Use Of Revascularization Procedures Research Articles

Comparison of Clinical Characteristics and Outcomes in Patients with STEMI in Croatia and Kosovo

INTRODUCTION The aim of our study was to compare clinical characteristics, risk factors, treatment modalities and medium-term outcomes in STEMI patients in two different countries, Croatia and Kosovo. MATERIAL AND METHODS The study included 77 consecutive patients from two regional hospitals, included in the STEMI network of University Clinical Center Zagreb, Croatia (group 1), and 75 STEMI consecutive patients treated in regional Hospital Gjakova, Kosovo (group 2). Standard laboratory tests were performed in both study groups. Patients were treated by the standard protocol of the country and hospital where they were treated. Immediate clinical outcomes and 6 months follow up results regarding MACE were compared. RESULTS There was no significant difference between groups in basic clinical characteristic except for diabetes mellitus, (x2 = 6.96, P = 0.008, P <0.01) and glycaemia control (U’ = 1530, P = 0.013).No significant difference between two groups in laboratory findings. There was a difference in percent of patients treated with primary PCI, 71 in gr 1 and 55 in group 2, reaching statistical significance (x2 test 8,261, p = 0.0045). In patients treated with PCI, there was no difference in “door to balloon time” (DTB) between groups. There was a remarkable difference in proportion of drug eluting stent (DES) implantation (3.5% in group 1, 29.1% in group 2 (x2 test 13.5, P = 0.0002).The difference partly derives from the relatively large number of balloon interventions in group 2. There was 2 deaths in group 1 in early hospital period, both during interventional procedure, one of the patients was in cardiogenic shock. There was no early mortality in group 2. In 6 month clinical follow up there were 3 deaths in group 2, all in patient with no revascularization, and no death in group 1. CONCLUSION We compared the clinical characteristics, treatment strategies and outcomes, in STEMI patients from two countries. After initial mortality, patients from Croatia had a better mid-term survival after recovery from their AMI compared to patients from Kosovo. Use of revascularization procedures was beneficial, but it was less often performed in Kosovo

Moyamoya disease in Mexico: our experience

IntroductionMoyamoya disease (MD) is a progressive, occlusive disease of the arteries of the anterior cerebral circulation that may cause ischaemia or haemorrhage. Patient management aims to prevent new cerebrovascular events through surgical revascularisation and/or pharmacological treatment. Materials and methodsWe studied a series of 17 patients with MD (n = 14) or moyamoya syndrome (MS; n = 3), who were evaluated between January 1989 and December 2016; 11 patients were women and 6 were men. Thirteen patients had definitive MD (76%), one had unilateral MD (5.2%), and 3 had MS (18%). The condition manifested as intraparenchymal haemorrhage (in 35.2% of patients), brain ischaemia (29.4%), subarachnoid haemorrhage (17.6%), seizures (11.7%), and headache with no associated haemorrhage (1 patient). ResultsTen patients (58.8%) underwent revascularisation and 7 (41.2%) received pharmacological treatment. All patients were evaluated with the modified Rankin Scale (mRs) at admission and at the last consultation; mRs scores were significantly lower in the group undergoing surgery (P < .04). During follow-up, none of the patients undergoing revascularisation experienced recurrences, whereas 2 patients receiving pharmacological treatment did experience a new vascular event (one ischaemic and one haemorrhagic) (P < .05). No significant differences were observed between the treatment outcomes of different revascularisation techniques. ConclusionsAlthough our population has different demographic characteristics from those of other non-Asian populations, ours is the largest published series of Hispanic individuals with MD. Our results support the use of revascularisation procedures to improve these patients’ neurological status and to prevent new cerebrovascular events.

Factors associated with the rates of coronary artery bypass graft and percutaneous coronary intervention

BackgroundKorea has seen a rapid increase in the use of percutaneous coronary intervention (PCI) with the ratio of PCI to coronary artery bypass graft (CABG) the highest in the world. This study was performed to examine the factors associated with the rates of CABG and PCI.MethodsThe data were acquired from the National Health Insurance database in Korea in 2013. We calculated the age-sex standardized rates of CABG and PCI. We examined the factors associated with the CABG and PCI rates by performing a regression analysis.ResultsThe rate of CABG showed a negative association with the deprivation index score, and other factors, such as the number of providers or hospital beds, did not show any significant association with the CABG rate. The rate of PCI had a strong negative association with the number of cardiothoracic surgeons and a strong positive association with the number of hospital beds.ConclusionsThe positive association between the PCI rate and the number of hospital beds suggests that the use of PCI may be driven by the supply of beds, and the inverse association between the PCI rate and the number of cardiothoracic surgeons indicates the overuse of PCI due to lack of the providers of CABG. Policy measures should be taken to optimize the use of revascularization procedures, the choice of which should primarily be based on the patient’s need.

Enfermedad moyamoya en México. Experiencia institucional

IntroductionMoyamoya disease (MD) is a progressive, occlusive disease of the arteries of the anterior cerebral circulation that may cause ischaemia or haemorrhage. Patient management aims to prevent new cerebrovascular events through surgical revascularisation and/or pharmacological treatment. MethodsWe studied a series of 17 patients with MD (n = 14) or moyamoya syndrome (n = 3), who were evaluated between January 1989 and December 2016; 11 patients were women and 6 were men. Thirteen patients had definitive MD (76%), one had unilateral MD (5.2%), and 3 had moyamoya syndrome (18%). The condition manifested as intraparenchymal haemorrhage (in 35.2% of patients), brain ischaemia (29.4%), subarachnoid haemorrhage (17.6%), seizures (11.7%), and headache with no associated haemorrhage (one patient). ResultsTen patients (58.8%) underwent revascularisation and 7 (41.2%) received pharmacological treatment. All patients were evaluated with the modified Rankin Scale (mRs) at admission and at the last consultation; mRs scores were significantly lower in the group undergoing surgery (P < .04). During follow-up, none of the patients undergoing revascularisation experienced recurrences, whereas 2 patients receiving pharmacological treatment did experience a new vascular event (one ischaemic and one haemorrhagic) (P < .05). No significant differences were observed between the treatment outcomes of different revascularisation techniques. ConclusionsAlthough our population has different demographic characteristics from those of other non-Asian populations, ours is the largest published series of Hispanic individuals with MD. Our results support the use of revascularisation procedures to improve these patients’ neurological status and to prevent new cerebrovascular events.

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program.

BackgroundLittle is known about facility‐level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures.Methods and ResultsWe evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk‐adjusted facility‐level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility‐level rates of revascularization and post‐PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%–66.7%). Across all facilities, risk‐adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%–47.1%). There was no evidence of correlation between facility‐level rate of revascularization and follow‐up stress testing.ConclusionsWithin the Veterans Affairs system, we observed large facility‐level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility‐level use of revascularization and follow‐up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility‐level use.

Mortality and Health Service Use Following Acute Myocardial Infarction Among Persons with HIV: A Population-Based Study.

People with HIV have higher rates of acute myocardial infarction (AMI) than HIV-negative individuals. We compared mortality risk and health service use following AMI among people with and without HIV between January 1, 2002, and March 31, 2015. We conducted a population-based study using Ontario's administrative databases. Our primary outcomes were risk of inpatient death and death at 30 days following hospital discharge. In secondary analyses, we compared use of revascularization procedures within 90 days of AMI, as well as readmission or emergency department visits for heart disease and cardiology follow-up within 90 days of discharge. We studied 259,475 AMI patients, of whom 345 (0.13%) were people with HIV. AMI patients with HIV were younger than HIV-negative patients (mean age ± standard deviation: 54.4 ± 10.5 years vs. 69.3 ± 14.3 years). Following multivariable adjustment, the odds ratios for inpatient death and death at 30 days following discharge were 1.04 [95% confidence intervals (CI) 0.64-1.56] and 2.42 (95% CI 1.00-4.92), respectively. In secondary analyses, no differences were observed in receipt of revascularization procedures (hazard ratio (HR) 0.98; 95% CI 0.85-1.12), readmission or emergency department visit for heart disease (HR 1.18; 95% CI 0.85-1.62), or cardiology follow-up (HR 0.88; 95% CI 0.76-1.01). People with HIV experience AMI at younger ages and may be at higher risk of death in the 30 days following hospital discharge, underscoring the importance of targeting modifiable cardiovascular disease risk factors in these patients.

Treatment of osteonecrosis of the femoral head with vascularized bone grafting.

Osteonecrosis of the femoral head (ONFH) is a challenging diagnosis for the patient and treating surgeon. Though its cause is poorly understood, several methods of surgical treatment exist and are performed with variable success. Vascularized bone grafting is one such treatment that attempts to restore viable bone, structural support, and blood supply to the avascular portion of the femoral head. This review summarizes the various approaches to this technique that have been proposed and put into practice. The cost effectiveness of these procedures, both in time and resources, has been evaluated and found to be favorable. The use of revascularization procedures, along with the introduction of other potentiating factors, may signal an exciting future for this debilitating disease process.

Outcomes of Neuroischemic Wounds Treated by a Multidisciplinary Amputation Prevention Service

Multidisciplinary amputation prevention teams decrease the frequency of major amputations by increasing the use of revascularization procedures and minor amputations. The outcomes of wound healing, wound recurrence, and ambulatory status are assumed to be improved but are not routinely reported. This study investigates the midterm outcomes of neuroischemic wounds treated by our multidisciplinary team. A retrospective review of patients with neuroischemic wounds treated at a single institution amputation prevention clinic from March 2012 to July 2013. Patient demographics, wound characteristics, procedural details, and clinical and functional outcomes were reviewed. Clinical end points under study included time to wound healing, reulceration rate, and ambulatory status. Over 16 months, there were 202 new patients and 1,355 clinic visits. Ninety-one limbs from 89 patients were treated for complex neuroischemic wounds. In 67% (61 of 91) of limbs, wounds were present for >6 weeks before referral. A history of previous revascularization was present in 39% (31 of 91), and 28% (22 of 91) had a previous minor amputation. Forty-one percent of wounds (38 of 91) were limited to the toes or the forefoot whereas 24% (22 of 91) involved the hindfoot or ankle. A total of 151 podiatric and 86 vascular interventions were performed, with an equal distribution of endovascular and open revascularizations. Complete healing was observed for 59% of wounds (54 of 91) over the observation period (median follow up, 207 days; range 56-561 days), and the average time to full healing was 12 weeks. Hindfoot wounds were predictive of failure to heal (odds ratio, 0.21; P < 0.01; 95% confidence interval, 0.06-0.68). Nineteen percent of patients (17 of 91) developed a new wound in the ipsilateral leg during follow-up. Three major amputations were performed (2 below-knee amputation and 1 above-knee amputation) for a major/minor amputation ratio of 0.06. Ambulatory status was preserved or improved in 74% (67 of 91) of patients. The 30-day readmission rate was 11%, which was lower than that observed (21%) in a contemporaneous but all-inclusive population of lower extremity revascularization procedures performed at our institution. Multidisciplinary limb salvage teams effectively heal wounds and maintain ambulatory status in patients with limb-threatening neuroischemic wounds. Patient specific factors, such as hindfoot or ankle wounds, can adversely influence the outcome. Even with aggressive care, healing can be prolonged and a substantial proportion of patients can be expected to have a recurrence, making subsequent surveillance mandatory. Our data also suggest that a coordinated amputation prevention program may help to minimize hospital readmissions in this high-risk population.

Gender, socioeconomic position, revascularization procedures and mortality in patients presenting with STEMI and NSTEMI in the era of primary PCI. Differences or inequities?

BackgroundSeveral studies have reported gender and socioeconomic differences in the use of revascularization procedures in patients with acute myocardial infarction. However, it is not clear whether these differences influence patients' survival. Moreover, most of the studies neither considered STEMI and NSTEMI separately, nor included primary PCI, which nowadays is the treatment of choice in case of AMI. In an unselected population of patients admitted to hospital with a first episode of STEMI and NSTEMI we examined gender and socioeconomic differences in the use of cardiac invasive procedures and in one-year mortality. MethodsSubjects hospitalized with a first episode of STEMI (n=3506) or NSTEMI (n=2286) were selected from the Piedmont (Italy) hospital discharge database. We considered the percentage of patients undergoing PCI, primary PCI and CABG, and in-hospital mortality. Out of hospital mortality was calculated through record linkage with the regional register. The relation between outcomes and gender or educational level was investigated using appropriate multivariate regression models adjusting for available confounders. ResultsAfter adjustment for age, comorbidity and hospital characteristics, women and low educated patients had a lower probability of undergoing revascularization procedures. However, neither in-hospital, nor 30-day, nor 1-year mortality showed gender or social disparities. ConclusionsDespite gender and socioeconomic differences in the use of revascularization, no differences emerged in in-hospital and 1-year mortality. These findings could suggest that patients are differently, but equitably, treated; differences are more likely due to an inability to fully adjust for clinical conditions rather than to a selection process at admission.

Sex differences in cardiovascular outcomes, pharmacological treatments and indicators of care in patients with newly diagnosed diabetes: Analyses on administrative database

BackgroundThe impact of diabetes on cardiovascular disease in both sexes is known, but the specifics have not been fully clarified. We investigated whether sex-related differences exist in terms of management and hospitalization in patients with newly diagnosed diabetes. MethodsWe examined the rates of hospitalization for cardiovascular causes, mortality, treatments and management of patients with diabetes compared to subjects without, from administrative database. Interaction between sex and diabetes on clinical outcomes were calculated using a Cox regression model. Pharmacological treatments and recommended examinations by sex were calculated using logistic regression. ResultsFrom 2002 to 2006, 158,426 patients with diabetes and 314,115 subjects without were identified and followed up for a mean of 33months (±17.5).Diabetes confers a higher risk for all clinical outcomes. Females with diabetes have a risk profile for hospitalization for coronary heart disease comparable to males without (4.6% and 5.3%). Interaction between sex and diabetes shows that females with diabetes had an added 19% higher risk of total death (95% CI 1.13–1.24). No differences were observed in hospitalizations, although females with diabetes were less likely to undergo revascularization after myocardial infarction. Females received cardiovascular prevention drugs less frequently than males and had a slight tendency to get fewer examinations. ConclusionDiabetes is linked to a higher increase of mortality in females relative to males. This might reflect sex differences in the use of revascularization procedures or therapeutic regimens. Closer attention and implementation of standard care for females are necessary from the onset of diabetes.

PP05 Shifts in the type of Coronary Heart Disease Hospitalisations: Increasing Proportions of Chronic forms, Especially among the Elderly

BackgroundShifts in the burden of coronary heart disease (CHD) from an acute to chronic illness may have important public health consequences. The objective of this study was to assess age-gender-specific...

A prospective, randomized trial of continuous lateral rotation (“kinetic therapy”) in patients with cardiogenic shock

Continuous lateral rotation ["Kinetic therapy" (KT)] has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients is inconclusive. Retrospective data suggest a beneficial effect of KT in patients with cardiogenic shock (CS) requiring ventilator therapy. KT, however, has not been tested prospectively in those patients. A prospective, randomized, open-label trial was performed to compare KT using oscillating beds (TryaDyne Proventa, KCI) with standard care (SC). Patients with cardiogenic shock requiring ventilator therapy for more than 24 h were included. Primary endpoint was the occurrence of hospital-acquired pneumonia. Secondary endpoints were the occurrence of pressure ulcers during the hospital stay and 1-year all-cause mortality. Forty-five patients were randomized to KT, and 44 to SC. All patients required at least one inotropic agent and one vasopressor for circulatory assistance. The groups were comparable in the etiology of heart disease, in the use of revascularization procedures, the use of balloon counterpulsation, and APACHE-II score (33 ± 5 vs. 33 ± 4) and SOFA score (11 ± 1 vs. 11 ± 1) at inclusion; however, more patients in SC were subject to resuscitation before inclusion. Hospital-acquired pneumonia occurred in 10 patients in KT and 28 patients in SC (p < 0.001); pressure ulcers were seen in 10 versus 2 patients (p < 0.001). Hospital mortality tended to be lower in KT, and 1-year all-cause mortality was 41 % in KT and 66 % in SC (p = 0.028). The use of KT reduces rates of pneumonia and pressure ulcers as compared to SC. Moreover, in this study, patients with KT had a better outcome. The study suggests that KT should be used in patients with cardiogenic shock requiring ventilator therapy for a prolonged time.

Gender outcomes in acute myocardial infarction: are women from Venus and men from Mars?

Mortality rate differences observed between men and women presenting with acute myocardial infarction (AMI) have been the focus of clinical trials and registry analyses over the past two decades. Despite advances in cardiovascular therapies over this time, studies have shown that women presenting with AMI have increased early mortality compared to their male counterparts. The cause of mortality discrepancy after AMI in women has been the subject of much debate and has become one of many areas of interest regarding sex-specific outcomes in cardiovascular disease (CVD). Research suggests potential baseline risk profile differences and treatment biases among women compared to men as a reason for the AMI mortality gap. While the exploration of gender differences in coronary artery disease (CAD) has increased, the low proportion of female patients included in CVD trials as well as the lack of published studies results sorted by sex, leaves this an area in need of further study. The current issue of EuroIntervention includes two papers addressing this topic. Both studies assessed different European populations for gender-related differences in mortality after STsegment elevation myocardial infarction (STEMI) and come to the conclusions that female gender is an independent predictor of inhospital mortality following AMI. Benamer et al analysed 16,760 patients (3,664 women) treated by PCI for STEMI from 2003 to 2007 in the CARDIO-ARHIF registry and determined that women tended to be older, had more diabetes, were more likely to present in cardiogenic shock and had a lower success rate of PCI when compared to men. After multivariate logistic regression adjusted for these risks, the authors concluded female gender was associated with higher in-hospital mortality (OR 1.38 [1.16-1.63], p=0.0002) but only after age of 75. Sadowski and colleagues analysed 26,035 consecutive patients (8,989 women) with STEMI enrolled in the Polish Registry of Acute Coronary Syndromes (PL-ACS). Like Benamer’s study, Sadowski et al determined these women were older with higher incidences of comorbidities such as hypertension, diabetes, obesity (BMI>30kg/m) and cardiogenic shock at presentation compared to males, and found a higher in-hospital mortality (1.13 [1.01-1.26], p<0.03), but not 12-month mortality (1.02 [0.96-1.09], p=NS) after multivariate adjustment. Given the data presented from these two studies, three important issues need further discussion. First, CVD is the most common cause of death among women, yet women remain poorly represented in randomised clinical trials investigating cardiovascular disease and treatment. As a society we have enjoyed a steady reduction in age-adjusted mortality for CVD, but only recently has the rate of mortality decline for women approached that of men. Reasons for this delay may include less frequent use of revascularisation procedures or evidence-based therapies in female patients with CVD. Others postulate an overall lack of awareness of the prevalence of CVD in women, on the part of patients, policy makers and healthcare professionals. A 2005 online survey of primary care physicians, gynaecologists and cardiologists found that fewer than 20% of physicians were aware that more women die annually of CAD than men – a finding that highlights the need for awareness campaigns among healthcare providers. There is a paucity of well-designed clinical trials assessing outcomes in women with cardiovascular disease and as a result, women have been under-represented in CVD clinical trials. In early studies investigating therapies employed in the treatment of AMI, fewer than 20% of subjects were women. Reasons for this

Outcomes After Acute Myocardial Infarction in South Asian, Chinese, and White Patients

Cardiac mortality rates vary substantially between countries and ethnic groups. It is unclear, however, whether South Asian, Chinese, and white populations have a variable prognosis after acute myocardial infarction (AMI). To clarify this association, we compared mortality, use of revascularization procedures, and risk of recurrent AMI and hospitalization for heart failure between these ethnic groups in a universal-access healthcare system. We used a population cohort study design using hospital administrative data linked to cardiac procedure registries from British Columbia and the Calgary Health Region Area in Alberta (1994 to 2003) to identify AMI cases. Patient ethnicity was categorized using validated surname algorithms. There were 2190 South Asian, 946 Chinese, and 38479 white patients with AMI identified. There was no significant difference in use of revascularization procedures between ethnic groups at 30 d and 1 year. Short-term (30-day) mortality was higher among Chinese relative to white patients (odds ratio, 1.23; 95% confidence interval, 1.02 to 1.48). There was no significant difference in 30-day mortality between South Asian and white patients. South Asian patients had a 35% lower relative risk of long-term mortality compared with white patients (hazard ratio, 0.65; 95% confidence interval, 0.57 to 0.72). There was no significant difference in long-term mortality between Chinese and white patients. Among AMI survivors, Chinese patients had a lower risk of recurrent AMI, whereas there was no difference between South Asian and white patients. The ethnic groups studied have striking differences in outcomes after AMI, with South Asian patients having significantly lower long-term mortality after AMI.

Atherosclerotic renovascular disease in the United States

Atherosclerotic renovascular disease (ARVD) is an increasingly recognized clinical condition that is diagnosed predominantly in older patients. Here we used annual United States Medicare 5% Denominator Files and studied 16,036,904 patients, 66 years of age and older, to quantify trends in diagnostic rates, associations, treatment, and outcomes of ARVD over a 13-year period. Overall, there was an ARVD rate of 3.09 per 1000 patient-years, which rose progressively with an adjusted hazard ratio of 3.35, comparing data from 1992 to 2004. Within 6 months of disease diagnosis, 13.4% of patients had undergone revascularization. A biphasic pattern of revascularization was found where the adjusted hazard ratios significantly increased in a progressive manner until 1999, following which there was a decline through 2004, which was not significant. The method of revascularization changed markedly over time with endovascular intervention steadily replacing direct surgical revascularization. As a time-dependent variable, ARVD was associated with excess mortality in each calendar year, albeit with declining hazard ratio estimates in more recent years. Among patients with this disease, revascularization was associated with mortality adjusted hazard ratios <1 in each year. Our study shows the diagnosis of ARVD has substantially risen in the United States but the survival implications were not fully explained by other comorbid vascular diseases.

Combined secondary prevention after hospitalization for myocardial infarction in France: Analysis from a large administrative database

Both French and international guidelines recommend long-term use of betablockers, antiplatelet drugs, statins, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (ACE-I/ARB) after a myocardial infarction (MI), but data on their combined use are scarce in France. To evaluate the use of combined medication 6 months after hospital admission for MI and the factors that can significantly influence their use. All hospital admissions for MI in France from January to June 2006 were selected from the national hospital discharge database. Data on medications used 6 months before and after hospitalization for patients covered by the general health insurance scheme (70% of French population) were collected from the reimbursement information system. A medication was considered to be used when there were more than three reimbursement applications over the 6 months following the index episode. Comorbidities were ascertained from the use of disease-specific medication reimbursements and registration in the national database of full coverage for 30 long-term disorders. Of the 11,671 patients included, 82% were reimbursed for betablockers, 92% for antiplatelets, 85% for statins, 80% for ACE-I/ARBs and 62% for all four classes. After adjustment, significant underuse was found for women, the elderly and those with several comorbidities. Treatment at a university hospital or high-volume centre, follow-up by a cardiologist and use of revascularization procedures were associated with improved rates of combination therapy use. Overall, use of recommended medications after MI in France is satisfactory, though not optimal. Specific recommendations focusing on subgroups such as older patients or those with comorbidities, as well as information directed towards non-specialized healthcare professionals, should help to improve appropriate use of these medications.

Temporal Changes in Coronary Revascularization Procedures, Outcomes, and Costs in the Bare-Metal Stent and Drug-Eluting Stent Eras

Although drug-eluting stents have been shown to be cost-effective compared with bare-metal stents for select clinical trial patients, whether these findings apply to the general population is unknown. We used data from the Medicare 5% Standard Analytic Files to compare the practice and outcomes of coronary revascularization (by either percutaneous coronary intervention or coronary artery bypass grafting) in the United States between 2001 (pre-drug-eluting stent era, n=14 362) and 2004 (post-drug-eluting stent era, n=16 374). Between 2001 and 2004, the rate of revascularization increased from 837 to 931 per 100 000, whereas the proportion of patients who underwent percutaneous coronary intervention as an initial revascularization procedure increased from 67.5% to 75.2% (P<0.001). Over a median follow-up period of 25.5 months, no significant changes in mortality were found between 2001 and 2004 (13.8% versus 13.3%, P=0.193). Significant decreases were seen, however, in the incidence of repeat revascularization (17.1% versus 16.0%, P=0.012) and myocardial infarction (10.6% versus 8.5%, P<0.001). Over this same time period, total cardiovascular care costs per revascularized patient decreased by $1680 (95% confidence interval $1164 to $2196, P<0.001) whereas total noncardiovascular costs increased by $2481 per patient (95% confidence interval $1844 to $3118, P<0.001). When the impact of overall procedural volumes was considered, aggregate cost to the Medicare program for cardiovascular services increased by $544 million over the 2-year follow-up period. Risk-adjusted results for both the clinical and economic outcomes showed similar trends. Among the Medicare population undergoing coronary revascularization, the introduction of drug-eluting stents was associated with increased use of initial percutaneous coronary intervention and reduced bypass surgery along with improved clinical outcomes over approximately 2 years of follow-up. Although total cardiovascular-related costs per revascularized patient decreased over this time period, total cost to the Medicare system still increased owing to greater overall use of revascularization procedures.

Elevated Body Mass Index and Use of Coronary Revascularization after Cardiac Catheterization

Background Obese persons suffer discrimination in society that may extend to health care use. We investigated whether overweight and obese patients are as likely to undergo coronary reperfusion or revascularization as patients of normal body weight. Methods Detailed clinical data were collected for an inception cohort of patients from Alberta, Canada, who underwent cardiac catheterization between April 2001 and March 2004. The patients' likelihood of receiving any revascularization, percutaneous coronary intervention, or coronary artery bypass graft surgery in the year after cardiac catheterization was examined on the basis of body mass index (BMI) grouping. Use of revascularization was examined separately for patients with high- and low-risk coronary disease. Results Of 27,460 patients who had BMI data recorded, 24% were of normal weight, 42% were overweight, and 35% were obese. Although overweight and obese patients were more likely to have percutaneous coronary intervention (adjusted hazard ratio [HR] = 1.07, 95% confidence interval [CI], 1.01-1.12 and HR 1.08, 95% CI, 1.01-1.13, respectively), obese patients (BMI > 30) were less likely to receive coronary artery bypass graft surgery (adjusted HR = 0.93, 95% CI, 0.87-1.00). This was primarily because of less use of coronary artery bypass graft surgery for the most obese patients (obesity class III) with low-risk coronary anatomy (adjusted HR = 0.61, 95% CI, 0.36-1.02). Conclusion The pattern of use of revascularization procedures after cardiac catheterization differs somewhat across BMI subgroups. These differences might be clinically appropriate, but they warrant further exploration.

Current trends in coronary revascularization

The options for coronary revascularization broadened in recent years with the introduction of bare-metal stents in the 1990s and drug-eluting stents in 2003. Since then, the rates of percutaneous coronary intervention (PCI) have increased whereas the use of coronary artery bypass grafting (CABG) has decreased. Although historically there have been disparities in the use of revascularization procedures in women, the elderly, and nonwhite patients, there is some evidence to suggest these gaps have narrowed in recent years. In any given clinical circumstance, there is ongoing debate as to whether PCI or CABG is the more appropriate revascularization method depending on coronary anatomy, ventricular function, and associated conditions. Also, trends in coronary revascularization are potentially influenced by emerging clinical evidence and new technologies, national guidelines and appropriateness criteria, procedure reimbursement, and changes in the population being treated. Accordingly, it is unclear whether the trend in increased use of PCI versus CABG will continue.

The association between socioeconomic position, use of revascularization procedures and five-year survival after recovery from acute myocardial infarction

BackgroundPatients living under better socioeconomic circumstances often receive more active treatments after an acute myocardial infarction (AMI) compared to less affluent patients. However, most previous studies were performed in countries with less comprehensive coverage for medical services. In this Swedish nation-wide longitudinal study we wanted to evaluate long-term survival after AMI in relation to socioeconomic position (SEP) and use of revascularization.MethodsFrom the Swedish Myocardial Infarction Register we identified all 45 to 84-year-old patients (16,041 women and 30,366 men) alive 28 days after their first AMI during the period 1993 to 1996. We obtained detailed information on the use of revascularization, cumulative household income from the 1975 and 1990 censuses and 5-year survival after the AMI.ResultsPatients with the highest cumulative income (adding the values of the quartile categories of income in 1975 and 1990) underwent a revascularization procedure within one month after their first AMI two to three times as often as patients with the lowest cumulative income and had half the risk of death within five years. The socioeconomic differences in the use of revascularization procedures could not be explained by differences in co-morbidity or type of hospital at first admission. Patients who underwent revascularization showed a similar lowered mortality risk in the different income groups, while there were strong socioeconomic differences in long-term mortality among patients who did not undergo revascularization.ConclusionThis nationwide Swedish study showed that patients with high income had a better long-term survival after recovery from their AMI compared to patients with low income. Furthermore, even though the use of revascularization procedures is beneficial, low SEP groups receive it less often than high SEP groups.