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Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5), which are of uncertain prognostic importance. In addition, for both the MI types, cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than using an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a “clinically relevant MI.” The present document introduces a new definition for “clinically relevant MI” after coronary revascularization (PCI or CABG), which is applicable for use in clinical trials, patient care, and quality outcomes assessment. [Copyright &y& Elsevier]

The article discusses the likely innovations in design and function in the neurointerventional procedure room. It says that rapid and remarkable innovations in clinical care, techniques and tools have created the current discipline of neurointerventional surgery (NIS). The author adds that the future NIS operating room will be distinguished by architectural features, significantly increased information technology features and other differences. The features of future rooms are also discussed.

The Multispecialty Occupational Health Group (MSOHG), formed in 2005, is an informal coalition of societies representing professionals who work in or are concerned with interventional fluoroscopy. The group's long term goals are to improve occupational health and operator and staff safety in the interventional laboratory while maintaining quality patient care and optimal use of the laboratory. MSOHG has conducted a dialog with equipment manufacturers and has developed a list of specific objectives for research and development. The group has also represented the member societies in educating regulators, in educating interventionalists and in fostering and collaborating on research into occupational health issues affecting interventionalists. Not least of the group's accomplishments, as a result of their collaboration in MSOHG, the group's members have developed a mutual respect that can serve as a basis for joint efforts in the future among interventionalists of different medical specialties. [ABSTRACT FROM PUBLISHER]

Drug-eluting stents (DES) constitute a major breakthrough in restenosis prevention after initial percutaneous coronary intervention (PCI). Target lesion and vessel revascularization rates of <10% at six months follow-up represent a significant medical advance. Many cardiologists consider it reasonable to assume that PCI using DES ought to be considered equivalent, if not superior, to bypass surgery. The argument made is that in previous randomized clinical trials comparing PCI to coronary artery bypass grafting, restenosis was the determining factor favoring surgery, an event that clinical experience suggests is no longer as frequent. In the absence of a definitive clinical trial to support this view, how should the prudent, cutting edge cardiologist evaluate the data and manage their patients? [Copyright &y& Elsevier]

Although percutaneous coronary intervention (PCI) in the setting of cardiogenic shock has a high in-hospital mortality rate, it has been shown to decrease the mortality rate in certain subgroups. The identity and relative importance of variables that are predictive of in-hospital mortality rate after PCI for cardiogenic shock are uncertain. Accordingly, we examined data of >300,000 patients in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR) that were collected from 1998 to 2002 and evaluated the outcomes in 483 consecutive patients who underwent emergency PCI for cardiogenic shock. Patients’ mean age was 65 ± 13 years, with men predominating (61%). All underwent emergency/salvage PCI in the setting of cardiogenic shock after acute myocardial infarction. Mean left ventricular ejection fraction was 30 ± 16%. Stents were placed in 64% of patients, and thrombolytic agents were administered in 26%. Although PCI was angiographically successful in 79% of patients, the in-hospital mortality rate was 59.4%. Length of stay after PCI was 7.2 ± 8 days. Logistic regression using all available variables identified 6 multivariate predictors of death: age (odds ratio [OR] 2.34, 95% confidence interval [CI] 1.68 to 3.28, p &#60;0.001) for each 10-year increment, female gender (OR 1.55, 95% CI 1.00 to 2.41, p &#60;0.001), baseline renal insufficiency (creatinine >2.0 mg/dl; OR 4.69, 95% CI 1.96 to 11.23, p &#60;0.001), total occlusion in the left anterior descending artery (OR 1.99, 95% confidence interval 1.28 to 3.09, p &#60;0.01), no stent used (OR 2.55, 95% CI 1.63 to 3.96, p &#60;0.01), and no glycoprotein IIb/IIIa inhibitor used during PCI (OR 1.96, 95% CI 1.30 to 2.98, p &#60;0.01). In a second analysis using only variables known to the clinician at the time of initial presentation, gender, age, renal insufficiency, and total occlusion of the left anterior descending coronary artery were significant. In conclusion, analysis of patients from the ACC-NCDR who underwent emergency PCI for acute myocardial infarction in the presence of cardiogenic shock shows an in-hospital mortality rate of ∼60% when PCI is attempted. [Copyright &y& Elsevier]

: ObjectiveCoronary endothelial dysfunction may be an early marker for cardiac allograft vasculopathy (CAV) in orthotopic heart transplant recipients. We used serial studies to evaluate changes in coronary endothelial function in patients with and without clinically evident CAV.: BackgroundIn serial studies with intravascular ultrasound (IVUS) and Doppler flow wire measurements, we previously demonstrated that annual decrements in coronary endothelial function are associated with progressive intimal thickening.: MethodsWe studied 45 patients annually, beginning at transplantation until pre-specified end-points (angiographic CAV or cardiac death) were reached. At each study, we measured coronary endothelial function using intracoronary infusions of adenosine, acetylcholine, and nitroglycerin. We simultaneously recorded IVUS images and Doppler velocities.: ResultsOf the 45 patients studied, 9 reached end-points during the study (6 had CAV and 3 died). The mean annual change in area response to acetylcholine was −4.5% ± 3.0% in patients who reached end-points and −0.9% ± 1.5% in those who did not (p = 0.04). The mean annual decrement in flow response to acetylcholine was greater in patients who reached end-points (−31% ± 11% vs −5% ± 5%, p = 0.08). Responses to adenosine and nitroglycerin did not differ.: ConclusionsWhen serial responses were evaluated, patients with end-points had more rapid decreases in endothelial function. The rate of disease progression may be more important than the absolute degree of intimal thickening in early CAV. These data implicate endothelial dysfunction in the development of clinically significant vasculopathy and suggest that serial studies of endothelial function may provide important prognostic information about the development of CAV after heart transplantation. [Copyright &y& Elsevier]

Humanist perspectives on criminology incorporate the role of the state in affecting basic justice processes. Separate scholarly work by Alfred McClung Lee, Richard Quinney, and others set the stage for viable alternatives embodied in peacemaking and restorative justice. Tie-ins between critical humanist criminology critiques, basic sociology views toward society, and current developments in alternative justice models are assessed. An evaluation of how humanist criminology has transformed conceptions of community participation (as stressed in the original humanist sociology perspective) will serve as an integral analysis in assessing the impact of social justice models. [ABSTRACT FROM AUTHOR]

: ObjectivesWe sought to evaluate the results of percutaneous coronary intervention (PCI) in elderly patients in contemporary practice.: BackgroundPrior studies of PCI in the elderly population demonstrate increased in-hospital mortality, but these studies are limited by small population size.: MethodsUsing the American College of Cardiology–National Cardiovascular Data Registry (ACC–NCDR) of 100,253 patients, the in-hospital outcomes in all 8,828 PCI procedures performed on octogenarians were evaluated. Patients underwent PCI between 1998 and 2000 at over 145 participating centers.: ResultsThe mean age was 83.72 ± 3.02 years, with female preponderance (53%). The PCI was considered angiographically successful in 93%, stents were placed in 75%, and the post-PCI length of stay was 3.3 ± 5.1 days. Overall in-hospital mortality was 3.77% but was only 1.35% in PCI without recent myocardial infarction (MI) within one week (p < 0.0001). Patients having PCI within 6 h of the onset of their MI had an increase in mortality tenfold (13.79%) compared with patients without a recent MI (p < 0.0001). All groups that were defined based on time of PCI after MI onset up to seven days had increased mortality (all p < 0.0001). Older age (odds ratio [OR] of 1.03 per incremental year), depressed ejection fraction (EF) (OR 0.69 per 10 points for EF <60%), and time of PCI after MI onset (<6 h, OR 6.87; 6 to 24 h, OR 5.66; 24 h to one week, OR 2.93) were most strongly predictive of outcome by multivariate analysis. The predicted mortality from the multivariate model correlated well with the observed in-hospital mortality up to 20% mortality. A 254-point nomogram was constructed employing the logistic model using a weighted point system.: ConclusionsIn patients ≥80 years old, PCI has good success and acceptable mortality. The presence of an acute or recent MI substantially increases the risk of in-hospital death. [Copyright &y& Elsevier]

Describes a case of hypersensitivity myocarditis which appears to be attributable to ingestion of Ma Huang or ephedra. Medical profile of the patient; Drug causes of eosinophilic myocarditis; Information on the ephedra species of plants.

Evaluates which element of the Braunwald classification independently contribute risk for major cardiac complications. Method of combining predictive factors into an overall odds ration for complications; Identification of four clinical factors used in the Braunwald classification.

Comparison of procedural outcomes in patients with unstable angina treated with heparin and aspirin for >48 hours than in those treated ...48 hours. Factors incorporated in the acuity model used; Intervention procedures; Results suggesting that the optimal duration of heparin therapy is up to 48 hours after admission in unstable angina.

Focuses on a study which analyzed the growth and impact of private policing industry and community efforts on crime prevention in the United States. Development of private policing; Impact of private security; Role of neighborhood crime prevention.

Background: National trends in acute coronary syndrome (ACS) treatment strategy show increasing utilization of percutaneous coronary interventions (PCI) over coronary artery bypass graft (CABG). We evaluated whether the increased use of PCI in some hospitals results in high PCI:CABG ratios, leading to higher PCI or overall mortality due to aggressive case selection. Methodology: The National Inpatient Sample (NIS) for the year 2014 was queried. All patients (pts) admitted for ACS who received either CABG or PCI were selected. We identified the 100 hospitals with highest volume of either kind of revascularization. PCI:CABG ratio was calculated and overall and PCI mortality rate for each hospital collected. Pearson correlation coefficient was utilized to assess for linear correlation of mortality vs. ratio. Results: Out of 72,755 pts selected, 81.3% received PCI and 18.7% received CABG. Mean age was 63.6±12.4 years and 69.2% were women. Mean number of PCIs performed per hospital was 591.4±194.7 and for CABG was 136.2 ±70.7. The average PCI:CABG ratio per hospital was 5.18±2.55 (range 1.4-15.0). Mean PCI in-hospital mortality was 2.90±1.67% and for CABG was 3.32%±3.91% p=0.324. Combined mortality for either strategy was 2.97%±1.56%. There was no relationship between PCI:CABG ratio and overall mortality rate (r =.008, P=.940) or PCI related mortality (r= -.002, P=.984). Conclusions: Increased relative utilization of PCI versus CABG has had no deleterious impact on mortality in ACS. PCI vs CABG case selection in ACS does not appear to be useful as a quality indicator. [ABSTRACT FROM AUTHOR]

Introduction: Coronary artery calcium (CAC) is considered as an adverse cardiovascular events predictor. However, its prognostic impact on heart failure with preserved ejection fraction (HFpEF) patients in the absence of coronary artery disease history (CAD Hx) remains unclear and that is what we aimed to evaluate. Methods: In this cohort, we queried our institutional HF database and identified 249 patients with a new HFpEF diagnosis during 2006 who had CT coronary calcium score within 12 months of admission. Average follow up was 10 years (10.2±2.3). CAC Agatston score of >100 was considered significant. Measured outcomes were cardiovascular disease (CVD) mortality and HF re-admissions (poor outcome was defined as ≥2 HF re-admissions in 12 months) Results: Women constituted 56.6%. CAD Hx was documented in 124 patients , 70 patients had neither CAD Hx nor CAC, and 55 patients had no CAD Hx but demonstrated CAC score >100 on CT. Mean age was 72.1±13.4 years. The CVD mortality rate for patients with CAD Hx was relatively similar to those without CAD Hx but significant CAC, 25% and 23.6%, respectively. However, the CVD mortality rate for those with neither CAC nor CAD Hx was only 7.1% (p=0.008). Poor outcome was identified in 54.5% of patients with CAC and in 44.3% of those with no CAC (p=0.25). Only 36.4% of patients with CAC and no CAD Hx were on optimal therapy. Conclusions: In HFpEF patients, the presence of CAC >100 is significantly associated with CVD mortality despite the absence of CAD hx. Accordingly, screening for CAC in HFpEF patients should be considered for detecting those at risk for CVD mortality and to aid in optimizing medical therapy. [ABSTRACT FROM AUTHOR]

Objective: We aimed to study the impact of atrial fibrillation (AF) on hospitalization outcomes of abdominal aortic artery (AAA) endovascular aneurysm repair (EVAR) at a large-scale sample size representative of the entire United States (U.S.) population.Methods: We included all adults who were hospitalized in the U.S. for AAA repair with EVAR between 2016 and 2017 using the International Classification of Diseases-10th Revision, Clinical procedural diagnosis codes. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were stroke, myocardial infarction, respiratory failure, acute kidney injury (AKI), bleeding event, vascular complications, aortic dissection, length of stay (LOS), and hospitalization cost. Hospitalization outcomes were modeled using logistic regression for binary outcomes and Poisson or log-gamma regression for count or right-skewed numeric outcomes, respectively.Results: We included a total of 39,330 records for patients with AAA who underwent EVAR. There were 5.940 patients with AF. On multivariable analysis, EVAR patients with AF had significantly higher odds for mortality with adjusted OR 2.06 (95%CI: 1.09-3.91). They also had significantly higher odds for AKI (A-OR: 1.79 (95%CI: 1.38-2.32), p < 0.001), acute myocardial infarction (A-OR: 2.72 (95%CI: 1.39-5.32), p = 0.004), post procedural bleedings (A-OR: 1.51 (95%CI: 1.20-1.89), p < 0.001), LOS (1.35 (95%CI: 1.24-1.47) p < 0.001) and higher cost (A-OR: 1.06 (9% CI, 1.03-1.09) p < 0.001). There was no significant difference in risk of stroke, vascular complications, and aortic dissection.Conclusion: AF is an important independent predictor for mortality and adverse outcomes in patients with AAA undergoing EVAR. [ABSTRACT FROM AUTHOR]

Objective: We aimed to study the impact of frailty on the outcome of transcatheter aortic valve replacement (TAVR) procedures.Methods: The National Inpatient Sample (NIS) database was queried for all patients aged ≥65 years who underwent a TAVR procedure during the years 2016-2017. Frailty was measured using a previously validated Hospital Frailty Risk Score (HFRS) scoring system. The score is ICD-10 code based; thus, it can be calculated from an administrative database. Study outcomes were in-hospital all-cause mortality, peri-procedural complications, length of stay, and total cost. Outcomes were modeled using logistic regression for binary outcomes and generalized linear regression for continuous outcomes.Results: There were 84,750 patients included in the study. These patients were divided into low-risk (61,050), intermediate-risk (22,955), and high-risk (744), based on average frailty index scores of 2, 7, and 16.8, respectively. On multivariable analysis, the HFRS correlated with increased odds for mortality with an adjusted odd ratio (a-OR) of 1.25 (95% CI: 1.22-1.29, p < 0.001), myocardial infarction [a-OR 1.10 (95% CI: 1.07-1.13, p < 0.001)], pericardiocentesis [a-OR 1.16 (95% CI: 1.12-1.20, p < 0.001)], pacemaker insertion [a-OR 1.06 (95% CI: 1.04-1.08, p < 0.001)], blood transfusion [a-OR 1.14 (95% CI: 1.11-1.16, p < 0.001)], vascular complications [a-OR 1.05 (95% CI: 1.00-1.09, p = 0.03)], longer length of stay [a-MR 1.10 (95% CI: 1.10-1.11, p < 0.001)] and higher cost [a-MR: 1.04 (95% CI: 1.03-1.04, p < 0.001)].Conclusion: The HFRS can be utilized in the risk stratification of older patients undergoing TAVR. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to characterize long-term outcomes of percutaneous coronary intervention (PCI) in elderly diabetic patients in routine practice. Background: Although drug-eluting stent (DES) implantation in diabetic patients is common practice, pivotal randomized trials enrolled <2,500 diabetic patients, most of whom were <65 years of age. Methods: Data from 405,679 patients ≥65 years old (33% had diabetes mellitus, of whom 9.8% had insulin-treated diabetes mellitus [ITDM], and 23.3% had noninsulin-treated diabetes mellitus [NITDM]) undergoing PCI from 2004 to 2008 at 946 U.S. hospitals were linked with Medicare inpatient claims data. Results: Over 18.4 months median follow-up (25th to 75th percentile: 8.0 to 30.8 months), ITDM/NITDM were associated with significantly increased adjusted hazards of death (hazard ratio [HR]: 1.91 [95% confidence interval (CI): 1.86 to 1.96], p < 0.001/HR: 1.32 [95% CI: 1.29 to 1.35], p < 0.001) and myocardial infarction (HR: 1.87 [95% CI: 1.79 to 1.95], p < 0.001/HR: 1.29 [95% CI: 1.25 to 1.34], p < 0.001) compared with nondiabetic patients. The adjusted hazard of undergoing additional revascularization procedures (HR: 1.14 [95% CI: 1.10 to 1.18, p < 0.001/HR: 1.08 [95% CI: 1.05 to 1.10], p < 0.001) and subsequent hospitalization for bleeding (HR: 1.40 [95% CI: 1.31 to 1.50], p < 0.001/HR: 1.18 [95% CI: 1.13 to 1.24], p < 0.001) were also significantly increased. Compared with nondiabetic patients, there were similar excess risks associated with ITDM/NITDM in patients selected for DES and BMS use; selection for use of DES was associated with reductions in death in ITDM/NITDM and myocardial infarction in ITDM, but not NITDM. There were no significant interactions between diabetes status and stent type for revascularization or bleeding. Conclusions: One-third of older patients undergoing PCI have diabetes. After adjustment for other comorbidities, diabetes, particularly ITDM, remains independently and strongly associated with increased long-term adverse events after both DES and BMS implantation. [Copyright &y& Elsevier]

The article discusses the relevance of percutaneous coronary intervention (PCI), which is performed in about 600,000 cases in the U.S. per year and costs a total of 12 billion U.S. dollars. In a study conducted by the authors to understand the need for the procedure, they use data from the National Cardiovascular Data Registry between July 1, 2009 and September 30, 2010 with an aim of finding the proportion of appropriate, uncertain or inappropriate PCI. They conclude that most PCIs done in the U.S. were appropriate with only 12% being tagged as inappropriate.

In 1988 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Coronary Angioplasty proposed a lesion classification system to stratify lesions by difficulty and risk to better understand the outcomes of coronary interventions. It was a 3-level (A, B, and C) classification based on 11 lesion characteristics. A modification, dividing the intermediate B category into B1 and B2, is also in common use. Recently, a simplification of this classification was evaluated using the large Society for Cardiac Angiography and Interventions (SCAI) Registry (SCAI I = non-C/patent; SCAI II = C/patent; SCAI III = non-C/occluded; SCAI IV = C/occluded). The lesion classification systems were evaluated in 61,926 patients from the ACC National Cardiovascular Data Registry who underwent single-vessel percutaneous coronary intervention between January 1998 and September 2000. Stents were placed in 74.5% of patients. Logistic models for lesion success and complications were constructed and compared. The c statistic for success using the ACC/AHA original classification system was 0.69, 0.71 for the modified ACC/AHA system, and 0.75 for the SCAI classification. The range of complication and success rates was greater using the SCAI models, and the logistic models for success and complication were more robust for the SCAI system. Thus, in the large ACC-National Cardiovascular Data Registry, with a high percentage of stent usage, the simpler SCAI lesion classification provided better discrimination for success and complications than the more complex ACC/AHA lesion classification system—original or modified. [Copyright &y& Elsevier]

Background: To evaluate the trends in complication rates following transcatheter aortic valve replacement (TAVR) procedures according to the type of vascular approach (endovascular vs. transapical) in a large US population sample.Methods: The National Inpatient Sample (NIS) was queried for all patients diagnosed with aortic stenosis who underwent a TAVR procedure in the United States during the years 2012-2016. Outcomes assessed were peri-procedural mortality, cardiac, and non-cardiac complications. Hospitalization outcomes were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes.Results: There were 97,320 endovascular-TAVR patients and 11,140 transapical-TAVR patients. The mean age was 80.8 years (standard error of the mean: ± 0.1). Most patients were males (53.7%) and Caucasian (87.1%). On multivariate analysis, after adjusting for age, gender, comorbidities, as well as hospital factors, patients with the transapical approach had a higher risk for mortality and adverse outcomes. Among the endovascular-TAVR group, national trends showed a diminishing incidence of procedural mortality (incidence rate ratio [IRR] 0.77; 95% CI: 0.72-0.84, p < 0.001), stroke (IRR 0.80; 95% CI: 0.73-0.87, p < 0.001), and all secondary outcomes, but no significant change in myocardial infarction. In contrast, most transapical-TAVR related procedural complications remained unchanged over time, except for a significant decrease in stroke, acute respiratory failure and need for pacemaker insertion.Conclusion: National trends show a steady increase in the number of endovascular-TAVR procedures with a concurrent decrease in procedural complications. [ABSTRACT FROM AUTHOR]

Introduction: Obstructive sleep apnea (OSA) is associated with adverse clinical outcomes in ACS (STEMI, NSTEMI, & unstable angina). Hypothesis: This study was undertaken to evaluate whether OSA is predictive of worse procedural outcomes, independent of comorbidities, in patients undergoing percutaneous intervention (PCI) for ACS. Methods: The National Inpatient Sample (NIS) registry from 2011-2014 was queried to identify all patients age ≥ 21 years admitted for ACS who received PCI. The primary end-point was in-hospital mortality; secondary endpoints were cardiogenic shock, stroke, respiratory failure and acute kidney injury (AKI). Multivariable logistic regression analyses were performed. Results: A total of 285,097 patients with ACS comprised the study group; of these, 17,369 (6.1%) had a diagnosis of OSA. The OSA cohort was younger (61.8+11.4 vs 63.2+13.0, p<0.001) and had more men (76% vs 67.9%, p<0.001). The non-OSA group had a higher frequency of mortality (3.0% vs 2.0%, p<0.001) and cardiogenic shock on presentation (6.3% vs 5.5%, p<0.001) but lower rate of respiratory failure (7.7% vs 10.7%, p<0.001) and AKI (9.4% vs 12.8%, p<0.001). Multivariate logistic regression analysis showed OSA was independently associated with a higher risk for respiratory failure (adjusted OR: 1.314, CI: 1.240 - 1.393 ;p<0.001), lower risk for in-hospital mortality (adjusted OR: 0.761, CI: 0.678 - 0.854; p<0.001) and peri-procedural cardiogenic shock (adjusted OR: 0.882, CI: 0.820 - 0.948; p<0.001). There was no significant difference in stroke or AKI. Conclusions: OSA patients undergoing PCI for ACS had a lower risk of mortality and peri-procedural cardiogenic shock than those without OSA. Results of this study challenge our previous expectations regarding the influence of OSA on cardiovascular disease. It is reasonable to further assess the impact of screening & managing OSA during the peri-operative PCI period. [ABSTRACT FROM AUTHOR]

Background ASCERT (American College of Cardiology Foundation and the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies) was a large observational study designed to compare the long-term effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) to treat coronary artery disease (CAD) over 4 to 5 years. Objectives This study examined the cost-effectiveness of CABG versus PCI for stable ischemic heart disease. Methods The Society of Thoracic Surgeons and American College of Cardiology Foundation databases were linked to the Centers for Medicare and Medicaid Services claims data. Costs for the index and observation period (2004 to 2008) hospitalizations were assessed by diagnosis-related group Medicare reimbursement rates; costs beyond the observation period were estimated from average Medicare participant per capita expenditure. Effectiveness was measured via mortality and life-expectancy data. Cost and effectiveness comparisons were adjusted using propensity score matching with the incremental cost-effectiveness ratio expressed as cost per quality-adjusted life-year gained. Results CABG patients (n = 86,244) and PCI patients (n = 103,549) were at least 65 years old with 2- or 3-vessel coronary artery disease. Adjusted costs were higher for CABG for the index hospitalization, study period, and lifetime by $10,670, $8,145, and $11,575, respectively. Patients undergoing CABG gained an adjusted average of 0.2525 and 0.3801 life-years relative to PCI over the observation period and lifetime, respectively. The life-time incremental cost-effectiveness ratio of CABG compared to PCI was $30,454/QALY gained. Conclusions Over a period of 4 years or longer, patients undergoing CABG had better outcomes but at higher costs than those undergoing PCI. [ABSTRACT FROM AUTHOR]

Previous studies describing the no-reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) were largely confined to single-center studies or small registries. To better characterize the incidence, predictors, and outcomes of the no-reflow phenomenon in a large contemporary population, we analyzed patients with AMI who were undergoing PCI of native coronary artery stenoses in the CathPCI Registry from January 1, 2004 through September 5, 2008 (n = 291,380). The angiographic no-reflow phenomenon was site reported using a standardized definition. No-reflow developed in 2.3% of the patients with AMI (n = 6,553) during PCI. Older age, ST-segment elevation AMI, prolonged interval from symptom onset to admission, and cardiogenic shock were clinical variables independently associated with the development of no-reflow (p <0.001). The angiographic factors independently associated with no-reflow included longer lesion length, higher risk class C lesions, bifurcation lesions, and impaired preprocedure Thrombolysis In Myocardial Infarction flow (p <0.001). Noreflow was associated with greater in-hospital mortality (12.6% vs 3.8%, adjusted odds ratio 2.20, 95% confidence interval 1.97 to 2.47, p <0.001) and unsuccessful lesion outcome (29.7% vs 6.6%, adjusted odds ratio 4.70, 95% confidence interval 4.28 to 5.17, p <0.001) compared to patients without no-reflow. In conclusion, the development of no-reflow, although relatively uncommon during PCI for AMI, is associated with adverse clinical outcomes. Upfront strategies to reduce the incidence of no-reflow could be considered for high-risk patients to improve outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to examine temporal trends in post-percutaneous coronary intervention (PCI) bleeding among patients with elective PCI, unstable angina (UA)/non–ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Background: The impact of bleeding avoidance strategies on post-PCI bleeding rates over time is unknown. Methods: Using the CathPCI Registry, we examined temporal trends in post-PCI bleeding from 2005 to 2009 among patients with elective PCI (n = 599,524), UA/NSTEMI (n = 836,103), and STEMI (n = 267,632). We quantified the linear time trend in bleeding using 3 sequential logistic regression models: 1) clinical factors; 2) clinical + vascular access strategies (femoral vs. radial, use of closure devices); and 3) clinical, vascular strategies + antithrombotic treatments (anticoagulant ± glycoprotein IIb/IIIa inhibitor [GPI]). Changes in the odds ratio for time trend in bleeding were compared using bootstrapping and converted to risk ratio. Results: An approximate 20% reduction in post-PCI bleeding was seen (elective PCI: 1.4% to 1.1%; UA/NSTEMI: 2.3% to 1.8; STEMI: 4.9% to 4.5%). Radial approach remained low (<3%), and closure device use increased marginally from 44% to 49%. Bivalirudin use increased (17% to 30%), whereas any heparin + GPI decreased (41% to 28%). There was a significant 6% to 8% per year reduction in annual bleeding risk in UA/NSTEMI and elective PCI, but not in STEMI. Antithrombotic strategies were associated with roughly half of the reduction in annual bleeding risk: change in risk ratio from 7.5% to 4% for elective PCI, and 5.7% to 2.8% for UA/NSTEMI (both p <0.001). Conclusions: The nearly 20% reduction in post-PCI bleeding over time was largely due to temporal changes in antithrombotic strategies. Further reductions in bleeding complications may be possible as bleeding avoidance strategies evolve, especially in STEMI. [ABSTRACT FROM AUTHOR]

Background: Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG. Methods: We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias. Results: Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis. Conclusions: In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.) [ABSTRACT FROM PUBLISHER]

Background--Most survival prediction models for coronary artery bypass grafting surgery are limited to in-hospital or 30-day end points. We estimate a long-term survival model using data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database and Centers for Medicare and Medicaid Services. Methods and Results--The final study cohort included 348 341 isolated coronary artery bypass grafting patients aged &Methods and Results--The final study cohort included 348 341 isolated coronary artery bypass grafting patients aged 65 years, discharged between January 1, 2002, and December 31, 2007, from 917 Society of Thoracic Surgeons-participating hospitals, randomly divided into training (n= 174 506) and validation (n= 173 835) samples. Through linkage with Centers for Medicare and Medicaid Services claims data, we ascertained vital status from date of surgery through December 31, 2008 (1- to 6-year follow-up). Because the proportional hazards assumption was violated, we fit 4 Cox regression models conditional on being alive at the beginning of the following intervals: 0 to 30 days, 31 to 180 days, 181 days to 2 years, and >2 years. Kaplan-Meier-estimated mortality was 3.2% at 30 days, 6.4% at 180 days, 8.1% at 1 year, and 23.3% at 3 years of follow-up. Harrell's C statistic for predicting overall survival time was 0.732. Some risk factors (eg, emergency status, shock, reoperation) were strong predictors of short-term outcome but, for early survivors, became nonsignificant within 2 years. The adverse impact of some other risk factors (eg, dialysis-dependent renal failure, insulin-dependent diabetes mellitus) continued to increase.;65 years, discharged between January 1, 2002, and December 31, 2007, from 917 Society of Thoracic Surgeons-participating hospitals, randomly divided into training (n= 174 506) and validation (n= 173 835) samples. Through linkage with Centers for Medicare and Medicaid Services claims data, we ascertained vital status from date of surgery through December 31, 2008 (1- to 6-year follow-up). Because the proportional hazards assumption was violated, we fit 4 Cox regression models conditional on being alive at the beginning of the following intervals: 0 to 30 days, 31 to 180 days, 181 days to 2 years, and >2 years. Kaplan-Meier-estimated mortality was 3.2% at 30 days, 6.4% at 180 days, 8.1% at 1 year, and 23.3% at 3 years of follow-up. Harrell's C statistic for predicting overall survival time was 0.732. Some risk factors (eg, emergency status, shock, reoperation) were strong predictors of short-term outcome but, for early survivors, became nonsignificant within 2 years. The adverse impact of some other risk factors (eg, dialysis-dependent renal failure, insulin-dependent diabetes mellitus) continued to increase. Conclusions--Using clinical registry data and longitudinal claims data, we developed a long-term survival prediction model for isolated coronary artery bypass grafting. This provides valuable information for shared decision making, comparative effectiveness research, quality improvement, and provider profiling. [ABSTRACT FROM AUTHOR]

Background--The purpose of this study was to develop a long-term model to predict mortality after percutaneous coronary intervention in both patients with ST-segment elevation myocardial infarction and those with more stable coronary disease. Methods and Results--The American College of Cardiology Foundation CathPCI Registry data were linked to the Centers for Medicare and Medicaid Services 100% denominator file by probabilistic matching. Preprocedure demographic and clinical variables from the CathPCI Registry were used to predict the probability of death over 3 years as recorded in the Centers for Medicare and Medicaid Services database. Between 2004 and 2007, 343 466 patients (66%) of 518 195 patients aged &ges;65 years undergoing first percutaneous coronary intervention in the CathPCI Registry were successfully linked to Centers for Medicare and Medicaid Services data. This study population was randomly divided into 60% derivation and 40% validation cohorts. Median follow-up was 15 months, with mortality of 3.0% at 30 days and 8.7%, 13.4%, and 18.7% at 1,2, and 3 years, respectively. Twenty-four characteristics related to demographics, clinical comorbidity, prior history of disease, and indices of disease severity and acuity were identified as being associated with mortality. The C indices in the validation cohorts for patients with and without ST-segment elevation myocardial infarction were 0.79 and 0.78. The model calibrated well across a wide range of predicted probabilities. Conclusions--On the basis of the large and nationally representative CathPCI Registry, we have developed a model that has excellent discrimination, calibration, and validation to predict survival up to 3 years after percutaneous coronary intervention. [ABSTRACT FROM AUTHOR]

Objectives: We sought to create contemporary models for predicting mortality risk following percutaneous coronary intervention (PCI). Background: There is a need to identify PCI risk factors and accurately quantify procedural risks to facilitate comparative effectiveness research, provider comparisons, and informed patient decision making. Methods: Data from 181,775 procedures performed from January 2004 to March 2006 were used to develop risk models based on pre-procedural and/or angiographic factors using logistic regression. These models were independently evaluated in 2 validation cohorts: contemporary (n = 121,183, January 2004 to March 2006) and prospective (n = 285,440, March 2006 to March 2007). Results: Overall, PCI in-hospital mortality was 1.27%, ranging from 0.65% in elective PCI to 4.81% in ST-segment elevation myocardial infarction patients. Multiple pre-procedural clinical factors were significantly associated with in-hospital mortality. Angiographic variables provided only modest incremental information to pre-procedural risk assessments. The overall National Cardiovascular Data Registry (NCDR) model, as well as a simplified NCDR risk score (based on 8 key pre-procedure factors), had excellent discrimination (c-index: 0.93 and 0.91, respectively). Discrimination and calibration of both risk tools were retained among specific patient subgroups, in the validation samples, and when used to estimate 30-day mortality rates among Medicare patients. Conclusions: Risks for early mortality following PCI can be accurately predicted in contemporary practice. Incorporation of such risk tools should facilitate research, clinical decisions, and policy applications. [Copyright &y& Elsevier]

Stroke is a serious complication of percutaneous coronary intervention (PCI). Clinical characteristics associated with this complication have not been well defined. Data were analyzed from the National Cardiovascular Data Registry. All patients undergoing PCI from January 1, 2004, to March 30, 2007, were included in the analysis (n = 706,782). Stroke is defined in the National Cardiovascular Data Registry as a central neurologic deficit persisting >72 hours with onset starting anytime in the cardiac catheterization laboratory until the time of hospital discharge. Periprocedural stroke developed in 0.22% of patients (n = 1,540). Patients who developed a stroke had a greater prevalence of concomitant medical illnesses and were more likely to present with an acute coronary syndrome. Patients with a stroke had a greater percentage of high-risk coronary lesions and worse PCI angiographic results. In multivariable analysis, known cerebrovascular disease, older age, acute coronary syndromes (unstable angina, ST- and non–ST-elevation myocardial infarction), and use of an intra-aortic balloon pump were factors most strongly associated with stroke. In-hospital mortality was 30% for patients who developed a stroke compared with 1% for those without stroke. In conclusion, stroke developing in association with PCI is rare but a devastating complication. Older patients and those with known cerebrovascular disease and acute coronary syndromes appear to be at the highest risk of stroke. The strong association of in-hospital stroke after PCI with acute coronary syndromes is noteworthy. [Copyright &y& Elsevier]

Age and chronic kidney disease are major risk factors for poor cardiovascular outcome; however, renal function is often estimated on the basis of serum creatinine levels, and advanced renal impairment may be hidden behind near normal creatinine levels. We assessed the impact of estimated glomerular filtration rate (GFR) on in-hospital mortality in young (<65 years old), old (65 to 84 years old), and very old (≥85 years old) patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction. The adjusted risk of death was calculated in 169,826 patients from the American College of Cardiology National Cardiovascular Data Registry undergoing primary PCI for acute myocardial infarction. Younger patients had fewer co-morbidities, higher estimated GFR, less frequent multivessel disease, and lower unadjusted mortality rates than older patients (p <0.0001 for all comparisons). However, the adjusted risk of in-hospital mortality for patients with severe renal insufficiency (estimated GFR <30 ml/min/1.73 m2) compared with those with normal renal function (estimated GFR ≥60 ml/min/1.73 m2) was higher in young patients (adjusted odds ratio = 7.58, 95% confidence interval 6.18 to 9.29) than old (adjusted odds ratio = 4.75, 95% confidence interval 4.14 to 5.45) and very old patients (adjusted odds ratio = 3.50, confidence interval 2.50 to 4.89). In conclusion, severe renal insufficiency is associated with a greater risk of in-hospital mortality in young than old and very old patients after primary PCI. Risk stratification for patients with acute myocardial infarction should incorporate an assessment of renal function with estimated GFR values rather than absolute serum creatinine levels as done in the currently utilized risk scoring algorithms. [Copyright &y& Elsevier]

The periprocedural management, bleeding risks, and outcomes of patients taking warfarin previous to percutaneous coronary intervention (PCI) have not been well characterized. All patients undergoing PCI in the National Cardiovascular Data Registry from January 1, 2004 to March 31, 2006 were analyzed (n = 307,443). Multivariable modeling was used to evaluate the association between home warfarin use and in-hospital mortality and bleeding (requiring blood transfusion and/or prolonging hospital stay and/or causing hemoglobin drop >3.0 g/dl). Patients undergoing elective PCI and urgent PCI (primary/rescue/facilitated PCI with symptoms fewer than 24 hours) were analyzed separately. Overall, 11,173 patients (3.6%) were taking warfarin previous to PCI. Compared with patients not taking warfarin, patients taking warfarin were older and had greater burden of comorbidities. Patients taking warfarin were less likely to receive aspirin, theinopyridines, and glycoprotein IIb-IIIa antagonists during PCI. Unadjusted bleeding rates (elective PCI = 3.2% vs 1.9%; urgent PCI = 8.2% vs 4.8%) and in-hospital mortality (elective PCI = 1.4% vs. 0.6%; urgent PCI = 8.6% vs. 4.5%) were higher among patients taking warfarin. After adjustment for clinical characteristics, the risk of in-hospital mortality was similar with and without previous warfarin use. However, the adjusted risk of bleeding was significantly higher in patients receiving warfarin, for both elective (odds ratio = 1.26, 95% confidence interval = 1.09 to 1.46) and urgent PCI (odds ratio = 1.42, 95% confidence interval = 1.14 to 1.76). In conclusion, while fewer than 5% of patients undergoing PCI are taking previous warfarin, these patients have a higher risk of in-hospital bleeding events but a similar risk of mortality despite lower use of antiplatelet agents. [Copyright &y& Elsevier]

In clinical trials, the use of a distal embolic protection device (EPD) during saphenous vein graft (SVG) percutaneous intervention (PCI) decreases the incidence of major adverse events. However, the frequency of EPD use during SVG PCI in clinical practice is unknown. We evaluated 19,546 SVG PCI procedures in the American College of Cardiology–National Cardiovascular Data Registry from January 1, 2004, through March 30, 2006. EPD use was the primary outcome. Univariate and multivariable analyses were used to assess for characteristics associated with EPD use and to determine the association between EPD use and 2 outcomes: no-reflow and in-hospital mortality. EPDs were used in 22% of patients who underwent SVG PCI. Characteristics independently associated with EPD use were age (odds ratio [OR] 1.04, p = 0.03), male gender (OR 1.12, p = 0.02), older grafts (p <0.001 for the group), longer lesions (OR 1.16, p <0.001), and American College of Cardiology/American Heart Association class C lesions (OR 1.41, p <0.001). Patients were less likely to receive an EPD if they had class <3 grade flow according to Thrombolysis in Myocardial Infarction classification (p <0.001) or previously treated lesions (OR 0.55, p <0.001). There was a weak correlation between annual hospital PCI volume and EPD use (r = 0.2, p <0.001). Nineteen percent of centers did not use EPDs and 41% used them in <10% of cases. EPD use was independently associated with a lower incidence of no-reflow (OR 0.68, p = 0.032), but not in-hospital mortality (1.0% vs 0.9%, p = NS). In conclusion, in current practice, EPDs are used in <25% of SVG PCI procedures. [Copyright &y& Elsevier]

An American College of Cardiology (ACC)/American Heart Association (AHA) task force on practice guidelines in 2001 published evidence-based recommendations for performing percutaneous coronary interventions (PCIs). These guidelines grouped the indications for PCI into 4 classes (I, IIa, IIb, and III) based on analyses of risks and benefits. In a previous study, we found that clinical success and in-hospital adverse events varied by indications class. However, no adjustment for risk was used in those comparisons. The ACC/National Cardiovascular Data Registry (ACC-NCDR) previously developed a risk-adjustment model for the adverse event of in-hospital PCI mortality. We investigated how the 14 individual risk factors in the ACC-NCDR PCI mortality model might differ across the 4 indications classes and whether estimated mortality for each class approximated the observed mortality for that class. We analyzed the ACC-NCDR PCI database for January 1, 2001 to December 31, 2004. We excluded procedures performed for treatment of acute ST-segment elevation myocardial infarction; all others were included, yielding 559,273 procedures for analysis. An algorithm derived from the 2001 guidelines was used to assign procedures to an indications class. Increasing frequencies of risk components were observed across classes I, IIa, IIb, and III. Expected mortalities for each class calculated by the risk-adjustment model were close to observed values (expected 0.52%, 0.59%, 1.72%, and 1.96%, respectively; observed 0.49%, 0.63%, 1.88%, and 1.60%, respectively). In conclusion, the ACC-NCDR risk-adjusted mortality model can be linked to the ACC/AHA PCI guidelines, and together these produce mortality risk estimates by indications classes that are close to actual observed values. With further refinement, these methods should be able to be used as powerful analytic tools for quality assurance and appropriateness purposes. [Copyright &y& Elsevier]

Limited data are available on the off-label use of drug-eluting stents (DESs) in clinical practice. We used data from the American College of Cardiology National Cardiovascular Data Registry to describe the rates and outcomes of DES use in 4 common off-label situations: ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafts, and chronic total occlusions. The rates of in-hospital adverse events for each off-label situation were determined and compared with the expected rates calculated from a validated model. From approval of DESs to the end of 2004, a total of 408,033 procedures involved placement of a DES. The use of DESs increased from 19.7% at the start of the study to 78.2% by the end of fourth quarter of 2004. Off-label use of DESs occurred in 24.1% of procedures. The rates of in-hospital adverse events with DES use in ST-elevation myocardial infarction, in-stent restenosis, coronary artery bypass grafting, and chronic total occlusions were lower than expected from the validated model. In conclusion, off-label use of DESs is common and is associated with a low rate of short-term adverse events. Randomized clinical trials are needed to confirm the efficacy of DESs in these clinical and angiographic settings. These data also highlight the importance of multicenter registries in tracking new technologies. [Copyright &y& Elsevier]

In 1988 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Coronary Angioplasty proposed a lesion classification system to stratify lesions by difficulty and risk to better understand the outcomes of coronary interventions. It was a 3-level (A, B, and C) classification based on 11 lesion characteristics. A modification, dividing the intermediate B category into B1 and B2, is also in common use. Recently, a simplification of this classification was evaluated using the large Society for Cardiac Angiography and Interventions (SCAI) Registry (SCAI I = non-C/patent; SCAI II = C/patent; SCAI III = non-C/occluded; SCAI IV = C/occluded). The lesion classification systems were evaluated in 61,926 patients from the ACC National Cardiovascular Data Registry who underwent single-vessel percutaneous coronary intervention between January 1998 and September 2000. Stents were placed in 74.5% of patients. Logistic models for lesion success and complications were constructed and compared. The c statistic for success using the ACC/AHA original classification system was 0.69, 0.71 for the modified ACC/AHA system, and 0.75 for the SCAI classification. The range of complication and success rates was greater using the SCAI models, and the logistic models for success and complication were more robust for the SCAI system. Thus, in the large ACC-National Cardiovascular Data Registry, with a high percentage of stent usage, the simpler SCAI lesion classification provided better discrimination for success and complications than the more complex ACC/AHA lesion classification system-original or modified. [ABSTRACT FROM AUTHOR]

While performance of percutaneous coronary intervention (PCI) remains the domain of specialized cardiologists, patients undergoing PCI are cared for by noninvasive cardiologists, internists, and primary care physicians. Therefore, patient care is optimized when the entire patient care team understands procedural risks and complications as well as optimum patient management before, during, and after PCI. Before PCI, patients with contrast dye allergies should be identified and pretreated with steroids and an H[SUB]1-blocker. Hydration should be initiated and maintained before and after the procedure to minimize the risks for contrast nephropathy. Periproce-dure, patients should be monitored clinically for evidence of ischemia. In patients with significant groin, flank, abdominal, or back pain, as well as those with decrease in hematocrit or unexplained hypotension, the diagnosis of groin or retroperitoneal he-matoma should be considered and promptly evaluated. Groin tenderness, pulsatile mass, or bruit should prompt evaluation for possible femoral pseudoaneurysm or arteriovenous fistulae. After the procedure, all patients treated with coronary stents should receive aspirin plus clopidogrel. Patients who develop typical an-ginal symptoms between the 1st and 6th to 8th months after PCI are likely to have restenosis and can be evaluated by an imaging study or repeated catheterization. [ABSTRACT FROM AUTHOR]

While performance of percutaneous coronary intervention (PCI) remains the domain of specialized cardiologists, patients undergoing PCI are cared for by noninvasive cardiologists, internists, and primary care physicians. Therefore, patient care is optimized when the entire patient care team understands procedural risks and complications as well as optimum patient management before, during, and after PCI. Before PCI, patients with contrast dye allergies should be identified and pretreated with steroids and an H1-blocker. Hydration should be initiated and maintained before and after the procedure to minimize the risks for contrast nephropathy. Periprocedure, patients should be monitored clinically for evidence of ischemia. In patients with significant groin, flank, abdominal, or back pain, as well as those with decrease in hematocrit or unexplained hypotension, the diagnosis of groin or retroperitoneal hematoma should be considered and promptly evaluated. Groin tenderness, pulsatile mass, or bruit should prompt evaluation for possible femoral pseudoaneurysm or arteriovenous fistulae. After the procedure, all patients treated with coronary stents should receive aspirin plus clopidogrel. Patients who develop typical anginal symptoms between the 1st and 6th to 8th months after PCI are likely to have restenosis and can be evaluated by an imaging study or repeated catheterization. [ABSTRACT FROM AUTHOR]

The aims of this study were to analyze the contemporary trends in the changing incidence of abrupt vessel closure (AVC) after percutaneous coronary intervention (PCI), to determine the impact of intracoronary stenting and glycoprotein IIb/IIIa inhibitors (GPIs) on complication rates and etiologies, and to determine the incidence of side branch occlusion (SBO) as the etiology of AVC in the stent era, complications occurring during 3,300 consecutive PCIs performed from April 1994 to December 2000 at a single referral institution. In this consecutive patient cohort of PCI cases collected over a 6.5-year period, AVC occurred in 103 of 3,300 cases (3.12%). Linear regression analysis over this time frame documented a steadily decreasing incidence of AVC from 5.9% in 1994 to 1.1% in 2000 (−0.76%/per year, 95% confidence interval −0.99 to 0.52, p <0.05). Analysis using Pearson’s correlation showed that the decreasing incidence of AVC was inversely correlated with the increasing percentage of intracoronary stents placed over this time period (r = −0.94, p <0.001). Additionally, GPI use increased from 0% in 1995 to 36.0% in 2000 (p = 0.009). The absolute incidence of SBO of a major branch vessel remained relatively stable over this 6.5-year period. However, SBO appeared to be increasing as the etiology of AVC, and accounted for 9.0% of AVC in 1995 compared with 28.0% of AVC in 2000. This increasing trend of the percentage of SBO as the etiology of AVC appeared to correlate with the increased use of stents (r = 0.85, p = 0.015). Thus, the incidence of AVC steadily decreased over the 6.5-year time period, and was associated with the increased use of stents and GPIs; conversely, SBO accounted for an increasing percentage of AVC over this time period. [Copyright &y& Elsevier]

: ObjectivesWe sought to develop and evaluate a risk adjustment model for in-hospital mortality following percutaneous coronary intervention (PCI) procedures using data from a large, multi-center registry.: BackgroundThe 1998–2000 American College of Cardiology–National Cardiovascular Data Registry (ACC–NCDR) dataset was used to overcome limitations of prior risk-adjustment analyses.: MethodsData on 100,253 PCI procedures collected at the ACC–NCDR between January 1, 1998, and September 30, 2000, were analyzed. A training set/test set approach was used. Separate models were developed for presentation with and without acute myocardial infarction (MI) within 24 h.: ResultsFactors associated with increased risk of PCI mortality (with odds ratios in parentheses) included cardiogenic shock (8.49), increasing age (2.61 to 11.25), salvage (13.38) urgent (1.78) or emergent PCI (5.75), pre-procedure intra-aortic balloon pump insertion (1.68), decreasing left ventricular ejection fraction (0.87 to 3.93), presentation with acute MI (1.31), diabetes (1.41), renal failure (3.04), chronic lung disease (1.33); treatment approaches including thrombolytic therapy (1.39) and non-stent devices (1.64); and lesion characteristics including left main (2.04), proximal left anterior descending disease (1.97) and Society for Cardiac Angiography and Interventions lesion classification (1.64 to 2.11). Overall, excellent discrimination was achieved (C-index = 0.89) and application of the model to high-risk patient groups demonstrated C-indexes exceeding 0.80. Patient factors were more predictive in the MI model, while lesion and procedural factors were more predictive in the analysis of non-MI patients.: ConclusionsA risk adjustment model for in-hospital mortality after PCI was successfully developed using a contemporary multi-center registry. This model is an important tool for valid comparison of in-hospital mortality after PCI. [Copyright &y& Elsevier]

A 48-year-old white woman presented with a chief complaint of numerous fleeting episodes of rapid heart rate over the previous 6 months. The symptoms mainly occurred at night and were exacerbated by exercise. They were accompanied by dizziness and dyspnea but not syncope or chest pain. The episodes lasted seconds to minutes and spontaneously resolved. They were significant enough to wake her out of sleep once per night. The episodes were becoming more frequent and prolonged. Her review of systems was otherwise unremarkable. Her prior workup included a Holter monitor, which showed a heart rate ranging from 43 to 107 bpm with a normal sinus rhythm, one premature ventricular contraction, and two premature atrial contractions. An event recorder did not capture any episodes in progress. An echocardiogram was normal. All other laboratory tests were normal. Her past medical history is unremarkable. She has no past surgical history. She has no known drug allergies. She takes lansoprazole 30 mg daily. She uses alcohol socially and denies tobacco or IV drug use. Her family tree is shown as Figure 1. Physical examination revealed a thin white female in no acute distress. Temperature was 98.4°F. Pulse was 55 bpm and regular. Blood pressure was 110/70 mm Hg in the right arm and 100/70 mm Hg in the left arm. Respiratory rate was 12 BPM. Weight was 110 lb. The eye, ears, nose, throat, neck, lung, abdominal, musculoskeletal, and neurologic exams were all normal. Cardiovascular examination revealed a regular rate and rhythm, normal point of maximal impulse,a split S1 and a normal S2. There was no murmur, rub, S3, or S4. Carotid arteries were 2+ and without bruits. No abdominal aortic aneurysm was present. Pedal pulses were 2+. There was no peripheral edema. The complete blood count, electrolytes, blood urea nitrogen, creatinine, and liver function tests were all normal. Echocardiogram revealed a normal-sized left ventricle. The left ventricle ejection fraction was normal at... [ABSTRACT FROM AUTHOR]