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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2008.08.029 Byline: Troy LaBounty (a), Hitinder S. Gurm (b)(c), Shaun G. Goodman (d)(e), Gilles Montalescot (f), Jose Lopez-Sendon (g), Ann Quill (h), Kim A. Eagle (b) Keywords: Acute coronary syndrome; Electrocardiography; Myocardial infarction; Myocardial ischemia Abstract: Q-waves in ST-elevation acute coronary syndromes carry adverse implications. We sought to determine the frequency, predictors, and implications of Q-waves in the current era that includes primary percutaneous coronary interventions. Author Affiliation: (a) Weill Cornell Medical College, New York, NY (b) University of Michigan, Ann Arbor, Mich (c) Ann Arbor Veterans Administration Hospital, Ann Arbor, Mich (d) Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, Ontario, Canada (e) Canadian Heart Research Centre, Toronto, Ontario, Canada (f) Centre Hospitalier Universitaire Pitie-SalpA*triere, Paris, France (g) Hospital Universitario La Paz, Madrid, Spain (h) University of Massachusetts, Worcester Article Note: (footnote) Funding: This research was supported by an unrestricted grant from Sanofi-Aventis, Paris, France. The Global Registry of Acute Coronary Events is supported by an unrestricted educational grant from Sanofi-Aventis to the Center for Outcomes Research, University of Massachusetts Medical School. Sanofi-Aventis had no involvement in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The design, conduction, and interpretation were undertaken by an independent steering committee., Conflict of Interest: There are no other conflicts of interest for any of the authors., Authorship: All authors meet criteria for authorship including access to the data and all authors had a role in the writing of the manuscript.

Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders.

Contrast-induced acute kidney injury is a common complication in patients undergoing invasive procedures and is associated with increased mortality and morbidity. There is no effective approach to the management of this complication, and prevention remains of paramount importance. The 3 pillars of prevention are identification of high-risk patients, appropriate hydration before and after contrast exposure, eGFR-based contrast dosing and use of ultra-low contrast volume in high-risk patients. Most evidence supporting these practices is derived from patients undergoing coronary angiography or percutaneous coronary intervention but these basic principles can be applied to most patients undergoing contrast-based procedures in the catheterization laboratory.

Acute limb ischemia (ALI) of the lower extremity is a potentially devastating condition that requires urgent and definitive management. This challenging scenario is often treated with endovascular, open surgical, or hybrid revascularization (HyR) in an urgent basis, but the comparative effects of such therapies remain poorly defined. The purpose of this study was to compare the outcomes of endovascular, open surgical, and HyR for ALI in the contemporary era.

Contrast media use is ubiquitous in the catheterization laboratory. Contrast-associated acute kidney injury (CA-AKI) is a key concern among patients undergoing coronary angiography and percutaneous coronary interventions. The risk of CA-AKI can be minimized by careful attention to hydration status and renal function-based contrast dosing in all patients. In patients with Stage IV chronic kidney disease, ultra low contrast procedure (contrast dose ≤ GFR) may be especially beneficial.

IntroductionPredicting personalized risk for adverse events following percutaneous coronary intervention (PCI) remains critical in weighing treatment options, employing risk-mitigation strategies, and enhancing shared decision-making.HypothesisWe hypothesized that by employing machine learning models, we would be able to use pre-procedural factors to predict common post-PCI complications.MethodsA patient panel ranked the importance of common PCI complications. A separate group of 66 adults underwent a semiquantitative survey assessing for a preferred list of outcomes and model display. Our cohort included 71,963 PCI procedures performed at 48 hospitals in Michigan between 4/1/2018 and 9/30/2020 in the BMC2 registry divided into two groups for training (75%) and validation (25%). XGBoost and random forest models were created to predict the risk of in-hospital outcomes.ResultsThe overall rate of mortality was 1.76% (n=1,264), AKI 2.64% (n=1,712), new need for dialysis 0.41% (n=295), major bleeding 0.89% (n=631), and transfusion 2.43% (n=1,746). The XGBoost model was selected as the final model and demonstrated excellent discrimination and calibration for all outcomes including mortality (AUC: 0.950 [95%CI 0.939-0.962]), AKI (AUC: 0.889 [95%CI 0.874-0.904]), dialysis (AUC: 0.949 [95%CI 0.928-0.969]), transfusion (AUC: 0.918 [95%CI 0.905-0.931]), and major bleeding (AUC: 0.892 [95%CI 0.861-0.922]). Survey subjects preferred a comprehensive list of individually reported post-procedure outcomes.ConclusionUsing common pre-procedural risk factors, we designed an XGBoost machine learning model that accurately predicts individualized post-PCI outcomes. Utilizing patient feedback, we created a patient-centered tool to clearly display risks to patients and providers (Figure, shiny.bmc2.org/pci-prediction/). Enhanced risk prediction prior to PCI could help inform treatment selection and shared decision-making discussions.

Whether increasing use of radial access has improved percutaneous coronary intervention outcomes remains unknown. We sought to determine the relationship between increasing facility-level use of transradial percutaneous coronary intervention (TRI) and periprocedural outcomes.

Kidney injury following cardiac catheterization is an infrequent, though persistent, complication, which in some cases may be preventable. Patients at increased risk for renal complications following catheterization can be identified through individual and procedural risk factors, and several risk-prediction models are readily available. The authors advocate for the development of an easily implemented and standardized protocol, readily accessible to catheterization laboratory staff, for the identification and treatment of those patients who may be at increased risk for renal complications following cardiac catheterization.

Risk scores should undergo 3 analytical phases before they are suitable for adoption in clinical practice, namely, derivation, external validation, and assessment of effect on clinical outcomes of use of the risk score in a so-called impact study. Major risk factors for renal complications after percutaneous coronary intervention are pre-existing chronic kidney disease, diabetes mellitus, use of a high contrast dose, and hemodynamic instability. Unfortunately, only 3 of these 10 risk scores have undergone external validation. As a result, there is a great need for further research on the already designed risk scores.

Use of bivalirudin has been associated with a reduction in the incidence of bleeding in patients undergoing percutaneous coronary intervention. Patients with chronic kidney disease, a known predictor of post–percutaneous coronary intervention bleeding, are under-represented in clinical trials.

Prasugrel is a recently approved thienopyridine for use in patients with acute coronary syndromes undergoing percutaneous coronary intervention. There are no data on contemporary use of prasugrel in routine clinical practice.

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with higher adverse event rates, lower procedural success, and inferior longterm patency rates compared with native vessel PCI. The ability to comply with dual antiplatelet therapy, and whether the patient will need an interruption in dual antiplatelet therapy, should be considered when deciding whether to implant a drug-eluting stent (DES) or bare metal stent (BMS) in an SVG. DES should be used for SVG PCI because they seem to reduce target vessel revascularization. This article reviews the evolution and contemporary evidence regarding use of DES versus BMS in SVG PCI.

Peripheral arterial disease is a manifestation of systemic atherosclerosis and is predictive of future cardiovascular events. Clinical trial data have demonstrated that medical therapy can attenuate cardiovascular morbidity and mortality in patients with peripheral arterial disease. The utilization and impact of recommended medical therapy in a contemporary population of patients who undergo percutaneous interventions for lifestyle-limiting peripheral arterial disease is unknown.

Prior studies suggest that most deaths in patients undergoing percutaneous coronary intervention (PCI) are related to procedural complications. Mortality associated with PCI has steadily declined during the past decade, and the cause and circumstance of death among patients undergoing PCI in the contemporary era remain unknown.

The optimal degree of heparin anticoagulation for peripheral vascular interventions (PVIs) has not been defined. We sought to correlate total heparin dose and peak procedural activated clotting time (ACT) with postprocedural outcomes in patients undergoing PVI.

Introduction:Precise risk-prediction of post-procedural adverse events and outcomes after percutaneous coronary intervention (PCI) is critical to weighing treatment options and shared decision-making. Post-PCI complications are becoming less coming with quality improvement initiatives, however, there remains a significant risk for acute kidney injury (AKI), bleeding, and death. We hypothesized that with the use of random forest algorithms, we would be able to create accurate models to predict post-PCI complications.Methods:Our study cohort included 71,963 PCI procedures from the BMC2 registry performed at 48 hospitals in Michigan between 4/1/2018 and 9/30/2020. Random forest models were created using 74 pre-procedural clinical and laboratory variables to estimate the risk of each in-hospital outcome including mortality, AKI, major bleeding, and the need for a blood transfusion. A reduced model was created with the 20 most influential variables. The entire cohort was randomly separated into two groups for training (n=35,981) and validation (n=35,982). Model performance was evaluated in an independent validation data set using area under the receiver-operating characteristic curve (AUC).Results:The overall mortality was 1.76% (n = 1,264), there were 1,743 (2,42%) AKI events, 665 (0.92%) major bleeds, and 1,745 (2.42%) transfusions. The reduced models demonstrated excellent discrimination for all measured outcomes (Fig. 1) including mortality (AUC: 0.936 [95%CI 0.931-0.941]), AKI (AUC: 0.857 [95%CI 0.848-0.865]), major bleeding (AUC: 0.859 [95%CI 0.846-0.872]), and need for transfusion (AUC: 0.881 [95%CI 0.874-0.888]).Conclusions:The risk of post-PCI complications including mortality, AKI, major bleeding, and need for transfusion can be accurately calculated using a random forest algorithm of common pre-procedural factors to help better inform clinicians of a patient’s risk for better treatment selection and shared decision-making.

Background: Abciximab is a monoclonal antibody that prevents platelet aggregation by blocking platelet glycoprotein (GP) IIb/IIIa receptor. Objective: To study the safety profile of this agent in contemporary clinical practice. Methods: We evaluated efficacy and safety end points (major and minor bleeding, thrombocytopenia) in patients treated with abciximab and compared them to those treated with placebo in main randomized clinical trials of patients with acute coronary syndromes (ACS) or those undergoing percutaneous coronary intervention (PCI). Results/conclusion: Use of abciximab is associated with an improved outcome in high-risk patients undergoing PCI but with a worse outcome in ACS patients treated conservatively. Use of abciximab is associated with an acceptable safety profile even when used on a background of aspirin and high doses of thienopyridine but has a potential to increase thrombocytopenia and minor bleeding. Small molecule GP IIb/IIIa antagonists are increasingly preferred over abciximab in clinical practice, and recent observational data have demonstrated these agents to have a similar efficacy and safety profile. As an increasing number of agents are being evaluated for peri-PCI anti-thrombotic therapy, the role of abciximab is likely to be further restricted to the highest risk patients.

BackgroundProteinuria is a marker for underlying diabetic nephropathy and may be a surrogate marker for advanced atherosclerosis. It is unknown if proteinuria is a determinant of death in patients with diabetes after coronary artery bypass grafting. We hypothesized that diabetic patients with evidence of proteinuria would have increased mortality and clinical event rates after isolated coronary artery bypass grafting compared with nonproteinuric diabetic patients. Methods and ResultsWe performed an observational of study of 905 diabetic patients with urinalysis and available follow-up data (nonproteinuria, n = 651; proteinuria, n = 254) after isolated coronary artery bypass grafting at the Cleveland Clinic Foundation between January 1989 and December 1992. The proteinuria group was further prospectively stratified into low-concentration (n = 225) and high-concentration (n = 29) groups. The end points of this study were all-cause mortality and the composite end point of death, nonfatal myocardial infarction, and need for repeat revascularization. The mean follow-up time was 66 months. The 5-year mortality rate for the nonproteinuria and proteinuria groups was 20.2% and 29.1% (P<.001), respectively. The 5-year rate of death, nonfatal myocardial infarction, and need for repeat revascularization for the nonproteinuria and proteinuria groups was 25.2% and 36.2% (P<.001), respectively. Significant multivariate predictors of 5-year mortality included age, not using a left internal mammary artery graft to the left anterior descending coronary artery, proteinuria, lower body weight, and increased creatinine level. ConclusionsAmong diabetic patients, proteinuria appears to be an important predictor of death after isolated coronary artery bypass grafting. (Am Heart J 2000;139:939-44.)

Platelet inhibition is integral to the contemporary management of acute coronary syndromes. While aspirin and clopidogrel are used almost universally in patients treated with an early invasive strategy, the optimal dosing strategy for these drugs remains unknown. In a large randomized trial, the OASIS-CURRENT 7, investigators demonstrated no benefit of a higher dose of aspirin. There was no overall benefit of a higher dose of clopidogrel, although in patients treated with percutaneous coronary intervention a double-dose strategy was associated with a reduction in stent thrombosis and other ischemic events at the cost of an increased risk of bleeding events.

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Objective:To evaluate the association of hospital and operator chronic total occlusion (CTO) percutaneous coronary interventions (PCI) volume with success rates and outcomes of patients undergoing CTO-PCI.Background:Few data exist for the association of CTO procedural volume and outcomes for CTO-PCI.Methods:We analyzed data from the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) registry in Michigan (2010-2017) to evaluate the association of hospital and operator volumes with procedural success rates and outcomes of patients undergoing CTO PCI volumes. CTO PCI was defined as PCI of a 100% occluded major coronary artery presumed to be at least >3 months old.Results:Among 210,172 patients enrolled in the registry, 7,389 CTO PCIs were attempted with success rate of 53%. CTO-PCI success increased with hospital volume and was significantly higher in low volume operators at high volume centers than low volume operators at low volume hospitals (Figure 1). Major adverse events and death showed an inverse relationship with volume with highest mortality for CTO-PCI by low volume operators at low volume centers and lowest for high volume operators at high-volume centers (Figure 2).Conclusions:Operator and hospital CTO-PCI volumes were directly related to procedural success and inversely to death among patients undergoing CTO-PCIs. Low volume operators at high volume centers had significantly higher success and lower death rates compared with low volume operators at low volume centers. These data suggested that oversight of CTO-PCIs at low volume centers by high volume operators has the potential for improving the success rates and outcomes of CTO-PCIs at such hospitals.

Introduction:Radial arterial access for percutaneous coronary intervention (PCI) is associated with improved outcomes when compared with femoral arterial access. End stage renal disease patients on dialysis are known to have a higher risk of post-PCI bleeding. We sought to determine whether increasing use of radial artery access for PCI in general had permeated PCI in dialysis patients and to describe the outcomes of radial artery access for PCI in this population.Methods:The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) is a prospective, multicenter registry that collects in-hospital outcomes data from PCI cases at all nonfederal hospitals in the state of Michigan. Using the BMC2 database, we report patterns of radial access use in dialysis patients and in-hospital outcomes in patients on dialysis who underwent PCI through the radial or femoral artery.Results:From 2010 until 2018, 6,359 dialysis patients (representing 2.5% of 251,168 PCIs) underwent PCI in hospitals participating in the BMC2 registry. During the study period, 86.9% patients on dialysis underwent PCI via the femoral artery, and 12.5% patients underwent PCI using the radial artery. The percent of PCIs performed radially on patients on dialysis increased from 2.4% in 2010 to 22.3% in 2018 (Figure). Patients who had their PCI performed through the femoral artery had a higher risk of transfusion (12.3% vs. 6.5%), bleeding (5.4% vs. 2.9%), and retroperitoneal bleeding (0.4% vs. 0.1%) compared with patients who had their PCI performed through radial access. In-hospital risk-adjusted mortality was higher in patients with femoral access (3.9% vs 2.3%, p < 0.05) compared with patients with radial access.Conclusions:We present here the largest real-world experience with dialysis patients undergoing PCI via the radial artery. We demonstrate that increasing use of radial access for PCI in dialysis patients over time was associated with a lower risk of post-procedural bleeding and death.

Background:Interventions on CTO have been shown to be associated with improvement in angina. Previous data from registries have shown increased risk of adverse cardiac events for CTO compared with non-CTO PCI.Methods:To study the uptake and outcomes of CTO-PCI in Michigan, we evaluated all patients (excluding those with STEMI) enrolled in Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry (2010-2017). CTO PCI was defined as PCI of a 100% occluded major coronary artery presumed to be >3 months old.Results:Among 210,172 patients in the BMC2 registry, 7,389 CTO PCIs were attempted with 3,947 (53%) achieving post-PCI TIMI 3 flow. Overall the proportion of CTO-PCI among all PCI procedures increased over the study period (2.7%-2010 to 4.5%-2017). Pre-PCI assessment for ischemia was performed in 47% of patients and remained similar over time, Angina class <2 was present in a quarter of patients. Major complications occurred in 245 patients (3.3%) and included death in 106 (1.4%), post procedural stroke in 27 (0.4%), cardiac tamponade in 35 (0.5%) and urgent CABG in 95 patients (1.3%). Procedural success (defined as TIMI 3 flow without MACE and <50% residual stenosis) improved modestly (45%-2010 to 55%-2017 (p for trend <0.001, Figure). However, hospital death and MACE for CTO-PCI remained unchanged over the study period (p for trends 0.247 and 0.859) (Figure). These events were lowest for stable angina and highest in NSTE patients undergoing CTO-PCI.Conclusions:Performance of CTO-PCI in Michigan has increased over time. While the success rate of CTO-PCI has increased modestly, procedural MACE or death have remained steady over the study period. With expected increased in the performance of CTO PCIs, our data suggested room for improvement in the selection and functional assessment of patients undergoing CTO-PCI before subjecting them to the increased risk of this procedure.

Background:Rates of transradial percutaneous coronary intervention (PCI) are increasing. There is concern that with declining rates of femoral access, operators and patient care teams may become less proficient with femoral access, thereby leading to increased transfemoral complications. We used the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) PCI registry to define the optimal volume threshold to maintain proficiency in transfemoral PCI.Methods:All PCIs from 2013-2017 from the BMC2 registry were included. To determine the impact of recent operator transfemoral experience on vascular complications, as of the date of each PCI procedure, we determined the total number of transfemoral procedures the operator had performed within the previous 365 days. Logistic regression models adjusting for patient and procedural characteristics were then fitted to the data to evaluate the impact on vascular complications of prior operator experience dichotomized at each integer threshold between 1st and the 75thpercentile of operator experience.Results:The study cohort comprised of 152,073 treated by 372 operators (97,540 (64.1%) femoral and 54,533 (35.9%) radial PCIs). During the study period transradial PCI increased from 25.9% to 45.2%. A nonlinear inverse relationship was noted between the total annual volume of transfemoral PCI volume and risk-adjusted vascular complication rate. A threshold volume of 30 annual transfemoral PCIs was identified as being associated with a statistically significant lowering of the risk for vascular complications (maximal effect at 38, Figure).Conclusions:Although transradial PCI has reduced vascular access site complications compared to transfemoral, operators need to maintain proficiency with both approaches. The number of transfemoral cases per year to maintain proficiency is 30. The optimal balance of transradial and transfemoral PCI to ensure the best patient outcome remains unknown.

Introduction:Cardiac rehabilitation (CR) confers significant clinical benefit after coronary artery disease (CAD) events, yet data on its use across and within hospitals is sparse.Hypothesis:Post-discharge CR use after CAD events varies across hospitals, but is correlated within hospitals by CAD event type: percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and acute myocardial infarction with medical management alone (AMI-MM).Methods:We identified 71,064 90-day episodes of CAD from 33 hospitals in the Michigan Value Collaborative multipayer registry (2014-2017), and compared CR use across CAD event type with a chi-square test: AMI-MM (n=17,779), PCI (n=42,832) and CABG (n=10,453). We defined CR use as having at least one facility or professional claim within 90 days of discharge using CPT (93797, 93798) and HCPCS (G0422, G0423) codes. We used hierarchical logistic regression to estimate hospital risk-adjusted CR rates, and the percent of variation attributed to the hospital-level (intraclass correlation coefficient, ICC). We also estimated the Pearson correlation coefficient (r) for within-hospital CR use across CAD event types.Results:Overall, 18,792 patients (26%) used any CR, with significant differences by CAD event type: CABG=52%, PCI=27%, AMI-MM=11% (p<0.001). We found over 10-fold variation in risk-adjusted CR use across hospitals (4% to 51%), with 12% of the variation attributed to the hospital (Figure). We observed similar variation in AMI-MM and PCI, but less variation in CABG. Within hospitals, CR use by event type was highly correlated, with the strongest correlation between AMI-MM vs. PCI (r=0.85), followed by PCI vs. CABG (r=0.79) and AMI-MM vs. CABG (r=0.70, all p<0.001).Conclusions:We found dramatic variation in CR use across hospitals and CAD event types. However, use within hospitals by CAD event type was similar. Work is ongoing to identify the determinants of CR use.

Background:There is a large body of data demonstrating the impact of patient gender on outcome of PCI. Recent studies suggest that physician gender may impact outcome for certain patient cohorts. There is no data evaluating impact of operator gender on outcome of PCI.Objectives:To examine the impact of operator gender on appropriateness and outcome of PCI.Methods:We assessed the outcome of all PCI procedures performed between January 2010 and December 2017 in Michigan and enrolled in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry and compared the outcome of procedures performed by a male versus a female interventional cardiologist.Results:A total of 239,420 PCI procedures performed between 2010 and 2017 were utilized for analysis; 6,362 (2.66%) of these cases were performed by female interventionalists. There was no difference in the risk adjusted mortality (1.56% versus 1.48%, adjusted OR 1.138, 95% CI: 0.891-1.452), transfusion (2.85%, versus 2.59%, adjusted OR 1.168, 95% CI: 0.980-1.390) or acute kidney injury (3.28% versus 3.42%, adjusted OR 1.027, 95% CI: 0.819-1.288) between patients treated by male versus female operators. Similar findings were observed in propensity matched analysis (1.6% vs 1.7%, p-value 0.428). While the absolute differences were small, procedures performed by female operators were more likely to be rated as appropriate (86.64% of cases versus 84.45%, p-value <0.0001) when assessed by Appropriate Use Criteria (AUC).Conclusions:Female interventional cardiologists are scarce and only perform a small percentage of PCI cases. There is no significant difference in risk adjusted outcomes of procedures performed by male versus female interventional cardiologists in Michigan. Female operators scored higher on appropriateness metrics.

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Supplemental Digital Content is available in the text.

Supplemental Digital Content is available in the text.

Supplemental Digital Content is available in the text.

Supplemental Digital Content is available in the text.

Acute kidney injury (AKI) post percutaneous coronary intervention (PCI) is associated with increased mortality but both death and AKI share common risk factors. Moreover, the effect of a high contrast dose, a known modifiable risk factor for AKI, on mortality is unknown. The aim of our study was to analyze the association between AKI and in-hospital mortality post PCI after adjustment for confounding by common risk factors.

The purpose of this study was to evaluate the frequency and temporal trends in use of transradial access (TRA) for percutaneous coronary intervention (PCI) in ST-segment–elevation myocardial infarction (STEMI). The use of TRA has been associated with less bleeding and improved clinical outcomes in patients undergoing PCI for STEMI.

Eptifibatide, a small-molecule glycoprotein IIbIIIa inhibitor, is conventionally administered as a bolus plus infusion. A growing number of clinicians are using a strategy of catheterization laboratory–only eptifibatide (an off-label use) as procedural pharmacotherapy for patients undergoing percutaneous coronary intervention although the comparative effectiveness of this approach is unknown.

Background:Although radial artery access reduces access site bleeding, increasing use of transradial PCI (TRI) may compromise facility-level outcomes due to patient selection, procedural learning curve, and unintended consequences on femoral PCI management. We sought to determine the relationship between increasing facility-level use of TRI and change in rates of access site bleeding.