Search

Background: The association of short-term readmissions after percutaneous coronary intervention (PCI) on healthcare costs has not been well studied., Methods and Results: The Healthcare Cost and Utilization Project National Readmission Database encompassing 722 US hospitals was used to identify index PCI cases in patients ≥18 years old. Hierarchical regression analyses were used to examine the factors associated with risk of 30-day readmission and higher cumulative costs. We evaluated 206 869 hospitalized patients who survived to discharge after PCI from January through November 2013 and analyzed readmissions over 30 days after discharge. A total of 24 889 patients (12%) were readmitted within 30 days, with rates ranging from 6% to 17% across hospitals. Among the readmitted patients, 13% had PCI, 2% had coronary artery bypass surgery, and 3% died during the readmission. The most common reasons for readmission included nonspecific chest pain/angina (24%) and heart failure (11%). Mean cumulative costs were higher for those with readmissions ($39 634 versus $22 058; P <0.001). The multivariable analyses showed that readmission increased the log 10 cumulative costs by 45% (β: 0.445; P <0.001). There was no significant difference in cumulative costs by the type of insurance., Conclusions: In a national sample of inpatient PCI cases, 30-day readmissions were associated with a significant increase in cumulative costs. The majority of readmissions were because of low-risk chest pain that did not require any intervention. Ongoing effort is warranted to recognize and mitigate potentially preventable post-PCI readmissions., (© 2017 American Heart Association, Inc.)

Background: The Physician Consortium for Performance Improvement recently proposed percutaneous coronary intervention (PCI)-specific process measures. However, information about hospital performance on these measures and the association of PCI process and outcomes measures are not available., Methods and Results: We linked the National Cardiovascular Data Registry (NCDR) CathPCI Registry with Medicare claims data to assess hospital performance on established PCI process measures (aspirin, thienopyridines, and statins on discharge; door-to-balloon time; and referral to cardiac rehabilitation), newly proposed PCI process measures (documentation of contrast dose, glomerular filtration rate, and PCI indication; appropriate indication for elective PCI; and use of embolic protection device), and a composite of all process measures. We calculated weighted pair-wise correlations between each set of process metrics and performed weighted correlation analyses to assess the association between composite measure performance with corresponding 30-day risk-standardized mortality and readmission rates. We reported the variance in risk-standardized 30-day outcome rates explained by process measures. We analyzed 1 268 860 PCIs from 1331 hospitals. For many process measures, median hospital performance exceeded 90%. We found strong correlations between medication-specific process measures ( P <0.01) and weak correlations between hospital performance on the newly proposed and established process measures. The composite process measure explained only 1.3% and 2.0% of the observed variation in mortality and readmission rates, respectively., Conclusions: Hospital performance on many PCI-specific process measures demonstrated little opportunity for improvement and explained only a small percentage of hospital variation in 30-day outcomes. Efforts to measure and improve hospital quality for PCI patients should focus on both process and outcome measures., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Revascularization decisions can profoundly impact patient survival, quality of life, and procedural risk. Although use of Heart Teams to make revascularization decisions is growing, data on their implementation in the real-world are limited. Our objective was to assess the prevalence of Heart Teams and their association with collaboration in routine practice., Methods: A survey of cardiologists and cardiac surgeons at 31 hospitals in Michigan was performed in May, 2011--prior to the recommendation for using Heart Teams in national guidelines. This survey included all percutaneous coronary intervention-performing hospitals in Michigan participating in the Blue Cross/Blue Shield of Michigan Cardiovascular Consortium and Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. It targeted both the use of Heart Teams and multidisciplinary Case Conferences., Results: There were 53 physician survey respondents from 27 hospitals with 4 hospitals not responding. Among respondents, 11 (40.7%) hospitals reported no Heart Teams or Case Conferences while 7 (25.9%) hospitals reported either a Heart Team or Case Conference. However, there was disagreement about the presence of a Heart Team at seven hospitals, and about Case Conferences at nine hospitals. Hospitals with definite Heart Teams reported significantly greater levels of collaboration between cardiologists and cardiac surgeons., Conclusion: The overall presence of Heart Teams prior to their recommendation in national guidelines was limited. Even among hospitals with a potential Heart Team, there was substantial disagreement between respondents about their presence. Further refinement of the definition of a Heart Team and measures of successful implementation are needed.

Background: Intra-aortic balloon pumps (IABP) frequently are used to provide hemodynamic support during high risk percutaneous coronary intervention (PCI), but clinical evidence to support their use is mixed. We examined hospital variation in IABP use among high risk PCI patients, and determined the association of IABP use on mortality in this population., Methods and Results: We analyzed data submitted to the CathPCI Registry between January 2005 and December 2007. High risk PCI was defined as having at least 1 of the following features: unprotected left main artery as the target vessel, cardiogenic shock, severely depressed left ventricular function, or ST segment elevation myocardial infarction. Hospitals were categorized into quartiles by their proportional use of IABP. We examined differences in in-hospital mortality across hospital quartiles using a hierarchical logistic regression model to adjust for differences in patient and hospital characteristics across hospital quartiles of IABP use. IABPs were used in 18,990 (10.5%) of 181,599 high risk PCIs. Proportional use of IABP varied significantly across hospital quartiles: Q1, 0.0 to 6.5%; Q2, 6.6 to 9.2%; Q3, 9.3 to 14.1%; Q4, 14.2 to 40.0%. In multivariable analysis, after adjustment for differences in patient and hospital characteristics, in-hospital mortality was comparable across quartiles of hospital IABP usage (Q1, Ref; Q2, odds ratio 1.11, 95% CI 0.99-1.24; Q3, OR 1.03, 95% CI 0.92-1.15; Q4, OR 1.06, 95% CI 0.94-1.18)., Conclusions: IABP use varied significantly across hospitals for high risk PCI. However, this variation in IABP use was not associated with differences in in-hospital mortality.

Objective: Cardiac troponin levels help risk-stratify patients presenting with an acute coronary syndrome. Although cardiac troponin levels may be elevated in patients presenting with non-acute coronary syndrome conditions, specific diagnoses and long-term outcomes within that cohort are unclear., Methods: By using the Veterans Affairs centralized databases, we identified all hospitalized patients in 2006 who had a troponin assay obtained during their initial reference hospitalization. On the basis of the diagnostic codes of the International Classification of Diseases, 9th Revision, primary diagnoses were categorized as acute coronary syndrome or non-acute coronary syndrome conditions., Results: Of a total of 21,668 patients with an elevated troponin level who were discharged from the hospital, 12,400 (57.2%) had a non-acute coronary syndrome condition. Among that cohort, the most common diagnostic category involved the cardiovascular system, and congestive heart failure (N=1661) and chronic coronary artery disease (N=1648) accounted for the major classifications. At 1 year after hospital discharge, mortality in patients with a non-acute coronary syndrome condition was 22.8% and was higher than in the acute coronary syndrome cohort (odds ratio 1.39; 95% confidence interval, 1.30-1.49). Despite the high prevalence of cardiovascular diseases in patients with a non-acute coronary syndrome diagnosis, use of cardiac imaging within 90 days of hospitalization was low compared with that in patients with acute coronary syndrome (odds ratio 0.25; 95% confidence interval, 0.23-0.27)., Conclusions: Hospitalized patients with an elevated troponin level more often have a primary diagnosis that is not an acute coronary syndrome. Their long-term survival is poor and justifies novel diagnostic or therapeutic strategy-based studies to target the highest risk subsets before hospital discharge., (Published by Elsevier Inc.)

Background: Research increasingly shows that blacks with coronary heart disease (CHD) are treated at lower-quality hospitals. Little is known about racial differences in admission to high-quality hospitals., Methods: We identified all black and white Medicare patients with acute myocardial infarction and coronary artery bypass grafting (CABG) admitted during 2002 through 2005 to hospitals located in markets with top-ranked cardiac hospitals, as ascertained from the US News and World Report "America's Best Hospitals" annual rankings. The relationship between race and admission to top-ranked hospitals was estimated using multinomial conditional logit models to account for distance from patient residence to all available hospitals., Results: In unadjusted analyses, blacks with AMI or undergoing CABG, compared with whites, were more likely to be admitted to top-ranked hospitals (18.3% vs 10.5% and 34.4% vs 22.7% [P < .001]) but also more likely to bypass top-ranked hospitals (25.8% vs 14.7% and 37.5% vs 26.3% [P < .001]). In models accounting for distance, blacks with acute myocardial infarction were more likely (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.16 [P < .001]), whereas blacks undergoing CABG were equally likely (OR, 1.05; 95% CI, 0.97-1.13; P = .27) to be admitted to top-ranked hospitals compared with whites. However, within socially disadvantaged zip codes, blacks undergoing CABG were less likely to receive care at top-ranked hospitals (OR, 0.75; 95% CI, 0.64-0.86 [P < .001]) compared with whites and more likely to bypass top-ranked hospitals located closer to their residence (OR, 1.16; 95% CI, 1.02-1.30 [P = .03])., Conclusion: Black Medicare patients with acute myocardial infarction or undergoing CABG were equally or more likely to be admitted to top-ranked hospitals, except for socially disadvantaged black patients undergoing CABG.

Background: Several meta-analyses have evaluated the efficacy of percutaneous coronary intervention (PCI) compared with medical therapy, but none has focused on angina relief., Purpose: To summarize the evidence on the degree of angina relief from PCI compared with medical therapy in patients with stable coronary artery disease., Data Sources: The Cochrane Library (1993 to June 2009), EMBASE (1980 to June 2009), and MEDLINE (1950 to June 2009), with no language restrictions., Study Selection: Two independent reviewers screened citations to identify randomized, controlled trials of PCI versus medical therapy in patients with stable coronary artery disease., Data Extraction: Two independent reviewers abstracted data on patient characteristics, study conduct, and outcomes. A random-effects model was used to combine data on freedom from angina and to perform stratified analyses based on duration of follow-up, inclusion of patients with recent myocardial infarction, coronary stent utilization, recruitment period, and utilization of evidence-based medications., Data Synthesis: A total of 14 trials, enrolling 7818 patients, met the inclusion criteria. Although PCI was associated with an overall benefit on angina relief (odds ratio, 1.69 [95% CI, 1.24 to 2.30]), important heterogeneity across trials was observed. The incremental benefit of PCI observed in older trials (odds ratio, 3.38 [CI, 1.89 to 6.04]) was substantially less and possibly absent in recent trials (odds ratio, 1.13 [CI, 0.76 to 1.68]). An inverse relationship between use of evidence-based therapies and the incremental benefit of PCI was observed., Limitations: Information about the long-term use of medication was incomplete in most trials. Few trials used drug-eluting stents. Meta-regression analyses used aggregated study-level data from few trials., Conclusion: Percutaneous coronary intervention was associated with greater freedom from angina compared with medical therapy, but this benefit was largely attenuated in contemporary studies. This observation may be related to greater use of evidence-based medications in contemporary trials., Primary Funding Source: Canadian Institutes of Health Research.

Background: Over the past 20 years, percutaneous transluminal balloon coronary angioplasty (PTCA), bare-metal stents (BMS), and drug-eluting stents (DES) succeeded each other as catheter-based treatments for coronary artery disease. We undertook a systematic overview of randomised trials comparing these interventions with each other and with medical therapy in patients with non-acute coronary artery disease., Methods: We searched Medline for trials contrasting at least two of the four interventions (PTCA, BMS, DES, and medical therapy). Eligible outcomes were death, myocardial infarction, coronary artery bypass grafting, target lesion or vessel revascularisation, and any revascularisation. Random effects meta-analyses summarised head-to-head (direct) comparisons, and network meta-analyses integrated direct and indirect evidence., Findings: 61 eligible trials (25 388 patients) investigated four of six possible comparisons between the four interventions; no trials directly compared DES with medical therapy or PTCA. In all direct or indirect comparisons, succeeding advancements in percutaneous coronary intervention did not produce detectable improvements in deaths or myocardial infarction. The risk ratio (RR) for indirect comparisons between DES and medical therapy was 0.96 (95% CI 0.60-1.52) for death and 1.15 (0.73-1.82) for myocardial infarction. By contrast, we recorded sequential significant reductions in target lesion or vessel revascularisation with BMS compared with PTCA (RR 0.68 [0-60.0.77]) and with DES compared with BMS (0.44 [0.35-0.56]). The RR for the indirect comparison between DES and PTCA for target lesion or vessel revascularisation was 0.30 (0.17-0.51)., Interpretation: Sequential innovations in the catheter-based treatment of non-acute coronary artery disease showed no evidence of an effect on death or myocardial infarction when compared with medical therapy. These results lend support to present recommendations to optimise medical therapy as an initial management strategy in patients with this disease.

Background: Recent clinical trials found that high-dose statin therapy, compared with conventional-dose statin therapy, reduces the risk of cardiovascular events in patients with acute coronary syndromes (ACS) and stable coronary artery disease (CAD). However, the actual benefit and cost-effectiveness of high-dose statin therapy are unknown., Methods and Results: We designed a Markov model to compare daily high-dose with conventional-dose statin therapy for hypothetical 60-year-old cohorts with ACS and stable CAD over patient lifetime. Pooled estimates for major clinical end points (all-cause mortality, myocardial infarction, stroke, rehospitalization, and revascularization) from relevant clinical trials were incorporated. Incremental benefit was quantified as quality-adjusted life-years (QALYs). Threshold analyses determined at what price difference high-dose statins would yield incremental cost-effective ratios below $50,000, $100,000, and $150,000 per QALY gained. In ACS patients, a high-dose versus conventional-dose statin strategy resulted in a gain of 0.35 QALYs. In threshold analyses, a high-dose statin strategy consistently yielded incremental cost-effective ratios below $30,000 per QALY even under conservative model assumptions. In stable CAD patients, a high-dose statin strategy yielded a gain of only 0.10 QALYs and was sensitive to model assumptions about statin efficacy. The daily cost difference between a high- and conventional-dose statin would need to be <$1.70, $2.65, and $3.55 to yield incremental cost-effective ratios below $50,000, $100,000, and $150,000 per QALY., Conclusions: High-dose statin therapy is potentially highly effective and cost-effective in patients with ACS. In patients with stable CAD, however, the cost-effectiveness of high-dose statin therapy is highly sensitive to model assumptions about statin efficacy and cost. Use of high-dose statins can be supported on health economic grounds in patients with ACS, but the case is less clear for patients with stable CAD.

A uniform policy for regionalization of ST-segment elevation myocardial infarction (STEMI) care raises several concerns. Transferring all STEMI patients to obtain primary percutaneous coronary intervention (PCI) may be less effective than transferring only high-risk STEMI patients. Delays in time to treatment >60 min associated with transferring patients for primary PCI may result in increased mortality for the average patient as compared with providing immediate fibrinolytic therapy at their initial hospital; yet more than 95% of patients transferred for primary PCI in the U.S. exceed this 60-min benchmark. Superior outcomes associated with treatment at higher-volume regional STEMI centers are inconsistent among centers, and there is no direct evidence that patients will benefit by a transfer to a high-volume hospital from a low-volume hospital. Published data suggest as many as 800 PCI patients would need to be transferred to a high-volume PCI hospital to avoid a single death at a low-volume PCI hospital. Although European randomized trial data suggest transferring patients with STEMI for primary PCI may be superior to immediate fibrinolytic therapy, these findings are unlikely to generalize to the U.S. health care system given size, geography, and organization. ST segment elevation myocardial infarction care regionalization would require a massive redistribution of health care resources, depriving several hospitals of advanced cardiac care facilities, expertise, and associated revenue. Clearer evidence of the benefits and discussion of potential harms are needed before adopting a national STEMI regionalization policy.

We identified 155 patients who were admitted with an acute coronary syndrome and a low-density lipoprotein cholesterol level

Patients with extracardiac vascular disease were identified from 2,372 consecutive percutaneous coronary intervention (PCI) cases performed between 1997 and 2001. After multivariate adjustment, we found the presence of extracardiac vascular disease to be associated with a significantly higher risk for late mortality (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0 to 2.0, p = 0.029). When extracardiac vascular disease was separated into cerebrovascular disease and peripheral vascular disease, cerebrovascular disease was less common but was associated with a trend towards worse survival.

Homocyst(e)ine, a sulphur-containing amino acid, is an intermediate formed during the metabolism of the essential amino acid methionine. Biological and epidemiological evidence suggest that elevated plasma levels of homocyst(e)ine are a risk factor for atherosclerosis and coronary heart disease (CHD). In the general US population, hyperhomocyst(e)inaemia is common and most often due to mild nutritional deficiencies in the B vitamins (folic acid, vitamin B(12) and vitamin B(6)). While high homocyst(e)ine levels can be effectively lowered using folic acid and other B vitamins, it is unknown whether such vitamin therapy will lead to clinical benefits. Given that strategies for homocyst(e)ine-lowering are safe and inexpensive, however, even small reductions in CHD risk will be highly cost effective. Thus, it may be prudent for patients to ensure an adequate daily intake of dietary folic acid and other B vitamins and for physicians to screen high-risk adults such as those with established CHD as we await definitive results from ongoing clinical trials.

Coronary artery disease (CAD) is the leading cause of death around the world. One of the most common imaging methods for diagnosing CAD is the X-ray angiography (XRA). Diagnosing using XRA images is usually challenging due to some reasons such as, non-uniform illumination, low contrast, presence of other body tissues, and presence of catheter. These challenges make the diagnosis task hard and more prone to misdiagnosis. In this paper, we propose a new method for coronary artery segmentation, catheter detection, and centerline extraction in X-ray angiography images. For the segmentation, initially, three different superpixel scales are exploited, and a measure for vesselness probability of each superpixel is determined. A voting mechanism is used for obtaining an initial segmentation map from the three superpixel scales. The initial segmentation is refined by finding the orthogonal line on each ridge pixel of vessel region. The catheter is detected in the first frame of the angiography sequence and is tracked in other frames by fitting a second order polynomial on it. Also, we use the image ridges for extracting the coronary artery centerlines. We evaluated and compared our method with one of the previous well-known coronary artery segmentation methods on two challenging datasets. The results show that our method can segment the vessels and also detect and track the catheter in the XRA sequences. In general, the results assessed by a cardiologist show that 83% of the images processed by our proposed segmentation method were labeled as good or excellent, while this score for the compared method is 48%. Also, the evaluation results show that our method performs 67% faster than the compared method. Graphical abstract Proposed framework for coronary artery detection. [ABSTRACT FROM AUTHOR]

Objective: This study aims to determine the relationship between door-to-balloon delay in primary percutaneous coronary intervention and ST-elevation myocardial infarction (MI) outcomes and examine for potential effect modifiers.Methods: We conducted a systematic review and meta-analysis of prospective observational studies that have investigated the relationship of door-to-balloon delay and clinical outcomes. The main outcomes include mortality and heart failure.Results: 32 studies involving 299 320 patients contained adequate data for quantitative reporting. Patients with ST-elevation MI who experienced longer (>90 min) door-to-balloon delay had a higher risk of short-term mortality (pooled OR 1.52, 95% CI 1.40 to 1.65) and medium-term to long-term mortality (pooled OR 1.53, 95% CI 1.13 to 2.06). A non-linear time-risk relation was observed (P=0.004 for non-linearity). The association between longer door-to-balloon delay and short-term mortality differed between those presented early and late after symptom onset (Cochran's Q 3.88, P value 0.049) with a stronger relationship among those with shorter prehospital delays.Conclusion: Longer door-to-balloon delay in primary percutaneous coronary intervention for ST-elevation MI is related to higher risk of adverse outcomes. Prehospital delays modified this effect. The non-linearity of the time-risk relation might explain the lack of population effect despite an improved door-to-balloon time in the USA.Clinical Trial Registration: PROSPERO (CRD42015026069). [ABSTRACT FROM AUTHOR]

The article discusses a study which examined the proportion of ST-elevation myocardial infarction (STEMI) patients who are transferred with a door-in to door-out (DIDO) time of 30 minutes or less and assessed patient factors linked with delays in DIDO time. It notes that the preferred method of reperfusion for STEMI patients is primary percutaneous coronary intervention (PCI). Results showed that median DIDO time was 68 minutes. Older age, female sex and off-hours presentation were some of the factors associated with a DIDO time greater than 30 minutes. The study also found that only .6% of patients with DIDO times greater than 30 minutes had an absolute contraindication to fibrinolysis.

The article focuses on an observational study which estimated hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with acute myocardial infarction (AMI). Administrative data and a validated risk model were used to evaluate 3,195,672 discharges in 2,755,370 patients discharged from nonfederal acute care hospitals in the U.S. between January 1, 1995 to December 31, 2006. A significant decrease was observed in the risk-standardized hospital mortality rate for Medicare patients discharged with AMI, as well as between-hospital variation.

Objective To evaluate the association between door-to- balloon time and mortality in hospital in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction to assess the incremental mortality benefit of reductions in door-to- balloon times of less than 90 minutes. Design Prospective cohort study of patients enrolled in the American College of Cardiology National Cardiovascular Data Registry, 2005-6. Setting Acute care hospitals. Participants 43 801 patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention. Main outcome measure Mortality in hospital. Results Median door-to-balloon time was 83 minutes (interquartile range 6-109, 57.9% treated within 90 minutes). Overall mortality in hospital was 4.6%. Multivariable logistic regression models with fractional polynomial models indicated that longer door-to-balloon times were associated with a higher adjusted risk of mortality in hospital in a continuous non-linear fashion (30 minutes=3.0%, 60 minutes=3.5%, 90 minutes=4.3%, 120 minutes=5.6%, 150 minutes=7.0%, 180 minutes =8.4%, P<0.001). A reduction in door-to-balloon time from 90 minutes to 60 minutes was associated with 0.8% lower mortality, and a reduction from 60 minutes to 30 minutes with a 0.5% lower mortality. Conclusion Any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes. [ABSTRACT FROM AUTHOR]

To improve hospital performance in door-to-balloon (DTB) times nationally, the American College of Cardiology D2B Alliance recently enrolled approximately 1,000 hospitals that perform percutaneous coronary intervention (PCI) across the United States in a large national quality improvement effort. We evaluated recent changes in DTB times in hospitals within the Get-With-The-Guidelines (GWTG) Coronary Artery Disease (CAD) program, a partner in the D2B Alliance. Within GWTG-CAD participating hospitals, we studied DTB in nontransferred patients with ST-elevation myocardial infarction treated with primary PCI from July 2006 to March 2008. We evaluated the percentage of patients treated within 90 minutes and used multivariable models with generalized estimating equations to examine trends over time after accounting for changes in patients'' characteristics. A total of 5,801 patients at 167 hospitals were included in our analysis, with 3,567 patients at 98 hospitals that joined the D2B Alliance. From July to September 2006, 54.1% of patients received primary PCI within 90 minutes. This number increased significantly during the study period: 335 (74.1%) of 452 patients at GWTG-CAD participating hospitals were treated within 90 minutes from January to March 2008, including 229 of 304 patients (75.3%) treated at hospitals that joined the D2B Alliance and 106 of 148 patients (71.6%) treated at other GWTG-CAD participating hospitals (p <0.001 for all comparisons over time). No statistically significant differences were noted in the rate of change between hospitals that joined the D2B Alliance and other GWTG-CAD participating hospitals. In conclusion, the percentage of patients treated with 90 minutes has dramatically increased at hospitals participating within the GWTG-CAD program, coinciding with the launch of the D2B Alliance. These improvements were broad and not limited to hospitals that joined the D2B Alliance. [Copyright &y& Elsevier]

Background: Supporters of specialty hospitals claim these facilities provide better patient care; however, empirical data on quality of care in specialty hospitals are limited.Methods: We used data reported to the Centers for Medicare and Medicaid Services (CMS) during 2005 to 2006 to compare the quality of care of specialty cardiac hospitals, competing general hospitals and a group of top-ranked cardiac hospitals as identified by the US News & World Report's list of "America's best cardiac hospitals" for acute myocardial infarction (AMI) and heart failure (HF). The main outcome was hospital compliance with CMS performance measures, expressed as the percentage of eligible patients with AMI or HF who received guidelines-based treatment.Results: The mean compliance for all 179 hospitals was 95% for AMI measures, 91% for HF measures, and 94% for all cardiac care (AMI plus HF measures). Specialty hospitals' compliance with AMI and HF guidelines (95.2% and 91.3%) was similar to that of competing general hospitals (94.7% and 90.5%), whereas top-ranked cardiac hospitals compliance with both AMI and CHF measures (96.8% and 94.1%) was higher (P < .001). In supplemental analyses, we found that 40% of specialty hospitals were ranked in the top quartile of all 179 hospitals, as compared with 22.9% of top-ranked cardiac hospitals. Conversely, 25% specialty hospitals were in the lowest quartile, as compared to 7% of top-ranked cardiac hospitals.Conclusions: Quality of care in specialty cardiac hospitals is similar to quality in competing general hospitals and top-ranked cardiac care hospitals, as measured by compliance with AMI and HF performance indicators. Quality of care appears to be slightly better for top-ranked cardiac hospitals as compared to general hospitals, but the overall performance of all hospitals is high. [ABSTRACT FROM AUTHOR]

Objectives: We sought to describe the rationale and methods for Door-to-Balloon (D2B): An Alliance for Quality, an international effort organized by the American College of Cardiology in partnership with the American Heart Association and 37 other organizations to rapidly translate research about how best to achieve outstanding D2B times for patients with ST-segment elevation myocardial infarction (STEMI) into practice. Background: The D2B time, the time between hospital arrival and primary percutaneous coronary intervention for patients with STEMI, is strongly associated with the likelihood of survival, yet the majority of patients are not treated within the guideline-recommended time of ≤90 min. Recent research has revealed key and underused strategies that are associated with achieving faster D2B times. Methods: The D2B Alliance has enrolled approximately 1,000 hospitals. Its goal is to achieve a D2B time of ≤90 min for at least 75% of non-transferred patients. The key strategies chosen by the D2B Alliance include having the emergency medicine physician activate the catheterization laboratory with a single call, having the team prepared within 20 to 30 min of the call; rapid data feedback; a team-based approach; and administrative support. The use of a pre-hospital electrocardiogram by emergency medical services personnel to activate the catheterization laboratory was also noted as an additional optional strategy. The project has many approaches to promote participation and adoption of effective strategies. An evaluation component is also described. Conclusions: The design of the D2B: An Alliance for Quality, a novel campaign to improve D2B time, is described. [Copyright &y& Elsevier]

Background: Appropriate utilization of acute reperfusion therapy is not a national performance measure for ST-elevation myocardial infarction at this time, and the extent of its contemporary use among ideal patients is unknown.Methods: From the National Registry of Myocardial Infarction, we identified 238,291 patients enrolled from June 1994 to May 2003 who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention. We determined rates of not receiving therapy across 3 time periods (June 1994-May 1997, June 1997-May 2000, June 2000-May 2003) and evaluated factors associated with underutilization.Results: The proportion of ideal patients not receiving acute reperfusion therapy decreased by one half throughout the past decade (time period 1: 20.6%; time period 2: 11.4%; time period 3: 11.6%; P <.001). Utilization remained significantly lower in key subgroups in the most recent time period: those without chest pain (odds ratio [OR] 0.29; 95% confidence interval [CI], 0.27-0.32); those presenting 6 to 12 hours after symptom onset (OR 0.57; 95% CI, 0.52-0.61); those 75 years or older (OR 0.63 compared with patients <55 years old; 95% CI, 0.58-0.68); women (OR 0.88; 95% CI, 0.84-0.93); and non-whites (OR 0.90; 95% CI, 0.83-0.97).Conclusions: Utilization of acute reperfusion therapy in ideal patients has improved over the last decade, but more than 10% remain untreated. Measuring and improving its use in this cohort represents an important opportunity to improve care. [ABSTRACT FROM AUTHOR]

Background: Individuals of low socioeconomic status (SES) have reduced access to coronary artery bypass graft surgery (CABG). It is unknown if low-SES CABG patients have reduced access to hospitals with better outcomes. Methods: We conducted a retrospective cohort analysis of the California CABG Mortality Reporting Program, consisting of individuals with zip code information who underwent CABG at participating hospitals in 1999-2000 (n = 18961). Primary outcome measures were inhospital mortality after CABG; primary independent variables of interest were area-level SES, clinical risk factors, and hospital volume. We used 2-level hierarchical random-effects logit models to estimate the relationship between explanatory variables and inhospital mortality. Results: Within high-volume hospitals, patients of low-SES areas had greater mortality than those of mid- and high-SES areas (2.5% vs 1.5% vs 1.8%, P = .024). However, there was no relationship between SES and mortality in lower-volume hospitals. Contrary to expectations, individuals of high-SES areas (42%) underwent surgery at low-volume hospitals more often than patients of low-SES areas (28%, P < .001), although mortality at low-volume hospitals was greater than that at high-volume facilities (P < .001). Discrepancies were not explained by distance traveled. Conclusions: Mortality after CABG is modified by both SES and hospital volume. Within high-volume hospitals, patients of low-SES areas fared worse than patients of higher-SES areas. Patients of high SES tended to have CABG surgery at low-volume hospitals where mortality was greater and therefore had higher mortality than expected. [Copyright &y& Elsevier]

Medical advances may be shifting patients with coronary artery disease away from the hospital setting despite an aging United States population. We explored this possibility using national inpatient data to estimate the number and population-based rates of hospitalization for acute myocardial infarction (AMI) and coronary revascularization from 2002 to 2005. Our primary data source was the Acute Care Tracker database, a proprietary administrative database that contains data on approximately 6 million discharges per year from 458 hospitals across the United States. Using the Acute Care Tracker database, we estimated the annual number and population-based rates of hospitalization for AMI (transmural, subendocardial) and coronary revascularization (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]). Hospitalizations for AMI steadily decreased from 661,000 to 591,000 per year between 2002 and 2005, primarily due to decreases in transmural AMI. Hospitalizations for coronary revascularizations during this period varied between 794,000 and 815,000 per year, with the number of PCIs increasing and the number of CABGs decreasing. In addition, rates of hospitalization for AMI decreased from 309 to 266 per 100,000 persons between 2002 and 2005, with rates of transmural AMI decreasing substantially from 118 to 87 per 100,000 persons. Rates of hospitalization for coronary revascularization also decreased from 382 to 358 per 100,000 during this period, primarily due to decreases in CABG. In conclusion, the number and rates of hospitalization for AMI and coronary revascularization in the United States are decreasing. [Copyright &y& Elsevier]

Many cardiovascular experts have called for the creation of specialized myocardial infarction centers and networks in the United States analogous to the current model for major trauma. Patients suffering ST-elevation myocardial infarction (STEMI) and trauma share an essential feature that makes the argument for regionalization persuasive: rapid triage and treatment by highly trained personnel improve survival in both conditions. Despite this similarity, however, the trauma system may be limited as a model for regionalizing STEMI care. First, the development of trauma systems has been hindered by the struggle for sufficient and stable funding, competing interests among individual stakeholders, and the overall lack of desire for state-sponsored healthcare planning in the United States. These same obstacles would need to be overcome if STEMI care is regionalized. Second, unique characteristics related to STEMI care, such as its varied clinical presentation and more lucrative reimbursement, will create new challenges. In this article, we briefly review the current status of trauma systems in the United States and describe why the regionalization of STEMI care may require different methods of healthcare organization. [Copyright &y& Elsevier]

Background Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule has the potential to affect data collection in outcomes research. Methods To examine the extent to which data collection may be affected by the HIPAA Privacy Rule, we used a quasi-experimental pretest-posttest study design to assess participation rates with informed consent in 2 cohorts of patients eligible for the University of Michigan Acute Coronary Syndrome registry. The pre-HIPAA period included telephone interviews conducted at 6 months that sought verbal informed consent from patients. In the post-HIPAA period, informed consent forms were mailed to ask for permission to call to conduct a telephone interview. The primary outcome measure was the percentage of patients who provided consent. Incremental costs associated with the post-HIPAA period were also assessed. Results The pre-HIPAA period included 1221 consecutive patients with acute coronary syndrome, and the post-HIPAA period included 967 patients. Consent for follow-up declined from 96.4% in the pre-HIPAA period to 34.0% in the post-HIPAA period (P<.01). In general, patients who returned written consent forms during the post-HIPAA period were older, were more likely to be married, and had lower mortality rates at 6 months. Incremental costs for complying with the HIPAA Privacy Rule were $8704.50 for the first year and $4558.50 annually thereafter. Conclusions The HIPAA Privacy Rule significantly decreases the number of patients available for outcomes research and introduces selection bias in data collection for patient registries. [ABSTRACT FROM AUTHOR]

Background: While the efficacy and safety of coronary artery bypass grafting (CABG) has been established in several clinical trials, little is known about its outcomes in Native Americans.Measurements and Main Results: We assessed clinical outcomes associated with CABG in 155 Native Americans using a national database of 18,061 patients from 25 nongovernmental, not-for-profit U.S. health care facilities. Patients were classified into five groups: 1) Native American, 2) white, 3) African American, 4) Hispanic, and 5) Asian. We evaluated for ethnic differences in in-hospital mortality and length of stay, and after adjusting for age, gender, surgical priority, case-mix severity, insurance status, and facility characteristics (volume, location, and teaching status). Overall, we found the adjusted risk for in-hospital death to be higher in Native Americans when compared to whites (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.5 to 9.8), African Americans (OR, 3.4; 95% CI, 1.1 to 9.9), Hispanics (OR, 7.1; 95% CI, 2.5 to 20.3), and Asians (OR, 2.8; 95% CI, 1.1 to 7.0). No significant differences were found in length of stay after adjustment across ethnic groups.Conclusions: The risk of in-hospital death following CABG may be higher in Native Americans than in other ethnic groups. Given the small number of Native Americans in the database (n = 155), however, further research will be needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Assesses the accuracy of electron-beam computed tomography (EBCT) in diagnosing obstructive coronary artery disease (CAD). Patient demographics; Pooled sensitivity rate for EBCT; False-positive and true-positive rates for EBCT; Limitations to use of EBCT.

The prevalence of coronary artery disease and ST-elevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention," by Thomas T. Tsai et al, as well as a response by the authors.

The author reflects on various clinical trials and studies on early invasive and selective invasive strategies for acute coronary syndrome (ACS) patients with routine cardiac catheterization. He muses on the systematic reviews and meta-analyses which resulted to disparity in findings and referrals for invasive strategies. The author stresses that both therapies are ideal for ACS patients but clinicians should consider patient preferences and tailor treatments to the patient's needs.

The article reports on the price regulation for coronary stents by the National Pharmaceutical and Pricing Authority (NPPA) in India. Topics mentioned include the price variation in coronary stents among hospitals in New Delhi, the price management for medical equipment, and the importance of coronary stents to control cardiovascular diseases.

Many patients undergo elective coronary angiography without preprocedural stress testing that may be suitable if performed in patients with more angina pectoris or more frequently identified obstructive coronary artery disease (CAD). Patients in the National Cardiovascular Data Registry CathPCI Registry undergoing elective coronary angiography from July 2009 to April 2013 were assessed for differences in angina (Canadian Cardiovascular Society [CCS] class) and severity of obstructive CAD in those with and without preprocedural stress testing, stratified by CAD history. Given the large sample size, differences were considered clinically meaningful if the standardized difference (SD) was >10%. Of 790,601 patients without CAD history, 36.9% did not undergo preprocedural stress testing. Compared with patients with preprocedural stress testing, patients without preprocedural stress testing were more frequently angina free (CCS class 0; 28.2% with stress test vs 38.5% without, SD = 14.8%) and had similar rates of obstructive CAD (40.1% with stress test vs 35.7% without, SD = 9.0). Of 449,579 patients with CAD history, 44.2% did not undergo preprocedural stress testing. Patients without preprocedural stress testing reported more angina (CCS class III/IV angina: 17.8% vs 13.4%; SD = 11.3%) but were not more likely to have obstructive CAD (78.7% vs 81.1%; SD = 5.8%) than patients with preprocedural stress testing. In conclusion, approximately 40% of patients undergoing elective coronary angiography did not have preprocedural risk stratification with stress testing. For these patients, the clinical decision to proceed directly to invasive evaluation was not driven primarily by severe angina and did not result in higher detection rates for obstructive CAD. [ABSTRACT FROM AUTHOR]

Current guidelines recommend patients with ST-elevation myocardial infarction receive primary percutaneous coronary intervention (PCI) within 90 minutes of admission, although there are conflicting data regarding the relation between time to treatment and mortality in these patients. We used logistic regression analyses employing a fractional polynomial model to evaluate the association between door-to-balloon time and 1-year mortality in patients with ST-elevation myocardial infarction ≥65 years old undergoing primary PCI from 1994 to 1996 (n = 1,932). Median door-to-balloon time was 128 minutes (interquartile range 92 to 178, 24.2% treated within 90 minutes). Overall 1-year mortality was 21.1%. Longer door-to-balloon times were associated with higher 1-year mortality in a continuous, nonlinear fashion (30 minutes 10.9%, 60 minutes 13.6%, 90 minutes 16.5%, 120 minutes 19.5%, 150 minutes 22.5%, 180 minutes 25.3%, 210 minutes 27.9%). The nature of the association between door-to-balloon time and 1-year mortality was best modeled by a second-degree fractional polynomial (p <0.001). Findings were similar after multivariable adjustment as any increase in door-to-balloon time was associated with successive increases in patients'' 1-year mortality (30 minutes 8.8%, 60 minutes 12.9%, 90 minutes 16.6%, 120 minutes 19.9%, 150 minutes 22.9%, 180 minutes 25.5%, 210 minutes 27.7%). In conclusion, any delay in primary PCI is associated with increased 1-year mortality, suggesting efforts should focus on decreasing time to treatment as much as possible, even among those centers currently providing primary PCI within 90 minutes. [Copyright &y& Elsevier]

Objectives: This study sought to examine whether rates of inappropriate percutaneous coronary intervention (PCI) differ by demographic characteristics and insurance status. Background: Prior studies have found that blacks, women, and those who have public or no health insurance are less likely to undergo PCI. Whether this reflects potential overuse in whites, men, and privately insured patients, in addition to underuse in disadvantaged populations, is unknown. Methods: Within the National Cardiovascular Data Registry CathPCI Registry, we identified 221,254 nonacute PCIs performed between July 2009 and March 2011. The appropriateness of PCI was determined using the Appropriate Use Criteria for coronary revascularization. Multivariable hierarchical regression was used to evaluate the association between patient demographics and insurance status and inappropriate PCI, as defined by the Appropriate Use Criteria. Results: Of 211,254 nonacute PCIs, 25,749 (12.2%) were classified as inappropriate. After multivariable adjustment, men (adjusted odd ratio [OR]: 1.08 [95% CI: 1.05 to 1.11]; p < 0.001) and whites (adjusted OR: 1.09 [95% CI: 1.05 to 1.14]; p < 0.001) were more likely to undergo an inappropriate PCI in comparison with women and nonwhites. Compared with privately insured patients, those who had Medicare (adjusted OR: 0.85 [95% CI: 0.83 to 0.88]), other public insurance (adjusted OR: 0.78 [95% CI: 0.73 to 0.83]), and no insurance (adjusted OR: 0.56 [95% CI: 0.50 to 0.61]) were less likely to undergo an inappropriate PCI (p < 0.001). In addition, compared with urban hospitals, those admitted at rural hospitals were less likely to undergo inappropriate PCI, whereas those at suburban hospitals were more likely. Conclusions: For nonacute indications, PCIs categorized as inappropriate were more commonly performed in men, whites, and those who had private insurance. Higher rates of PCI in these patient populations may, in part, be due to procedural overuse. [Copyright &y& Elsevier]

Fibrinolytic therapy is the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relation between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of a delay in door-to-needle time on mortality in a recent and representative cohort of patients with STEMI, a cohort of 62,470 patients with STEMI treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002 was analyzed. Hierarchical models were used to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% for ≤30 minutes, 4.1% for 31 to 45 minutes, and 6.2% for >45 minutes; p <0.001 for trend). Compared with those experiencing door-to-needle times ≤30 minutes, adjusted odd ratios (ORs) of dying were 1.17 (95% confidence interval [CI] 1.04 to 1.31) and 1.37 (95% CI 1.23 to 1.52; p for trend <0.001) for patients with door-to-needle times of 31 to 45 and >45 minutes, respectively. This relation was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time (OR 1.25, 95% CI 1.01 to 1.54; OR 1.54, 95% CI 1.27 to 1.87, respectively; p for trend <0.001). In conclusion, timely administration of fibrinolytic therapy continues to significantly impact on mortality in the modern era, particularly in patients presenting early after symptom onset. [Copyright &y& Elsevier]

Objectives: This study sought to assess whether implantable cardioverter-defibrillators (ICDs) have different mortality benefits among patients with ischemic cardiomyopathy who screen negative and non-negative (positive and indeterminate) for microvolt T-wave alternans (MTWA). Background: Microvolt T-wave alternans has been proposed as an effective tool for risk stratification. However, no studies have examined whether ICD benefits differ by MTWA group. Methods: We developed a prospective cohort of 768 patients with ischemic cardiomyopathy (left ventricular ejection fraction ≤35%) and no prior sustained ventricular arrhythmia, of which 392 (51%) received ICDs. The mean follow-up time was 27 ± 12 months. Propensity scores for ICD implantation based on the variables most likely to influence defibrillator implantation were developed for each MTWA cohort. Multivariable Cox analyses that controlled for propensity score, demographics, and clinical variables evaluated the degree to which ICDs decreased mortality risk for each MTWA group. Results: We identified 514 (67%) patients with a non-negative MTWA test result. After multivariable adjustment, ICDs were associated with lower all-cause mortality in MTWA-non-negative patients (hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.27 to 0.76, p = 0.003) but not in MTWA-negative patients (HR 0.85, 95% CI 0.33 to 2.20, p = 0.73) (for interaction, p = 0.04), with the mortality benefit in MTWA-non-negative patients largely mediated through arrhythmic mortality reduction (HR 0.30, 95% CI 0.13 to 0.68, p = 0.004). The number needed to treat with an ICD for 2 years to save 1 life was 9 among MTWA-non-negative patients and 76 among MTWA-negative patients. Conclusions: In patients with ischemic cardiomyopathy and no prior history of ventricular arrhythmia, mortality reduction with ICD implantation differs by MTWA status, with implications for risk stratification and health policy. [Copyright &y& Elsevier]

Objectives: The purpose of this study was to assess if microvolt T-wave alternans (MTWA) is an independent predictor of mortality in patients with ischemic cardiomyopathy. Background: Microvolt T-wave alternans has been proposed as an effective tool for identifying high-risk patients with ischemic cardiomyopathy who are likely to benefit from implantable cardioverter-defibrillator (ICD) therapy. However, earlier studies have been limited in their ability to control for baseline differences between MTWA-negative and -non-negative (positive and indeterminate) patients. Methods: We enrolled 768 consecutive patients with ischemic cardiomyopathy (left ventricular ejection fraction ≤35%) and no prior history of ventricular arrhythmia. All patients underwent baseline MTWA testing and were classified as MTWA negative or non-negative. Multivariable Cox regression analyses, stratified by ICD status, were used to determine the association between MTWA testing and mortality after adjusting for demographic, clinical, and treatment differences between MTWA-negative and -non-negative patients. Results: We identified 514 (67%) patients with a non-negative MTWA test. After multivariable adjustment, a non-negative MTWA test was associated with a significantly higher risk for all-cause (stratified hazard ratio [HR] = 2.24 [95% confidence interval 1.34 to 3.75]; p = 0.002) and arrhythmic mortality (stratified HR = 2.29 [1.00 to 5.24]; p = 0.049) but not for nonarrhythmic mortality (stratified HR = 1.77 [0.84 to 3.74]; p = 0.13). In subgroup analyses, a non-negative MTWA test was also associated with a higher risk for all-cause mortality in patients with ejection fractions ≤30% (stratified HR = 2.10 [1.18 to 3.73]; p = 0.01) and after excluding those with indeterminate MTWA tests (stratified HR = 2.08 [1.18 to 3.66]; p = 0.01). Conclusions: Microvolt T-wave alternans is a strong and independent predictor of all-cause and arrhythmic mortality in patients with ischemic cardiomyopathy. [Copyright &y& Elsevier]