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Background: Cardiac catheterization (CC) is a frequently performed procedure in US with over 1,000,000 procedures performed annually. Prior studies have demonstrated an inverse relationship between annual volume and complications with centers performing greater than 400 procedures annually having fewer complications. However, there has not been any investigation into the optimal daily volume of procedures to ensure the lowest risk. The objective of this study is to determine the relationship between daily volume and complication rates and to identify an optimal volume of procedures per day. Methods: We used data captured retrospectively from the NCDR and Lumedx© database of adult patients undergoing non-emergent CC at a high-volume (>400 procedures/year) tertiary care hospital catheterization laboratory from January 2005 - June 2013. We excluded patients undergoing CC on weekends and after business hours. In the event of multiple CC, only the first event was utilized for this analysis. Complications examined included: death, post-procedure MI, cardiogenic shock, heart failure, stroke, tamponade, major bleeding, hematoma or acute kidney injury as defined by the NCDR database. We analyzed the relationship between the volume of CC conducted per day and rates of complications. Results: Overall, 13,819 patients were included who underwent 18,287 CCs on 2,150 days. The average age was 63 years (SD 12.5; range 18-95) and 61% (8,430/13,819) were men. A total of 396 complications occurred in 305 patients on 292 separate days with a 2.2% (396/18,287) CC complication rate. The average volume per day was 8.5 CCs. On the days with a complication, the median procedural volume was 10 CCs compared to 8 CCs on days without a complication (p<0.01). We found a low correlation between the rates of complication and CC volume (Spearman's rho=0.12; p<0.01). There was a U-shaped relationship with a higher complication rates on days with 1-5 CC and days with > 12 CC. Overall, the lowest complication rates were observed on days with 10-12 events. Conclusions: There is a U-shaped association between CC volume and rates of CC related complications. Unlike prior studies which identified high annual volumes were associated with lower complication rate, our study results suggests that this relationship does not hold true for daily volume. There appears to be a daily limit at which complication rates begin to rise in proportion to volume. Higher complication rates were seen on days with very low CC volume (<5 procedures) and days with very high CC volume (>12 procedures). It is important that individual high volume CC labs consider a quality control analysis of their daily CC volume to determine the optimal volume associated with the fewest complications. [ABSTRACT FROM AUTHOR]

Although rare, severe hypercalcemia can cause significant conduction system alterations, including complete atrioventricular block., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Current guidelines recommend triple antithrombotic therapy (TT) consisting of warfarin, aspirin, and a P2Y12 inhibitor following an anterior ST elevation myocardial infarction (STEMI) complicated by extensive wall motion abnormalities. This recommendation, however, is based on data collected before percutaneous coronary intervention (PCI) became the standard of care for the treatment of STEMI. We designed a retrospective study of patients who received PCI for anterior STEMI over an 8-year period to compare rates of thromboembolic and bleeding events between patients receiving dual antiplatelet therapy (DAPT) and those receiving TT, including warfarin. Patients were included if the predischarge echocardiogram showed extensive wall motion abnormality and an ejection fraction ≤35%. Patients with known left ventricular thrombus were excluded. A total of 124 patients met the criteria, with 80 patients in the DAPT group and 44 in the TT group. The median age was 58 years in the TT group and 64 years in the DAPT group (P < 0.04), with an average ejection fraction of 31%. Thromboembolic events occurred in 4 patients (5%) in the DAPT group compared with 3 patients (6.8%) in the TT group (P = 0.70). Bleeding occurred in 2 patients in the DAPT group and 4 patients in the TT group (2.5% in DAPT vs. 9.1% in TT group, P = 0.18). No differences in rates of clinical embolism or left ventricular thrombus were found. Our data support recent findings that warfarin may not be indicated for patients following PCI for anterior STEMI, even when significant wall motion abnormalities and reduced ejection fraction ≤35% are present.