Use Of Coronary Angiography Research Articles

Abstract 222: Does Gender Matter for Postarrest Care?

Introduction: Studies have shown that after cardiac arrest women have lower survival to discharge rates than men. These differences are surprising, considering that women are more often successfully resuscitated in the prehospital setting. Differences in survival to discharge rates might be partially attributed to disparity in post arrest care, similar to what is seen in myocardial infarction (MI). Hypothesis: There is gender disparity in the provision of targeted post arrest care interventions. Methods: This prospective study explores gender disparity in a prospective Canadian data set of non-traumatic, EMS treated, out of hospital cardiac arrest (OHCA) patients presenting to hospitals in the Strategies for Post Arrest Care (SPARC) network between March 16, 2010 and March 31, 2012. All patients with sustained return of spontaneous circulation (palpable pulse for >20 mins) were included in the analysis. Unadjusted chi square tests and logistic regression models were employed to examine the relationship between gender, and provision of post arrest care interventions (coronary angiography, percutaneous coronary intervention (PCI), therapeutic hypothermia, electrical physiology consultation and internal cardiac defibrillator (ICD) placement and two or more neuroprognostic testing ≥ 72 hours). Results: From a total of 2,199 OHCA patients (1,447 men, 752 women), 992 had sustained return of spontaneous circulation (36.6% women, mean age 68.2 years; 63.4% men, mean age 63.9). There were gender differences in utilization of coronary angiography (12.1% in women vs. 20.8% in men, adjusted OR 0.53, 95% CI 0.36 to 0.77, p=0.013) and PCI (3.7% in women vs. 5.8% in men, adjusted OR 0.63, 95% CI 0.41 to 0.98, p=0.042). ICD was less utilized in women, but differences were not significantly different (4.9% in women vs. 8.1% in men, adjusted OR 0.59, 95% CI 0.33 to 1.02 p=0.062). There were no gender differences in utilization of therapeutic hypothermia and neuroprognostic testing ≥ 72 hours. Conclusion: The observed gender differences in utilization of coronary angiography and PCI intervention may be due to disparity in care and/or differences in underlying pathophysiology of cardiac arrest between men and women contributing to women’s unfavorable outcomes.

Optimal Initial Diagnostic Strategies for the Evaluation of Stable Angina Patients

For stable patients suspected of having coronary artery disease (CAD), myocardial perfusion imaging (MPI) or computed tomographic angiography (CT) is used for initial evaluation, while coronary angiography (CAG) is used for confirming the diagnosis. The choice of the initial diagnostic test might influence the treatment strategy. Patients scheduled for MPI, CT, or CAG as the initial diagnostic test were enrolled. The primary and secondary end-points were a major adverse cardiac event (MACE) and revascularization, respectively. Of the 2,878 patients enrolled, 2,825 underwent initial diagnostic tests, and 2,780 were followed up for 1.42±0.49 years. After adjustment for CAD severity, Cox proportional hazard regression analysis showed that the risk of MACE in the MPI and CT groups were similar and significantly less than that in the CAG group (hazard ratio, 0.82 vs. 2.19; 95% confidence interval [CI], 0.43-1.58 vs. 1.40-3.44). Furthermore, the rate of revascularization in the MPI group was less than that of the CT (odds ratio, 1.62; 95% CI, 1.20-2.18) and CAG (odds ratio, 5.36; 95% CI, 4.07-7.05) groups. These data indicate that for stable patients with suspected CAD, the use of MPI or CT as the initial diagnostic test was associated with better prognosis than the use of CAG, and that initial evaluation with MPI was associated with a lower requirement of coronary intervention.

Abstractss “From Qatar to the World”

The utilization of coronary angiography and percutaneous coronary intervention in the routine care for patients with acute coronary syndromes (ACS) has resulted in significant improvement in their prognosis. Consequently, recommendations on the use of these management strategies are reflected in the ACC/AHA guidelines for the management of patients with unstable angina and myocardial infarction. However, among other causes, the 'phobia' of nephrotoxicity of iodinated contrast media (ICM) in chronic kidney disease (CKD) patients and its claimed adverse effect on shortterm and longterm survival has led to a worryingly low use of ICM-based diagnostic and therapeutic interventions in patients with CKD. We argue that the fear of iodinated contrast media-induced acute kidney injury (ICI-AKI) is not a valid reason to avoid ICMbased investigations/interventions in CKD patients with ACS; the risks of myocardial infarction and death greatly outweigh the risk of ICI-AKI in most of these patients and hence they should always be considered for myocardial revascularization.

Management of Acute Coronary Syndrome in Patients with Chronic Kidney Disease: If We Don’t Risk Anything, We Risk Even More

The utilization of coronary angiography and percutaneous coronary intervention in the routine care for patients with acute coronary syndromes (ACS) has resulted in significant improvement in their prognosis. Consequently, recommendations on the use of these management strategies are reflected in the ACC/AHA guidelines for the management of patients with unstable angina and myocardial infarction. However, among other causes, the ‘phobia’ of nephrotoxicity of iodinated contrast media (ICM) in chronic kidney disease (CKD) patients and its claimed adverse effect on short-term and long-term survival has led to a worryingly low use of ICM-based diagnostic and therapeutic interventions in patients with CKD. We argue that the fear of iodinated contrast media-induced acute kidney injury (ICI-AKI) is not a valid reason to avoid ICM-based investigations/interventions in CKD patients with ACS; the risks of myocardial infarction and death greatly outweigh the risk of ICI-AKI in most of these patients and hence they should always be considered for myocardial revascularization.

"Renalism": inappropriately low rates of coronary angiography in elderly individuals with renal insufficiency.

Higher risk patients (including the elderly) receive more conservative therapy for cardiovascular diseases, even though the relative benefits of therapy tend to be greater. The perceived risk of radiocontrast-associated nephrotoxicity may influence the provision of coronary angiography and subsequent revascularization, especially among individuals with chronic kidney disease (CKD). The aim of this study was to determine whether there is excessive variation in the provision of coronary angiography after acute myocardial infarction on the basis of the presence of CKD and whether there is an association between angiography and mortality. Elderly (age 65 to 89 yr) individuals with acute myocardial infarction from the Cooperative Cardiovascular Project were classified by the presence or absence of CKD (defined as a baseline serum creatinine of 1.5 to 5.0 mg/dl). In CKD patients, the propensity to undergo coronary angiography was determined and the effect of coronary angiography on mortality was estimated using multivariable logistic regression and stratification. Mortality was significantly higher with CKD (52.6 versus 26.4%). Fewer patients with CKD underwent coronary angiography (25.2 versus 46.8%) despite the observation that a similar proportion of patients were deemed appropriate for angiography by standard, published criteria. When limiting the analysis to CKD patients who are considered appropriate, the multivariable estimate of the odds of death associated with coronary angiography was 0.58 (95% confidence interval, 0.50 to 0.67). With adjustment using propensity scores, the odds ratio averaged across propensity score quintiles was 0.62 (95% confidence interval, 0.54 to 0.70). Results were qualitatively similar when patients were stratified by CKD stage IV (estimated GFR <30 ml/min per 1.73 m(2)). There is a large relative decrease in utilization of coronary angiography among patients with CKD. Alteration in practice because of an aversion to the risk of radiocontrast-associated nephrotoxicity ("renalism") is inappropriate, even if the true relative benefit of invasive strategies is a fraction of what is estimated here.

Ethnic differences in utilization of invasive cardiac procedures and in long-term survival following acute myocardial infarction.

Ethnic differences in coronary mortality have been documented, and South Asians from the Indian subcontinent are particularly vulnerable. This study sought to determine whether there was a difference in the utilization of invasive cardiac procedures and long-term mortality in survivors of myocardial infarction (MI) among Chinese, Malays, and South Asians in Singapore. All MI events in the country were identified and defined by the Singapore Myocardial Infarction Register, which uses modified procedures of the World Health Organization MONICA Project. Information on utilization of coronary angiography, coronary angioplasty, coronary artery bypass graft, and survival was obtained by data linkage with national billing and death registries. Hazard ratios (HR) were calculated using the Cox proportional hazards model with adjustment for baseline characteristics. From 1991 to 1999, there were 10,294 patients who survived > or = 3 days of MI. Of these, 40.6% underwent coronary angiography and 16.5% a revascularization procedure < or = 28 days. Malays received substantially less angiography (34.0%) and revascularization (11.4%) than Chinese (41.9%, 17.9%) and South Asians (40.0%, 16.3%). The ethnic disparity increased during the 1990s, particularly in the performance of coronary angiography (p = 0.038). While fatality declined during the study period for Chinese and South Asians, the rate remained stable for Malays. After a median follow-up period of 4.1 years, survival was lowest among Malays (adjusted HR, 1.28; 95% confidence interval, 1.15-1.42, compared with Chinese). Ethnic inequalities in invasive cardiac procedures exist in Singapore and were exacerbated in the 1990s. Inequalities in medical care may contribute to the poorer longterm survival among Malays.

Comparison of six-month outcomes after percutaneous coronary intervention for Whites versus African-Americans

Substantial differences have been noted between whites and African Americans (AA) in the utilization of coronary angiography, coronary artery bypass grafting (CABG), and reperfusion therapy even after adjustment for clinical factors.1–4 Whites undergo a third more catheterizations and more than twice as many CABGs and percutaneous coronary interventions (PCIs).1,2,5–12 It could be suggested that the higher cardiovascular mortality rate among AA13,14 is related in part to the reported disparity in the use of these procedures. This apparent referral bias may reflect a perception that the outcomes of PCI and CABG are less favorable in AA.15,16 In a previous study from this institution we found no differences in in-hospital outcomes among different ethnic groups.17 We undertook this analysis to determine whether ethnicity plays a role in morbidity and mortality after PCI over a longer follow-up period.

Aspirin and Percutaneous Coronary Angioplasty Are Associated with a Decline in Mortality from Cardiogenic Shock

Background and Methods: Despite the significant progress in the care and outcome of patients with acute myocardial infarction (AMI), the impact of evolving therapies on the incidence and outcome of patients with cardiogenic shock complicating AMI has been questioned. We analyzed trends in the incidence, care and outcome of cardiogenic shock from four national surveys conducted during 1992–1998. Results: Of the 5,351 AMI patients admitted to all coronary care units in Israel, 254 (4.7%) developed cardiogenic shock. The incidence of cardiogenic shock decreased over time (5.8, 5.1, 4.3 and 4.4% for the years 1992, 1994, 1996 and 1998, respectively, p = 0.08). Concomitantly, there was an increase in utilization of coronary angiography, urgent angioplasty and intra-aortic balloon counterpulsation. In addition, there was an increase in hospital use of aspirin, nitrates, ACE inhibitors and β-blockers. Patients with shock were more likely to die within 7 days compared with AMI patients not having shock (65 vs. 4%; p < 0.001). During the study period, the mortality of patients with shock decreased: at 7 days (72% in 1992 to 60% in 1998; p = 0.09), at 30 days (87 to 70%, respectively; p = 0.01) and at 6 months (89 to 77%, respectively; p = 0.02). Both aspirin and angioplasty were independently associated with improved outcome after adjustment for baseline characteristics and study period. Conclusions: Although the mortality rate of cardiogenic shock complicating AMI remains high, the increased utilization of aspirin and angioplasty is associated with improved outcome.

Emergency department rest myocardial perfusion imaging results in more effective utilization of coronary angiography in low risk chest pain patients Michael C. Kontos, Rakesh K. Shah, Kristin L. Schmidt, RObert L. Jesse, Joseph P. Ornato, James L. Tatum. MCV/VCU, Richmond, VA

Emergency department rest myocardial perfusion imaging results in more effective utilization of coronary angiography in low risk chest pain patients Michael C. Kontos, Rakesh K. Shah, Kristin L. Schmidt, RObert L. Jesse, Joseph P. Ornato, James L. Tatum. MCV/VCU, Richmond, VA

Utilization of coronary angiography and revascularization after acute myocardial infarction in men and women risk stratified by the American College of Cardiology/American Heart Association guidelines

OBJECTIVESWe sought to determine whether men and women are equally likely to receive coronary angiography and revascularization after acute myocardial infarction (AMI) when they are risk stratified according to American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines for post-MI care.BACKGROUNDSeveral previous studies have suggested that women may undergo angiography and revascularization procedures less frequently than men.METHODSIn 439 consecutive patients admitted to a public hospital with AMI, rates of coronary angiography and revascularization were compared in men and women categorized, according to ACC/AHA practice guidelines, as having strong (class I or IIa) or weaker (class IIb) indications for angiography.RESULTSWomen were older and more likely to be diabetic or hypertensive, but men and women were equally likely to meet class I/IIa criteria for post-MI angiography (both 51%). Angiography rates were nearly identical in men and women overall (63% vs. 64%), as well as in patients in class I/IIa (80% vs. 82%) and class IIb (46% vs. 46%) (all p > 0.80, with >80% power to detect important differences); the only multivariate predictors of post-MI angiography were age and ACC/AHA class. Significant coronary artery disease was equally prevalent in men and women undergoing angiography, and men and women were equally likely to undergo revascularization, whether they were in class I/IIa (both 55%, p = 0.90) or class IIb (59% vs. 58%, p = 0.88). No significant differences in mortality were noted between men and women.CONCLUSIONSDespite being older and having more risk factors than men, women were equally likely to undergo coronary angiography and revascularization procedures after AMI, and they had in-hospital clinical outcomes that were at least as favorable.

Hierarchical Generalized Linear Models in the Analysis of Variations in Health Care Utilization

In recent years many studies have reported large differences in the use of medical treatments and procedures across geographic regions, hospitals, and individual health care providers. Beyond reporting on the extent of observed variations, these studies examine the role of contributing factors including patient, regional, and provider characteristics. In addition, they may assess the relation between health care processes and outcomes, such as patient mortality, morbidity, and functioning. Studies of variations in health care utilization and outcomes involve the analysis of multilevel clustered data; for example, data on patients clustered by hospital and/or geographic region. The goals of the analysis include the estimation of cluster-specific adjusted responses, covariate effects, and components of variance. The analytic strategy needs to account for correlations induced by clustering and to handle the presence of large variations in cluster size. In this article we formulate a broad class of hierarchical generalized linear models (HGLMs) and discuss their applications to the analysis of health care utilization data. The models can incorporate covariates at each level of the hierarchical data structure, can account for greater variation than what is allowed by the variance in a one-parameter exponential family, and permit the use of heavy-tailed distributions for the random effects. We develop a Bayesian approach to fitting HGLMs using Markov chain Monte Carlo methods and discuss several methods for model checking. The HGLM analysis is presented in the context of two examples of applications to the study of variations in the utilization of medical procedures for elderly Medicare beneficiaries who sustained a heart attack. The first example involves the analysis of clustered longitudinal data with binomial responses and examines geographic and temporal trends in the utilization of coronary angiography across the United States during the 4-year period 1987–1990. The second example involves the analysis of multilevel, clustered data with Poisson responses and examines hospital variations in the utilization of coronary artery bypass graft surgery in 1990. The HGLM analysis incorporates state-level and hospital-level covariates and makes it possible to estimate covariate effects and cluster-specific rates of utilization for both hospitals and states.

Use of coronary angiography and revascularization procedures following acute myocardial infarction. A European perspective.

There is little evidence to inform routine practice in the use of coronary angiography and revascularization procedures after acute myocardial infarction. Large differences in the uptake of these procedures have been reported but representative data are scarce. Outcome studies have produced opposing conclusions concerning the impact of the high rate of these cardiac procedures. A population-based patient sampling approach was utilized to identify routine practice in representative samples from 11 European countries. Data were collected retrospectively on treatment in the 6 months following acute myocardial infarction (n=2807). There was wide variation in utilization of coronary angiography and revascularization procedures. Even after restricting the analysis to patients <65 years (n=1262), there remained a 6 13 fold variation in the use of these procedures. A decreased likelihood of undergoing these procedures was associated with older age. In addition, there was an independent and negative association between female sex and utilization of coronary angiography and coronary artery bypass grafting (CABG). The effect on patient outcome of the observed variation in use of these procedures is not known but has important cost and resource implications for the health services. Outcome research is needed to define patient selection criteria and to measure the cost-utility of different angiography and revascularization rates.

Epidemiology of idiopathic dilated cardiomyopathy in the elderly: pooled results from two case-control studies.

Although idiopathic dilated cardiomyopathy is often viewed as an affliction of young of middle-aged adults, morbidity and mortality rates from idiopathic dilated cardiomyopathy rise sharply with age and are the highest in the elderly. To learn more about the determinants of this increasingly important cause of heart failure in the elderly, the authors conducted a pooled analysis of data from two case-control studies of idiopathic dilated cardiomyopathy carried out in Baltimore, Maryland (1984-1986), and in Washington, DC (1990-1992). Identical diagnostic criteria and interviewing procedures had been used in both studies. All of the cases of idiopathic dilated cardiomyopathy had evidence of ventricular dilation and hypokinesis, with a left ventricular ejection fraction of < 40%. Cases with a history of coronary artery disease were excluded along with those with known secondary forms of cardiomyopathy, Up to two neighborhood controls of the same sex and appropriate age (+/- 5 years) were selected for each case using a random digit dialing technique. The subjects or a suitable surrogate was interviewed by telephone to obtain medical history information. The present analysis was limited to 94 cases and 152 matched controls who were at least 60 years of age. Conditional logistic regression methods were used in the analysis. Significant associations were observed with lower educational attainment and a history of hypertension (P < 0.05). The association with hypertension (relative odds = 2.2, 95% confidence interval 1.1-4.6) persisted after adjustment for race, education, and diabetes and was not accounted for by coronary angiography utilization patterns. The association with diabetes was of borderline significance (p < 0.10). The pattern of risk factors identified in this analysis may allow for the early identification of elderly persons who are at increased risk of idiopathic dilated cardiomyopathy.

Racial Inequalities in the Use of Procedures for Patients With Ischemic Heart Disease in Massachusetts

To examine interracial differences in the utilization of coronary angiography, coronary artery bypass grafting, and coronary angioplasty for white and black patients, we examined all admissions for circulatory diseases or chest pain to Massachusetts hospitals in 1985. After controlling for age, sex, payer, income, primary diagnoses, and the number of secondary diagnoses, whites underwent significantly more angiography and coronary artery bypass grafting procedures. Whites also underwent more angioplasty procedures, but the difference was not statistically significant. Although utilization differences may reflect patient preference or different levels of disease severity and socioeconomic status not adequately accounted for, this study suggests that substantial racial inequalities exist in the use of procedures for patients hospitalized with coronary heart disease.