Need For Cardiac Catheterization Research Articles

Abstract 17263: Outcomes and Trends of Percutaneous Coronary Intervention in Nonagenarians With Acute Myocardial Infarction: Results From National Inpatient Sample 2016-2020

Background: Acute myocardial infarction (MI) is a leading cause of mortality and morbidity among the elderly. Multiple co-morbidities and advanced age often impede the need for cardiac catheterization in these patients. The literature studying percutaneous coronary intervention (PCI) in nonagenarian patients with acute MI is limited. Methods: We examined hospitalized acute MI patients with age 90 or above that were included in the National Inpatient Sample 2016-2020. Acute MI was defined by using the International Classification of Diseases -10. Patients aged less than 90 years were excluded. Outcomes were expressed as percentages. Multivariable logistic regression analysis was used to examine the association of PCI and age 90 or above with primary outcome of mortality, and secondary outcomes [ Figure1]. We also studied the yearly trends of PCI in nonagenarian patients with acute MI patients. Results: Of the total hospitalized patients with acute MI (n = 3,120,759), 4.6% (n=142,675) patients were aged 90 years or above. Of these, 9.4% (n= 3,615) died in PCI group and 12.7% (n= 13,215) died in non - PCI group. PCI was performed in 27% (n= 38,430) of the nonagenarian patients with acute MI. The most common outcomes in PCI group were acute heart failure (37.5%), Acute kidney injury (28 %), and atrial arrhythmia (23%). PCI in nonagenarian patients with acute MI was associated with decreased odds of mortality (OR 0.75, 95% CI 0.68-0.82, p value <0.001) and having any of the secondary outcomes (OR 0.74, 95% CI 0.69- 0.79, p value <0.001) [Figure 1]. From 2016-2020, there are increasing yearly trends of PCI in nonagenarian patients with acute MI (p value <0.001). Conclusion: Acute MI in elderly patients is associated with significant increased mortality and adverse events. PCI in acute MI patients with age 90 years or above was associated with decreased odds of mortality.

Pediatric restrictive cardiomyopathy: a case report.

Restrictive cardiomyopathy (RCM) is a rare childhood cardiomyopathy that is a challenging diagnostic problem for clinicians. We describe a case of an 8-year-old girl with a 2-year history of shortness of breath on exertion. Electrocardiogram and echocardiography showed biatrial enlargement, while cardiac magnetic resonance showed biatrial dilation and normal pericardial thickness. Left and right heart catheterization revealed a left ventricular (LV) end-diastolic pressure (EDP) of 20 mmHg, right ventricular (RV) EDP of 13 mmHg, and pulmonary arterial systolic pressure of 51 mmHg. LV and RV pressure traces showed that LV and RV pressures moved concordantly with respiration, and that the systolic area index was 0.98. Cardiac catheterization data were therefore supportive of RCM. Next-generation sequencing identified a heterozygous variant of the troponin I gene (TNNI3; c.574C>T). Combining these findings led to a diagnosis of RCM. The patient's parents chose conservative treatment, but at the 12-month follow-up she died of worsening heart failure and cerebral infarction. This case emphasizes the need for cardiac catheterization and genetic testing in RCM, and suggests that anticoagulants should be recommended to reduce the risk of thromboembolic events.

Evaluating the Utility of High Sensitivity Troponin in Blunt Cardiac Injury

IntroductionScreening for blunt cardiac injury (BCI) includes obtaining a serum troponin level and an electrocardiogram for patients diagnosed with a sternal fracture. Our institution has transitioned to the use of a high sensitivity troponin I (hsTnI). The aim of this study was to determine whether hsTnI is comparable to troponin I (TnI) in identifying clinically significant BCI. Materials and methodsTrauma patients presenting to a level I trauma center over a 24-mo period with the diagnosis of sternal fracture were screened for BCI. Any initial TnI more than 0.04 ng/mL or hsTnI more than 18 ng/L was considered positive for potential BCI. Clinically significant BCI was defined as a new-bundle branch block, ST wave change, echocardiogram change, or need for cardiac catheterization. ResultsTwo hundred sixty five patients with a sternal fracture were identified, 161 underwent screening with TnI and 104 with hsTnI. For TnI, the sensitivity and specificity for detection of clinically significant BCI was 0.80 and 0.79, respectively. For hsTnI, the sensitivity and specificity for detection of clinically significant BCI was 0.71 and 0.69, respectively. A multivariate analysis demonstrated the odds ratio for significant BCI with a positive TnI was 14.4 (95% confidence interval, 3.9-55.8, P < 0.0001) versus an odds ratio of 5.48 (95% confidence interval 1.9-15.7, P = 0.002) in the hsTnI group. ConclusionsThe sensitivity of hsTnI is comparable to TnI for detection of significant BCI. Additional investigation is needed to determine the necessity and interval for repeat testing and the need for additional diagnostic testing.

Relationship between right atrial pressure and the Model for End-Stage Liver Disease (MELD) score in patients with advanced heart failure.

Background This study aims to investigate the association between right atrial pressure and the Model for End-Stage Liver Disease score and to evaluate the ability of this scoring system to accurately predict the value of right atrial pressure. Methods Between April 2016 and November 2018, a total of 137 patients (118 males, 19 females; median age: 49 years; range, 40 to 54 years) with advanced heart failure who were candidates for left ventricular assist device implantation or heart transplantation were retrospectively analyzed. We developed a formula calculated by using the biochemical and cardiac catheterization parameters of the patients. Results There was a strong correlation between the right atrial pressure and the scores (r=0.510, p<0.001). The estimated right atrial pressure was calculated as "2 + (0.92 x Model for End-Stage Liver Disease Score)" (unstandardized coefficient 0.920, t value 7.674, p<0.001). The Model for End-Stage Liver Disease score was found to be an independent predictor of high right atrial pressure (odds ratio=1.491, 95% confidence interval: 1.244-1.786, p<0.001). The calculated area under the curve was 0.789 (95% confidence interval: 0.710-0.867, p<0.001) and the cut-off value of the Model for End-Stage Liver Disease score in the prediction of high right atrial pressure was 10.5 with 75% sensitivity and 73% specificity. Conclusion We define a method to calculate right atrial pressure obtained by using the Model for End-Stage Liver Disease score without the need for cardiac catheterization during the hospitalization and follow-up period of patients with advanced heart failure.

Levels of GP-Iib/Iiia Positive Platelet Microparticles (PMP) but Not CD31+/CD42+ PMP Predict Adverse Outcomes in Troponin-Negative Patients with Chest Pain.

Background: Cell derived microparticles (MP) are useful biomarkers in various thrombotic and inflammatory disorders. However, MP are heterogeneous in their phenotypes, functional properties, and origin. Platelet-derived microparticles (PMP) have been shown to be elevated in acute coronary syndromes but different species of PMP have not been compared. We performed a study to compare two subspecies of PMP, those identified by anti-GP-IIb/IIIa vs. those by CD31+/CD42+, for predicting adverse outcomes in patients with chest pain of possible ischemic cause.Methods: The study population consisted of 105 patients who presented to the emergency department with chest pain, non-diagnostic electrocardiograms and negative serial cardiac troponin I levels. Blood was obtained after the third negative troponin result for determination of levels of GP-IIb/IIIa positive PMP (PMPIIb/IIIa) and CD31+/CD42+ PMP (PMP31). All treatment decisions were left at the caregiver's discretion. Telephone follow-up was done at 6 months for the development of a combined endpoint of death, myocardial infarction or need for cardiac catheterization or revascularization. The mean age of our patients was 57.5 years. The age, diabetes, hypertension, smoking and history of coronary artery disease was not significantly different between patients who reached an endpoint at 6 months versus those who did not. Overall 19% reached an endpoint at 6 months. The endpoint was largely driven by the need for cardiac catheterization due to positive stress test results.Results: On univariate analysis, patients who reached an endpoint at 6 months had higher levels of PMPIIb/IIIa than those who did not (geometric means 2059.6 vs. 924.4 counts/μL; p=0.04; medians 2157.5 vs 1764.0 counts/μL; p=0.009). When adjusted for age, diabetes, hypertension, dyslipidemia, aspirin use and current smoking by analysis of covariance, the difference persisted (adjusted geometric means: 2484.9 vs. 829.5 counts/μL; p=0.01). In contrast, PMP31 levels were not significantly different between patients who reached an endpoint at 6 months versus those who did not (5908 ±7990 vs. 3812 ±3109 counts/μL; p=0.26).Conclusions: Our findings suggest that different subspecies of PMPs may reflect different pathophysiological phenomena. PMP31 levels did not correlate with the risk of adverse outcomes in this population. In contrast, GpIIb/IIIa-positive PMP appear to be promising prognostic indicators in chest pain patients with negative troponins and nondiagnostic EKGs. Our results are consistent with prior studies showing association between PMP and thrombosis, but suggest that not all PMP are equal. Further research is needed to investigate a possible role of PMP in the pathogenesis of ACS, and as prognostic markers in current stratification strategies. Assay of different species of MP is likely to provide more discriminating diagnostic and prognostic information.

Impact of Pulmonary Hypertension on in-hospital outcomes amongst Sickle Cell Disease hospitalizations

Introduction: Pulmonary hypertension (PH) is a common and severe complication of Sickle Cell Disease (SCD), and an independent risk factor for mortality. While there is a clear association between SCD and PH, the predictors of PH in SCD and the impact of PH on in-hospital outcomes of SCD hospitalizations remains unknown. In our study, we sought to assess the in-hospital prevalence, predictors, and the impact of PH in SCD hospitalizations. Methods: We used the 2016 and 2017 National Inpatient Sample (NIS) to identify all adult hospitalizations with a primary discharge diagnosis of SCD. The sample was then stratified based on the presence or absence of PH. We used the Pearson chi-square test and weighted Student's t-test to analyze categorical and continuous variables, respectively. Multivariate logistic regression analysis was performed to calculate the adjusted odds ratio for various clinical outcomes. SAS was used for the analysis, and the p-value was defined as &amp;lt;0.05. Results: We identified n=191,080 weighted hospitalizations for SCD, of which, 5.54% (n=10590) had concomitant PH. Female gender and comorbidities including hypertension, obesity, illicit drug use, hepatic cirrhosis, renal failure, prior venous-thromboembolism, valvular, and congenital heart disease were identified as significant predictors of PH in SCD. PH was associated with increased in-hospital mortality (1.04% vs 0.22%, AOR=2.14, 95% CI 1.15-3.98, p=0.0158). PH in SCD hospitalizations also increased the odds of - acute kidney injury (AKI), need for dialysis, acute respiratory failure (ARF), and need for mechanical ventilation for &amp;gt; 96 hours. The adjusted odds ratio for venous thromboembolism, shock-state, and the need for cardiac catheterization (both right and bilateral) were also higher in patients with PH. Overall hospitalization cost and length of stay increased (7.06±0.16 vs 1.82±0.02 days) in patients with SCD and PH (see table 1). Conclusion: In sickle cell disease hospitalizations, PH is independently associated with increased in-hospital morbidity and mortality, with an increased need for in-hospital catheterizations thereby, prolonging the length of stay and overall health care costs. Identifying and treating PH in the SCD population would improve in-hospital outcomes. Disclosures No relevant conflicts of interest to declare.

Gene Expression Profiling Scores (Allomap) Can Successfully Predict the Absence of Serious Rejection in a Pediatric Heart Transplant Population; Single Center Experience

Allomap has been used successfully in adult cardiac transplantation as a screening tool to predict the absence of serious rejection. In adult studies, an Allomap score less than 34 has been highly correlated (Negative Predictive Value [NPV] of 98%) with biopsy grade 0-1R rejection. However, there are minimal studies using Allomap in pediatric patients. We sought to determine if using an Allomap score in pediatric patients ages 10-21 years old could also predict absence of serious rejection in our population. Heart transplant recipients >more than 3 months after transplant, who were between 10-21 years of age at the time of testing, who were taking a prednisone dose less than 15 mg/day and who had cardiac catheterization with biopsy performed had blood drawn for Allomap testing the same day. The blood was handled by a certified lab according to CareDx protocol and then sent to CareDx for testing. Allomap scores were then compared to cellular biopsy grading (serious rejection = 2R or greater). The data points were assessed for sensitivity and specificity using the Youden index and distance to (0,1), as was done in the CARGO studies. Eighty-one patients (mean age 14 +/- 2.9 years, 44% female) had 265 total Allomap tests and biopsy pairs evaluated between 2013 and 2019. Sixty-three (63) patients had more than one Allomap sample and biopsy pair. Race mix was Caucasian 44%, Hispanic 38%, African American 12%, Asian 2.5%, others 3.5%. Biopsy grade 0-1R represented 94% of the sample population. The NPVs for Allomap scores were 100% at 32 and 98.8% at 34, similar to what was found for adults in the CARGO studies. ROC curve demonstrates a c-statistic of 0.7566. Allomap scores in children and adolescents can be used to successfully predict absence of rejection with NPVs between 98%-100%; scores less than or equal to 32 correlated 100% with biopsy grades of 0-1R in this population. Given these results, we speculate that Allomap use will lead to a reduced need for cardiac catheterization and biopsy in this population but further studies in a larger pediatric transplant population is warranted.

Comparison of In-Hospital Outcomes When Repair of Tetralogy of Fallot Is in the Neonatal Period Versus in the Post-Neonatal Period

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD) and optimal timing for total repair of TOF is controversial. We hypothesize that TOF repair in the neonatal period is associated with worse outcomes compared with those who undergo repair later in infancy. We analyzed data using the Kids' Inpatient Database (KID) from 2003 to 2012. We used multivariable logistic regression analyses to compare the in-hospital outcomes between those who underwent total repair of TOF during the neonatal period vs the postneonatal period. There were 6,856 cases of TOF and 7.83% (n = 537) of those underwent repair during the neonatal period. The average mortality in all TOF repair was 2.1% (n = 147). In multiple regression model, compared with repair in postneonatal period, neonatal repair was associated with increased mortality, with adjusted odds ratio of 2.2 (95% confidence interval [CI]: 1.1 to 4.3, p = 0.023). Regarding complications, the neonatal group was associated with higher risk of acute renal failure (8.9% vs 2.3%, p <0.001), need for cardiac catheterization (18.6% vs 8.3%, p <0.001), and ECMO use (4.4% vs1.6%, p <0.001). There was no difference in the rates of arrhythmia, respiratory failure, pulmonary hypertension, or sudden cardiac arrest. Children who underwent repair in the neonatal period had longer hospital stay compared with the postneonatal group (45.5 days [95% CI: 39.3 to 51.7] vs 12.6 days [95% CI: 11.7 to 13.4], p <0.001). Hospital charges were higher for children who underwent repair in the neonatal period compared with those in the postneonatal period. In conclusion, TOF repair in the neonatal period is associated with higher rates of mortality, more postoperative complications, longer hospital stays, and higher hospitalization cost.

Accuracy of echocardiography in diagnosing total anomalous pulmonary venous return.

Objective:Total anomalous pulmonary venous return is an uncommon cyanotic congenital heart defect. Echocardiography is the initial diagnostic tool. Complimentary non-invasive modalities like cardiac computerized tomographic angiography and cardiac magnetic resonance imaging have replaced the need for cardiac catheterization in difficult cases. This study aimed to determine the accuracy of echocardiography in diagnosing total anomalous pulmonary venous return, and to determine the factors that may decrease its sensitivity.Methods:This was a cross-sectional study conducted at the Aga Khan University Hospital Karachi, Pakistan from January 2010 to August 2016. All patients who were diagnosed with Total anomalous pulmonary venous return on echocardiography and had subsequent confirmation either on cardiac CT angiography or surgery were included. The diagnostic accuracy of echocardiography was expressed as sensitivity. Previously described taxonomy was used to define diagnostic error. Univariate and multivariate analysis were done by logistic regression OR (95% CI) were reported to identify factors causing the diagnostic error.Results:High diagnostic sensitivity (81%) was found in isolated total anomalous pulmonary venous return and low (27%) in heterotaxy and mixed (20%) varieties. Poor acoustic windows and right isomerism were found to be significant factors responsible for the diagnostic error on multivariate analysis.Conclusion:Echocardiography can diagnose isolated total anomalous pulmonary venous return with high accuracy. Use of additional modalities may be required for a complete diagnosis in cases with mixed variety, heterotaxy and poor acoustic windows.

Abstract 10188: Circulating Levels of MIF, GROα And RANTES Chemokines and Interleukin 17E Correlate With Severity of Pulmonary Hypertension in Young Pediatric Patients With Congenital Heart Disease

Introduction: Inflammation and immunity are central in the pathogenesis of pulmonary arterial hypertension (PAH), but have not been fully explored in young patients with congenital heart disease and elevated pulmonary artery pressure (PAH-CHD) undergoing surgical repair. Hypothesis: Cytokines and related proteins may be differentially expressed in PAH-CHD patients with distinct hemodynamic patterns. Methods: Sixteen patients with PAH-CHD were enrolled (Group 1, age 1.13 (0.76-2.48) years, median and interquartile range). Pulmonary artery pressure was 52 (43-66) mmHg, and pulmonary vascular resistance was 5.2 (4.2-8.9) Wood units•m 2 . Patients with pulmonary overcirculation, with no need for cardiac catheterization were included for comparison (Group 2, N=31, age 0.71 (0.43-1.02) years). Pulmonary-to-systemic blood flow ratio (echocardiography) in Group 1 and Group 2 was 1.9 (1.3-2.6) and 2.8 (2.3-3.3) respectively (p=0.008). Thirty-six cytokines were analyzed in serum using a chemiluminescence array. Results: In the whole patient group (N=47), MIF chemokine (macrophage migration inhibitory factor) was significantly increased compared to pediatric controls (respective densities 7510±2755 pixels and 5697±2051 pixels, mean±SD, p=0.027). In patients, GROα chemokine (growth-regulated oncogene alpha) was elevated early in life, but decreased exponentially with the age (R 2 =0.21, p=0.001), while interleukin 17E (also called IL-25) increased progressively (R 2 =0.24, p&lt;0.001). MIF was specifically increased in Group 1 compared to Group 2 and controls (respectively, 8494±619 pixels, 6618±477 pixels and 6548±726 pixels, age-adjusted mean±SEM, p=0.037). In contrast, RANTES chemokine (regulated on activation, normal T cell expressed and secreted) was specifically elevated in Group 2 compared to Group 1 and controls (respectively, 74183±3865 pixels, 60130±6455 pixels and 59332±3970 pixels, mean±SEM, p=0.039). Conclusion: The data indicate a relationship between cytokine levels and severity of the disease (age, groups), with potential pathophysiological implications. Furthermore, involvement of interleukin 17E and MIF emphasize the role of Th2 immune response already described in PAH.

Heart Rythm Society expert consensus statement on electrophysiology laboratory standards: process, protocols, equipment, personnel, and safety.

ABBREVIATIONS CIED = cardiovascular implantable electronic device; CT=computed tomography; EP=electrophysiology; FDA= U.S. Food and Drug Administration; ICD=implantable cardioverterdefibrillator; MRI = magnetic resonance imaging; QA = quality assurance; QI = quality improvement; RF = radiofrequency; VT = ventricular tachycardia (Heart Rhythm 2014;11:e9–e51)

Investigation route of the coronary patient in the public health system in Curitiba, São Paulo and in InCor--IMPACT study.

Background:The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization.Objective:To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP.Methods:Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies.Results:There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure.Conclusion:Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

THE USE OF CARDIAC CATHETERISATION IN PRE-OPERATIVE WORK-UP FOR LIVER TRANSPLANTATION

IntroductionSignificant cardiac disease may exclude patients from orthotopic liver transplantation (OLT) or may require intervention to make OLT feasible. Non-invasive methods of cardiac assessment (ECHO and cardiopulmonary exercise stress test...

Abstract 268: The Use of Coronary Computed Tomography Angiography in Chest Pain Patients in the Emergency Departments Reduces Future Hospital Admissions and Does Not Impact The Need for Cardiac Catheterizations: A busting meta-analysis

Background: Coronary Computed Tomography Angiography (CCTA) has been deemed appropriate to use in evaluating chest pain in the emergency department (ED). However, concerns remain regarding downstream resource utilization post CCTA. We performed a meta-analysis of existing studies to address whether there is an increase in downstream testing in patients undergoing CCTA vs. the standard of care. Methods: We performed a search of PubMed and Scopus databases from 1966 through October 2012. We evaluated the number of hospital readmissions and subsequent visits to the ED after the initial evaluation. In addition, we evaluated the total number of left heart cardiac catheterizations (CATH), and the need for late non-invasive tests. We used fixed effect analysis when the I 2 was up to 50% and the P at least 0.05, otherwise we used random effect. Results: Out of 2333 articles, 4 randomized controlled trials and 3 prospective studies with control groups were included in the analysis. Out of 4466 patients, 2508 underwent CCTA as the initial test and 1958 were assigned to standard of care (SOC) as defined by the investigators which included evaluation with stress testing. In patients evaluated with CCTA, there was a 36% reduction in the chance of future hospital admissions (OR: 0.64, 95%CI: 0.41-0.99; p=0.04) (Figure) and a trend towards fewer ED revisits (OR: 0.63, 95%CI: 0.38-1.07, p=0.09). The total CATH and late non-invasive testing utilization was similar among the groups (p=0.48 and 0.32). Conclusions: A meta-analysis of the existing literature suggests that the use of CCTA to evaluate chest pain in the ED results in a reduction in hospital readmissions and ED revisits without an increase in downstream testing.

Is cardiac catheterization necessary before initial management of patients with stable ischemic heart disease? Results from a Web-based survey of cardiologists

It is unknown whether preconceived beliefs regarding the need for cardiac catheterization and revascularization in patients with stable ischemic heart disease (SIHD) would preclude a study randomizing patients with significant ischemia to a conservative strategy. Given the widespread practice of performing revascularization in patients with SIHD, we assessed the feasibility of conducting a randomized trial comparing initial invasive and conservative strategies in patients with SIHD and moderate or severe ischemia. An online survey to cardiologists queried their willingness to enroll a sample patient with frequent stable angina, >10% myocardial ischemia, and normal ejection fraction into a randomized trial with a 50% chance of being conservatively managed without cardiac catheterization. Among 499 respondents, 57% (95% CI 53%-62%) were willing to enroll the patient. Among 207 cardiologists unwilling to enroll, 55% (95% CI 48%-61%) would be willing if they knew the patient did not have very high-risk features on stress imaging, yielding a total of 80% (95% CI 76%-83%) of cardiologists willing to enroll. No differences were observed among different types of cardiologists (interventional, invasive/noninterventional, and noninvasive). Seventy-one percent (95% CI 67%-75%) were more likely to try initial medical therapy after the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial results. Most surveyed cardiologists were willing to enroll SIHD patients with at least moderate ischemia into a trial with an initial noninvasive strategy arm. These findings support the feasibility of planning a large-scale trial to test the role of cardiac catheterization and revascularization in the initial management of SIHD patients with moderate or severe ischemia.

Utility of Cardiac Computed Tomography Angiography to Exclude Clinically Significant Obstructive Coronary Artery Disease in Patients After Myocardial Perfusion Imaging

Patients with mildly abnormal or equivocal results on myocardial perfusion imaging (MPI) typically undergo diagnostic angiography or receive medical management for coronary artery disease. Catheterization is often required for either appropriate diagnosis or management. With its very high negative predictive rate, coronary computed tomographic angiography (CCTA) has great potential to rule out clinically significant coronary artery disease in this setting. The aim of this study was to analyze the clinical utility and cost implications of CCTA before invasive angiography in patients with abnormal or equivocal results on MPI. Consecutive patients referred by their physicians to our center with abnormal or equivocal results on MPI were reviewed. Patients with histories of myocardial infarction or of revascularization (coronary artery bypass grafting or percutaneous coronary intervention) were excluded. All patients underwent CCTA. Of 241 participants, only 66 (27%) of the studies with abnormal or equivocal nuclear findings revealed obstructive disease on CCTA (>50% stenosis). Fifty-five of 241 patients had normal coronary arteries, 97 patients had nonsignificant disease (<30%), and 23 patients had mild disease (30% to 50% stenosis) on CCTA, leading to diagnoses of noncardiac chest pain. Selective catheterization (for >50% stenosis on CCTA) demonstrated an average cost reduction of $1,295 per patient. Sensitivity analysis revealed cost savings to be preserved even if up to 70% of the patient cohort underwent catheterization after CCTA and across a wide range of procedural costs. In conclusion, CCTA after equivocal or mild or moderate abnormal MPI findings results in significant cost savings and a robust reduction in the need for cardiac catheterization and excludes obstructive coronary artery disease in almost 75% of patients.

621 Bosnian Registry of Therapeutic Cardiac Catheterisation

Introduction Cardiac catheterization (CC) in treatment of congenital heart disease (CHD) nowdays has much more therapeutic, then diagnostic importance. In Bosnia and Herzegovina post war CC is in process of development.Aim: To present a review of Bosnian registry of cardiac therapeutic catheterization cases.Subjects and Methods Patients with CHD during May 1998- February 2010 hospitalised at Paediatric clinic were included. An evaluation of pts was conducted by history, physical examination, chest X-ray, electrocardiograms and Colour Doppler echocardiogram. The need for cardiac catheterization was primarily determined by paediatric cardiologist or suggested by paediatric cardiac surgeon.Results: 180 cardiac catheterizations were performed. Diagnostic catheterization was done in 155(86%) and therapeutic in 25 (14%) patients, with age ranging from 2 days to 21 years, mean 5,3 years. 53% pts were females. Indications for therapeutic catheterizations were:pulmonary valve stenosis 11 (44%), patent ductus arteriosus (PDA) 8 (32%), aortic valve stenosis (AS), coarctation of aorta 3(12%), atrial septal defect closure 2 (8%), one extraction of foreign body from right ventricle. CC team did five successful balloon atrial septostomy. Duration of the performing catheterization lasted for PDA 13′, PS 8,4′ and AS 10,3′. Complication was: coil to the right branch of pulmonary artery (2), unsuccessful pulmonary valve balloon dilatation with displastic valve (1), airway spasm during anethesia (1).Conclusion: A limited experience with cardiac catheterisation in patients presenting with CHD has been reported in an attempt to highlight the importance of advancements in the use of this technology in Bosnia and Herzegovina.

Adenosine-stress cardiac magnetic resonance imaging in the assessment of coronary artery disease: A net cost analysis and reimbursement implications

Methods 218 patients from a registry on 605 consecutive CMR patients were matched to a prior sample in which CMR was demonstrated to reliably stratify patients regarding their risk of major cardiac events [1]. Propensity scoring methods were used to match on comorbidity profiles, demographics, CAD-related clinical presentation, and CAD risk as measured by their Morise scores. The matched sample included adult subjects with suspected CAD who were evaluated by stress CMR. We identified the proportion of patients who were able to avoid cardiac catheterization based upon the results of their CMR tests. Given this information, and data on the costs of cardiac catheterization and CMR tests, a net cost analysis was performed. Results CMR use substantially reduces the need for cardiac catheterization by 62.4%. Assuming catheterization costs of EUR 619 based on Diagnosis Related Groups (DRG) reimbursement rates in Germany, use of CMR leads to cost savings of EUR 90 on average. The breakeven-level for CMR costs at which it is cost neutral is EUR 386. These results were robust in sensitivity analysis. Cost savings are greatest for patients with lowest risk of CAD as measured by their baseline Morise scores. However, cost savings are likely for all Morise sub groups examined, with the exception of patients at the highest risk of CAD as measured by their Morise score.

Economic evaluation of sirolimus-eluting stents

Sirolimus-eluting stents have recently been shown to reduce the risk of restenosis among patients who undergo percutaneous coronary intervention (PCI). Given that sirolimus-eluting stents cost about 4 times as much as conventional stents, and considering the volume of PCI procedures, the decision to use sirolimus-eluting stents has large economic implications. We performed an economic evaluation comparing treatment with sirolimus-eluting and conventional stents in patients undergoing PCI and in subgroups based on age and diabetes mellitus status. The probabilities of transition between clinical states and estimates of resource use and health-related quality of life were derived from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Information on effectiveness was based on a meta-analysis of randomized controlled clinical trials (RCTs) comparing sirolimus-eluting and conventional stents. Cost per quality-adjusted life year (QALY) gained in the baseline analysis was Can58,721 dollars. Sirolimus-eluting stents were more cost-effective in patients with diabetes and in those over 75 years of age, the costs per QALY gained being 44,135 dollars and 40,129 dollars, respectively. The results were sensitive to plausible variations in the cost of stents, the estimate of the effectiveness of sirolimus-eluting stents and the assumption that sirolimus-eluting stents would prevent the need for cardiac catheterizations in the subsequent year when no revascularization procedure was performed to treat restenosis. The use of sirolimus-eluting stents is associated with a cost per QALY that is similar to or higher than that of other accepted medical forms of therapy and is associated with a significant incremental cost. Sirolimus-eluting stents are more economically attractive for patients who are at higher risk of restenosis or at a high risk of death if a second revascularization procedure were to be required.

Diagnosis of ischemia--adequate clinical and exercise-ECG for indicating the need for cardiac catheterization?--Pro

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study