An early invasive strategy versus ischemia-guided management after fibrinolytic therapy for ST-segment elevation myocardial infarction: a meta-analysis of contemporary randomized controlled trials

BACKGROUND

Although the use of an early invasive strategy among patients with ST-segment elevation myocardial infarctions (STEMI) who are treated initially with fibrinolytic therapy is common, the safety and efficacy of this approach remains uncertain. We performed a meta-analysis to best estimate the benefits and harms of an early invasive strategy in STEMI patients treated initially with full-dose intravenous fibrinolytic therapy, as compared to a traditional strategy of ischemia-guided management.

METHODS

We included contemporary randomized controlled trials, defined a priori as those with >50% stent use during percutaneous coronary intervention (PCI). Outcomes extracted from the published results of eligible trials included all-cause mortality, reinfarction, stroke, and in-hospital major bleeding.

RESULTS

We identified 5 contemporary trials enrolling 1,235 patients who met our inclusion criteria. Of the patients randomized to an early invasive strategy, 86% underwent PCI with 87% receiving stents. Follow-up duration ranged from 30 days to 1 year. An early invasive strategy was associated with significant reductions in mortality (odds ratio [OR] 0.55, 95% CI 0.34-0.90) and reinfarction (OR 0.53, 95% CI 0.33-0.86) compared with ischemia-guided management. There were no significant differences in the risk of stroke (OR 1.31, 95% CI 0.42-4.10) or major bleeding (OR 1.41, 95% CI 0.74-2.69).

CONCLUSIONS

An early invasive strategy after fibrinolytic therapy is associated with significant reductions in mortality and reinfarction. Our results suggest a potentially important role for this strategy in the management of STEMI patients but should be confirmed by large randomized trials.

Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go

AIM

Many patients who are eligible for acute reperfusion therapy receive it after substantial delays or not at all. We wanted to determine whether over the years more patients are receiving reperfusion therapy.

METHODS AND RESULTS

This analysis is based on 10 954 patients with ST elevation or left bundle-branch block presenting within 12 h of symptom onset and enrolled in the GRACE registry between April 1999 and June 2006. Over this time, there was an increasing trend in use of primary percutaneous coronary intervention (PCI) from 15% to 44% (P < 0.001), while use of fibrinolytic therapy decreased (from 41 to 16%; P < 0.01). No trend in median time to primary PCI was seen but that for fibrinolysis declined significantly (from 40 to 34%; P < 0.0001). Hospital mortality declined (6.9-5.4%; P < 0.01); the relationship between observed and expected mortality improved over time (P = 0.06). Nevertheless, 33% of patients still received no reperfusion therapy. Factors associated with reperfusion use included age; prior myocardial infarction, heart failure or coronary artery bypass graft surgery; history of diabetes; female sex; and delay from symptom onset to hospital arrival. In 2006, 52% of patients receiving fibrinolysis had door-to-needle times >30 min and 42% of those undergoing primary PCI had door-to-balloon times >90 min.

CONCLUSION

Primary PCI is now used much more than fibrinolysis. Although hospital mortality and delays to fibrinolytic reperfusion have improved, over 40% of patients reperfused still receive it outside the time window recommended, and one-third of potentially eligible patients receive no reperfusion.

The University of Michigan Specialist-Hospitalist Allied Research Program: jumpstarting hospital medicine research

BACKGROUND

Clinical research has developed slowly in most academic hospitalist programs, possibly because of a failure to recognize the important role of specialists in the diagnosis and management of complex medical patients as well as their expertise in clinical research. Ideally, a successful hospital-based clinical research program will need to partner hospitalists with specialists.

PURPOSE

The University of Michigan's Specialist-Hospitalist Allied Research Program (SHARP) was designed to jumpstart hospital-based clinical and translational research at a major academic medical center by pairing specialists and hospitalists to ask and answer novel research questions.

DESCRIPTION

SHARP is codirected by a hospitalist and a subspecialist and includes key personnel such as a hospitalist investigator, a clinical research nurse, a research associate, and a clinical epidemiologist. The program is guided by an oversight committee that includes institutional research leadership. Two initial projects have already been supported. The first, a collaboration between infectious disease specialists and hospitalists, is a prospective trial of antiseptic agents and techniques to reduce false-positive blood cultures. The second pairs geriatricians and clinical pharmacists with hospitalists to prospectively study techniques to reduce medication errors around the time of hospital discharge. Although initial pilot projects are single-institution studies, SHARP's goal is to expand its clinical research to include multicenter investigation. Metrics to evaluate SHARP include the number of successfully completed projects, extramural grants submitted and funded, and peer-reviewed publications.

CONCLUSION

A successful hospital-based clinical research program combines hospitalists and specialists in a collaborative environment to identify optimal strategies for delivering inpatient care.

Contemporary evidence: baseline data from the D2B Alliance

BACKGROUND

Less than half of U.S. hospitals meet guidelines for prompt treatment of ST-segment elevation myocardial infarction (STEMI). The Door-to-Balloon (D2B) Alliance is a collaborative effort of more than 900 hospitals committed to implementing a set of evidence-based strategies for reducing D2B time. This study presents data on (1) the prevalence of evidence-based strategies in U.S. hospitals that participated in the D2B Alliance and (2) identifies key hospital characteristics associated with their use.

METHODS

We conducted a cross-sectional study of U.S. hospitals that joined the D2B Alliance through a Web-based survey about their current practices for patients with STEMI who received primary percutaneous coronary intervention (PCI). We used multivariate logistic regression to identify hospital characteristics associated with use of each strategy.

RESULTS

Of the 915 U.S. hospitals enrolled in the D2B Alliance as of June 2007, 797 (87%) completed the survey. Only 30.4% of responding hospitals reported employing at least 4 of the 5 key strategies (emergency medicine activates catheterization laboratory, single-call activation, expectation that catheterization team is available in the laboratory within 20-30 minutes after page, prompt data feedback on D2B times, use of pre-hospital electrocardiograms to activate the laboratory while the patient is en route to the hospital); 9.3% employed none of the strategies. There was no clear pattern of correlation between hospital characteristics and reported strategies.

CONCLUSION

As of 2007, many hospitals had implemented few of the key strategies to reduce D2B time, suggesting substantial opportunity to improve care for patients with STEMI.

Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction

BACKGROUND

Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction.

METHODS

We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482,327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic.

RESULTS

The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P < .001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those < 70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P < .01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes).

CONCLUSIONS

Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.

Primary percutaneous coronary intervention expansion to hospitals without on-site cardiac surgery in Michigan: a geographic information systems analysis

BACKGROUND

In 2005, Michigan expanded primary percutaneous coronary intervention (P-PCI) capability to 12 hospitals without on-site cardiac surgery. We determined the potential impact of this expansion on geographic access to P-PCI for patients.

METHODS

Geographic information systems using the US Census Survey and hospital data from the state of Michigan were used to construct maps with 20-mile hospital service areas around P-PCI hospitals with and without on-site cardiac surgery. Geographic access was calculated as the percentage of the population living within the hospital service areas of these 2 types of hospitals.

RESULTS

Of 9,938,444 persons in Michigan, 7,694,834 (77.4%) lived within 20 miles of a P-PCI hospital. Thirty centers with on-site cardiac surgery provided access for 7,219,995 persons (72.6%). The 12 P-PCI hospitals without on-site cardiac surgery increased access by 474,839 persons (4.8%). Of these, 3 geographically isolated facilities, which were at least 20 miles away from another P-PCI hospital, accounted for the greatest improvement in geographic access (n = 425,700 [4.3%]), whereas the remaining 9 hospitals increased access by only 49,139 persons (0.5%).

CONCLUSIONS

Expansion of P-PCI to hospitals without on-site cardiac surgery in Michigan improved geographic access to a modest extent.

Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction

BACKGROUND

We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time.

METHODS

Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as < or =1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time.

RESULTS

In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting < or =1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively.

CONCLUSIONS

Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Delayed time to defibrillation after in-hospital cardiac arrest

BACKGROUND

Expert guidelines advocate defibrillation within 2 minutes after an in-hospital cardiac arrest caused by ventricular arrhythmia. However, empirical data on the prevalence of delayed defibrillation in the United States and its effect on survival are limited.

METHODS

We identified 6789 patients who had cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals participating in the National Registry of Cardiopulmonary Resuscitation. Using multivariable logistic regression, we identified characteristics associated with delayed defibrillation. We then examined the association between delayed defibrillation (more than 2 minutes) and survival to discharge after adjusting for differences in patient and hospital characteristics.

RESULTS

The overall median time to defibrillation was 1 minute (interquartile range, <1 to 3 minutes); delayed defibrillation occurred in 2045 patients (30.1%). Characteristics associated with delayed defibrillation included black race, noncardiac admitting diagnosis, and occurrence of cardiac arrest at a hospital with fewer than 250 beds, in an unmonitored hospital unit, and during after-hours periods (5 p.m. to 8 a.m. or weekends). Delayed defibrillation was associated with a significantly lower probability of surviving to hospital discharge (22.2%, vs. 39.3% when defibrillation was not delayed; adjusted odds ratio, 0.48; 95% confidence interval, 0.42 to 0.54; P<0.001). In addition, a graded association was seen between increasing time to defibrillation and lower rates of survival to hospital discharge for each minute of delay (P for trend <0.001).

CONCLUSIONS

Delayed defibrillation is common and is associated with lower rates of survival after in-hospital cardiac arrest.

Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis

AIMS

Clinical trials comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA) for patients with symptomatic carotid artery disease have produced conflicting results. We performed a meta-analysis to systematically evaluate currently available data by comparing CAS with CEA in patients with symptomatic carotid artery disease.

METHODS AND RESULTS

We searched MEDLINE, Embase, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts databases, the Cochrane Central Register of Controlled Trials, and scientific meeting abstracts up to 31 October 2006 and then calculated summary risk ratios (RRs) for mortality, stroke, disabling stroke, and death using random- and fixed-effect models. Data from five trials with 2122 patients were pooled. There was no difference in risk of 30-day mortality (summary RR 0.57, 95% CI 0.22-1.47, P = 0.25), stroke (summary RR 1.64, 95% CI 0.67-4.00, P = 0.34), disabling stroke (summary RR 1.67, 95% CI 0.50-5.62, P = 0.50), death and stroke (summary RR 1.54, 95% CI 0.81-2.92, P = 0.19), or death and disabling stroke (summary RR 1.19, 95% CI 0.57-2.51, P = 0.64) among patients randomized to CAS, compared with CEA.

CONCLUSIONS

No significant differences could be identified between CAS and CEA in the treatment of patients with symptomatic carotid artery disease. Larger randomized controlled trials are warranted to compare the two strategies.

Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction

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 < or =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 < or =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.

Cardiac Certificate of Need regulations and the availability and use of revascularization services

BACKGROUND

Many states enforce Certificate of Need (CON) regulations for cardiac procedures, but little is known about how CON affects utilization. We assessed the association between cardiac CON regulations, availability of revascularization facilities, and revascularization rates.

METHODS

We determined when state cardiac CON regulations were active and obtained data for Medicare beneficiaries > or = 65 years old who received coronary artery bypass graft surgery (CABG) or a percutaneous coronary intervention (PCI) between 1989 and 2002. We compared the number of hospitals performing revascularization and patient utilization in states with and without CON regulations, and in states which discontinued CON regulations during 1989 to 2002.

RESULTS

Each year, the per capita number of hospitals performing CABG and PCI was higher in states without CON (3.7 per 100,000 elderly for CABG, 4.5 for PCI in 2002), compared with CON states (2.5 for CABG, 3.0 for PCI in 2002). Multivariate regressions that adjusted for market and population characteristics found no difference in CABG utilization rates between states with and without CON (P = .7). However, CON was associated with 19.2% fewer PCIs per 1000 elderly (P = .01), equivalent to 322,526 fewer PCIs for 1989 to 2002. Among most states that discontinued CON, the number of hospitals performing PCI rose in the mid 1990s, but there were no consistent trends in the number of hospitals performing CABG or in PCIs or CABGs per capita.

CONCLUSIONS

Certificate of Need restricts the number of cardiac facilities, but its effect on utilization rates may vary by procedure.

Summary of evidence regarding hospital strategies to reduce door-to-balloon times for patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Despite the clinical importance of prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction, many hospitals do not routinely achieve the guideline-recommended 90-minute door-to-balloon times. In this review, we evaluate existing evidence that identifies effective hospital strategies for reducing door-to-balloon time. We performed a computerized search of MEDLINE and Current Contents for studies conducted in the last 10 years of hospital efforts to improve door-to-balloon times. We excluded studies that had <10 patients, had nonspecific efforts, or, for quantitative studies, lacked statistical tests; each study was independently evaluated by 3 researchers. We found 13 studies that examined the relationship between hospital-based strategies and door-to-balloon times. Three examined national samples of hospitals using cross-sectional designs; 8 were conducted in a single or small number of hospitals using pre/post interventional or cross-sectional designs, and 2 were qualitative in design. Strategies with the strongest evidence include (1) activation of the catheterization laboratory using emergency medicine physicians rather than cardiologists, (2) effective use of prehospital electrocardiograms, (3) performance data monitoring/feedback. Reasonable evidence exists for establishing a single-call system for activating the catheterization laboratory, setting the expectation that the catheterization team be available 20-30 minutes after being paged, and having an organizational environment with strong senior management support and culture to foster changes directed at improving door-to-balloon time. In conclusion, although evidence of "what works" is based on observational studies rather than randomized trials, there is evidence on effective interventions to reduce door-to-balloon time.

Area socioeconomic status and mortality after coronary artery bypass graft surgery: the role of hospital volume

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 = 18,961). 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.

Acute reperfusion therapy in ST-elevation myocardial infarction from 1994-2003

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.

Meta-analysis of randomized trials of drug-eluting stents versus bare metal stents in patients with diabetes mellitus

Diabetes mellitus is a major risk factor for restenosis in patients undergoing percutaneous coronary intervention. Randomized controlled trials comparing drug-eluting stents (DESs) with bare metal stents (BMSs) showed a marked decrease in in-stent restenosis and target lesion revascularization with DESs in the total patient population enrolled in the studies, including patients with diabetes. However, it remains unclear whether the antirestenotic benefit of DESs is preserved in the high-risk diabetic subgroup. MEDLINE, EMBASE, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts, and recent Scientific Sessions databases were searched to identify relevant clinical trials comparing DESs with BMSs. A randomized controlled trial was included if it provided outcome data for patients with diabetes for > or =1 of the following: late lumen loss, in-stent restenosis, or target lesion revascularization. Data were combined using fixed-effects models, and standard tests for heterogeneity were performed. Eight studies with 1,520 patients with diabetes were identified that reported > or =1 outcome of interest. Mean late lumen losses (7 studies) were 0.93 mm (95% confidence interval [CI] 0.510 to 1.348) with BMSs and 0.18 mm (95% CI -0.088 to +0.446) with DESs. For patients receiving a DES, this translated into a marked decrease in in-stent restenosis (7 studies, RR 0.14, 95% CI 0.10 to 0.22, p <0.001) and target lesion revascularization (8 studies, RR 0.34, 95% CI 0.26 to 0.45, p <0.001). DES use is associated with a marked decrease in in-stent restenosis and target lesion revascularization in patients with diabetes. In conclusion, the analysis supports the current widespread use of DESs in these high-risk patients.

Incremental benefit and cost-effectiveness of high-dose statin therapy in high-risk patients with coronary artery 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.

Vasodilator therapy in patients with aortic insufficiency: a systematic review

BACKGROUND

The use of vasodilators to improve long-term outcomes in asymptomatic patients with chronic aortic insufficiency (AI) is controversial.

METHODS

We reviewed MEDLINE, PREMEDLINE, Current Contents, and Cochrane databases to identify relevant clinical trials on asymptomatic patients with chronic AI of at least moderate severity. We included those studies that involved long-term vasodilator therapy (including hydralazine, calcium-channel blockers, and angiotensin-converting enzyme inhibitors) and assessed either hemodynamic and structural parameters or clinical outcomes. Data on patient demographics, study protocols, and outcomes were abstracted.

RESULTS

Ten studies with 544 asymptomatic patients with chronic AI were identified. Treatment duration with vasodilators ranged from 12 weeks to 7 years. Of these, 8 studies compared vasodilators with placebo or no therapy, with 5 demonstrating improvements in at least 1 hemodynamic or structural parameter with vasodilators and 3 showing little or no apparent benefit. The remaining 2 studies directly compared outcomes between 2 different vasodilators. Both of these studies demonstrated greater improvements in hemodynamic and structural parameters with angiotensin-converting enzyme inhibitors compared with hydralazine and nifedipine. Clinical outcomes were primarily reported in only 2 of the 10 studies. Although one study suggested that the use of vasodilators slowed the rate of progression to surgery for aortic valve replacement, another showed no difference.

CONCLUSIONS

Vasodilators inconsistently improve hemodynamic and structural parameters in asymptomatic patients with chronic AI. In addition, the impact of vasodilators on clinical outcomes is largely uncertain and requires further study.

Recent trends in hospital utilization for acute myocardial infarction and coronary revascularization in the United States

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.

Opening of specialty cardiac hospitals and use of coronary revascularization in medicare beneficiaries

CONTEXT

Although proponents argue that specialty cardiac hospitals provide high-quality cost-efficient care, strong financial incentives for physicians at these facilities could result in greater procedure utilization.

OBJECTIVE

To determine whether the opening of cardiac hospitals was associated with increasing population-based rates of coronary revascularization.

DESIGN, SETTING, AND PATIENTS

In a study of Medicare beneficiaries from 1995 through 2003, we calculated annual population-based rates for total revascularization (coronary artery bypass graft [CABG] plus percutaneous coronary intervention [PCI]), CABG, and PCI. Hospital referral regions (HRRs) were used to categorize health care markets into those where (1) cardiac hospitals opened (n = 13), (2) new cardiac programs opened at general hospitals (n = 142), and (3) no new programs opened (n = 151).

MAIN OUTCOME MEASURES

Rates of change in total revascularization, CABG, and PCI using multivariable linear regression models with generalized estimating equations.

RESULTS

Overall, rates of change for total revascularization were higher in HRRs after cardiac hospitals opened when compared with HRRs where new cardiac programs opened at general hospitals and HRRs with no new programs (P<.001 for both comparisons). Four years after their opening, the relative increase in adjusted rates was more than 2-fold higher in HRRs where cardiac hospitals opened (19.2% [95% confidence interval {CI}, 6.1%-32.2%], P<.001) when compared with HRRs where new cardiac programs opened at general hospitals (6.5% [95% CI, 3.2%-9.9%], P<.001) and HRRs with no new programs (7.4% [95% CI, 3.2%-11.5%], P<.001). These findings were consistent when rates for CABG and PCI were considered separately. For PCI, this growth appeared largely driven by increased utilization among patients without acute myocardial infarction (42.1% [95% CI, 21.4%-62.9%], P<.001).

CONCLUSION

The opening of a cardiac hospital within an HRR is associated with increasing population-based rates of coronary revascularization in Medicare beneficiaries.

Certificate of Need Regulation and Cardiac Catheterization Appropriateness After Acute Myocardial Infarction

BACKGROUND

Certificate of need (CON) regulation was introduced to control healthcare costs and improve quality of care in part by limiting the number of facilities providing complex medical care. Our objective was to examine whether rates of appropriate cardiac catheterization after admission for acute myocardial infarction varied between states with and without CON regulation of cardiac catheterization.

METHODS AND RESULTS

We performed a retrospective analysis of chart-abstracted data for 137,279 Medicare patients admitted for acute myocardial infarction between 1994 and 1996 at 4179 US acute-care hospitals. Using 3-level hierarchical generalized linear modeling adjusted for patient sociodemographic and clinical characteristics and physician and hospital characteristics, we compared catheterization rates within 60 days of admission for states (and the District of Columbia) with (n=32) and without (n=19) CON regulation in the full cohort and stratified by catheterization appropriateness. Appropriateness was categorized as strongly, equivocally, or weakly indicated. We found CON regulation was associated with a borderline-significant lower rate of catheterization overall (45.8% versus 46.5%; adjusted risk ratio [RR] 0.91, 95% confidence interval 0.82 to 1.00, P=0.06). After stratification by appropriateness, CON regulation was not associated with a significantly lower rate of catheterization among 63,823 patients with strong indications (49.9% versus 50.3%; adjusted RR 0.94, 95% confidence interval 0.86 to 1.02, P=0.17). However, CON regulation was associated with significantly lower rates of catheterization among 65,077 patients with equivocal indication (45.0% versus 46.0%; adjusted RR 0.88, 95% confidence interval 0.78 to 1.00, P=0.05) and among 8379 patients with weak indications (19.8% versus 21.8%; adjusted RR 0.84, 95% confidence interval 0.71 to 0.98, P=0.04). Associations were weakened substantially after adjustment for hospital coronary artery bypass graft surgery or cardiac catheterization capability.

CONCLUSIONS

CON regulation was associated with modestly lower rates of equivocally and weakly indicated cardiac catheterization after admission for acute myocardial infarction, but no significant differences existed in rates of strongly indicated catheterization.

Rescue Angioplasty or Repeat Fibrinolysis After Failed Fibrinolytic Therapy for ST-Segment Myocardial Infarction

OBJECTIVES

We sought to best estimate the benefits and risks associated with rescue percutaneous coronary intervention (PCI) and repeat fibrinolytic therapy as compared with conservative management in patients with failed fibrinolytic therapy for ST-segment myocardial infarction (STEMI).

BACKGROUND

Fibrinolytic therapy is the most common treatment for STEMI; however, the best therapy in patients who fail to achieve reperfusion after fibrinolytic therapy remains uncertain.

METHODS

We performed a meta-analysis of randomized trials using a fixed-effects model. We included 8 trials enrolling 1,177 patients with follow-up duration ranging from hospital discharge to 6 months.

RESULTS

Rescue PCI was associated with no significant reduction in all-cause mortality (relative risk [RR] 0.69; 95% confidence interval [CI] 0.46 to 1.05), but was associated with significant risk reductions in heart failure (RR 0.73; 95% CI 0.54 to 1.00) and reinfarction (RR 0.58; 95% CI 0.35 to 0.97) when compared with conservative treatment. Rescue PCI was associated with an increased risk of stroke (RR 4.98; 95% CI 1.10 to 22.5) and minor bleeding (RR 4.58; 95% CI 2.46 to 8.55). Repeat fibrinolytic therapy was not associated with significant improvements in all-cause mortality (RR 0.68; 95% CI 0.41 to 1.14) or reinfarction (RR 1.79; 95% CI 0.92 to 3.48), but was associated with an increased risk for minor bleeding (RR 1.84; 95% CI 1.06 to 3.18).

CONCLUSIONS

Rescue PCI is associated with improved clinical outcomes for STEMI patients after failed fibrinolytic therapy, but these benefits must be interpreted in the context of potential risks. On the other hand, repeat fibrinolytic therapy is not associated with significant clinical improvement and may be associated with increased harm.

Microvolt T-Wave Alternans Identifies Patients With Ischemic Cardiomyopathy Who Benefit From Implantable Cardioverter-Defibrillator Therapy

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 < or =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.

Allogeneic blood transfusions explain increased mortality in women after coronary artery bypass graft surgery

BACKGROUND

Postoperative mortality is greater in women than men after coronary artery bypass graft surgery. Because allogeneic blood transfusions are more common in women and have been associated with immunomodulation, the impact of transfusion on sex differences in infection and mortality was examined.

METHODS

A cohort study was conducted using Michigan Medicare beneficiaries who had undergone coronary artery bypass graft surgery. Information was used regarding allogeneic blood transfusion, infection, and mortality within the 100-day period after surgery.

RESULTS

Blood transfusions were more common in women than in men (88.2%, 95% CI 87.1%-89.2% vs 66.7%, 95% CI 65.5%-67.9%). Patients who received transfused blood were more likely to have an infection than patients who did not (14.6%, 95% CI 13.8%-15.5% vs 4.9%, 95% CI 4.1%-5.9%). There was a dose-response relationship between the number of units of whole blood or packed red cells received and the prevalence of infection (P = .035). The unadjusted risk of mortality attributable to female sex was 13.9% (95% CI 8.1%-19.6%), but was no longer statistically significant when adjusted for blood transfusion (population attributable risk 0.6%, 95% CI -6.0% to 6.6%). Patients who received a transfusion were 5.6 times as likely to die within 100 days after surgery as those who did not receive a transfusion (95% CI 3.7-8.6).

CONCLUSION

The increased risk of mortality in women after bypass surgery may be explained by transfusion-related immunosuppression.

Strategies for reducing the door-to-balloon time in acute myocardial infarction

BACKGROUND

Prompt reperfusion treatment is essential for patients who have myocardial infarction with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) during primary percutaneous coronary intervention should be 90 minutes or less. However, few hospitals meet this objective. We sought to identify hospital strategies that were significantly associated with a faster door-to-balloon time.

METHODS

We surveyed 365 hospitals to determine whether each of 28 specific strategies was in use. We used hierarchical generalized linear models and data on patients from the Centers for Medicare and Medicaid Services to determine the association between hospital strategies and the door-to-balloon time.

RESULTS

In multivariate analysis, six strategies were significantly associated with a faster door-to-balloon time. These strategies included having emergency medicine physicians activate the catheterization laboratory (mean reduction in door-to-balloon time, 8.2 minutes), having a single call to a central page operator activate the laboratory (13.8 minutes), having the emergency department activate the catheterization laboratory while the patient is en route to the hospital (15.4 minutes), expecting staff to arrive in the catheterization laboratory within 20 minutes after being paged (vs. >30 minutes) (19.3 minutes), having an attending cardiologist always on site (14.6 minutes), and having staff in the emergency department and the catheterization laboratory use real-time data feedback (8.6 minutes). Despite the effectiveness of these strategies, only a minority of hospitals surveyed were using them.

CONCLUSIONS

Several specific hospital strategies are associated with a significant reduction in the door-to-balloon time in the management of myocardial infarction with ST-segment elevation.

Hospital Delays in Reperfusion for ST-Elevation Myocardial Infarction

Background— It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.

Methods and Results— DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192 509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality ( P <0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.

Conclusions— As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.

Broken bodies, broken hearts? Limitations of the trauma system as a model for regionalizing care for ST-elevation myocardial infarction in the United States

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.

Hospital quality for acute myocardial infarction: correlation among process measures and relationship with short-term mortality

CONTEXT

The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes.

OBJECTIVE

To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates.

DESIGN, SETTING, AND PARTICIPANTS

We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data.

MAIN OUTCOME MEASURES

Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older.

RESULTS

We found moderately strong correlations (correlation coefficients > or =0.40; P values <.001) for all pairwise comparisons between beta-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.

CONCLUSIONS

The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.

Prognostic utility of microvolt T-wave alternans in risk stratification of patients with ischemic cardiomyopathy

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 < or =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 < or =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.

Contribution of infection to increased mortality in women after cardiac surgery

BACKGROUND

Women have higher mortality rates after coronary artery bypass graft (CABG) surgery compared with men. Explanations for this sex difference are controversial. The objective of this study was to assess whether infection contributes to the increased risk of mortality in women.

METHODS

We conducted a cohort study of 9218 Michigan Medicare beneficiaries hospitalized for CABG surgery. The prevalence of infection at any site during hospitalization was determined. Patients were followed up for 100 days after surgery to assess vital status. Analyses were conducted using proportional hazards regression and population attributable risk.

RESULTS

Women hospitalized for CABG surgery were more likely to have an infection than men (16.1% vs 9.8%, P<.001), regardless of age, race, type of admission, hospital volume, or presence of comorbidities. Infections of the respiratory tract, urinary tract, digestive tract, and skin and subcutaneous tissue were more common in women than in men. The risk of death in men increased 3-fold with infection, whereas the risk in women increased 1.8-fold. The interaction between infection and sex on mortality was significant after adjusting for age, type of admission, and presence of comorbidities (P = .008). The unadjusted percentage of deaths attributable to female sex was 13.9%, which decreased to 0.3% when adjusted for infection. Of the excess deaths in women, 96% could be accounted for by the differential distribution of infection between the sexes.

CONCLUSION

The increased risk of mortality after CABG surgery in women may be explained by underlying differences in the prevalence of infection among men and women.

Regionalization of ST-segment elevation acute coronary syndromes care: putting a national policy in proper perspective

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.

Driving Times and Distances to Hospitals With Percutaneous Coronary Intervention in the United States

Background— The success of prehospital triage protocols for patients with ST-elevation myocardial infarction (STEMI) will depend, in part, on how patients are geographically distributed around hospitals that perform percutaneous coronary intervention (PCI). Accordingly, we determined the proportion of the adult population in the United States with timely access to PCI hospitals using driving times and distances.

Methods and Results— We performed a cross-sectional study using hospital-level data from the American Hospital Association Annual Survey and Census tract-level data on adults 18 years of age or older from the 2000 United States Census. Our aims were to determine the proportion of the adult population who (1) lived within 60 minutes of a PCI hospital and (2) had additional transport times within 30 minutes if directly referred to a PCI hospital as opposed to a closer, non-PCI hospital. Median times and distances to the closest PCI hospital were 11.3 (interquartile range [IQR] 5.7 to 28.5) minutes and 7.9 (IQR 3.5 to 22.4) miles, respectively. A total of 79.0% of the adult population lived within 60 minutes of a PCI hospital. Among those with a non-PCI hospital as their closest facility, 74.0% required additional transport times of <30 minutes if directly referred to a PCI hospital as opposed to the non-PCI hospital. These estimates varied substantially across regions and urban, suburban, and rural Census tracts.

Conclusions— Nearly 80% of the adult population in the United States lived within 60 minutes of a PCI hospital in 2000. Even among those living closer to non-PCI hospitals, almost three fourths would experience <30 minutes of additional delay with direct referral to a PCI hospital, which suggests that such a strategy might be feasible for these individuals.

Relation Between Hospital Specialization With Primary Percutaneous Coronary Intervention and Clinical Outcomes in ST-Segment Elevation Myocardial Infarction

Background— Hospitals with primary percutaneous coronary intervention (PPCI) capability may choose to predominately offer PPCI to their patients with ST-segment elevation myocardial infarction (STEMI), or they may selectively offer PPCI or fibrinolytic therapy based on patient and hospital-level factors. Whether a greater level of hospital specialization with PPCI is associated with better quality of care is unknown.

Methods and Results— We analyzed data from the National Registry of Myocardial Infarction-4 to compare in-hospital mortality and times to treatment in STEMI across different levels of hospital specialization with PPCI. We divided 463 hospitals into quartiles of PPCI specialization based on the relative proportion of reperfusion-treated patients who underwent PPCI (≤34.0%, >34.0 to 62.5%, >62.5 to 88.5%, >88.5%). Hierarchical multivariable regression assessed whether PPCI specialization was associated with better outcomes, after adjusting for patient and hospital characteristics, including PPCI volume. We found that greater PPCI specialization was associated with a lower relative risk of in-hospital mortality in patients treated with PPCI (adjusted relative risk comparing the highest and lowest quartiles, 0.64; P =0.006) but not in those treated with fibrinolytic therapy. Compared with patients at hospitals in the lowest quartile of PPCI specialization, adjusted door-to-balloon times in the highest quartile were significantly shorter (99.6 versus 118.3 minutes; P <0.001), and the likelihood of door-to-balloon times exceeding 90 minutes was significantly lower (relative risk, 0.78; P <0.001). Adjusting for PPCI specialization diminished the association between PPCI volume and clinical outcomes.

Conclusions— Greater specialization with PPCI is associated with lower in-hospital mortality and shorter door-to-balloon times in STEMI patients treated with PPCI.

Effect of statin use in patients with acute coronary syndromes and a serum low-density lipoprotein<or=80 mg/dl

We identified 155 patients who were admitted with an acute coronary syndrome and a low-density lipoprotein cholesterol level<or=80 mg/dl and were not on statin therapy at hospital admission. The relation between statin therapy at discharge and clinical outcome was evaluated in these patients. Compared with patients who were not discharged on statins, those who were had a lower incidence of death, reinfarction, or stroke at 6 months (29.0% vs 9.5%, p=0.005). These results suggest that patients who have an acute coronary syndrome and a low-density lipoprotein cholesterol level<or=80 mg/dl in the absence of statin therapy may benefit from such therapy at discharge.

Skilled care requirements for elderly patients after coronary artery bypass grafting

OBJECTIVES

To examine the extent to which elderly individuals use various skilled care facilities after coronary artery bypass grafting (CABG).

DESIGN

Retrospective cohort study.

SETTING

State of Michigan from 1997 to 1998.

PARTICIPANTS

Residents aged 65 and older enrolled in Medicare who underwent CABG.

MEASUREMENTS

Cumulative incidence of admission within 100 days of hospital discharge, relative risk (RR) of admission, readmission or extended stay at a skilled care facility, and length of stay in a skilled care facility.

RESULTS

Fifty percent of patients aged 80 and older used a skilled care facility after CABG, with most requiring admission to a skilled nursing facility (SNF) or readmission to an acute-care hospital within 100 days after discharge. Patients aged 80 and older had a significantly higher risk of admission to a SNF (adjusted RR=3.3, 95% confidence interval (CI)=2.8-4.0) than did those aged 65 to 69, as did patients aged 75 to 79 (adjusted RR=2.2, 95% CI=1.8-2.6) and those aged 70 to 74 (adjusted RR=1.5, 95% CI=1.3-1.8). The length of time spent in skilled care facilities significantly increased with age (mean days=13.3 for aged 65-69, 16.9 for 70-74, 19.6 for 75-79, and 22.9 for 80 and older; P<.001).

CONCLUSION

Older patients are more likely to be admitted to a SNF, be readmitted to an acute-care hospital, and have longer institutional stays after CABG. When balancing the risks and benefits of CABG, physicians, patients, families, and policy-makers need to carefully consider the likelihood of follow-up institutional care in elderly patients.

Potential impact of the HIPAA privacy rule on data collection in a registry of patients with acute coronary syndrome

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.

Development of a multicenter peripheral arterial interventional database: the PVD-QI2

BACKGROUND

The number of peripheral vascular intervention (PVI) procedures performed is steadily increasing in the United States. PVD-QI 2 is a prospective, multicenter observational study designed to improve the quality of care for patients undergoing PVI and to better understand the effectiveness and appropriateness of PVI in improving outcomes of peripheral arterial disease. The registry aims to elucidate which comorbid conditions and procedure-related variables are associated with beneficial or adverse outcomes after vascular interventions.

METHODS

Five centers are currently prospectively collecting data on consecutive PVIs performed at their institutions and will include patients with both claudication and critical limb ischemia. A common data collection form and a standard set of definitions were developed during several planning meetings. Information on patient demographics, clinical history, comorbid conditions, treatment approaches, and in hospital outcomes are being collected. Patients will be followed up at 30 days, 6 months, and 1 year after each procedure to identify recurrent vascular events, medication use, lifestyle modifications (regular exercise, dietary modification), self-reported walking scores, and mortality. Data validity will be assured through review of data form accuracy by a trained nurse, by automatic database diagnostic routines, and by site visits that include review of angiography suite logs and randomly selected charts.

CONCLUSIONS

The development of a quality-controlled PVI registry requires the commitment and collaboration of clinician-investigators and hospital systems devoted to understanding factors that contribute to quality outcomes. Central to achievement of this goal is the creation of a careful diagnostic and data quality assessment system. This registry will provide important clinical insights into patient demographic and clinical characteristics, procedural characteristics, and current practice patterns that foster or impede achievement of long-term quality-based clinical outcomes for patients with peripheral arterial disease.