Economic and clinical outcomes of a physician-led continuous quality improvement intervention in the delivery of percutaneous coronary intervention

OBJECTIVE

To compare clinical and economic outcomes associated with percutaneous coronary intervention (PCI) in cohorts before and after continuous quality improvement (CQI) was instituted.

STUDY DESIGN

Observational study.

METHODS

Clinical, angiographic, procedural, and outcome data on 1441 pre-CQI and 1760 post-CQI PCIs (performed in 1997 and 1998, respectively) were derived from an institutional PCI registry. Administrative data were used to estimate total procedural and postprocedural costs and length of stay (LOS). Logistic and generalized linear modeling was used to adjust in-hospital clinical and economic outcomes, respectively, for differences in patient characteristics.

RESULTS

The 2 cohorts were similar in terms of age, sex, and rate of diabetes. Post-CQI patients more often received intracoronary stents, had urgent PCIs, had a history of prior PCI, and received glycoprotein IIb/IIIa inhibitors. Procedural success without in-hospital complications occurred in 90% of both cohorts and did not differ statistically in adjusted analyses. Compared with patients treated pre-CQI, those treated post-CQI had a reduced adjusted odds ratio for in-hospital death or any myocardial infarction (odds ratio = 0.66; 95% confidence interval = 0.46, 0.95). Models predicted a mean postprocedural LOS difference of 0.8 days (2.8 days pre-CQI vs 2.0 days post-CQI; P <.001) and an average post-CQI cost savings of $5430 (P <.001).

CONCLUSION

Physician-led, multidisciplinary practice management efforts were successful at significantly reducing PCI-related costs in an era of rapid technological advances while maintaining and perhaps improving quality of care.

Implementation of a continuous quality improvement program for percutaneous coronary intervention and cardiac surgery at a large community hospital

BACKGROUND

Continuous quality improvement (CQI) is widely used in other industries and has been promoted as a method for quality control in medicine. The national databases developed by the American College of Cardiology and the Society of Thoracic Surgeons have greatly facilitated data collection for CQI. Hospitals can encounter barriers to CQI, however, which include creating the proper organizational infrastructure and engaging physicians and hospital administrators in the process. These barriers are particularly evident in large community hospitals.

METHODS

We describe the organizational infrastructure for CQI, including committee structure, methods of repeated data collection and feedback, and maintenance of data integrity and confidentiality. We report demographic data and clinical outcomes for patients undergoing percutaneous coronary intervention and coronary artery bypass surgery before and after implementation of our CQI program.

RESULTS

Since 1995, we have maintained a CQI process driven by repeated collection of valid, confidential, operator-specific data. We have observed sustained physician and administration participation and buy-in. During the follow-up period, patient complexity increased and observed outcomes improved, although the improvement was clearly multifactorial.

CONCLUSIONS

We describe the organization of a CQI program at a large complex community hospital. Our CQI program was successfully implemented, has been sustained, and is associated in observed improvement in patient outcomes. The program described here may be a useful model for other similar hospitals that are attempting to create a program to address quality improvement.

Kodak EDR2 film for patient skin dose assessment in cardiac catheterization procedures

Patient skin doses were measured using Kodak EDR2 film for 20 coronary angiography (CA) and 32 percutaneous transluminal coronary angioplasty (PTCA) procedures. For CA, all skin doses were well below 1 Gy. However, 23% of PTCA patients received skin doses of 1 Gy or more. Dose-area product (DAP) was also recorded and was found to be an inadequate indicator of maximum skin dose. Practical compliance with ICRP recommendations requires a robust method for skin dosimetry that is more accurate than DAP and is applicable over a wider dose range than EDR2 film.

Implementation of Guidelines Improves the Standard of Care

Background— The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area.

Methods and Results— We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours’ duration.

Conclusions— Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.

[Treatment of ST segment elevation myocardial infarctions according to the guidelines]

The guidelines "Akutes Koronarsyndrom" published by the German Society of Cardiology, "Management of acute myocardial infarction in patients presenting with ST-segment elevation", and "Guidelines for percutaneous coronary interventions" published by the European Society of Cardiology evaluate diagnostic tools and treatment strategies for ST segment elevation myocardial infarctions. These guidelines offer evidence-based recommendations and allow a standardized therapeutic approach thereby improving the patient's treatment and reducing the mortality. The optimal care for patients presenting with ST segment elevation myocardial infarctions consists of a prehospital phase where an immediate diagnosis should be reached by means of a twelve-channel ECG followed by basic medical treatment with administration of acetylsalicylic acid, heparin, beta-blocker, and nitrates by an emergency physician. The hospital phase can be optimized by integrated myocardial infarction networks with coronary care units offering primary percutaneous coronary interventions (PCIs) and adjuvant medical treatment including the administration of glycoprotein IIb/IIIa inhibitors. If the onset of symptoms is < 3 h and the transportation time to a coronary care unit > 90 min, the indication of primary fibrinolysis should be given by the emergency physician. If fibrinolysis fails, there is a clear indication for rescue PCI. Even with successful thrombolysis PCI should be performed within 24 h. A dual oral antithrombotic therapy starting immediately after diagnosis with a loading dose of 600 mg clopidogrel should be continued with 75 mg/d clopidogrel for 9-12 months on top of 100 mg/d acetylsalicylic acid.

[Comparative analysis of intimal hyperplasia after sirolimus-eluting stent and thin-strut bare-metal stent implantation in small coronary arteries]

OBJECTIVE

This study aimed at evaluating reduction in intimal hyperplasia volume following angioplasty using sirolimus-eluting stents (Cypher) compared with thin-strut bare-metal stents (Pixel) in patients with small vessels.

METHODS

Eighty patients with coronary artery disease were prospectively included in two consecutive series, the first using sirolimus-eluting stents (50) and the second using bare-metal stents (30).

RESULTS

The use of sirolimus-eluting stents reduced: in-stent net volume obstruction [5.0% (SE = 0.77) x 39.0% (SE = 4.72), p < 0.001], in-stent late loss [0.25 mm (SE = 0.03) x 1,11 mm (SE = 0.13), p < 0.001], in-segment late loss [0.30 mm (SE = 0.04) x 0.83 mm (SE = 0.11), p < 0.001], in-stent restenosis (0% x 33.3%, p < 0.001) and in-segment restenosis (4% x 36.7%, p < 0.001). The event-free survival rate was 96% in the sirolimus-eluting stent group versus 86.7% in the bare-metal stent group (BMS) (p = 0.190).

CONCLUSION

Sirolimus-eluting stents are superior to thin-strut bare-metal stents in reducing intimal hyperplasia (less in-stent obstruction and less late lumen loss) in patients with small vessels. The use of these stents significantly reduced angiographic restenosis at eight months.

Same-day transfer of patients with unstable angina and non-ST segment elevation myocardial infarction back to their referring hospital after angioplasty

BACKGROUND

Recent evidence has shown the advantages of an early invasive strategy for patients with high-risk unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). However, the number of beds available for postangioplasty monitoring limits the use of this approach at the Centre hospitalier universitaire de Sherbrooke (Fleurimont, Quebec).

OBJECTIVES

To study the safety of a protocol allowing the same-day return of patients with UA or NSTEMI to their referring hospital after angioplasty at the Centre hospitalier universitaire de Sherbrooke.

METHODS

From June 2001 to June 2003, of the 532 patients with UA and NSTEMI who underwent percutaneous coronary intervention with planned same-day transfer back to their referring hospital, 419 consecutive patients who were eligible to return the same day were prospectively followed for 24 h.

RESULTS

Stents were used in 94.7% of patients and platelet glycoprotein IIb/IIIa receptor antagonists were used in 34.8% of patients. For 85% of patients, the femoral artery was used as the access route for percutaneous coronary intervention. The mean time that patients stayed in the hospital after angioplasty before returning to their referring centres was 4.4 h. No deaths, life-threatening arrhythmias or urgent revascularizations were reported during the 24 h postangioplasty follow-up period, but one patient had a major bleeding complication. During the study period, the mean angioplasty waiting time decreased from 5.7 days to 2.1 days.

CONCLUSIONS

The protocol evaluated in the present article is safe. It frees more beds, thus reducing the waiting list and allowing patients with high-risk acute coronary syndromes without ST segment elevation from community hospitals to benefit from the advantages of an early invasive strategy.

Do operator volumes relate to clinical outcomes after percutaneous coronary intervention in the Canadian health care system?

BACKGROUND

Many US studies have documented an association between operator volume and outcomes after percutaneous coronary intervention (PCI). No study has assessed whether this relationship exists in Canada, where PCI is performed only at a limited number of regional centers and operator volumes are higher.

METHODS

All PCI procedures performed in the province of Ontario from 1995 to 2001 were analyzed using administrative databases. The outcomes of interest were coronary artery bypass graft during the same hospitalization, mortality at 30 days, or the combined end point.

RESULTS

A total of 38,561 PCI procedures were performed by 65 physicians at 8 centers. Over the study period, risk-adjusted coronary artery bypass graft rates fell from 2.0% in 1995 to 0.7% in 2000 (P < .0001) with no change in mortality. The median annual PCI volume was 132 (25th, 75th percentile: 81, 182) cases. After stratifying operators by average annual PCI volume into low (< 155 cases), intermediate (155-195 cases), and high (> 195 cases) volume, there were no significant linear relationships between risk-adjusted outcomes and operator terciles. No significant correlations were seen between individual PCI volume and risk-adjusted rates of mortality, bypass surgery, or the combined end point (P = .2, P = .35, and P = .95, respectively).

CONCLUSIONS

In contrast to US studies, there does not appear to be an association between PCI volume and outcomes in Ontario. These findings may be related to the high annual volumes of most operators and institutions within Ontario.

Achieving Rapid Door-To-Balloon Times

BACKGROUND

Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999-2002.

METHODS AND RESULTS

We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of < or =90 minutes during 2001-2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals' experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts.

CONCLUSIONS

Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.

Association of a Continuous Quality Improvement Initiative With Practice and Outcome Variations of Contemporary Percutaneous Coronary Interventions

BACKGROUND

The objective of this study was to evaluate the association of a continuous quality improvement program with practice and outcome variations of percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Data on consecutive PCI were collected in a consortium of 5 hospitals; 3731 PCIs reflected care provided at baseline (January 1, 1998, to December 31, 1998), and 5901 PCIs reflected care provided after implementation of a continuous quality improvement intervention (January 1, 2002, to December 31, 2002). The intervention included feedback on outcomes, working group meetings, site visits, selection of quality indicators, and use of bedside tools for quality improvement and risk assessment. Postintervention data were compared with baseline and with 10,287 PCIs from 7 hospitals added to the consortium in 2002. Quality indicators included use of preprocedural aspirin or clopidogrel, use of glycoprotein IIb/IIIa receptor blockers and postprocedural heparin, and amount of contrast media per case. Outcomes selected included emergency CABG, contrast nephropathy, myocardial infarction, stroke, transfusion, and in-hospital death. Compared with baseline and the control group, the intervention group at follow-up had higher use of preprocedural aspirin and glycoprotein IIb/IIIa blockers, lower use of postprocedural heparin, and a lower amount of contrast media per case (P<0.05). These changes were associated with lower rates of transfusions, vascular complications, contrast nephropathy, stroke, transient ischemic attack, and combined end points (all P<0.05).

CONCLUSIONS

Our nonrandomized, observational data suggest that implementation of a regional continuous quality improvement program appears to be associated with enhanced adherence to quality indicators and improved outcomes of PCI. A randomized clinical trial is needed to determine whether this is a "causal" or a "casual" relationship.

Patients enrolled in coronary intervention trials are not representative of patients in clinical practice: results from the Euro Heart Survey on Coronary Revascularization

AIMS

Revascularization in patients with coronary artery disease changed over the last two decades, favouring the number of patients treated by means of percutaneous coronary interventions (PCI) when compared with coronary artery bypass grafting (CABG). Many randomized controlled trials (RCTs) have been performed to compare these two competing revascularization techniques. Because of the strict enrolment criteria of RCTs in which highly selected patients are recruited, the applicability of the results may be limited in clinical practice. The current study evaluates to what extent patients in clinical practice were similar to those who participated in RCTs comparing PCI with CABG.

METHODS AND RESULTS

Clinical characteristics and 1-year outcome of 4713 patients enrolled in the Euro Heart Survey on Coronary Revascularization were compared with 8647 patients who participated in 14 major RCTs, comparing PCI with CABG. In addition, we analysed which proportion of survey patients would have disqualified for trial participation (n=3033, 64%), aiming at identifying differences between trial-eligible and trial-ineligible survey patients. In general, important differences were observed between trial participants and survey patients. Patients in clinical practice were older, more often had comorbid conditions, single-vessel disease, and left main stem stenosis when compared with trial participants. Almost identical differences were observed between trial-eligible and trial-ineligible survey patients. In clinical practice, PCI was the treatment of choice, even in patients who were trial-ineligible (46% PCI, 26% CABG, 28% medical). PCI remained the preferred treatment option in patients with multi-vessel disease (57% in trial-eligible and 40% in trial-ineligible patients, respectively, P<0.001); yet, the risk profile of patients treated by PCI was better than that for patients treated either by CABG or by medical therapy. In the RCTs, there was no mortality difference between PCI and CABG. In clinical practice, however, we observed 1-year unadjusted survival benefit for PCI vs. CABG (2.9 vs. 5.4%, P<0.001). Survival benefit was only observed in trial-ineligible patients (3.3 vs. 6.2%, P<0.001).

CONCLUSION

Many patients in clinical practice were not represented in RCTs. Moreover, only 36% of these patients were considered eligible for participating in a trial comparing PCI with CABG. We demonstrated that RCTs included younger patients with a better cardiovascular risk profile when compared with patients in everyday clinical practice. This study highlights the disparity between patients in clinical practice and patients in whom the studies that provide the evidence for treatment guidelines are performed.

Percutaneous coronary intervention: recommendations for good practice and training

Cardiologists undertaking percutaneous coronary intervention (PCI) are excited by the combination of patient and physician satisfaction and technological advance occurring on the background of the necessary manual dexterity. Progress and applicability of percutaneous techniques since their inception in 1977 have been remarkable; a sound evidence base coupled with the enthusiasm and ingenuity of the medical device industry has resulted in a sea change in the treatment of coronary heart disease (CHD), which continues to evolve at breakneck speed. This is the third set of guidelines produced by the British Cardiovascular Intervention Society and the British Cardiac Society. Following the last set of guidelines published in 2000, we have seen PCI activity in the UK increase from 33,652 to 62,780 (87% in four years) such that the PCI to coronary artery bypass grafting ratio has increased to 2.5:1. The impact of drug eluting stents has been profound, and the Department of Health is investigating the feasibility of primary PCI for acute myocardial infarction. Nevertheless, the changes in the structure of National Health Service funding are likely to focus our attention on cost effective treatments and will require physician engagement and sensitive handling if we are to continue the rapid and appropriate growth in our chosen field. It is important with this burgeoning development now occurring on a broad front (in both regional centres and district general hospitals) that we maintain our vigilance on audit and outcome measures so that standards are maintained for both operators and institutions alike. This set of guidelines includes new sections on training, informed consent, and a core evidence base, which we hope you will find useful and informative.

[From the single vulnerable plaque, to the multiple complex coronary plaques. From their basis, to the modern therapeutic approach. A clinical reality in the spectrum of the acute coronary syndromes]

Contemporary clinical and laboratory data have challenged our classical concepts of the pathogenesis of the acute coronary syndromes [ACS]. Indeed, several independent lines of clinical evidence have supported that the critical stenoses cause only a fraction of the ACS. Acute myocardial infarction is believed to be caused by rupture of a vulnerable coronary-artery plaque that appears as a single lesion on angiography. However, plaque instability might be caused by pathophysiologic processes, such as inflammation, that exert adverse effects throughout the coronary vasculature and therefore result in multiple unstable lesions. Recent studies have demonstrated that ruptured or vulnerable plaques exist not only at the culprit lesion but also in the whole coronary artery in some ACS patients. It has also been reported that a ruptured plaque at the culprit lesion is associated with elevated C- reactive protein and other inflammatory markers, which indeed indicate a poor prognosis in patients with ACS. Also, multiple plaque rupture is associated with systemic inflammation, and patients with multiple plaque rupture can be expected to show a poor prognosis. Therefore some ACS patients [20-40%] may harbor multiple complex coronary plaques that are associated with adverse clinical outcomes. It should be accepted that this ACS population represent a part of the spectrum of the ACS, and in particular in this group of patients treatment should focus not only on the stabilization of the culprit site but also warrants a broader approach to systemic stabilization of the arteries. However, recurrent cardiovascular events in this population still remain unacceptably high, indicating that plaque rupture or vulnerability of multiple plaques is a current challenge in the management of ACS patients.

Improving systems of care in primary angioplasty

AMI is a life-threatening condition. Poor performance on the part of caregivers can result in the death of a patient. It is critical that a PPCI capability be developed in such a way that error is minimized. It is not enough that the system works well or very well. Aviation is often used as the example that medical systems should emulate. In developing the many interrelated systems required to function properly to ensure safe, effective,prompt, and appropriate application of PPCI,an aviation parallel should be kept in mind. If you were walking on the jetway toward a plane and were greeted by the pilot who said to you, "You know, I can land this thing 99% of the time," you would never get on that plane. It is important to develop a PPCI system that is absolutely never the cause of harm to any patient. Doing so requires exquisite attention to detail, algorithms of care when possible, redundancy, and clear orders for all drugs and procedures.

The lack of a simple relation between physician's percutaneous coronary intervention volume and outcomes in the era of coronary stenting: a two-centre experience

The 2001 ACC/AHA guidelines recommend that percutaneous coronary intervention (PCI) operators perform at least 75 procedures per year to maintain their competency. We performed a post hoc analysis of prospectively gathered PCI data, in the current era of ubiquitous stent use, at two tertiary cardiac care centres. Operators were assigned to a low (<50 cases per year), intermediate (50-74 cases per year) or high volume (>or=75 cases per year) group. Complications evaluated were death, myocardial infarction, coronary perforation, emergent coronary artery bypass surgery and pericardial tamponade. Between 2000 and 2002, 51 operators performed 6,510 PCIs. Stents were used in 79% of cases. Major complications occurred in 0.45% (7/1,572 cases) for the low-volume group, 1.1% in the intermediate-volume group (16/1,438 cases) and 0.86% (30/3,500 cases) for the high-volume group. After adjusting for baseline factors, low- and intermediate-volume operators were not significantly associated with major complications. This study questions the relationship between operator volume and PCI complications in the current era.

Implementation of reperfusion therapy in acute myocardial infarction. A policy statement from the European Society of Cardiology

Reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) is the most important component of treatment, as it strongly influences short- and long-term patient outcome. The main objective of healthcare providers should be to achieve at least 75% of reperfusion therapy applied to patients suffering from STEMI in a timely manner, and preferably within the first 3 h after onset of symptoms. Establishing networks of reperfusion at regional and national level, implying close collaboration between all the actors involved in reperfusion therapy, namely hospitals, departments of cardiology, PCI centres, emergency medical systems (EMS), (para)medically staffed ambulances, private cardiologists, primary care physicians, etc., is a key issue. All forms of reperfusion, depending on local facilities, need to be available to patients. Protocols must be written and agreed for the strategy of reperfusion to be applied within a network. Early diagnosis of STEMI is essential and is best achieved by rapid ECG recording and interpretation at first medical contact, wherever this contact takes place (hospital or ambulance). Tele-transmission of ECG for immediate interpretation by experienced cardiologists is an alternative. Primary PCI is the preferred reperfusion option if it can be performed by experienced staff within 90 min after first medical contact. Thrombolytic treatment, administered if possible in the pre-hospital setting, is a valid option if PCI cannot be performed in a timely manner, particularly within the first 3 h following onset of symptoms. Thrombolysis is not the end of the reperfusion therapy. Rescue PCI must be performed in the case of thrombolysis failure. Next-day PCI after successful thrombolysis has been proven efficacious. Quality control is important for monitoring the efficacy of networks of reperfusion. All elements that influence time to reperfusion must be taken into account, particularly transfer delays, in-hospital delays, and door-to-balloon or door-to-needle times. The rate of reperfusion achieved must also be taken into consideration. Professional organizations such as the European Society of Cardiology (ESC) have the responsibility to impart this message to the cardiology community, and inform politicians and health authorities about the best possible strategy to achieve reperfusion therapy.

[State of the art of percutaneous procedure: octogenarian patient successfully submitted, in a single session, to a pulmonary valvotomy, coronary stent implantation and permanent pacemaker implantation]

This report describes a case involving an 82 year old patient with mild renal insufficiency, severe pulmonary valve stenosis (PVS), severe anterior descending artery stenosis and complete atrioventricular block, who successfully underwent, in a single session, coronary angioplasty and a stent implant, pulmonary valvotomy and a permanent pacemaker implant.

Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines

BACKGROUND

An American College of Cardiology/American Heart Association (ACC/AHA) Task Force periodically revises and publishes guidelines with evidence-based recommendations for appropriate use of percutaneous coronary intervention (PCI). Some studies have suggested that closer adherence to guidelines can reduce variations in care, can improve quality, and may ultimately result in better outcomes, but this finding is incompletely understood. Guidelines themselves must change to be responsive to continuously evolving clinical practice. Our goal here was to investigate whether any relationship existed between the most recent ACC/AHA recommended indications for PCI and short term in-hospital outcomes.

METHODS AND RESULTS

We analyzed the ACC National Cardiovascular Data Registry for the period of January 1, 2001, through March 31, 2004. We excluded PCI procedures performed for acute myocardial infarction (ST-segment elevation myocardial infarction); all others were grouped by their indications according to the standard ACC/AHA scheme: Class I, evidence and/or agreement that PCI is useful and effective; Class IIa, conflicting evidence and/or divergent opinions, weight is in favor; Class IIb, usefulness/efficacy is less well established; and Class III, evidence and/or agreement that PCI is not useful or effective and may be harmful. Clinical success was defined as angiographic success (<20% residual stenosis) at all lesions attempted without the adverse events of myocardial infarction, same-admission bypass surgery, or death. There were 412 617 PCI procedures included in the analysis. Frequency of indications was as follows: Class I, 64%; Class IIa, 21%; Class IIb, 7%; and Class III, 8%. Clinical success declined across the indications classes (92.8%, 91.7%, 89%, and 85.5%, respectively; P<0.001), whereas adverse events increased.

CONCLUSIONS

In this large survey of contemporary PCI practice, most procedures were performed for Class I indications. A significant relationship between evidence-based indications recommended by the ACC/AHA Task Force and in-hospital outcomes was noted.

Assessment of Health-Related Quality of Life after Coronary Revascularization

The use of patient-oriented outcomes, in particular health-related quality if life (HRQOL), to evaluate coronary revascularization is continuously increasing. Current data underline that patients undergoing conventional CABG show a tremendous improvement of HRQOL status as early as 3 months postoperatively. There seems to be no clear benefit concerning HRQOL for off-pump coronary surgery versus conventional CABG. The benefits of minimal invasive CABG via mini-thoracotomy are compromised by increased incidence of pain during the immediate postoperative period. Totally endoscopic approaches seem to be more effective with regard to pain reduction and resume of every day activities. Compared to catheter-based interventions there is evidence that conventional CABG offers significant advantages over PCI. The influence of drug-eluting stents and newer surgical techniques on HRQOL remains to be determined. Inclusion of HRQOL data in CABG and PCI databases can play a central role in order to identify patient groups who benefit the most from each revascularization strategy.

Efficacy and safety of contrast injection beyond total occlusions in acute cardiac patients: a method to confirm balloon position within coronary lumen

OBJECTIVES

To evaluate the sensitivity and safety of contrast injection beyond total occlusions in acute cardiac patients in order to ensure balloon position within the coronary lumen and occasionally to enable the estimate of occlusion length.

BACKGROUND

Percutaneous therapy of total coronary occlusions is generally more challenging than the treatment of stenotic lesions. It more frequently entails the risk of irreversibly disrupting a protruding plaque, of advancing the wire through a false route, or rarely, of causing coronary perforation. Therefore, ascertaining intraluminal position prior to inflation is important.

METHODS

In a large group of consecutive acute cardiac patients undergoing percutaneous coronary intervention (PCI) we employed a technique of crossing the lesion with a soft-tipped guidewire supported by an over-the-wire (OTW) balloon catheter, and then injecting dilute contrast through the balloon under fluoroscopy to achieve distal lumen visualization.

RESULTS

In 106 patients, this technique yielded a sensitivity of 94%, a specificity of 70%, a positive predictive accuracy of 97%, and a negative predictive accuracy of 54% for intraluminal position of the balloon.

CONCLUSIONS

The technique of lumen demonstration by contrast injection through an OTW balloon beyond acute or subacute total obstructions was shown to be a safe and effective method to ascertain proper position of the angioplasty balloon. Occasionally, it enabled the estimation of lesion length or the identification of lesions distal to the obstruction. This technique was found to be valuable in doubtful situations where the determination of wire position was crucial for achieving procedural success.

Volume-Outcome Relationships for Percutaneous Coronary Interventions in the Stent Era

Background— Most studies that are the basis of recommended volume thresholds for percutaneous coronary interventions (PCIs) predate the routine use of stent placement.

Methods and Results— Data from New York’s Percutaneous Coronary Interventions Reporting System in 1998 to 2000 (n=107 713) were used to examine the impact of annual hospital volume and annual operator volume on in-hospital mortality, same-day coronary artery bypass graft (CABG) surgery, and same-stay CABG surgery after adjustment for differences in patients’ severity of illness. For a hospital-volume threshold of 400, the odds ratios for low-volume hospitals versus high-volume hospitals were 1.98 (95% CI, 1.17, 3.35) for in-hospital mortality, 2.07 (95% CI, 1.36, 3.15) for same-day CABG surgery, and 1.51 (95% CI, 1.03, 2.21) for same-stay CABG surgery. For an operator-volume threshold of 75, the odds ratios for low-volume versus high-volume operators were 1.65 (95% CI, 1.05, 2.60) for same-day CABG surgery and 1.55 (95% CI, 1.10, 2.18) for same-stay CABG surgery. Operator volume was not significantly associated with mortality. Also, for hospital volumes below 400 and operator volumes below 75, the respective odds of mortality, same-day CABG surgery, and same-stay CABG surgery were 5.92, 4.02, and 3.92 times the odds for hospital volumes of 400 or higher and operator volumes of 75 or higher.

Conclusions— Higher-volume operators and hospitals continue to experience lower risk-adjusted PCI outcome rates.

Primary percutaneous coronary intervention in acute myocardial infarction: time, time, and time!

Longer door-to-balloon times, total duration of ischaemia, and time of presentation relative to symptom onset all have an impact on outcome following primary percutaneous coronary intervention.

In-hospital time to treatment of patients with acute ST elevation myocardial infarction treated with primary angioplasty: determinants and outcome. Results from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte

OBJECTIVE

To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice.

DESIGN

Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK).

PATIENTS

Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed.

RESULTS

Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography" time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% > or = 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for > or = 20/year, p = 0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p = 0.397).

CONCLUSIONS

In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.

Procedure rates and outcomes of coronary revascularization procedures in California and New York

OBJECTIVE

Background data were obtained on all California hospitals performing coronary artery bypass grafting and percutaneous coronary intervention procedures and compared with reports published by the state of New York to develop a collaborative quality improvement program for cardiac surgery programs.

METHODS

The Patient Discharge Database of the Office of Statewide Health Planning and Development was queried for the years 1999-2001. In-hospital mortality and risk factors for coronary artery bypass grafting and percutaneous coronary intervention were obtained by using demographic data and International Classification of Diseases-Ninth Revision-Clinical Modification procedure and diagnosis codes. Risk models were developed by means of logistic regression analysis.

RESULTS

Overall coronary artery bypass grafting mortality was 33% higher and percutaneous coronary intervention mortality was twice as high in California compared with that in New York. Procedural volume (per unit population) was higher in New York. In high-volume California hospitals (>300 procedures per year), coronary artery bypass grafting mortality was similar (California, 2.42%; New York, 2.25%). Excess coronary artery bypass grafting mortality (>4.0%) occurred only in low-volume programs. Risk adjustment did not change the volume effect for coronary artery bypass grafting. No volume effect was noted for risk-adjusted percutaneous coronary intervention mortality. There were no obvious differences in risk factors between California and New York. Programs performing relatively fewer coronary artery bypass grafting procedures compared with percutaneous coronary interventions were found to have significantly higher coronary artery bypass grafting mortality after adjusting for volume effects. Percutaneous coronary intervention volume is increasing and coronary artery bypass grafting volume is decreasing in both California and New York.

CONCLUSIONS

Excess coronary artery bypass grafting mortality in California is related to the large number of low-volume programs. Excess percutaneous coronary intervention mortality might be related to case selection or timing of intervention. A relationship between percutaneous coronary intervention volume and coronary artery bypass grafting mortality is suggested in which increasing percutaneous coronary intervention volume relative to coronary artery bypass grafting volume might have the effect of shifting patients with undefined higher risk characteristics to coronary artery bypass grafting.

High-tech primary percutaneous coronary intervention

Coronary recanalization by means of primary percutaneous coronary intervention is actually the treatment of choice in patients with ST-elevation myocardial infarction. However, conventional primary percutaneous coronary intervention still presents several limitations. In recent years sophisticated new devices and techniques have been developed to further improve the results of primary percutaneous coronary intervention: it seems to be appropriate to refer to their utilization using the definition "high-tech primary percutaneous coronary intervention". Although the study data available are controversial and clinical benefits have not clearly been shown, adjunctive devices have been used in many procedures. Patient and lesion selection appears to be crucial and the health economics as well as the safety of high-tech devices should be carefully evaluated.

Brachytherapy for restenosis after stenting for coronary artery disease: its role in the drug-eluting stent era

PURPOSE OF REVIEW

Recent years have brought remarkable changes to the field of interventional cardiology. The need for repeat intervention due to restenosis, the most vexing long-term failure of percutaneous coronary intervention, has been significantly reduced owing to the introduction of two major advances, the vascular brachytherapy (VBT) and the drug-eluting stents (DES).

RECENT FINDINGS

Vascular brachytherapy has demonstrated its efficacy in limiting recurrence of existing in-stent restenosis. The past 2 years have sealed its reputation, with a variety of studies demonstrating its superiority over conventional therapy in challenging patient subsets with high risk for restenosis recurrence. Moreover, the long-term follow-up confirmed durability of this therapy, and the failures of VBT were characterized as easy to treat. Conversely, DES have shown spectacular efficacy at primarily preventing the first restenosis episode following the initial stent placement. Consequently, the role of VBT may be minimized, as the overall need for repeat revascularization is diminished as a result of the wide acceptance of DES. Furthermore, if the capacity of DES to treat in-stent restenosis is confirmed in randomized trials, they may eventually supersede VBT as the therapy of choice for in-stent restenosis.

SUMMARY

At present, VBT is the proven and durable therapeutic choice for patients with complex, diffuse in-stent restenosis who would otherwise have a very poor prognosis for long-term event-free survival. DES have emerged as remarkably effective in minimizing the first restenosis occurrence; they also represent a promising and competitive alternative to VBT for the treatment of in-stent restenosis.

Outcomes following elective percutaneous coronary intervention without on-site surgical backup in a community hospital

Despite guidelines to the contrary, limited numbers of elective percutaneous coronary intervention (PCI) procedures without on-site surgical backup are being performed, particularly in Europe and Canada. In the United States, many hospitals are considering establishing on-site surgical programs, in part to facilitate PCI. At a hospital with only off-site surgical backup, 562 elective PCI procedures were performed on 489 consecutive patients. Of these, 551 (98.0%) were successfully completed without major in-hospital complications; 5 patients (1.0%) had in-hospital complications, and 4 (0.8%) were urgently transferred. It is concluded that elective PCI with off-site surgical backup is feasible and safe for selected patients under specific conditions.