Although glycoprotein (GP) IIb/IIIa inhibitors are recommended for patients with unstable angina and non–ST-segment elevation myocardial infarction who undergo percutaneous coronary intervention ...(PCI), the American College of Cardiology/American Heart Association guidelines do not specify optimal timing for their initiation. We compared patient characteristics and clinical outcomes in 30,830 patients with non–ST-segment elevation myocardial infarction included in the CRUSADE initiative (January 2001 to December 2004) who underwent PCI with upstream (>1 hour before PCI) or periprocedural use of GP IIb/IIIa inhibitors. GP IIb/IIIa inhibitors were administered upstream in 43% of patients versus periprocedurally in 57%. Time from arrival to PCI was longer for patients who received GP IIb/IIIa inhibitors upstream (median 25.6 hours) compared with periprocedurally (18.2 hours). Unadjusted incidence of in-hospital death or reinfarction was lower with upstream GP IIb/IIIa inhibitor use (3.8% vs 4.3%, p = 0.046), but after adjusting for patient and hospital characteristics, this difference was not statistically significant. Treatment with upstream GP IIb/IIIa inhibitors was associated with a lower incidence of unadjusted death or reinfarction in patients who underwent PCI <12 hours from hospital arrival. In conclusion, in this observational analysis, overall ischemic outcomes were similar between the 2 groups, but clinical trials are needed to solve the controversy over optional timing of GP IIb/IIIa inhibitor use.
We evaluated the reported contraindications to early β-blocker use and associated mortality within and across patient age groups. Contraindications to early β-blocker use were evaluated in patients ...with non-ST-elevation acute coronary syndrome in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative from February 2003 to December 2006. The prevalence, reasons, and trends in the contraindications were evaluated by age (≤65, 66 to 74, and ≥75 years). The associations between the reported contraindications and in-hospital mortality were determined within and compared across age groups using the logistic generalized estimating equations method, adjusting for baseline patient characteristics. Of 112,448 patients, 11,711 (10.4%) had a reported contraindication to early β-blocker use. The prevalence varied by age (≤65, 7.9%; 66 to 74, 10.6%; and ≥75, 13.4%; p <0.0001). No significant changes were seen over time, except for a small increase in patients ≤65 years (p = 0.001). Among the hospitals with >40 patients in the registry, the median hospital level rate of reported contraindications was 9.9% (interquartile range 6.7% to 14.3%). The distribution of rates was more widespread among the hospitals' older versus younger patients. In all age groups, a statistically significant greater association was found with in-hospital mortality in those with reported contraindications versus those without contraindications who received a β blocker (adjusted odds ratio 2.81, 95% confidence interval 2.28 to 3.46; adjusted odds ratio 2.50, 95% confidence interval 2.07 to 3.03; adjusted odds ratio 2.11, 95% confidence interval 1.88 to 2.37, for ages ≤65, 66 to 74, and ≥75 years, respectively). The strength of the association was similar across all age groups (interaction p = 0.19). The reported contraindications to early β-blocker use were common and increased with age. The contraindications were independently associated with greater in-hospital mortality, underscoring the importance of accurately identifying contraindications. In conclusion, the results did not indicate any disparity in reporting the contraindications according to patient age.
Previous studies of non–ST-segment elevation acute coronary syndromes (NSTE ACSs) complicated by heart failure (HF) have focused primarily on patients with left ventricular systolic dysfunction ...defined by an ejection fraction (EF) <40%. Little is known about HF with preserved systolic function (EF ≥40%) in the NSTE ACS population. We identified high-risk patients with NSTE ACS (ischemic electrocardiographic changes and/or positive cardiac markers) from the CRUSADE quality improvement initiative who had an EF recorded and who had information on HF status. Management and outcomes were analyzed and compared based on the presence or absence of HF and whether left ventricular EF was ≥40%. Of 94,558 patients with NSTE ACS, 21,561 (22.8%) presented with signs of HF, and most had HF with preserved systolic function (n = 11,860, 55%). Mortality rates were 10.7% for HF/systolic dysfunction, 5.8% for HF/preserved systolic function, 5.7% for no HF/systolic dysfunction, and 1.5% for no HF/preserved systolic function. Use of guideline-recommended medical therapies and interventions was frequently significantly lower in those with HF regardless of EF compared with those without HF, except for use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In conclusion, NSTE ACS complicated by HF with preserved systolic function is common and associated with a 2.3-fold higher mortality compared with NSTE ACS without HF or systolic dysfunction. Guideline-recommended therapies and interventions are under-utilized in patients with NSTE ACS and HF, with and without preserved systolic function, compared with those without HF.
Objectives The aim of this study was to examine timing of in-hospital coronary artery bypass graft surgery (CABG) for non–ST-segment elevation myocardial infarction (NSTEMI) patients. Background ...Although practice guidelines recommend delaying CABG for a few days after presentation for ST-segment elevation myocardial infarction patients, current guidelines for NSTEMI patients do not address optimal CABG timing. Methods We evaluated rates and timing of in-hospital CABG among NSTEMI patients treated at U.S. hospitals from 2002 to 2008 with the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) (January 2002 to December 2006) and ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines) (January 2007 to June 2008) programs. Analyses designed to study the clinical characteristics and outcomes of early (≤48 h, n = 825) versus late (>48 h, n = 1,822) CABG focused upon more recent NSTEMI patients from the ACTION Registry–GWTG. Results Both the rate (11% to 13%) and timing (30% early and 70% late) of in-hospital CABG remained consistent from 2002 to 2008. In the ACTION Registry–GWTG program, NSTEMI patients undergoing late CABG tended to have a higher risk profile than those undergoing early CABG. In-hospital mortality (3.6% vs. 3.8%, adjusted odds ratio: 1.12, 95% confidence interval: 0.71 to 1.78) and the composite outcome of death, myocardial infarction, congestive heart failure, or cardiogenic shock (12.6% vs. 12.4%, adjusted odds ratio: 0.94, 95% confidence interval: 0.69 to 1.28) were similar between patients undergoing early versus late CABG. Conclusions Most NSTEMI patients undergo late CABG after hospital arrival. Although these patients have higher-risk clinical characteristics, they have the same risk of adverse clinical outcomes compared with patients who undergo early CABG. Thus, delaying CABG routinely after NSTEMI might increase resource use without improving outcomes. Additionally, the timing of CABG for NSTEMI patients might be appropriately determined by clinicians to minimize the risk of adverse clinical events.
Objectives This study sought to determine the association of pre-hospital electrocardiograms (ECGs) and the timing of reperfusion therapy for patients with ST-segment elevation myocardial infarction ...(STEMI). Background Pre-hospital ECGs have been recommended in the management of patients with chest pain transported by emergency medical services (EMS). Methods We evaluated patients with STEMI from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry who were transported by EMS from January 1, 2007, through December 31, 2007. Patients were stratified by the use of pre-hospital ECGs, and timing of reperfusion therapy was compared between the 2 groups. Results A total of 7,098 of 12,097 patients (58.7%) utilized EMS, and 1,941 of these 7,098 EMS transport patients (27.4%) received a pre-hospital ECG. Among the EMS transport population, primary percutaneous coronary intervention was performed in 92.1% of patients with a pre-hospital ECG versus 86.3% with an in-hospital ECG, whereas fibrinolytic therapy was used in 4.6% versus 4.2% of patients. Median door-to-needle times for patients receiving fibrinolytic therapy (19 min vs. 29 min, p = 0.003) and median door-to-balloon times for patients undergoing primary percutaneous coronary intervention (61 min vs. 75 min, p < 0.0001) were significantly shorter for patients with a pre-hospital ECG. A suggestive trend for a lower risk of in-hospital mortality was observed with pre-hospital ECG use (adjusted odds ratio: 0.80, 95% confidence interval: 0.63 to 1.01). Conclusions Only one-quarter of these patients transported by EMS receive a pre-hospital ECG. The use of a pre-hospital ECG was associated with a greater use of reperfusion therapy, faster reperfusion times, and a suggested trend for a lower risk of mortality.
Objectives The aim of this study was to examine the use of and outcomes associated with antithrombotic strategies in patients with non–ST-segment elevation myocardial infarction (NSTEMI) who undergo ...percutaneous coronary intervention (PCI). Background A variety of antithrombotic strategies have been tested in clinical trials for NSTEMI patients treated with PCI. Methods Antithrombotic strategies for NSTEMI patients undergoing PCI at 217 ACTION (Acute Coronary Treatment and Intervention Outcomes Network) hospitals from January 1, 2007, to December 31, 2007, (n = 11,085) were classified into commonly observed antithrombotic groups: heparin alone (Hep alone; low-molecular-weight heparin or unfractionated heparin), bivalirudin alone (Bival alone), heparin with glycoprotein IIb/IIIa inhibitors (Hep/GPI), and bivalirudin with GPI (Bival/GPI). Baseline characteristics are shown across treatment groups. In addition, unadjusted and adjusted rates of in-hospital major bleeding and death are shown. Results The standard strategy used was Hep/GPI (64%), followed by Hep or Bival alone (28%), and Bival/GPI (8%). Patients who received Hep or Bival alone were older with more comorbidities, higher baseline bleeding and mortality risk, and lower peak troponin. Compared with patients who received Hep/GPI , those who received Hep alone and Bival alone had lower rates of major bleeding (adjusted odds ratio OR: 0.52; 95% confidence interval CI: 0.42 to 0.65; adjusted OR: 0.48; 95% CI: 0.39 to 0.60; respectively), yet only patients who received Bival alone had lower mortality (adjusted OR: 0.39; 95% CI: 0.21 to 0.71). Conclusions NSTEMI patients undergoing PCI are more likely to receive Bival or Hep alone when at higher baseline bleeding risk than when at lower baseline bleeding risk. Despite higher baseline risk, those receiving Bival or Hep alone had less bleeding.
Background In 2001-2002, the American Heart Association and National Heart, Lung, and Blood Institute initiated national campaigns with the aim of increasing women's awareness of their risk of heart ...disease, with particular focus on women aged 40 to 60 years. Our aim is to determine if these women's awareness campaigns were associated with a reduction in the time to hospital presentation for myocardial infarction in women. Methods The study population comprised patients who presented with a non–ST-segment elevation myocardial infarction in the C an R apid Risk Stratification of U nstable Angina Patients S uppress AD verse Outcomes with E arly Implementation of the American College of Cardiology/American Heart Association Guidelines Registry and the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network–Get with the Guidelines registry. Analysis was done based on the introduction of the educational intervention: preintervention 2002-2003, intermediate 2004-2005, and post 2006-2007. Results Of 125,161 patients, 50,162 (40.1%) are women. The median time from symptom onset to presentation was significantly longer in women than men: 3 hours (interquartile range 1.4-7.6) versus 2.8 hours (interquartile range 1.3-7.2, P < .0001), a difference that remained significant after adjusting for clinical characteristics. There was no measurable reduction in the time from symptom onset to presentation over the period of the awareness campaigns: post- versus preintervention period (−0.18%, 95% CI −3.02% to 2.74%). After adjustment for covariates, women aged 40 to 60 years had a 3.46% longer time to presentation than men (95% CI 1.06-5.92, P = .005). Conclusions There was no reduction in time from symptom onset to hospital presentation for myocardial infarction patients since national awareness campaigns in women were initiated, and a significant gender gap remains.
Cockcroft-Gault Versus Modification of Diet in Renal Disease: Importance of Glomerular Filtration Rate Formula for Classification of Chronic Kidney Disease in Patients With Non–ST-Segment Elevation ...Acute Coronary Syndromes Chiara Melloni, Eric D. Peterson, Anita Y. Chen, Lynda A. Szczech, L. Kristin Newby, Robert A. Harrington, W. Brian Gibler, E. Magnus Ohman, Sarah A. Spinler, Matthew T. Roe, Karen P. Alexander We calculated estimated glomerular filtration rate (GFR) by Cockcroft-Gault (C-G) and Modification of Diet in Renal Disease formulae in 46,942 non–ST-segment elevation acute coronary syndromes patients from 408 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) hospitals. The C-G formula provides a more conservative estimate of GFR, particularly in high-risk subgroups. More patients require dose adjustments based on C-G, and those adjusted by C-G bleed less. Dosing based on the C-G formula is preferable, particularly in the small, female, or elderly patient.
Characteristics, Management, and Outcomes of 5,557 Patients Age ≥90 With Acute Coronary Syndromes: Results From the CRUSADE Initiative Adam H. Skolnick, Karen P. Alexander, Anita Y. Chen, Matthew T. ...Roe, Charles V. Pollack, Jr, E. Magnus Ohman, John S. Rumsfeld, W. Brian Gibler, Eric D. Peterson, David J. Cohen We examined baseline characteristics, treatment patterns, and in-hospital outcomes among 5,557 patients with non–ST-segment elevation acute coronary syndromes entered into the CRUSADE registry age ≥90 years compared with a younger elderly cohort age 75 to 89 years. The older elderly were similar to the younger group in many respects but had lower rates of smoking, diabetes, or obesity and were less likely to receive heparin, glycoprotein IIb/IIIa inhibitors, or statins. They were more likely to die or experience any adverse event. Among both groups, increasing adherence to guideline-recommended therapies was associated with both increased bleeding and lower risk-adjusted in-hospital mortality.
Several quantification algorithms for measuring left ventricular (LV) size and function are used in clinical and research settings. The aims of this study were to investigate the effects of ...measurement algorithm and beat averaging on the reproducibility of measurements of the left ventricle and to assess the magnitude of agreement among the algorithms in children with dilated cardiomyopathy.
Echocardiograms were obtained in 169 children from eight clinical centers. Inter- and intrareader reproducibility was assessed on measurements of LV volumes using the biplane Simpson, modified Simpson, and 5/6 × area × length (5/6AL) algorithms. Percentage error was calculated as inter- or intrareader difference/mean × 100. Single-beat measurements and the three-beat average (3BA) were compared. Intraclass correlation coefficients were calculated to assess agreement.
Single-beat interreader reproducibility was lowest (percentage error was highest) using biplane Simpson; 5/6AL and modified Simpson were similar but significantly better than biplane Simpson (P < .05). Single-beat intrareader reproducibility was highest using 5/6AL (P < .05). The 3BA improved reproducibility for almost all measures (P < .05). Reproducibility in both single-beat and 3BA values fell with greater LV dilation and systolic dysfunction (P < .05). Intraclass correlation coefficients were >0.95 across measures, although absolute volume and mass values were systematically lower for biplane Simpson compared with modified Simpson and 5/6AL.
The reproducibility of LV size and functional measurements in children with dilated cardiomyopathy is highest using the 5/6AL algorithm and can be further improved by using the 3BA. However, values derived from different algorithms are not interchangeable.
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