Because the ACC/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are currently unavailable in North America are discussed in the ...text without a specific COR. For studies performed in large numbers of subjects outside North America, a writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.\n Sabik Content Reviewer--ACC Surgeons' Scientific Council Cleveland Clinic--Department Chair, Thoracic and Cardiovascular Surgery Edwards Lifesciences Medtronic None Abbott Laboratoriesdagger Edwards Lifesciencesdagger None Vikas Saini Content Reviewer The Lown Institute--President None None None None Frank W. Sellke Content Reviewer--ACC/AHA Task Force on Practice Guidelines Brown Medical School and Lifespan--Chief of Cardiothoracic Surgery None None The Medicines Company None William S. Weintraub Content Reviewer Christiana Care Health System--Section Chief, Cardiology Bristol-Myers Squibb Daiichi-Sankyo Eli Lilly None None None Christopher J. White Content Reviewer Ochsner Health System--Director, John Ochsner Heart and Vascular Institute None None None St. Jude Medical (DSMB) Sankey V. Williams Content Reviewer--ACP University of Pennsylvania Health System--Professor of General Medicine None None None None Poh Shuan Daniel Yeo Content Reviewer--AIG Tan Tock Seng Hospital, Department of Cardiology--Cardiologist None None None Boston Scientificdagger Merckdagger Schering-Ploughdagger * No reviewer had a relevant ownership, partnership, or principal position to report.
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Atrial fibrillation (AF) is the most common cardiac arrhythmia, and multiple studies have reported increasing AF incidence rates over time, although the underlying explanations remain unclear.
To ...estimate AF incidence rates from 2006 to 2018 in a community-based setting and to investigate possible explanations for increasing AF by evaluating the changing features of incident AF cases and the pool of patients at risk for AF over time.
This cohort study included 500 684 patients who received primary care and other health care services for more than 2 years through a single integrated health care delivery network in Pennsylvania. Data collection was conducted from January 2003 to December 2018. The base study population had no documentation of AF in the electronic medical record for at least 2 years prior to baseline. Data analysis was conducted from May to December 2019.
Incident AF cases were identified through diagnostic codes recorded at inpatient or outpatient encounters. Age- and sex-adjusted AF incidence rates were estimated by calendar year from 2006 to 2018 both overall and across subgroups, including according to diagnostic setting (inpatient vs outpatient) and priority (primary vs secondary diagnosis).
Among 514 293 patients meeting criteria for the base study population, the mean (SD) age at baseline was 47 (18) years and 282 103 (54.9%) were women; 13 609 (2.6%) met AF diagnostic criteria on or prior to the baseline date and were excluded. Among 500 684 patients free of AF at baseline, standardized AF incidence rates from 2006 to 2018 increased from 4.74 (95% CI, 4.58-4.90) to 6.82 (95% CI, 6.65-7.00) cases per 1000 person-years, increasing significantly over time (P < .001). Incidence rates increased in all age and sex subgroups, although absolute rate increases were largest among those aged 85 years or older. The fraction of incident AF cases among individuals aged 85 years or older increased from 135 of 1075 (12.6%) in 2006 to 451 of 2427 (18.6%) in 2017. Patients with incident AF were more likely over time to have high body mass index (1351 of 3389 patients 39.9% in 2006-2008 vs 4504 of 9214 48.9% in 2015-2018; P < .001), hypertension (2764 81.6% in 2006-2008 vs 7937 86.1% in 2015-2018; P < .001), and ischemic stroke (328 9.7% in 2006-2008 vs 1455 15.8% in 2015-2018; P < .001), but less likely to have coronary artery disease (1533 45.2% in 2006-2008 vs 3810 41.4% in 2015-2018; P < .001). Among 22 077 new cases of AF, 9146 (41.4%) were diagnosed as inpatients and 5731 (26.0%) as the primary diagnosis. Incidence rates of AF increased significantly in all diagnostic setting and priority pairings (eg, inpatient, primary: rate ratio, 1.07; 95% CI, 1.06-1.08; P < .001). Among patients at risk for AF, high BMI and hypertension increased over time (BMI: 71 433 of 198 245 36.0% in 2007 to 130 218 of 282 270 46.1% in 2017; hypertension: 79 977 40.3% in 2007 to 134 404 47.6% in 2017). Documentation of short-term ECG increased over time (23 297 of 207 349 11.2% in 2008 to 45 027 16.0% in 2017); however, long-term ECG monitoring showed no change (1871 0.9% in 2007 to 4036 1.4% in 2017).
In this community-based study, AF incidence rates increased significantly during the study period. Concurrent increases were observed in AF risk factors in the at-risk population and short-term ECG use.
The first clinical manifestation of coronary artery disease (CAD) varies widely from unheralded myocardial infarction (MI) to mild, incidentally detected disease. The primary objective of this study ...was to quantify the association between different initial CAD diagnostic classifications and future heart failure.
This retrospective study incorporated the electronic health record of a single integrated health care system. Newly diagnosed CAD was classified into a mutually exclusive hierarchy as MI, CAD with coronary artery bypass graft (CABG), CAD with percutaneous coronary intervention, CAD only, unstable angina, and stable angina. An acute CAD presentation was defined when the diagnosis was associated with a hospital admission. New heart failure was identified after the CAD diagnosis.
Among 28 693 newly diagnosed CAD patients, initial presentation was acute in 47% and manifested as MI in 26%. Within 30 days of CAD diagnosis, MI hazard ratio (HR) = 5.1; 95% confidence interval: 4.1-6.5 and unstable angina (3.2; 2.4-4.4) classifications were associated with the highest heart failure risk (compared to stable angina), as was acute presentation (2.9; 2.7-3.2). Among stable, heart failure-free CAD patients followed on average 7.4 years, initial MI (adjusted HR = 1.6; 1.4-1.7) and CAD with CABG (1.5; 1.2-1.8) were associated with higher long-term heart failure risk, but an initial acute presentation was not (1.0; 0.9-1.0).
Nearly 50% of initial CAD diagnoses are associated with hospitalization, and these patients are at high risk of early heart failure. Among stable CAD patients, MI remained the diagnostic classification associated with the highest long-term heart failure risk, however, having an initial acute CAD presentation was not associated with long-term heart failure.
Bivalirudin is a new direct thrombin inhibitor. In patients undergoing PCI for stable coronary disease, bivalirudin and unfractionated heparin resulted in similar overall outcomes, but there was less ...major bleeding with bivalirudin.
Bivalirudin is a new direct thrombin inhibitor. In patients undergoing PCI for stable coronary disease, bivalirudin and unfractionated heparin resulted in similar overall outcomes, but there was less major bleeding with bivalirudin.
Percutaneous coronary intervention (PCI) is commonly used to treat patients with coronary artery disease. To minimize the risk of thrombotic complications during and shortly after the procedure, many different antithrombotic regimens have been investigated and are currently in use. Increasing evidence of the adverse consequences of periprocedural bleeding suggests that protection from thrombotic complications should not be the sole measure by which antithrombotic therapies are evaluated.
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Aspirin, clopidogrel, and heparin are established antithrombotic drugs that are widely recommended according to current guidelines on PCI.
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Pretreatment with 300 to 600 mg of clopidogrel increasingly is used before PCI because of mounting . . .
Despite the demonstrated safety of the same-day discharge (SDD) after percutaneous coronary intervention (PCI), uptake of this program has been relatively poor in the United States. We evaluated the ...temporal trends and variations in the utilization of SDD after PCI during the contemporary era. In addition, we evaluated the predictors of SDD (compared with next-day discharge) and the causes of readmission in these 2 patient cohorts.
Data were extracted from State Ambulatory Surgical Database and State Inpatient Database from Florida and New York ranging from 2009 to 2013. All adults undergoing PCI in an outpatient setting were included. Data were merged with the directory available from the American Hospital Association to obtain detailed information on hospital-related characteristics. Unplanned readmissions within 7 and 30 days constituted the coprimary outcomes. There was modest increase in the proportion of SDD after PCI from 2.5% in 2009 to 7.4% in 2013 (
-trend <0.001). SDD was more frequently used among male and younger patients with fewer comorbidities. There were considerable differences in the discharge practices among the different hospital types. Larger hospitals, teaching hospitals, and high PCI volume hospitals had higher utilization of SDD compared with their respective counterparts. SDD and next-day discharge cohorts had similar rates of unplanned readmissions, in-hospital mortality, and acute myocardial infarction during follow-up. Furthermore, uninsured patients had significantly lower odds of SDD along with higher incidence of unplanned readmission within 30 days after PCI compared with insured patients.
During 2009 to 2013, there has been a modest increase in SDD after PCI. Several demographic and clinical characteristics play critical role in determination of SDD after PCI. There were significant disparities in discharge practices between different sex, racial, and insurance-based strata.
The dinosaur that still roars Blankenship, James C.
Catheterization and cardiovascular interventions,
November 1, 2021, 2021-11-01, 2021-11-00, 20211101, Volume:
98, Issue:
5
Journal Article
Peer reviewed
Key Points
Rotational atherectomy (RA) and orbital atherectomy (OA) are both effective in ablating calcified lesions in preparation for coronary stenting. It remains unclear, which is superior.
This ...meta‐analysis of eight non‐randomized studies comparing OA and RA finds that RA causes fewer dissections and perforations but OA is associated with fewer myocardial infarctions, mortalities, and target vessel revascularizations.
Limitations of this meta‐analysis prevent any firm conclusions about which are superior. Experience with one device or the other may be more important than which is chosen.
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Ellis type 4 coronary artery perforation (CAP4), also referred to as Ellis type 3 cavity‐spilling perforation, is a rare but life‐threatening complication of percutaneous coronary intervention ...characterized by extravasation of blood into a cardiac chamber, anatomic cavity, or coronary sinus or vessel. CAP4 is uncommon, accounting for 1.9% to 3.0% of all CAP. Only 11 cases of CAP4 have been reported in detail; we report an additional two cases and review prior reports of this rare complication. Our first case highlights a patient with chronic anginal symptoms due to a 75% concentric stenotic lesion in the mid‐LAD. Revascularization was complicated by perforation during pre‐dilation with robust contrast extravasation into the left ventricle. Successful postperforation hemostasis was achieved with heparin reversal and covered stent placement. The second case demonstrates another major mechanism of CAP4: wire perforation. During intervention, the absence of blood flow distal to the lesion in the setting of an ST segment elevation myocardial infarction obscured the course of the nonhydrophilic floppy wire leading to perforation that was managed conservatively.
In our scoping review, we found that the majority of CAP4 occurred in the LAD. The most frequently involved cavity was the left ventricle—other cavities involved were the right ventricle and coronary veins. Common etiologies of CAP4 included guidewire perforation (62%) and balloon dilation (31%). Perforation was managed with reversal of anticoagulation in 46% of cases, prolonged balloon inflation in 54% of cases, and covered stent deployment in 15% of cases. No patients required surgical repair or pericardiocentesis and perforations were successfully sealed in all cases. In‐hospital mortality was 0%.
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