Obesity is a widespread problem, particularly in the cardiovascular disease population. Obese patients have a lower incidence of cardiovascular mortality after elective percutaneous coronary ...interventions (PCIs); however, there is a paucity of data in the acute myocardial infarction (AMI) setting. This study investigated the effects of body mass index (BMI) on outcomes after percutaneous coronary revascularization in patients with AMI. Patients were categorized into 3 groups based on their BMI, i.e., normal, overweight, or obese. Most patients undergoing primary PCI for AMI (70%) were overweight or obese. Obese patients were significantly younger and more often diabetic, hypertensive, and hyperlipidemic compared with other groups. Angiographically, there was no difference in presence of multivessel disease, final Thrombolysis In Myocardial Infarction grade 3 flow, and presence of thrombus or dissection. Mortality was significantly lower in the hospital at 6 and 12 months in the obese group. Multivariate analysis demonstrated age >70 years, final Thrombolysis In Myocardial Infarction grade <3 flow, history of peripheral vascular disease, and ejection fraction to be the strongest predictors of mortality at 12 months. In conclusion, our data show that obese patients with AMI have a lower risk for in-hospital, 6-month, and 12-month mortality and cardiovascular events than patients with a normal BMI.
Abstract The objective of this study was to compare outcomes in women following surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) utilizing a ...self-expanding prosthesis in patients with severe aortic stenosis who were at high risk for surgical AVR. Although registries and meta-analyses have suggested that TAVR is of considerable benefit in women, perhaps even more so than in men, a rigorous evaluation of TAVR with a self-expanding valve versus SAVR in women from a randomized trial has not been performed. Patients with severe aortic stenosis were randomized 1:1 to either TAVR or SAVR. Outcomes at 1 year are reported. Treatment was attempted in a total of 353 women (183 TAVR and 170 SAVR). Baseline characteristics and predicted risk of the 2 groups were comparable, although the frequency of diabetes mellitus was lower in TAVR patients (33.3% versus 45.3%; P = 0.02). TAVR-treated patients experienced a statistically significant 1-year survival advantage compared to SAVR patients (12.7% versus 21.8%; P = 0.03). The composite all-cause mortality or major stroke rate also favored TAVR (14.9% vs. 24.2%; P = 0.04). Quality of life (QoL), as measured by the Kansas City Cardiomyopathy Questionnaire summary score, for both the TAVR and SAVR groups increased significantly from baseline to 1 year. In conclusion, female TAVR patients had lower 1-year mortality and lower 1-year all-cause mortality or major stroke compared to females undergoing SAVR, with both cohorts experiencing improved QoL. Further studies specifically in women are warranted to validate these findings.
Objectives The purpose of this study was to demonstrate the feasibility of routine transfer of ST-segment elevation myocardial infarction (STEMI) patients to achieve percutaneous coronary ...intervention (PCI) in less than 90 min from presentation. Background Many PCI hospitals have achieved routine door-to-balloon times under 90 min for patients with STEMI presenting directly to the hospital. However, few patients transferred from a non-PCI center undergo PCI within 90 min of presentation. Methods Our rural PCI hospital implemented a program in 2005 for rapid triage, transfer, and treatment of STEMI patients and made additional improvements in 2006 and 2007. Intervals between milestones in the STEMI triage/transfer/treatment process were assessed before and after implementation of the program. Results During the 5-year study period, 676 patients with 687 STEMIs were transferred from 19 community hospitals and underwent PCI. Median door-to-balloon time decreased from 189 min to 88 min (p < 0.001). The time intervals reflecting efficiency of the referring hospitals, transfer services, and PCI hospital all significantly improved. In 2008, median door-to-balloon times were <90 min for 6 of the 7 most frequently referring hospitals. Delays during off-hours presentation in 2004 were abolished after the program was implemented in 2005. In-hospital mortality decreased from 6% before to 3% after implementation of the program. In multivariate modeling, presentation before initiation of the STEMI program predicted increased risk of in-hospital mortality (odds ratio: 3.74, 95% confidence interval: 1.22 to 11.51, p = 0.021). Conclusions A program of rapid triage, transfer, and treatment of STEMI patients presenting to non-PCI hospitals can reduce in-hospital mortality and produce progressive improvements in door-to-balloon time such that median door-to-balloon times under 90 min are feasible.
Objectives This study sought to identify the frequency and etiology of readmission within 30 days of percutaneous coronary intervention (PCI) in a large integrated healthcare system. Background ...One-fifth of Medicare patients are readmitted within 30 days of hospitalization. Identifying the causes of readmission may help identify strategies to prevent readmission. Methods All patients undergoing PCI (elective, urgent, and emergent) at our center between January 1, 2007, and April 12, 2010, were prospectively entered into the American College of Cardiology National Cardiovascular Data Registry. Patients readmitted to any hospital within 30 days of the index procedure were identified using an administrative database and telephone follow-up. Individual charts were reviewed independently by 2 investigators; disagreements regarding the cause for readmission were resolved by a third investigator. Results During the study period, 3,255 PCI were performed, and 262 patients (8.0%) were readmitted within 30 days. Of these, 261 (99.6%) had medical records available for review. Reasons for readmission included: complications related to the PCI (n = 31, 11.9%); non-PCI cardiac causes related to index admission (n = 93, 35.6%); noncardiac causes related to index admission (n = 34, 13%); causes unrelated to the index admission (n = 103, 39.5%). Multivariable logistic regression modeling revealed that female sex, advanced age, peripheral arterial disease, prior valvular surgery, and PCI complications during the index procedure were associated with 30-day readmission. Conclusions Readmissions within 30 days due to complications related to PCI performed on index admission are rare (0.9% of all PCI) and are an infrequent cause of readmission (<12% of readmissions). Thirty-day readmission after PCI should not be used as a quality metric of PCI performance.
Objective To evaluate access site and other bleeding complications associated with radial versus femoral access in patients receiving oral anticoagulation (OAC) with warfarin. Background Patients ...receiving OAC with warfarin undergoing coronary angiography and percutaneous coronary intervention (PCI) may have OAC continued despite the risk of bleeding. To what extent arterial access site impacts bleeding in such patients is not well studied. Methods Over 6 years, we identified 255 consecutive patients in whom warfarin was continued who underwent coronary angiography with an international normalized ratio >1.8. A total of 97 patients also underwent PCI at the same setting (27% femoral vs 73% radial). The primary outcome was Bleeding Academic Research Consortium bleeds; a secondary end point was frequency of access site complications in the 72 hours post-PCI. Complications were evaluated based on the initial access site attempted. Results Minimal baseline clinical characteristics differences existed between the groups. International normalized ratio was significantly higher in the radial group (2.42 ± 0.67 vs 2.24 ± 0.49, P = .02). Bivalirudin use was greater during radial PCI than femoral (76% vs 42%, P < .05), whereas unfractionated heparin alone was greater during femoral PCI than radial (46% vs 18%, P < .05). No significant difference was seen in the primary end point between femoral (2.8%) and radial (1.6%, P = .54) during coronary angiography alone. However, PCI via the femoral artery had significantly more Bleeding Academic Research Consortium bleeding (19.2% vs 1.4%, P = .005) and transfusions (15% vs 0%, P = .004) than via the radial artery. Patients who underwent PCI using radial access were less likely to have any vascular or bleeding complications (1% vs 23%, P = .001). Conclusions Patients who underwent coronary angiography during uninterrupted OAC had similar bleeding rates regardless of access site. However, when PCI was performed, radial access was associated with fewer bleeding and vascular complications than the femoral approach. Condensed Abstract We retrospectively identified 255 consecutive patients on warfarin who underwent coronary angiography, 97 of whom underwent a percutaneous coronary intervention. The data reveal a reduction in Bleeding Academic Research Consortium bleeds (1.6% vs 8.1%, P = .02) with radial versus femoral access. The radial approach was associated with an overall lower rate of any vascular or bleeding complication than the femoral approach during percutaneous coronary intervention (1% vs 23%, P = .001).
Primary percutaneous coronary intervention (PCI) is the optimal method of reperfusion when performed expeditiously. Factors contributing to delays in PCI for ST-segment elevation myocardial ...infarction (STEMI) have not been thoroughly characterized or quantified. We sought to identify the factors associated with the delays to reperfusion in patients with STEMI undergoing primary PCI. Primary PCI was performed in 3,340 patients with STEMI in the international, multicenter Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Multivariate analysis was used to identify independent predictors of delay in achieving reperfusion from 38 baseline and procedural variables. A total of 905 patients (27.1%) presented to non-PCI hospitals and were subsequently transferred; the remainder presented to PCI hospitals. The most powerful independent predictor of the interval from symptom onset to arrival at the PCI hospital and the first door-to-balloon time was an initial presentation at a non-PCI hospital (median incremental 58- and 54-minute delay, respectively, both p <0.001). Other independent predictors of prolonged door-to-balloon times included presentation with respiratory failure (42-minute incremental delay, p = 0.003), presentation during off-work hours (11-minute incremental delay, p <0.001), and co-morbid conditions such as diabetes and heart failure. In conclusion, among patients undergoing primary PCI, presentation to a non-PCI hospital was the variable associated with the greatest delay to reperfusion. Systems of care that encourage ambulance diagnosis and direct delivery of patients with STEMI to a PCI hospital might shorten the overall door-to-balloon times and improve the clinical outcomes.
The aim of this study was to determine whether patients from the Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Patients With de Novo Native Coronary ...Artery Lesions (SPIRIT) IV trial who underwent percutaneous coronary intervention, who had target lesions with jailed side branches, had improved clinical outcomes when treated with the XIENCE V versus Taxus Express2 drug-eluting stent. In the SPIRIT III randomized trial, patients with target lesions with jailed side branches after XIENCE V compared with Taxus Express2 implantation had lower 2-year rates of major adverse cardiac events. The SPIRIT IV trial represents a larger more diverse patient population compared with SPIRIT III. In the large-scale, prospective, multicenter, randomized SPIRIT IV trial, 3,687 patients who underwent coronary stenting with up to 3 de novo native coronary artery lesions were randomized 2:1 to receive XIENCE V versus Taxus Express2 stents. Two-year clinical outcomes of patients with or without jailed side branches after stenting were compared. A jailed side branch was defined as any side branch >1.0 mm in diameter within the target segment being stented, excluding bifurcations deemed to require treatment. Of the 3,687 patients in SPIRIT IV, a total of 1,426 had side branches that were jailed during angioplasty of the target lesion. Patients with jailed side branches after XIENCE V compared with Taxus Express2 implantation had significantly lower 2-year rates of target lesion failure (6.5% vs 11.9%, p = 0.001), major adverse cardiac events (6.6% vs 12.2%, p = 0.0008), ischemia-driven target vessel revascularization (4.1% vs 7.9%, p = 0.004), and stent thrombosis (0.6% vs 2.8%, p = 0.001). In conclusion, patients with jailed side branches after stenting with XIENCE V compared to Taxus Express2 devices had superior clinical outcomes at 2 years in the large-scale randomized SPIRIT IV trial.
Patients with previous adverse contrast reactions occasionally present with ST-segment elevation myocardial infarction. Whether they can undergo catheterization safely using current contrast and ...medications is unknown. We reviewed catheterization laboratory records of all 501 patients (January 2005 to December 2006) presenting with ST-segment elevation myocardial infarction who underwent emergency coronary angiography. Six patients (1.2%) reported a previous contrast reaction including rash, acute bronchospasm, or anaphylaxis. All received a combination of intravenous steroids and H1 and H2 blockers in the emergency department or catheterization laboratory before catheterization. None of these had complications or evidence of allergy in any patient. In conclusion, some patients with previous contrast reaction may undergo emergency catheterization without adverse consequences, although the safety of this approach has not been proved.
This study was conducted to evaluate door-to-treatment times before and after the implementation of a rapid triage and transfer system for patients with ST-elevation myocardial infarction transferred ...from community hospitals to a rural angioplasty center for primary percutaneous coronary intervention (PCI). The system was developed in late 2004 and implemented at a rural percutaneous coronary intervention center in early 2005. Helicopter transport was available for 97% of requests for transfer from community hospitals. All patients with ST-elevation myocardial infarction transferred during 2004 and 2005 (n = 226) were evaluated with respect to presentation and treatment times. Time from community hospital presentation to wire crossing decreased during the study from 205 to 105 minutes (p = 0.0001). One fourth of patients were treated <90 minutes after presentation, and 2/3 were treated in <120 minutes. In conclusion, the implementation of a rapid triage, transfer, and treatment protocol can achieve a significant shortening of presentation-to-treatment times. Efficient community hospitals working with an efficient angioplasty center can achieve presentation–to–wire crossing times of <90 minutes for some patients.
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