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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]