Frequency of major adverse cardiac events within one month of coronary angioplasty: a useful measure of operator performance

Long-term prognosis of patients with cardiac syndrome X: a review

Aims

Follow-up studies of patients with cardiac syndrome X (CSX) generally report good prognosis. However, some recent studies report an adverse outcome for women.

Methods and results

Structured literature search and meta-analysis for studies regarding prognosis of cardiac syndrome X patients. We identified 85 studies, ultimately selecting 16 for inclusion. Meta-analysis yielded a pooled major cardiac event percentage of 1.5% per 5 years and a pooled vascular event percentage of 4.8% per 5 years (n = 16 studies, n = 1694 patients). Fourteen studies reported upon the recurrence rate of angina pectoris: the pooled percentage of angina recurrence was 55% (n = 1336 patients).

Conclusion

The present review of recent archival literature demonstrates an overall major cardiac event rate of 1.5% per 5 years. Although this is an excellent prognosis for CSX patients, the quality of life is impaired because of the high recurrence rate of angina pectoris (55%).

The volume-outcome relationship of percutaneous coronary intervention: can current procedure volume minimums be applied to a developing country?

OBJECTIVES

A minimum percutaneous coronary intervention (PCI) hospital volume of 400 cases per year is recommended by the American College of Cardiology/American Heart Association (ACC/AHA). However, it is unclear whether this minimum value standard applies to non-Western developing countries, such as Taiwan. The aim of this study was to assess the application in Taiwan of current ACC/AHA practice guidelines for minimum hospital PCI volume.

METHODS

Using the 2003 Taiwan National Health Insurance Research Database and the Cause of Death Data File, we analyzed and compared the risk of 30-day mortality for patients (n = 12369) treated at low- (< 200 cases per year), medium- (200-399 cases per year), and high- (> or = 400 cases per year) PCI volume hospitals. A multivariable logistic regression using generalized estimating equations was conducted to assess the independent association of hospital PCI volume and patient 30-day mortality.

RESULTS

Crude 30-day mortality rates among low-, medium-, and high-PCI volume hospitals were 3.10%, 2.82%, and 1.80%, respectively. Patients treated at low-PCI volume hospitals had 1.54 (95% CI, 1.17-2.02) times higher odds of 30-day mortality than those treated at high-PCI volume hospitals after adjusting for other factors. The adjusted odds ratio between medium- and high-volume hospitals did not reach statistical significance (odds ratio 1.33, 95% CI 0.91-1.56).

CONCLUSIONS

Though greater, the adjusted odds of 30-day mortality for patients undergoing PCI at medium-volume hospitals was not significantly different from those of patients treated at high-volume hospitals. This suggests that current ACC/AHA PCI hospital volume minimums may need to be reevaluated in non-Western countries such as Taiwan.

Importance of the postdischarge interval in assessing major adverse clinical event rates following percutaneous coronary intervention

In-hospital major adverse clinical event (MACE) rates after percutaneous coronary intervention serve as benchmarks of performance. However, accelerated clinical pathways, decreased lengths of stay, and potential delayed effects of percutaneous coronary intervention may result in an underestimation of this traditional measurement of outcome. Records from patients in the first 3 waves of the National Heart, Lung, and Blood Institute's Dynamic Registry (n = 6,676) were reviewed for rates of composite in-hospital MACEs (death, myocardial infarction, and any repeat target vessel revascularization) and postdischarge MACEs (death, myocardial infarction, repeat hospitalization, and repeat target vessel revascularization) through 30 days. Rates for each composite MACE were compared across waves to assess changes over time. Predictors of each MACE category were identified using multivariate analysis. In-hospital MACE decreased significantly (5.4% of wave 1, 4.9% of wave 2, 3.1% of wave 3, p <0.001), whereas stent implantation increased significantly (67.5% of wave 1, 79.1% of wave 2, 86.2% of wave 3, p <0.001). Postdischarge MACE through 30 days remained unchanged (5.1% of wave 1, 5.1% of wave 2, 4.8% of wave 3, p = 0.6). Mean length of stay decreased (2.7 days for wave 1, 2.2 days for wave 3, p <0.001). Disparate clinical, procedural, and angiographic factors were associated with each MACE. Postdischarge MACE rates through 30 days comprise a significant and unchanging fraction of overall procedurally related MACE rates despite improving in-hospital outcomes. Most postdischarge events derive from pathology related to the controlled vessel. A 30-day MACE rate may serve as a more comprehensive measurement of procedural outcome.

Volume-Outcome Relation for Hospitals Performing Angioplasty for Acute Myocardial Infarction-Results From the Nationwide Japanese Registry-

BACKGROUND

The purpose of this study was to use a contemporary database to examine the relationship between annual hospital volume and the outcomes of percutaneous coronary interventions (PCIs) for acute myocardial infarction (AMI), given the wide spread use of coronary stents. An inverse relation exists between the number of PCIs and short-term outcome, but PCI practice has been changing with the availability of new devices such as stents.

METHODS AND RESULTS

Data from the 1997 Japanese nationwide registry were analyzed to determine the relation between the annual hospital volume of PCI procedures for patients with AMI and in-hospital mortality, as well as the need for coronary artery bypass graft (CABG) surgery. A total of 129 hospitals (2,491 patients) were divided into terciles according to the annual volume. Of the procedures, 39% involved coronary stents. Median annual PCI volumes varied across terciles from low =10, middle =33, and high =89. After adjusting for patient characteristics, there was no significant relationship between volume and in-hospital mortality (trend P=0.66) and CABG (trend P=0.35). Among patients who received stents (n=958), there was no significant association between volume and either mortality or CABG.

CONCLUSIONS

Using the contemporary database, there was no significant relationship between hospital volume and in-hospital outcome among AMI patients undergoing PCIs.

Preliminary experience with a high bolus dose of tirofiban during percutaneous coronary intervention

BACKGROUND

In the TARGET study, sub-optimal platelet inhibition with tirofiban was held responsible for the higher incidence of periprocedural CK-MB release compared to abciximab. Since then, a new, higher bolus dose of tirofiban has been proposed to increase blood concentrations very soon after the start of treatment.

OBJECTIVE

The aim of this study was to explore the bleeding risk and clinical outcome at 30 days in a series of patients undergoing percutaneous coronary intervention (PCI) with the new dosing regimen of tirofiban (25 microg/kg bolus followed by a 0.15 microg kg(-1) min(-1) infusion for 18 h).

METHODS

A total of 133 consecutive patients underwent a PCI and received a high bolus dose of tirofiban. Platelet function inhibition was measured using the Ultegra RPFA (Accumetrics) 10 min and 8 and 24 h after the start of therapy in the first 38 cases.

RESULTS

The procedural success rate was 98.5%. The mean level of platelet inhibition 10 min after the start of therapy was 94.7 +/- 5.9%. No major bleedings, no need for red blood cell transfusion and no episodes of severe thrombocytopoenia were recorded. Groin haematoma was observed in seven patients (5.3%). The cumulative incidence of 30-day major adverse cardiovascular events was 4.6% (five myocardial infarctions and one repeat PTCA for sub-acute stent thrombosis).

CONCLUSIONS

The use of a high bolus dose of tirofiban in patients undergoing PCI seems to be safe and not associated with an increased risk of major bleeding. This high bolus dose may help to further reduce the rate of periprocedural adverse events.

Relationship between coronary angioplasty laboratory volume and outcomes after hospital discharge

BACKGROUND

Although an inverse association has been established between short-term complications of percutaneous coronary interventions (PCIs) and the volume of angioplasty procedures performed by catheterization laboratories, no data are available on the association between laboratory volume and long-term outcomes.

METHODS

A cohort study of 25,222 patients undergoing PCI in 43 laboratories in Pennsylvania from October 1994 to December 1995 was performed by use of the Pennsylvania Health Care Cost Containment Council database. The association of laboratory volume with inhospital, 1-month, and 6-month events was estimated by use of multivariable analyses adjusting for patient and procedural characteristics.

RESULTS

Although a higher volume of procedures was associated with reduced inhospital coronary bypass ([CABG] 0.6 odds ratio [OR] for > or =400 vs <400 PCIs/year; 95% CI 0.4, 0.8), it was not associated with CABG occurring within 1 month after discharge (P =.71; OR 1.0, 95% CI 0.6, 1.7). Laboratory volume was also not significantly associated with postdischarge revascularization (PCI or CABG) at 1 month (P =.58; OR 1.1, 95% CI 0.8, 1.4) or 6 months (P =.47; OR 1.04, 95% CI 0.91, 1.19). In addition, laboratory volume was not associated with rates of myocardial infarction (P =.14), death (P =.28), or the combined outcome of PCI, CABG, myocardial infarction, or death (P =.90) at 1 month after hospital discharge.

CONCLUSIONS

Although our study confirmed the volume/complication relationship for inhospital CABG, it did not reveal an association between volume and postdischarge events. These results suggest that inhospital complications will remain the standard for assessing laboratory volume and that selective use of higher-volume laboratories may not improve long-term outcomes.

Volume-outcome relation for physicians and hospitals performing angioplasty for acute myocardial infarction in New York state

BACKGROUND

An inverse relation exists between the number of coronary angioplasty procedures performed by physicians or hospitals and short-term mortality. It is not known, however, whether a similar relation holds for physicians and hospitals that perform primary angioplasty for acute myocardial infarction.

METHODS AND RESULTS

We analyzed data from the 1995 New York State Coronary Angioplasty Reporting System Registry to determine the relation between the number of primary angioplasty procedures performed by physicians and hospitals and in-hospital mortality. Patients who underwent angioplasty procedures within 23 hours of onset of acute myocardial infarction without preceding thrombolytic therapy were included (n=1342). In-hospital mortality was reduced 57% among patients who underwent primary angioplasty by high-volume as opposed to low-volume physicians (adjusted relative risk 0.43; 95% CI 0.21 to 0.83). When patients with acute myocardial infarction were treated with primary angioplasty in high-volume hospitals rather than low-volume institutions, the relative risk reduction for in-hospital mortality was 44% (adjusted relative risk 0.56; 95% CI 0.29 to 1.1). Compared with patients treated at low-volume hospitals by low-volume physicians, patients treated at high-volume hospitals by high-volume physicians had a 49% reduction in the risk of in-hospital mortality (adjusted relative risk 0.51; 95% CI 0.26 to 0.99).

CONCLUSIONS

Among hospitals in New York State, a higher volume of primary angioplasty procedures performed by physicians and/or hospitals was associated with a lower mortality rate.

Benchmarking operator performance in percutaneous coronary intervention: a novel approach using 30-day events

The infrequency of adverse in-hospital events limits scorecarding individual angioplasty operators. We assessed 30-day events for this purpose. Thirty-nine operators performed 1,950 coronary interventions from 1 April to 30 September 1998. Thirty-day follow-up was obtained in 1,896 (97.2%), who form the basis for this analysis. We recorded 16 baseline variables and chose an endpoint of mortality or target vessel revascularization. The endpoint occurred in 103 (5.4%) patients by 30 days. Independent predictors were identified by multivariate modeling. The expected event rate for the set of patients treated by each operator was determined. Two operators had significantly more adverse events by 30 days than predicted and two others had an event rate approaching significance. Two of these four performed at least 60 procedures during the 6-month period. With 30-day events, operators whose complication rates exceed laboratory standards can be identified with achievable sample sizes. Volume alone does not appear to be sufficient assurance of quality outcomes.