Periodicals, Inc.     

Impact of Acute Blood Loss Anemia and Red Blood Cell Transfusion on Mortality after Percutaneous Coronary Intervention

The clinical impact of increasing levels of blood loss has been shown to increase morbidity and mortality after percutaneous coronary intervention (PCI). The impact of red blood cell (RBC) transfusion for severe bleeding is unknown. We systematically collected baseline and 8‐h postprocedure hematocrit (HCT) values on patients undergoing PCI. The incidence of adverse events, including death and recurrent myocardial infarction, was correlated to increasing blood loss. A total of 6,799 patients undergoing PCI (January 2000 to April 2002) had serial HCT levels. Negligible, mild, moderate, and severe blood loss occurred in 43, 25, 25, and 8% of patients, respectively. In‐hospital mortality was 0.3, 0.5, 1.4, and 5.7% (p < 0.0001) with increasing severity of blood loss. Blood transfusion was independently associated with mortality (relative risk [RR] 2.03, p = 0.028). A case‐controlled analysis of 146 transfused patients versus 292 nontransfused patients with severe bleeding found an independent association between RBC transfusion and increased risk of 1‐year mortality (RR 2.42, p = 0.0045). Patients receiving blood > 35 days old had significantly worse 1‐year survival rates compared with patients receiving blood < 35 days old and patients not transfused (36 vs. 24 vs. 10%, p < 0.0001). In a general PCI population, increasing levels of blood loss are associated with an increased incidence of major adverse cardiac events and in‐hospital mortality. RBC transfusion in the setting of severe bleeding is associated with an increased risk of 1‐year mortality. Transfusion of aged RBCs may also be detrimental in this setting. Copyright © 2007 Wiley Periodicals, Inc.     

Primary percutaneous coronary intervention for acute myocardial infarction caused by unprotected left main stem thrombosis

Background: There is a paucity of data on outcomes in patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) caused by left main stem (LMS) thrombosis. Objectives: We sought to determine (i) the clinical features, (ii) correlates of early mortality, and (iii) long‐term outcomes in contemporary patients undergoing primary PCI for unprotected LMS thrombosis. Methods: From 1,115 consecutive primary PCI cases at two tertiary referral centers between January 2004 and September 2007, 28 cases (2.5%) with unprotected LMS culprit lesions were identified. Data were obtained from review of institutional databases, folder audit, telephone survey of patients, and independent review of angiograms. Results: The mean age of patients was 68 ± 14 years. Males comprised 76%, and 21% had diabetes. Significant morbidity was noted at presentation: shock in 18 (62%), pulmonary oedema in 15 (52%), and cardiac arrest in 10 (35%) patients, respectively. Lesion location was ostial in 7 (25%), body in 8 (29%), and distal in 13 (46%) patients, respectively. Angiographic success was achieved in 24 patients (83%). Stents were deployed in 27 patients (96%); drug‐eluting stents in 11 patients (39%). No patient required in‐hospital CABG. Cumulative in‐hospital mortality was 36%. Univariate predictors of in‐hospital mortality included shock, preceding cardiac arrest, and angiographic failure (all P < 0.05). At a mean follow‐up of 26 ± 12 months in hospital survivors, there were two TVR (elective CABGs), one death, and no reinfarctions. Conclusion: We report a lower than previously reported in‐hospital mortality of 36% in contemporary patients undergoing primary PCI for unprotected LMS thrombosis. Long‐term outcomes in hospital survivors appear favorable. © 2009 Wiley‐Liss, Inc.     

Early and mid-term clinical outcome of emergency PCI in patients with STEMI due to unprotected left main coronary artery disease

Objectives: Evaluation of acute and mid‐term outcomes of patients with ST‐elevation myocardial infarction (STEMI) undergoing emergency PCI due to unprotected left main coronary artery (ULMCA) disease. Background: STEMI patients due to ULMCA disease represent a rare, high risk group. Percutaneous coronary intervention (PCI) may be the preferred strategy of myocardial revascularization but there are few data about this topic. Methods: We analyzed 30‐day and mid‐term mortality of 58 patients with STEMI and ULMCA disease as culprit lesion treated in our centre by emergency PCI between 2000 to 2010. Results: Mean age was 67.3 ± 11.5 years. Thirty (51.7%) patients had cardiogenic shock on admission. PCI success was achieved in 54 patients (93.1%). Mean follow‐up was 15.8 ± 10.9 months (median 14, range 6–45). Thirty‐day and mid‐term mortality rates were 39.7% and 44%. Backward binary logistic regression model identified cardiogenic shock at presentation (OR 12.6, 95% CI 2.97–53.6, P < 0.001), age ≥75 years (OR 5.9, 95% CI 1.3–26.5, P = 0.019) and post‐PCI TIMI flow grade <3 (OR 2.9, 95% CI 1.8–5.7 P = 0.02) as independent predictors of 30‐day mortality. Cox proportional hazard ratio (HR) identified shock at presentation (HR 5.2, 95% CI 1.8–14.3, P < 0.002), age ≥75 years (HR 3.9, 95% CI 1.8–8.7, P < 0.001), post‐PCI TIMI flow grade <3 (HR 4.9, 95% CI 1.6–14.6; P < 0.005) as independent predictors of mid‐term mortality. Conclusions: In patients with STEMI and ULMCA as culprit lesion, emergency PCI is a valuable therapeutic strategy. Early and mid‐term survival depends on cardiogenic shock, advanced age, and PCI failure. Patients surviving the first month have good mid‐term prognosis. (J Interven Cardiol 2012;25:215–222)     

Adiposity in relation to readmission and all‐cause mortality following coronary artery bypass grafting: A systematic review and meta‐analysis

This study systemically reviewed evidence linking adiposity to readmission and all‐cause mortality in post‐coronary artery bypass grafting (CABG) patients. Keyword/reference search was performed in PubMed, Web of Science, CINAHL, and Cochrane Library for articles published before June, 2018. Eligibility criteria included study designs: experimental/observational studies; subjects: adult patients undergoing CABG; and outcomes: hospital/clinic readmissions, and short‐term (≤30 days) and mid‐to‐long‐term (>30 days) all‐cause mortality. Seventy‐two studies were identified. Meta‐analysis showed that the odds of post‐CABG readmission among patients with overweight was 30% lower than their normal‐weight counterparts and the odds of mid‐to‐long‐term post‐CABG mortality among patients with overweight were 20% lower than their normal‐weight counterparts. In contrast, no difference in post‐CABG readmission rate was found between patients with obesity and their nonobese counterparts; no difference in short‐term or in‐hospital post‐CABG mortality rate was found between patients with overweight or obesity and their normal‐weight counterparts; and no difference in mid‐to‐long‐term post‐CABG mortality rate was found between patients with obesity and their normal‐weight counterparts. In conclusion, patients with overweight but not obesity had a lower readmission and mid‐to‐long‐term mortality rate following CABG relative to their normal‐weight counterparts. Preoperative weight loss may not be advised to patients with overweight undergoing CABG.     

Long-term mortality of patients admitted to the hospital with alcohol withdrawal syndrome

Background: Although it is well known that alcoholism increases long‐term mortality, there is a paucity of data regarding long‐term prognosis in alcoholic patients who have an episode of alcohol withdrawal syndrome (AWS). Methods: We studied a cohort of 1,265 individuals with severe AWS who were admitted to a single university hospital between 1996 and 2006. Median age was 49 years (range 18 to 89 years). A total of 1,085 (85.8%) were men. Median follow‐up was 34 months (range 0 to 121 months). Survival of patients with AWS was compared with that of a reference cohort of 1,362 individuals from the same area. In addition, age‐ and sex‐standardized mortality ratios were calculated using the general population from the region (Galicia, Spain) as the reference. Results: The risk of mortality was higher in the cohort of patients with AWS than in the reference cohort after adjusting for age, sex, and smoking (hazard ratio 12.7; 95% CI 9.1 to 17.6; p < 0.001). The standardized mortality ratio in patients with AWS was 8.6 (95% CI 7.7 to 9.7). Age, smoking, serum creatinine, serum bilirubin, and prothrombin time at baseline were independently associated with mortality among patients with AWS. Conclusions: Long‐term mortality is highly increased in patients who have a history of AWS. Liver and kidney dysfunction are independent predictors of long‐term mortality in patients with AWS.     

Prognostic significance of diabetes as a predictor of survival after cardiac catheterization. APPROACH Investigators. Alberta Provincial Program for Outcome Assessment in Coronary Heart Disease

PURPOSE: Diabetes is a recognized risk factor for the development of cardiac disease, but its importance as a prognostic factor among patients with known cardiovascular disease is less clear. We evaluated survival in patients with and without diabetes who underwent cardiac catheterization for presumed coronary artery disease. SUBJECTS AND METHODS: We analyzed data from a prospective cohort study that captures detailed clinical information and longitudinal outcomes for all patients who undergo cardiac catheterization in Alberta, Canada. We studied 11,468 patients, 1959 (17%) of whom had diabetes. Logistic regression was used to model predictors of 1-year mortality, and proportional hazards analysis was used to model predictors of survival up to 3 years after cardiac catheterization. RESULTS: One-year mortality was 7.6% for patients with diabetes versus 4.1% for those without diabetes (odds ratio = 1.9, 95% confidence interval [CI]: 1.6 to 2.3). After adjusting for other characteristics of the patients, including comorbid conditions, previous cardiac history, coronary anatomy, and renal function, the odds ratio for 1-year mortality was 1.1 (95% CI: 0.8 to 1.3). Similarly, the adjusted hazard ratio for longer term mortality was 1. 2 (95% CI: 1.0 to 1.4, mean follow-up of 702 days). CONCLUSIONS: These results suggest that there is little or no independent association between diabetes and mortality for up to 3 years after cardiac catheterization. Estimates of short- to intermediate-term prognosis for diabetic patients with coronary artery disease should be based on the presence of other prognostic factors associated with diabetes.     

Histopathology of aspirated thrombus and its association with ST‐segment recovery in patients undergoing primary percutaneous coronary intervention with routine thrombus aspiration

Background : In patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with thrombus aspiration, the histopathology of aspirated thrombus was previously related to long‐term mortality. In this study, we sought to investigate the association between histopathology of aspirated thrombus and ST‐segment recovery, a marker of microvascular dysfunction, immediately at the end of the PCI procedure. Methods : We included 892 STEMI patients who underwent primary PCI with routine thrombus aspiration and for whom combined data on histopathology of aspirated thrombus and ST‐segment recovery were available. Patients were categorized according to histopathology of aspirated thrombus: fresh only (<1 day), older (>1 day), or no material aspirated. ST‐segment recovery was defined as incomplete if <50%. Results : Incomplete ST‐segment recovery occurred in 134 of 363 patients (37%) with fresh thrombus, in 104 of 238 patients (44%) with older thrombus, and in 142 of 291 patients (49%) with no material. Unadjusted odds ratios for incomplete ST‐segment recovery of patients with older thrombus and no material, when compared with patients with fresh thrombus, were 1.33 (95% CI, 0.95–1.85; P = 0.097) and 1.63 (95% CI 1.19–2.23; P = 0.002), respectively. Both associations were unchanged after multivariable adjustment for clinical predictors of ST‐segment recovery. ST‐segment recovery was a strong predictor of long‐term mortality, independent of the histopathology of aspirated thrombus. Conclusions : This study shows that ST‐segment recovery immediately at the end of the PCI procedure was a significant prognosticator, independent of the histopathology of aspirated thrombus. We found that the histopathology of aspirated thrombus (fresh, older, no material) was associated with ST‐segment recovery in STEMI patients undergoing primary PCI with thrombus aspiration. © 2010 Wiley‐Liss, Inc.     

Prognostic value of biochemical markers, 12-lead ECG and patient characteristics amongst patients calling for an ambulance due to a suspected acute coronary syndrome

Objectives. To evaluate whether a 12‐lead ECG, together with a multi‐marker strategy that used point‐of‐care measurements of myoglobin, creatine kinase (CK‐MB) and troponin I, was able to predict patients at short‐ and long‐term risk of death, when simultaneously considering age, gender, previous history, symptoms and clinical findings on arrival of the ambulance. Design. Prospective observational study. Setting and subjects. Consecutive patients (n=511) in ambulances in Stockholm and Göteborg in Sweden who called for an ambulance due to chest pain or other symptoms raising a suspicion of acute coronary syndrome. Intervention. In almost all patients, a diagnostic ECG, patient baseline characteristics and measurements of CK‐MB, troponin I and myoglobin were recorded. Results. In univariate analysis, the highest 30‐day mortality (17%) was found amongst patients with the combination of ECG signs of myocardial ischaemia and the elevation of any biochemical marker. The highest 1‐year mortality (20%) was found amongst patients with ECG signs of myocardial ischaemia and the elevation of any biochemical marker. Increasing age (RR 1.07; 95 CI 1.02–1.13) lack of symptoms of chest pain and a previous history of hypertension (3.02; 1.08–8.79) were independent predictors of 30‐day mortality. Myoglobin was the only biochemical marker independently associated with 30‐day mortality (6.66; 1.83–22.3). Increasing age (1.11; 1.06–1.16), previous history of diabetes (3.42; 1.41–8.25) heart failure (2.64; 1.26–5.52) and other symptoms than chest pain and dyspnoea (5.23; 2.14–12.76) were independent predictors of 1‐year mortality. In many of the variables the confidence limits were wide. Conclusion. Amongst patients with a clinical suspicion of acute coronary syndrome, those with the combination of ECG signs of myocardial ischaemia and the elevation of any biochemical marker on arrival of the ambulance form a group with a particularly high risk of death. However, age as well as aspects of clinical history and type of symptoms independently contribute to prognostic information.     

Frequency,determinants, and prognostic effects of acute kidney injury and red blood cell transfusion in patients undergoing transcatheter aortic valve implantation

Objectives : To determine the frequency and independent predictors of acute kidney injury (AKI) in addition to the prognostic implications of both AKI and periprocedural red blood cell (RBC) transfusions on 30 day and cumulative late mortality in patients undergoing transcatheter aortic valve implantation (TAVI). Background : RBC transfusions have been reported to predict AKI following TAVI. Data on the prognostic implications of both factors, however, are lacking. Methods : 126 consecutive patients underwent TAVI with the Medtronic CoreValve Revalving System. AKI was defined according to the valve academic research consortium definitions as an absolute increase in serum creatinine ≥0.3 mg dL^?1 (≥26.4 μmol L^?1) or a percentage increase ≥50% within 72 hr following TAVI. Results : Five patients on chronic haemodialysis and three intraprocedural deaths were excluded, leading to a final study population of 118 patients. AKI occurred in 19% of the patients necessitating temporary haemodialysis in 2%. Independent predictors of AKI included: previous myocardial infarction (OR: 5.72; 95% CI: 1.64–19.94), periprocedural (<24 hr) RBC transfusions (OR: 1.29; 95% CI: 1.01–1.70), postprocedural (<72 hr) leucocyte count (OR: 1.18; 95% CI: 1.02–1.37), and logistic EuroSCORE (OR: 1.08; 95% CI: 1.01–1.14). In patients with AKI, 30‐day mortality was 23% and cumulative late mortality (median: 13 months) was 55%. AKI (OR: 5.47; 95% CI: 1.23–24.21) and postprocedural leucocyte count (OR: 1.20; 95% CI: 1.03–1.38) were independent predictors of 30‐day mortality while AKI (HR: 2.79; 95% CI: 1.36–5.71) was the only independent predictor of late mortality. Conclusions : AKI following TAVI occurred in 19% of the patients. RBC transfusion was found to be an independent predictor of AKI, which in turn predicted both 30‐day and cumulative late mortality. © 2011 Wiley‐Liss, Inc.     

A randomized controlled trial of stage-matched intervention for smoking cessation in cardiac out-patients

Aim To examine the effectiveness of a stage‐matched smoking cessation counselling intervention for smokers who had cardiac diseases. Methods A total of 1860 Chinese cardiac patients who smoked at least one cigarette in the past 7 days and aged 18 years or above recruited from cardiac out‐patient clinics in Hong Kong hospitals were allocated randomly to an intervention group or control group. The intervention group (n = 938) received counselling matched with their stage of readiness to quit by trained counsellors at baseline, 1 week and 1 month. The control group (n = 922) received brief counselling on healthy diet at baseline. The primary outcomes were self‐reported 7‐day and 30‐day point prevalence (PP) of tobacco abstinence at 12 months after baseline. The secondary outcome measures included biochemically validated abstinence at 12‐month follow‐up, self‐reported 7‐day and 30‐day PP abstinence and reduction of cigarette consumption by 50% at 3 and 6 months. Results By intention‐to‐treat analysis, the intervention and control groups showed no significant difference in self‐reported 7‐day PP abstinence (intervention: 26.5% versus control: 25.5%; P = 0.60) and 30‐day PP (intervention: 25.4% versus control: 24.2%; P = 0.55), biochemically validated abstinence (intervention: 6.6% versus control: 4.9%; P = 0.14) and overall quit attempts of least 24 hours (intervention: 40.3% versus control: 34.3%; P = 0.007) at the 12‐month follow‐up, adjusted for the baseline stage of readiness to quit smoking. Conclusions An intervention, based on the Stages of Change model, to promote smoking cessation in cardiac patients in China failed to find any long‐term benefit.