Consecutive Percutaneous Coronary Intervention Procedures Research Articles

Benchmarking System Monitoring on Quality Improvement in Percutaneous Coronary Intervention: A Nationwide Registry in Japan

BackgroundQuality indicators (QIs) have been developed to improve and standardize care quality in percutaneous coronary intervention (PCI). In Japan, consecutive PCI procedures are registered in a nationwide database (the Japanese Percutaneous Coronary Intervention registry), which introduces a benchmarking system for comparing individual institutional performance against the national average. ObjectivesThe aim of this study was to assess the impact of the benchmarking system implementation on QI improvement at the hospital level. MethodsA total of 734,264 PCIs were conducted at 1,194 institutions between January 2019 and December 2021. In January 2018, a web-based benchmarking system encompassing 7 QIs for PCI at the institutional level, including door-to-balloon time and rate of transradial intervention, was introduced. The process by which institutions tracked their QIs was centrally monitored. ResultsDuring the 3-year study period, the benchmarking system was reviewed at least once at 742 institutions (62.1%) (median 4 times; Q1-Q3: 2-7 times). The institutions that reviewed their records had higher PCI volumes. Among these institutions, although door-to-balloon time was not directly associated, the proportion of transradial intervention increased by 2.3% in the system review group during the initial year compared with 0.7% in their counterparts. However, in the subsequent year, the association between system reviews and QI improvement was attenuated. ConclusionsThe implementation of a benchmarking system, reviewed by participating institutions in Japan, was partially associated with improved QIs during the first year; however, this improvement was attenuated in the subsequent year, highlighting the need for further efforts to develop effective and sustainable interventions to enhance care quality in PCI.

Early in-hospital discontinuation of aspirin on the first post-procedural day after percutaneous coronary stent implantation in patients on direct oral anticoagulation.

Previous trials investigating antithrombotic therapy with a direct oral anticoagulant (DOAC) and a P2Y12 inhibitor after percutaneous coronary intervention (PCI), termed dual therapy, allowed a short period of triple therapy including a DOAC, a P2Y12 inhibitor, and aspirin. This study aimed to determine whether discontinuation of aspirin on the first post-procedural day is safe or causes ischemic events. Ischemic and bleeding events during hospitalization were investigated retrospectively in all patients treated with dual therapy (DOAC + P2Y12 inhibitor, designated as group 1) or triple therapy (DOAC + P2Y12 inhibitor+aspirin, designated as group 2) from day 1 after PCI at our center. Of 4,564 consecutive PCI procedures, 1,059 (23.2%) had an indication for OAC. Of these, 322 met the inclusion criteria for group 1 and 62 for group 2. Baseline characteristics, CHA2DS2-VASc and HAS-BLED scores showed no relevant differences between the two groups, and the main indication for DOAC therapy was atrial fibrillation in both groups. Approximately ¼ of patients were treated for acute coronary syndrome. The mean length of post-procedural hospitalization was 2.1 ± 2.5 and 2.2 ± 3.0 days in group 1 and 2, respectively (p = 0.305). One patient per group suffered a TIA (p = 0.297). There were no other ischemic events and no statistically significant differences in bleeding events. A subgroup analysis of cases hospitalized for ≥2 post-procedural days (group 1: 100 cases, mean 4.4 ± 3.4 days vs. group 2: 25 cases, mean 4.0 ± 4.1 days) confirmed these results. The initiation of dual therapy and thus discontinuation of aspirin on the first postprocedural day appears to be safe with respect to short-term ischemic events in a real-world population. Almost ¼ of patients undergoing PCI have an indication for OAC, highlighting the relevance of this issue.

Safety and efficacy of a novel calcified plaque modification technique - Shockwave Intravascular Lithotripsy - in patients with coronary artery disease: Mid-term outcomes.

Coronary interventions in calcified lesions are associated with a higher rate of adverse clinical events. Initial aggressive plaque modification along with post-implantation optimization is pivotal for achieving a favorable outcome of percutaneous coronary intervention (PCI). Recently, the Shockwave C2 Intravascular Lithotripsy (S-IVL) System, a novel acoustic wave-based device designed to modify calcified plaque, has been introduced into clinical practice. We evaluated the mid-term safety and efficiency of S-IVL in a cohort of 131 consecutive patients with severely calcified coronary lesions. We retrospectively analyzed a total of 131 consecutive S-IVL PCI procedures. The study had two main inclusion criteria - the presence of a calcified resistant lesion (defined by inadequate non-compliant balloon catheter inflation) or a significantly underexpanded stent (more than 20% of reference diameter). The study had two primary endpoints - successful clinical outcome and safety concerns. Clinical success was defined as effective stent deployment or optimization of a previously underexpanded stent (with less than <20% in-stent residual stenosis). Safety outcomes were defined as periprocedural complications, such as device failure and major adverse cardiac and cerebrovascular events (MACCE). Clinical follow-up was performed at the end of hospitalization and 6 months after the index procedure. In-hospital MACCE was 4.6% with 1.5% target lesion revascularization (TLR) and one case of subacute fatal stent thrombosis. At 6-month follow-up, the MACCE rate was 7.9% with a concomitant TLR rate of 3.8%. Our mid-term data confirm acceptable safety and efficacy of intravascular lithotripsy as a valuable strategy for lesion preparation and stent optimization in a cohort of 131 consecutive patients with severely calcified coronary lesions.

Incidence, Predictors and Clinical Outcomes of Stent Thrombosis Following Percutaneous Coronary Intervention in Contemporary Practice

Stent thrombosis (ST) is an uncommon but serious complication of percutaneous coronary intervention (PCI). The reported rate of definite ST with new generation drug-eluting stents ranges from 0.5 to 1% at 30 days. We aimed to examine the incidence and outcomes of ST in a real-world setting. The Victorian Cardiac Outcomes Registry was established in 2012 as a state-wide clinical quality registry, with all PCI capable centres contributing in 2017. Data were collected on 41,137 consecutive PCI procedures from 2013 to 2017. We describe the patient characteristics and clinical outcomes in definite and probable ST at 30 days. Stent thrombosis occurred in 225 patients (0.55%). Compared to patients without ST, these patients were more likely to be female (32.0% vs 23.4%, p≤0.01) and have a history of diabetes (28.6% vs 21.9%, p=0.02). ST was more common in patients with severely reduced left ventricular ejection fraction (14.9% vs 4.6%, p<0.001) and in patients presenting with ST-elevation myocardial infarction, cardiogenic shock and cardiac arrest for their index PCI (all p<0.001). Dual antiplatelet therapy at 30 days was less frequent in patients with ST (84.8% vs 92.0%, p<0.001), while 30-day mortality was more common: 23.6% versus 2.0% (p<0.001). Even with contemporary stents and adjunctive medications, ST still occurs following 1 in 200 PCIs, and is associated with increased mortality at 30 days.

P6516The association between prior coronary artery bypass graft surgery and outcome after percutaneous coronary intervention (PCI): an observational study of 123,780 patients

Abstract Background Limited information exists regarding procedural success and clinical outcomes in patients with previous CABG undergoing percutaneous coronary intervention (PCI). We sought to compare outcomes in patients undergoing PCI with or without previous coronary artery bypass grafts (CABG). Methods This was an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry, from January 2005 to December 2015. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (interquartile range 1.2–4.6 years). Results 12,641 (10.2%) patients had a history of previous CABG, of whom 29.3% (n=3,703) underwent PCI to native vessels and 70.7% (n=8,938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%) (p=0.0005) compared to patients with no history of prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%, p&lt;0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (HR 1.02, 95% CI 0.77–1.34; P=0.89) but a significant increase in mortality among patients with PCI to bypass grafts (HR 1.33 95% CI 1.03–1.71, P=0.026). This was seen after multivariate adjustment and propensity matching. Figure 1. Kaplan-Meier Curves Conclusion Patients with prior CABG are older, with a greater comorbid burden and more complex procedural characteristics, but after adjustment for these differences clinical outcomes are similar to patients undergoing PCI without prior CABG. In these patients, native vessel PCI was associated with better outcomes compared to the treatment of vein grafts.

Risk-Adjusting Key Outcome Measures in a Clinical Quality PCI Registry: Development of a Highly Predictive Model Without the Need to Exclude High-Risk Conditions

ObjectivesThis study sought to determine the most risk-adjustment model for 30-day all-cause mortality in order to report risk-adjusted outcomes. The study also explored whether the exclusion of extreme high-risk conditions of cardiogenic shock, intubated out-of-hospital cardiac arrest (OHCA), or the need for mechanical ventricular support affected the model’s predictive accuracy. BackgroundRobust risk-adjustment models are a critical component of clinical quality registries, allowing outcomes to be reported in a fair and meaningful way. The Victorian Cardiac Outcomes Registry encompasses all 30 hospitals in the state of Victoria, Australia, that undertake percutaneous coronary intervention. MethodsData were collected on 27,544 consecutive percutaneous coronary intervention procedures from 2014 to 2016. Twenty-eight patient risk factors and procedural variables were considered in the modeling process. The multivariable logistic regression analysis considered derivation and validation datasets, along with a temporal validation period. ResultsThe model included risk-adjustment for cardiogenic shock, intubated OHCA, estimated glomerular filtration rate, left ventricular ejection fraction, angina type, mechanical ventricular support, ≥80 years of age, lesion complexity, percutaneous access site, and peripheral vascular disease. The C-statistic for the derivation dataset was 0.921 (95% confidence interval: 0.905 to 0.936), with C-statistics of 0.931 and 0.934 for 2 validation datasets reflecting the 2014 to 2016 and 2017 periods. Subgroup modeling excluding cardiogenic shock and intubated OHCA provided similar risk-adjusted outcomes (p = 0.32). ConclusionsOur study has developed a highly predictive risk-adjustment model for 30-day mortality that included high-risk presentations. Therefore, we do not need to exclude high-risk cases in our model when determining risk-adjusted outcomes.

The association between the public reporting of individual operator outcomes with patient profiles, procedural management, and mortality after percutaneous coronary intervention: an observational study from the Pan-London PCI (BCIS) Registry using an interrupted time series analysis

The public reporting of healthcare outcomes has a number of potential benefits; however, unintended consequences may limit its effectiveness as a quality improvement process. We aimed to assess whether the introduction of individual operator specific outcome reporting after percutaneous coronary intervention (PCI) in the UK was associated with a change in patient risk factor profiles, procedural management, or 30-day mortality outcomes in a large cohort of consecutive patients. This was an observational cohort study of 123780 consecutive PCI procedures from the Pan-London (UK) PCI registry, from January 2005 to December 2015. Outcomes were compared pre- (2005-11) and post- (2011-15) public reporting including the use of an interrupted time series analysis. Patients treated after public reporting was introduced were older and had more complex medical problems. Despite this, reported in-hospital major adverse cardiovascular and cerebrovascular events rates were significantly lower after the introduction of public reporting (2.3 vs. 2.7%, P < 0.0001). Interrupted time series analysis demonstrated evidence of a reduction in 30-day mortality rates after the introduction of public reporting, which was over and above the existing trend in mortality before the introduction of public outcome reporting (35% decrease relative risk 0.64, 95% confidence interval 0.55-0.77; P < 0.0001). The introduction of public reporting has been associated with an improvement in outcomes after PCI in this data set, without evidence of risk-averse behaviour. However, the lower reported complication rates might suggest a change in operator behaviour and decision-making confirming the need for continued surveillance of the impact of public reporting on outcomes and operator behaviour.

Incidence, Predictors and Clinical Outcomes of Stent Thrombosis Following PCI

Background: Stent thrombosis is an uncommon but serious complication of percutaneous coronary intervention (PCI). The reported rate of definite stent thrombosis with new generation drug-eluting stents ranges from 0.5 to 1%. We aimed to examine the incidence and outcomes of stent thrombosis in a real-world setting. Methods: The Victorian Cardiac Outcomes Registry was established in 2013 as a state-wide clinical quality registry, with all PCI capable centres contributing in 2017. Data were collected on 41,137 consecutive PCI procedures from 2013 to 2017. We described the patient characteristics and clinical outcomes in definite and probable stent thrombosis at 30 days. Results: Stent thrombosis occurred in 225 patients (0.55%). These patients were more likely to be female (32.0% vs. 23.4%, p = 0.002) and have a history of diabetes (28.6% vs. 21.9%, p = 0.016). Stent thrombosis was more common in patients with severely reduced left ventricular ejection fraction (14.9% vs. 4.6%, p < 0.001) and in patients presenting with ST-elevation myocardial infarction, cardiogenic shock and cardiac arrest for their index PCI (all p < 0.001). Dual antiplatelet therapy at 30 days was less frequent in patients with stent thrombosis (84.8% vs. 92.0%, p < 0.001), while 30-day mortality was more common: 23.6% versus 2.0% (p < 0.001). Conclusions: Even with contemporary stents and adjunctive medications, ST still occurs following one in 200 PCIs, and is associated with significantly increased mortality at 30 days.

Percutaneous Coronary Intervention Outcomes Following Out-of-Hospital Cardiac Arrest For Patients With and Without ST-Elevation Myocardial Infarction

Background: Outcomes after out-of-hospital cardiac arrest (OHCA) remain poor, and percutaneous coronary intervention (PCI) may have prognostic benefit in patients with a culprit coronary lesion. We aimed to describe outcomes among patients undergoing PCI following OHCA and the effect of ST-elevation myocardial infarction on outcome. Methods: Data were prospectively collected on 1,047 consecutive PCI procedures following OHCA at six Victorian public hospitals from 2005 to 2017. Patients were divided into those with STEMI (OHCA-S) and those without (OHCA-NS). Outcomes were compared against patients with STEMI only without OHCA (n = 9,694). Results: OHCA-S patients were younger and the treated lesion was more commonly occluded at time of PCI (63% vs 22%, p < 0.001). GP-IIb/IIIa antagonists, thrombus aspiration and intra-aortic balloon pump insertion were more frequently used for OHCA-S (p < 0.01). Cardiogenic shock (CS) was present in 47% of OHCA-S and 29% of OHCA-NS (p < 0.001). 30-day mortality was 34% for the OHCA-S and 18% for the OHCA-NS group. However, OHCA-S and OHCA-NS had similar long-term outcomes to the STEMI only group if they survived to 30-days. Multivariable predictors for 30-day mortality after PCI for OHCA were diabetes, impaired renal or LV function, and CS.Tabled 1OHCA w STEMIOHCA w/out STEMIn = 840n = 207p-value30-Day Mortality, n (%)282 (33.6)37 (17.9)<0.00112-Month Mortality, n (%)292 (34.8)38 (18.4)<0.001NDI-Linked Mortality, n(%)344 (41.3)53 (25.6)<0.001NDI Follow-up (days), mean ± SD1,082 ± 11981,221 ± 11030.12 Open table in a new tab Conclusions: PCI following OHCA has a high 30-day mortality, with worse outcomes among patients with STEMI. Beyond 30-days, long-term outcomes are similar to uncomplicated STEMI cohorts.

Patterns of in-hospital mortality and bleeding complications following PCI for very elderly patients: insights from the Dartmouth Dynamic Registry.

BackgroundVery elderly patients (age ≥ 85 years) are a rapidly increasing segment of the population. As a group, they experience high rates of in-hospital mortality and bleeding complications following percutaneous coronary intervention (PCI). However, the relationship between bleeding and mortality in the very elderly is unknown.MethodsRetrospective review was performed on 17,378 consecutive PCI procedures from 2000 to 2015 at Dartmouth-Hitchcock Medical Center. Incidence of bleeding during the index PCI admission (bleeding requiring transfusion, access site hematoma > 5 cm, pseudoaneurysm, and retroperitoneal bleed) and in-hospital mortality were reported for four age groups (< 65 years, 65–74 years, 75–84 years, and ≥ 85 years). The mortality of patients who suffered bleeding complications and those who did not was calculated and multivariate analysis was performed for in-hospital mortality. Lastly, known predictors of bleeding were compared between patients age < 85 years and age ≥ 85 years.ResultsOf 17,378 patients studied, 1019 (5.9%) experienced bleeding and 369 (2.1%) died in-hospital following PCI. Incidence of bleeding and in-hospital mortality increased monotonically with increasing age (mortality: 0.94%, 2.27%, 4.24% and 4.58%; bleeding: 3.96%, 6.62%, 10.68% and 13.99% for ages < 65, 65–74, 75–84 and ≥ 85 years, respectively). On multivariate analysis, bleeding was associated with increased mortality for all age groups except patients age ≥ 85 years [odds ratio (95% CI): age < 65 years, 3.65 (1.99–6.74); age 65–74 years, 2.83 (1.62–4.94); age 75–84 years, 3.86 (2.56–5.82), age ≥ 85 years: 1.39 (0.49–3.95)].ConclusionsBleeding and mortality following PCI increase with increasing age. For the very elderly, despite high rates of bleeding, bleeding is no longer predictive of in-hospital mortality following PCI.

The data extraction and longitudinal trend analysis network study of distributed automated postmarket cardiovascular device safety surveillance.

Current approaches for postmarket medical device safety surveillance are limited in their ability to produce timely and accurate assessments of adverse event rates. The Data Extraction and Longitudinal Trend Analysis (DELTA) network study was a multicenter prospective observational study designed to evaluate the safety of devices used during percutaneous coronary interventions. All adult patients undergoing percutaneous coronary intervention from January 2008 to December 2012 at 5 participating Massachusetts sites were included. A safety alert was triggered if the cumulative observed adverse event rates for the study device exceeded the upper 95% confidence interval of the event rates of propensity-matched control cohort. Prespecified sensitivity analyses were developed to validate any identified safety signal. A total of 23,805 consecutive percutaneous coronary intervention procedures were evaluated. Two of 24 safety analyses triggered safety alerts. Patients receiving Perclose vascular closure device experienced an increased risk of minor vascular complications (relative risk, 4.14; P<0.01) and any vascular complication (relative risk, 2.06; P=0.01) when compared with propensity-matched patients receiving alternative vascular closure device, a result primarily driven by relatively high event rates at 1 participating center. Sensitivity analyses based on alternative risk adjustment methods confirmed a pattern of increased rate of complications at 1 of the 5 participating sites in their use of Perclose vascular closure device. The DELTA network study demonstrates that distributed automated prospective safety surveillance has the potential of providing near real-time assessment of safety risks of newly approved medical devices.

Elevation of biomarkers and long-term outcome after percutaneous coronary intervention.

The impact of an elevation of cardiac biomarkers occurring after percutaneous coronary intervention (PCI) on long-term outcome remains controversial. Most available data are based on observational registries using multivariable analysis. In this study, a case-control approach was used to assess separately the impact of post-PCI elevation of CK-MB on the short-term in-hospital outcome and on the long-term outcome after hospital discharge. Between 1 January 1996 and 31 December 2008, a postprocedural rise of CK-MB was observed in 363 among 8346 consecutive PCI procedures (4·3%). The overall in-hospital mortality for patients with or without CK-MB elevation after PCI was 8·5% and 1·5%, respectively (P < 0·001). For 245 hospital survivors with CK-MB elevation, we found 245 control cases matched for 9 relevant clinical parameters in our PCI database during the same period. The long-term survival of these patients was assessed by KM estimates. Despite an increased in-hospital mortality among patients with periprocedural elevation of CK-MB, the long-term outcome of patients who are discharged alive is independent of CK-MB release, curves of overall survival and of survival free of recurrence of myocardial infarction being similar up to 10 years after hospital discharge. In our population, the elevation of CK-MB after PCI identified a high-risk subgroup for in-hospital mortality but had no impact on the long-term prognosis, once the patient is discharged alive from the hospital.

Full conversion from transfemoral to transradial approach for percutaneous coronary interventions results in a similar success rate and a rapid reduction of in-hospital cardiac and vascular major events

The transradial approach (TRA) for percutaneous coronary intervention (PCI) recently emerged as a safer vascular access with a similar rate of MACE but a lower success rate requiring crossover to another approach when compared to the transfemoral approach (TFA). In our hospital the introduction of the TRA in November 2003 resulted in a progressive decline of TFA use. Over the five years of conversion to TRA, from 2002 (100% TFA) to 2007 (98% TRA), major adverse cardiac events (MACE) and all in-hospital vascular and bleeding events, related or not to vascular access, were prospectively collected to assess performances of each approach in the specific setting of PCI (percutaneous coronary interventions). Data of 1,928 TFA and 1,672 TRA for a total of 3,600 consecutive PCI procedures are reported. PCI success rate was unchanged by TRA (96.1% versus 95.3% for TFA, NS). TRA was associated with a reduction in the rate of post-PCI myocardial infarction (2.3% versus 3.6% for TFA, p=0.023) and with a significant reduction of MACE (3.8% versus 5.2% for TFA, p=0.041). TRA use was also associated with a marked reduction of blood transfusion and surgery for post-PCI bleeding (0.2% versus 1.5% for TFA, p<0.001), despite more frequent prescription of downstream glycoprotein IIb/IIIa inhibitors (23.7% versus 7.4% for TFA, p<0.001). Thus, TRA resulted in a rapid and significant reduction of all major in-hospital adverse events, cardiac as well as non-cardiac, pooled in a "Net Adverse Clinical Event (NACE) index" of non-desirable events: death, myocardial infarction, stroke, urgent CABG surgery, surgery for bleeding and vascular events and blood transfusion. Such events occurred in 4.1% of TRA (n=69) as compared to 7% of TFA (n=134) (p<0.001), accounting for a 41% relative reduction of this NACE index by TRA. By multivariate analysis, TRA was related to a better in-hospital outcome (OR 0.64, 95% confidence interval [CI] 0.47-0.87; p=0.005). TRA for PCI provides the same success rate as TFA but significantly reduces post hoc related complications.

Performance monitoring in interventional cardiology: application of statistical process control to a single-site database

Graphical Statistical Process Control (SPC) tools have been shown to promptly identify significant variations in clinical outcomes in a range of health care settings, but as yet have not been widely applied to performance monitoring in percutaneous coronary intervention (PCI). We explored the application of these techniques to a prospective PCI registry at a single site. Baseline clinical and procedural data along with one and twelve month major adverse cardiac event (MACE) details were prospectively collected in relation to 2,697 consecutive PCI procedures (2,417 patients) performed between the 1st January 2003 and the 31st December 2007. We investigated outcome measures which were both clinically relevant and occurred at a sufficient frequency (>1%) to allow valid application of SPC techniques, and found procedural and lesion failure, major postprocedural complications, and one and 12 month MACE to be suitable endpoints. Cumulative Sum (CUSUM) charts, Variable Life-Adjusted Display (VLAD) charts and Funnel Plots were employed in combination to evaluate both group and individual performance on a near "real time" basis. We found that the use of these charts provided complimentary prospective audit of clinical performance to identify variations in group and individual operator performance and to clarify these as either systemic or individual operator-related. We propose a system of integrating SPC tools as a component of the audit function of a PCI unit. SPC tools have the potential to provide near "real-time" performance monitoring and may allow early detection and intervention in altered performance for both the group and the individual operator. A clinically-integrated system of SPC tools may thus complement and enhance effectiveness of the traditional case-based morbidity and mortality audit.

Percutaneous Coronary Intervention in Very Elderly Patients. In-hospital Mortality and Clinical Outcome

There are very few data about percutaneous coronary intervention (PCI) in very elderly patients. This study was aimed at assessing the demographic, clinical and angiographic features, procedural characteristics and in-hospital results of very elderly patients (VEP), aged ≥85 years undergoing PCI and comparing their results with those of a control group (CG) of patients younger than 85 years undergoing PCI throughout the same period of time. Between November 2004 and January 2007, 1699 consecutive PCI procedures were evaluated, 102 (6%) PCI procedures were performed in VEP and 1597 (94%) in patients <85 years. The mean age in the VEP group was 87.4 ± 2.4 years vs. 66.7 ± 11.2 years in the CG (p<0.0001). There were more females in the VEP group 49% vs. 22% than in the CG p<0.0001. Acute coronary syndromes (ACS) were a more frequent indication for PCI in VEP than in the CG: ST segment elevation myocardial infarction (STEMI) 14.7% vs. 8.3%, p = 0.025 and non-ST segment elevation acute coronary syndromes 54.9% vs. 43.5%, p = 0.024. The proportion of drug-eluting stents used, although high in both groups, was lower in VEP than in the CG (86.5% vs. 92.9%, p = 0.005). Angiographic lesion success rates were similar in both groups (95.9%). Global unadjusted in-hospital mortality was higher in the VEP group in comparison with the CG 3.9% vs. 0.68%, p = 0.01. The difference in mortality was due only to PCI in patients presenting with STEMI (26.6% in VEP group vs. 3.7% in the CG p = 0.007). There were no in-hospital deaths in VEP presenting with stable coronary syndromes or other ACS. There were no differences in unadjusted in-hospital myocardial infarction, new revascularisation or stroke between both groups. In patients ≥85 years old, PCI seems effective and carries an acceptable in-hospital mortality rate. The presence of STEMI substantially increases the risk of in-hospital death.

Time of day and outcomes of nonurgent percutaneous coronary intervention performed during working hours

During daytime working hours, outcomes may be worse when percutaneous coronary intervention (PCI) is performed later in the day because of operator fatigue and differences in process of care. Using the APPROACH database, we analyzed 2,492 consecutive nonurgent PCI procedures performed during working hours. Patients undergoing PCI for acute coronary syndromes were excluded. Patients were separated into 2 groups based on whether PCI was started in the morning (7:00 am-12:00 pm, n = 1,446) or after noon (12:01 pm-6:00 pm, n = 1,037). Outcomes included procedural complications; target vessel revascularization (TVR); and death at 7 days, 30 days, and 1 year. Patients undergoing PCI in the afternoon were more likely to have heart failure, reduced ejection fraction, and Canadian Cardiovascular Society class IV or atypical angina symptoms; more likely to be inpatients; less likely to have stable angina; and less likely to receive glycoprotein IIb/IIIa inhibitors. Patients undergoing PCI in the afternoon had significantly higher unadjusted rates of the composite of death and TVR at 7 days (0.9% vs 0.3%, P = .04) and 30 days (2.0% vs 1.0%, P = .04) and death at 1 year (2.2% vs 1.1%, P = .03) compared with PCI performed in the morning. After multivariate adjustment, the differences in the composite of death and TVR at 30 days and at 1 year were not statistically significant. Patients undergoing nonurgent PCI during working hours after noon had higher rates of TVR in the first 30 days and death at 1 year. Further study is required to determine whether patient characteristics, operator fatigue, differences in process of care, or a combination of these factors accounts for the difference in outcomes.

Percutaneous Coronary Intervention in Women: In-Hospital Clinical Outcome: Experience from a Single Private Institution in Melbourne

Differences in outcome between women and men treated with percutaneous coronary intervention (PCI) have decreased. This study was aimed at assessing the demographic, clinical, and angiographic features, procedural characteristics and in-hospital results of women undergoing PCI and comparing their results with those of a group of men undergoing PCI throughout the same period of time. All consecutive PCI procedures performed at Epworth Hospital from November 2004 to January 2007 were analysed. Women and men were compared according to baseline clinical, angiographic and procedural characteristics, angiographic success rates and in-hospital outcomes. A total of 1699 consecutive PCI procedures were performed; of these, 405 PCI (23.8%) were performed in women. Women were older (73.9+/-10 years versus 66.1+/-11.9 years, p<0.0001), had a higher prevalence of hypertension (78% versus 63%, p<0.0001), had lower prevalence of prior myocardial infarction (21% versus 27%, p=0.026), and had less history of prior coronary artery by-pass surgery (13% versus 18%, p=0.023) than men. A greater proportion of women presented with acute coronary syndromes (ACS) to PCI than men (63.7% versus 52.9%, p<0.0001). Women had more complex lesions B2/C (78% versus 74%, p=0.049), a higher proportion of ostial lesions (10.5% versus 5.5%, p<0.0001) and less multivessel disease (48% versus 54% p=0.028) than men. Angiographic lesion success rates were similar in both groups. Total unadjusted in-hospital mortality was higher in women than in men (1.97% versus 0.54%, respectively, p=0.013). This difference in mortality was only at the expense of a higher unadjusted mortality in women presenting with ST segment elevation myocardial infarction (STEMI) than men (17.5% versus 1.87%, p=0.002). No women with a stable coronary syndrome or non-ST-segment elevation acute coronary syndrome (NSTE-ACS) died in hospital. There were no differences in in-hospital myocardial infarction, new revascularisation or stroke between both groups. PCI in women has good results but carries an increased unadjusted mortality than in men. This mortality difference between genders in our study, however, was solely at the expense of a higher unadjusted mortality in women than in men undergoing PCI for STEMI.

Percutaneous Coronary Intervention in the Very Elderly: In Hospital Clinical Outcomes: Experience from a Single Private Institution

Objective: To assess the in-hospital clinical outcome following percutaneous coronary intervention (PCI) in very elderly patients (VEP), aged≥85 years, compared to a control group (CG) of patients <85 years. Between November 2004 and January 2007, 1699 consecutive PCI procedures were evaluated, 102 (6%) PCI procedures were performed in VEP and 1597 (94%) in patients <85 years. Results: The mean age in the VEP group was 87.4± 2.4 years vs. 66.7± 11.2 years in the CG (p< 0.0001). There were more females in the VEP group 49% vs. 22% in the CG p< 0.0001. Acute coronary syndromes (ACS) were a more frequent indication for PCI in VEP than in the CG: ST elevation myocardial infarction (STEMI) 14.7% vs. 8.3% p= 0.025 and non-STEMI ACS 54.9% vs. 43.5% p= 0.024. The proportion of drug-eluting stents used was lower in VEP than in the CG (86.5% vs. 92.9% p= 0.005). Angiographic success rates were similar in both groups (95.9%). Global in-hospital mortality was higher in the V p d b t g V A C a o d

External validation of established risk adjustment models for procedural complications after percutaneous coronary intervention

Background: Workable risk models for patients undergoing percutaneous coronary intervention (PCI) are needed urgently. Objective: To validate two proposed risk adjustment models (Mayo Clinic Risk Score (MC), USA and North...

Influence of the target vessel on the location and area of maximum skin dose during percutaneous coronary intervention

A number of cases involving radiation-associated patient skin injury attributable to percutaneous coronary intervention (PCI) have been reported. Knowledge of the location and area of the patient's maximum skin dose (MSD) in PCI is necessary to reduce the risk of skin injury. To determine the location and area of the MSD in PCI, and separately analyze the effects of different target vessels. 197 consecutive PCI procedures were studied, and the location and area of the MSD were calculated by a skin-dose mapping software program: Caregraph. The target vessels of the PCI procedures were divided into four groups based on the American Heart Association (AHA) classification. The sites of the MSD for AHA #1-3, AHA #4, and AHA #11-15 were located mainly on the right back skin, the lower right or center back skin, and the upper back skin areas, respectively, whereas the MSD sites for the AHA #5-10 PCI were widely spread. The MSD area for the AHA #4 PCI was larger than that for the AHA #11-15 PCI (P<0.0001). Although the radiation associated with PCI can be widely spread and variable, we observed a tendency regarding the location and area of the MSD when we separately analyzed the data for different target vessels. We recommend the use of a smaller radiation field size and the elimination of overlapping fields during PCI.