Clinical effectiveness and cost-effectiveness of immediate angioplasty for acute myocardial infarction: systematic review and economic evaluation

Effects of art therapy for people with mild or major neurocognitive disorders: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to analyze the efficacy of non-pharmacological, interactive, and emotional art therapy interventions for patients with mild neurocognitive disorder (mild NCD) or major neurocognitive disorder (MNCD).

METHODS

A systematic review and meta-analysis assessed English-language literature published from January 1, 2001, to August 22, 2021, and indexed in CINAHL, EMBASE, MEDLINE, PubMed, Web of Science, and PsycINFO. People with mild NCD or MNCD who received art therapy were classified as the intervention group. Study quality was assessed using the Risk of Bias (RoB) 2 and the Joanna Briggs Institute tool.

RESULTS

Among nine included studies, depression was significantly reduced as compared with control groups (Cohen's d = -0.52 [95 % CI = -0.99-0.05], p < 0.001, I2 = 62.90 %) but not cognitive function or quality of life.

CONCLUSION

People with mild neurocognitive disorder or MNCD are encouraged to engage in art therapy delivered by art therapists collaborating with healthcare providers. The effects of specific types of art therapy should be explored.

PRACTICAL IMPLICATION

Healthcare providers should be encouraged to provide art therapy designed to reduce depression in patients with mild NCD or MNCD.

Communication of personalised disease risk by general practitioners to motivate smoking cessation in England: a cost-effectiveness and research prioritisation study

BACKGROUND AND AIMS

Communication of personalised disease risk can motivate smoking cessation. We assessed whether routine implementation of this intervention by general practitioners (GPs) in England is cost-effective or whether we need further research to better establish its effectiveness.

DESIGN

Cost-effectiveness analysis (CEA) with value of information (VoI) analysis from the UK National Health Service perspective, using GP communication of personalised disease risk on smoking cessation versus usual care.

SETTING

GP practices in England.

STUDY POPULATION

Healthy smokers aged 35-60 years attending the GP practice.

MEASUREMENTS

Effectiveness of GP communication of personalised disease risk on smoking cessation was estimated through systematic review and meta-analysis. A Bayesian CEA was then performed using a lifetime Markov model on smokers aged 35-60 years that measured lifetime costs and quality-adjusted life-years (QALYs) assigned to the four diseases contributing the most to smoking-related morbidity, mortality and costs: chronic obstructive pulmonary disease, lung cancer, myocardial infarction and stroke. Costs and QALYs for each disease state were obtained from the literature. VoI analysis identified sources of uncertainty in the CEA and assessed how much would be worth investing in further research to reduce this uncertainty.

FINDINGS

The meta-analysis odds ratio for the effectiveness estimate of GP communication of personalised disease risk was 1.48 (95% credibility interval, 0.91-2.26), an absolute increase in smoking cessation rates of 3.84%. The probability of cost-effectiveness ranged 89-94% depending on sex and age. VoI analysis indicated that: (i) uncertainty in the effectiveness of the intervention was the driver of the overall uncertainty in the CEA; and (ii) a research investment to reduce this uncertainty is justified if lower than £27.6 million (£7 per smoker).

CONCLUSIONS

Evidence to date shows that, in England, incorporating disease risk communication into general practitioners' practices to motivate smoking cessation is likely to be cost-effective compared with usual care.

Regional variation in coronary angiography rates: the association with supply factors and the role of indication: a spatial analysis

Background

Coronary angiographies (CAs) are among the most common diagnostic procedures carried out in German hospitals, and substantial regional differences in their frequency of use have been documented. Given the heterogeneity with regard to the expected benefits and the varying scope for discretion depending on the indication for the procedure, we hypothesized that the observed variation and the association of need and supply factors differs by indication for CA.

Methods

We investigated the correlation between supply factors and the regional rates of CAs in Germany while controlling for need using spatial‐autoregressive error models (SARE) and spatial cross-regressive models with autoregressive errors (SCRARE). The overall rates of CAs and the rates in specific patient subgroups, namely, patients with and without myocardial infarction (MI), were calculated based on a comprehensive set of nationwide routine data from three statutory health insurances at the district level.

Results

Although little variation was found in cases with MI, considerable variation was seen in the overall cases and cases without MI. The SARE models revealed a positive association between the number of hospitals with a cardiac catheterization laboratory per 10,000 population and the rates of overall cases and cases without MI, whereas no such relationship existed in cases with MI. Additionally, an association between regional deprivation and the rates of CAs was found in cases with MI, but no such association was seen in cases without MI.

Conclusions

The results supported the hypothesis that the relative association of need and supply factors differed by the indication for CA. Although the regional differences in the frequency of use of CAs can only be explained in part by the factors examined in our study, it offers insight into patient access to and the provision of CA services and can provide a platform for further local research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02513-z.

Effects of animal-assisted interventions for people with dementia: A systematic review and meta-analysis

Animal-assisted interventions (AAIs) are non-pharmacological, cost-effective interventions developed to improve outcomes in patients with dementia; however, the effects remain inconclusive. The purpose of this study was to analyze the efficacy of AAIs for people with dementia. A systematic review and meta-analysis was performed of English-language literature published from January 1, 2001, to July 3,2021, and indexed in the following databases: CINAHL, EMBASE, MEDLINE, PubMed, Web of Science, Cochrane, and PsycINFO. Intervention groups were people with dementia who received AAIs. Study quality was assessed using the Joanna Briggs Institute tool. Among 10 included studies, significant differences in depression levels were identified between the intervention and control groups (p < 0.001). No significant differences in cognitive function, neuropsychiatric syndrome, or independence in activities of daily living were observed between groups. Future research remains necessary to examine the effects of AAIs on depression during different stages of dementia. AAIs therapists may collaborate with healthcare workers to improve AAIs benefits.

Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data

BACKGROUND & AIMS

Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS.

METHODS

We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients.

RESULTS

Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323-0.607; P < .001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307-0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253-0.553; P < .001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy.

CONCLUSIONS

In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.

Where does TIPS fit in the management of patients with cirrhosis?

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

Systematic investment in the delivery of guideline-coherent therapy reduces mortality and overall costs in patients with ST-elevation myocardial infarction: Results from the Stent for Life economic model for Romania, Portugal, Basque Country and Kemerovo region

AIMS

The Stent for Life initiative aims at the reduction of mortality in patients with ST-elevation myocardial infarction by enhancing timely access to primary percutaneous coronary intervention. To assess the associated health and socioeconomic impact, the Stent for Life economic project was launched and applied to four model regions: Romania, Portugal, the Basque Country in Spain, and the Kemerovo region in the Russian Federation.

METHODS AND RESULTS

The Stent for Life economic model is based on a decision tree that incorporates primary percutaneous coronary intervention rates and mortality. Healthcare costs and indirect costs caused by loss of productivity were estimated. A baseline scenario simulating the status quo was compared to the Stent for Life scenario which integrated changes initiated by the Stent for Life programme. In the four model regions, primary percutaneous coronary intervention numbers rose substantially between 29-303%, while ST-elevation myocardial infarction mortality was reduced between 3-10%. Healthcare costs increased by 8% to 70%. Indirect cost savings ranged from 2-7%. Net societal costs were reduced in all model regions by 2-4%.

CONCLUSION

The joint effort of the Stent for Life initiative and their local partners successfully saves lives. Moreover, the increase in healthcare costs was outweighed by indirect cost savings, leading to a net cost reduction in all four model regions. These findings demonstrate that systematic investments to improve the access of ST-elevation myocardial infarction patients to guideline-coherent therapy is beneficial, not only for the individual, but also for the society at large.

Meta-Analysis of Cell Therapy Studies in Heart Failure and Acute Myocardial Infarction

Heart failure (HF) is one of the leading causes of death worldwide and has reached epidemic proportions in most industrialized nations. Despite major improvements in the treatment and management of the disease, the prognosis for patients with HF remains poor with approximately only half of patients surviving for 5 years or longer after diagnosis. The poor prognosis of HF patients is in part because of irreparable damage to cardiac tissue and concomitant maladaptive changes associated with the disease. Cell-based therapies may have the potential to transform the treatment and prognosis of HF through regeneration or repair of damaged cardiac tissue. Accordingly, numerous phase I and II randomized clinical trials have tested the clinical benefits of cell transplant, mostly autologous bone marrow-derived mononuclear cells, in patients with HF, ischemic heart disease, and acute myocardial infarction. Although many of these trials were relatively small, meta-analyses of cell-based therapies have attempted to apply rigorous statistical methodology to assess the potential clinical benefits of the intervention. As a prelude to larger phase III trials, meta-analyses, therefore, remain the obvious means of evaluating the available clinical evidence. Here, we review the different meta-analyses of randomized clinical trials that evaluate the safety and potential beneficial effect of cell therapies in HF and acute myocardial infarction spanning nearly 2 decades since the first pioneering trials were conducted.

Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model

OBJECTIVES

This research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective?

SETTING

A single National Health Service ambulance service and a charity-funded prehospital critical care service in England.

PARTICIPANTS

The patient population is adult, non-traumatic OHCA.

METHODS

We combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses.

RESULTS

Costs of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%-5%.

CONCLUSION

This is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field.

TRIAL REGISTRATION NUMBER

ISRCTN18375201.

Stem cell therapy for chronic ischaemic heart disease and congestive heart failure

BACKGROUND

A promising approach to the treatment of chronic ischaemic heart disease and congestive heart failure is the use of stem cells. The last decade has seen a plethora of randomised controlled trials developed worldwide, which have generated conflicting results.

OBJECTIVES

The critical evaluation of clinical evidence on the safety and efficacy of autologous adult bone marrow-derived stem/progenitor cells as a treatment for chronic ischaemic heart disease and congestive heart failure.

SEARCH METHODS

We searched CENTRAL in the Cochrane Library, MEDLINE, Embase, CINAHL, LILACS, and four ongoing trial databases for relevant trials up to 14 December 2015.

SELECTION CRITERIA

Eligible studies were randomised controlled trials comparing autologous adult stem/progenitor cells with no cells in people with chronic ischaemic heart disease and congestive heart failure. We included co-interventions, such as primary angioplasty, surgery, or administration of stem cell mobilising agents, when administered to treatment and control arms equally.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all references for eligibility, assessed trial quality, and extracted data. We undertook a quantitative evaluation of data using random-effects meta-analyses. We evaluated heterogeneity using the I2 statistic and explored substantial heterogeneity (I2 greater than 50%) through subgroup analyses. We assessed the quality of the evidence using the GRADE approach. We created a 'Summary of findings' table using GRADEprofiler (GRADEpro), excluding studies with a high or unclear risk of selection bias. We focused our summary of findings on long-term follow-up of mortality, morbidity outcomes, and left ventricular ejection fraction measured by magnetic resonance imaging.

MAIN RESULTS

We included 38 randomised controlled trials involving 1907 participants (1114 cell therapy, 793 controls) in this review update. Twenty-three trials were at high or unclear risk of selection bias. Other sources of potential bias included lack of blinding of participants (12 trials) and full or partial commercial sponsorship (13 trials).Cell therapy reduced the incidence of long-term mortality (≥ 12 months) (risk ratio (RR) 0.42, 95% confidence interval (CI) 0.21 to 0.87; participants = 491; studies = 9; I2 = 0%; low-quality evidence). Periprocedural adverse events associated with the mapping or cell/placebo injection procedure were infrequent. Cell therapy was also associated with a long-term reduction in the incidence of non-fatal myocardial infarction (RR 0.38, 95% CI 0.15 to 0.97; participants = 345; studies = 5; I2 = 0%; low-quality evidence) and incidence of arrhythmias (RR 0.42, 95% CI 0.18 to 0.99; participants = 82; studies = 1; low-quality evidence). However, we found no evidence that cell therapy affects the risk of rehospitalisation for heart failure (RR 0.63, 95% CI 0.36 to 1.09; participants = 375; studies = 6; I2 = 0%; low-quality evidence) or composite incidence of mortality, non-fatal myocardial infarction, and/or rehospitalisation for heart failure (RR 0.64, 95% CI 0.38 to 1.08; participants = 141; studies = 3; I2 = 0%; low-quality evidence), or long-term left ventricular ejection fraction when measured by magnetic resonance imaging (mean difference -1.60, 95% CI -8.70 to 5.50; participants = 25; studies = 1; low-quality evidence).

AUTHORS' CONCLUSIONS

This systematic review and meta-analysis found low-quality evidence that treatment with bone marrow-derived stem/progenitor cells reduces mortality and improves left ventricular ejection fraction over short- and long-term follow-up and may reduce the incidence of non-fatal myocardial infarction and improve New York Heart Association (NYHA) Functional Classification in people with chronic ischaemic heart disease and congestive heart failure. These findings should be interpreted with caution, as event rates were generally low, leading to a lack of precision.

Meta-Analyses of Human Cell-Based Cardiac Regeneration Therapies: What Can Systematic Reviews Tell Us About Cell Therapies for Ischemic Heart Disease?

Controversies from basic science, discrepancies from clinical trials, and divergent results from meta-analyses have recently arisen in the field of cell therapies for cardiovascular repair and regeneration. Noticeably, there are almost as many systematic reviews and meta-analyses published as there are well-conducted clinical studies. But how do we disentangle the confusion they have raised? This article addresses why results obtained from systematic reviews and meta-analyses of human cell-based cardiac regeneration therapies are still valid to inform the design of future clinical trials. It also addresses how meta-analyses are not free from limitations and how important it is to assess the quality of the evidence and the quality of the systematic reviews and finally how stronger conclusions can be drawn when several pieces of evidence converge.

Calycosin‑7‑O‑β‑D‑glucoside attenuates ischemia‑reperfusion injury in vivo via activation of the PI3K/Akt pathway

The aim of the present study was to investigate the effects and mechanisms of calycosin‑7‑O‑β‑D‑glucoside (CG) on ischemia‑reperfusion (I/R) injury in vivo. Hemodynamic parameters, including ejection fraction (EF), fractional shortening (FS), left ventricular end‑systolic pressure (LVESP) and left ventricular end‑diastolic pressure (LVEDP) were monitored using an ultrasound system, and infarct size was measured using Evans blue/tetrazolium chloride double staining. The activities of serum creatine kinase (CK), lactate dehydrogenase (LDH) and superoxide dismutase (SOD), and the levels of malondialdehyde (MDA) were determined to assess the degree of myocardial injury and oxidative stress‑induced damage. The protein expression levels of cleaved‑caspase‑3, cleaved‑caspase‑9, phosphorylated (p)‑phosphatidylinositol 3‑kinase (PI3K) p85, PI3K p85, p‑Akt and Akt were determined using western blotting. The results demonstrated that pretreatment with high dose (H)‑CG markedly improved cardiac function, as evidenced by upregulated EF, FS and LVESP, and downregulated LVEDP. In addition, administration of CG resulted in significant decreases in infarct size in the I/R+low dose‑CG and I/R+H‑CG groups, compared with the I/R group. The activities of CK and LDH, and the levels of MDA in the I/R+H‑CG group were reduced, compared with those in the I/R group, whereas SOD activity was elevated. Treatment with CG inhibited the cleavage and activity of caspase‑3 and caspase‑9, and enhanced the phosphorylation of PI3K p85 and Akt. Notably, administration of the PI3K inhibitor, LY294002, markedly lowered the levels of p‑PI3K p85/p‑Akt, and eradicated the inhibitory effects of H‑CG on infarct size, myocardial injury and oxidative stress‑induced damage. Taken together, the results suggested that CG may alleviate I/R injury by activating the PI3K/Akt signaling pathway.

Stem cell treatment for acute myocardial infarction

BACKGROUND

Cell transplantation offers a potential therapeutic approach to the repair and regeneration of damaged vascular and cardiac tissue after acute myocardial infarction (AMI). This has resulted in multiple randomised controlled trials (RCTs) across the world.

OBJECTIVES

To determine the safety and efficacy of autologous adult bone marrow stem cells as a treatment for acute myocardial infarction (AMI), focusing on clinical outcomes.

SEARCH METHODS

This Cochrane review is an update of a previous version (published in 2012). We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 2), MEDLINE (1950 to March 2015), EMBASE (1974 to March 2015), CINAHL (1982 to March 2015) and the Transfusion Evidence Library (1980 to March 2015). In addition, we searched several international and ongoing trial databases in March 2015 and handsearched relevant conference proceedings to January 2011.

SELECTION CRITERIA

RCTs comparing autologous bone marrow-derived cells with no cells in patients diagnosed with AMI were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all references, assessed the risk of bias of the included trials and extracted data. We conducted meta-analyses using random-effects models throughout. We analysed outcomes at short-term (less than 12 months) and long-term (12 months or more) follow-up. Dichotomous outcomes are reported as risk ratio (RR) and continuous outcomes are reported as mean difference (MD) or standardised MD (SMD). We performed sensitivity analyses to evaluate the results in the context of the risk of selection, performance and attrition bias. Exploratory subgroup analysis investigated the effects of baseline cardiac function (left ventricular ejection fraction, LVEF) and cell dose, type and timing of administration, as well as the use of heparin in the final cell solution.

MAIN RESULTS

Forty-one RCTs with a total of 2732 participants (1564 cell therapy, 1168 controls) were eligible for inclusion. Cell treatment was not associated with any changes in the risk of all-cause mortality (34/538 versus 32/458; RR 0.93, 95% CI 0.58 to 1.50; 996 participants; 14 studies; moderate quality evidence), cardiovascular mortality (23/277 versus 18/250; RR 1.04, 95% CI 0.54 to 1.99; 527 participants; nine studies; moderate quality evidence) or a composite measure of mortality, reinfarction and re-hospitalisation for heart failure (24/262 versus 33/235; RR 0.63, 95% CI 0.36 to 1.10; 497 participants; six studies; moderate quality evidence) at long-term follow-up. Statistical heterogeneity was low (I(2) = 0% to 12%). Serious periprocedural adverse events were rare and were generally unlikely to be related to cell therapy. Additionally, cell therapy had no effect on morbidity, quality of life/performance or LVEF measured by magnetic resonance imaging. Meta-analyses of LVEF measured by echocardiography, single photon emission computed tomography and left ventricular angiography showed evidence of differences in mean LVEF between treatment groups although the mean differences ranged between 2% and 5%, which are accepted not to be clinically relevant. Results were robust to the risk of selection, performance and attrition bias from individual studies.

AUTHORS' CONCLUSIONS

The results of this review suggest that there is insufficient evidence for a beneficial effect of cell therapy for AMI patients. However, most of the evidence comes from small trials that showed no difference in clinically relevant outcomes. Further adequately powered trials are needed and until then the efficacy of this intervention remains unproven.

Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals

OBJECTIVE

To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, 'STEMI referral hospitals').

BACKGROUND

Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact.

METHODS

Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the 'worst case' scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients.

RESULTS

PRLs were $0.33 for every $100 of patient revenue statewide for STEMI and $1.73 for ACS. At the individual hospital level, the 90th centile PRL was $0.74 for STEMI and $2.77 for ACS. PRLs for STEMI were not greater in rural areas compared with major metropolitan areas. Hospital revenue centres that would be most impacted by loss of patients with STEMI were cardiology procedures and intensive care units.

CONCLUSIONS

Loss of patient with STEMI revenues would result in only a small financial impact on STEMI referral hospitals in Florida under proposed STEMI diversion/rapid transfer protocols. However, spillover loss of patients with ACS would increase revenue loss for many hospitals.

The national infarct angioplasty project: UK experience and subsequent developments

The UK had previously established a comprehensive strategy for in-hospital nurse-led thrombolysis for patients with ST-elevation myocardial infarction, with a growing use of pre-hospital thrombolysis by paramedical staff in the ambulance services. The National Infarct Angioplasty Project was sponsored by the government and examined the introduction of primary percutaneous coronary angioplasty (PPCI) in a variety of urban, rural and mixed communities. The project found that PPCI could be delivered within acceptable timelines, would be cost-effective, and could be delivered to the majority of the population. A project was therefore undertaken in England to transform services. There has been a rapid change and by 2012/13 over 95% of eligible patients received PPCI. Survival of patients with STEMI has improved over time and length of stay in hospital halved. However, nearly a quarter of STEMI patients do not receive reperfusion therapy (often because of late presentation) and additional work is needed to minimise delays to treatment. There are unexplained differences between regions in numbers of PPCI procedures per million population, and there is also variance between centres in the proportion of patients who are in shock or on a ventilator. Additional research is needed to ensure a consistent approach for these sick patients, who might have the most to gain from early treatment. The national audit programmes have been instrumental in measuring the changes in strategies, monitoring performance and highlighting the associated improvements in outcomes. A new risk model is being developed to allow a more comprehensive comparison of outcomes in different hospitals.

Challenges in identifying the best source of stem cells for cardiac regeneration therapy

The overall clinical cardiac regeneration experience suggests that stem cell therapy can be safely performed, but it also underlines the need for reproducible results for their effective use in a real-world scenario. One of the significant challenges is the identification and selection of the best suited stem cell type for regeneration therapy. Bone marrow mononuclear cells, bone marrow-derived mesenchymal stem cells, resident or endogenous cardiac stem cells, endothelial progenitor cells and induced pluripotent stem cells are some of the stem cell types which have been extensively tested for their ability to regenerate the lost myocardium. While most of these cell types are being evaluated in clinical trials for their safety and efficacy, results show significant heterogeneity in terms of efficacy. The enthusiasm surrounding regenerative medicine in the heart has been dampened by the reports of poor survival, proliferation, engraftment, and differentiation of the transplanted cells. Therefore, the primary challenge is to create clearcut evidence on what actually drives the improvement of cardiac function after the administration of stem cells. In this review, we provide an overview of different types of stem cells currently being considered for cardiac regeneration and discuss why associated factors such as practicality and difficulty in cell collection should also be considered when selecting the stem cells for transplantation. Next, we discuss how the experimental variables (type of disease, marker-based selection and use of different isolation techniques) can influence the study outcome. Finally, we provide an outline of the molecular and genetic approaches to increase the functional ability of stem cells before and after transplantation.

Variable penetration of primary angioplasty in Europe--what determines the implementation rate?

Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). A survey conducted in 2008 in the European Society of Cardiology (ESC) countries reported that the annual incidence of hospital admissions for acute STEMI is around 800 patients per million inhabitants. The survey also showed that STEMI patients' access to reperfusion therapy and the use of PPCI or thrombolytic therapy (TT) vary considerably among countries. Northern, Western and Central Europe already had well-developed PPCI services, offering PPCI to 60-90% of all STEMI patients. Southern Europe and the Balkans were still predominantly using TT and had a higher proportion of patients who were left without any reperfusion treatment. The survey concluded that a nationwide PPCI strategy results in more patients being offered reperfusion therapy. To address the inequalities in STEMI patients' access to life-saving PPCI and to support the implementation of the ESC STEMI treatment guidelines in Europe, the Stent for Life (SFL) Initiative was launched jointly by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR in 2008. The aim of the SFL Initiative is to improve the delivery of life-saving PPCI for STEMI patients. Currently, 10 national cardiac societies support the SFL Initiative in their respective countries. SFL national action programmes have been developed and are being implemented in several countries. The formation of regional PPCI networks involving emergency medical services, non-PPCI hospitals and PPCI centres is considered to be a critical factor in implementing PPCI services effectively. Better monitoring of STEMI incidence and prospective registration of PPCI in all countries is required to document improvements in health care and to identify areas where further effort is required. Furthermore, studies on potential factors or characteristics that explain the national penetration of PPCI are needed. Such knowledge will be necessary to increase the effectiveness and efficiency of the implementation, and will be the first step in ensuring equal access to PPCI treatment for STEMI patients in Europe. Establishing the delivery of PPCI in an effective, high-quality and timely manner is a great challenge.

Economic evidence of interventions for acute myocardial infarction: a review of the literature

AIMS

The aims of this review are to identify and evaluate studies exploring the cost-effectiveness of primary angioplasty (PPCI) vs. thrombolysis (TL) for treating acute myocardial infarction (AMI).

METHODS AND RESULTS

A comprehensive free-text searching identified economic evaluation studies that were reviewed with respect to their effectiveness data, identification, measurement and valuation of resource data, measurement and valuation of health outcomes (clinical and QALYs) and uncertainty analysis. A total of 14 studies were included in the review: seven were economic evaluations alongside RCTs, two community-based studies or registries and five decision-analytical models. PPCI was found to be cost-effective when compared with TL in eight studies, cost-saving in three, cost-neutral in one, and not significantly different in terms of both cost and benefits in two studies.

CONCLUSIONS

The cost-effective evidence available is mainly derived from RCTs with stringent inclusion criteria using established catheter laboratories for providing PPCI treatment; these two components might restrict the generalisability of their "for managing patients with STEMI in hospital" settings. In order to aid policy makers on the real costs and benefits of the PPCI and TL, it is necessary to conduct more analyses with data from the real world in which there are more strategies evaluated for delivering PPCI than merely those in established catheter laboratories.

Granulocyte colony stimulating factor therapy for acute myocardial infarction

BACKGROUND

Acute myocardial infarction (AMI) is the leading cause of death in developed countries, and current treatment modalities have failed to regenerate the dead myocardium resulting from the ischemic damage. Stem cells have the potential to regenerate the damaged myocardium. These cells can be mobilized from the bone marrow by factors such as granulocyte colony stimulating factor (G-CSF).

OBJECTIVES

To assess the effects of stem cell mobilization following granulocyte colony stimulating factor therapy in patients with acute myocardial infarction.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library Issue 4, 2010), MEDLINE (1950 to November week 3, 2010), EMBASE (1980 to 2010 week 48), BIOSIS Previews (1969 to 30 November 2010), ISI Science Citation Index Expanded (1970 to 4 December 2010) and ISI Conference Proceedings Citation Index - Science (1990 to 4 December 2010). We also checked reference lists of articles.

SELECTION CRITERIA

We included randomized controlled trials including participants with a clinical diagnosis of AMI who were randomly allocated to the subcutaneous administration of G-CSF through a daily dose of 2.5, 5 or 10 microgram/kg for four to six days or placebo. No age or other restrictions were applied for the selection of patients.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data regarding the clinical efficacy and adverse outcomes. Disagreements were resolved by the third author.

MAIN RESULTS

We included seven trials reported in 30 references in the review (354 participants). In all trials, G-CSF was compared with placebo preparations. Dosage of G-CSF varied among studies, ranging from 2.5 to 10 microgram/kg/day. Regarding overall risk of bias, data regarding the generation of randomization sequence and incomplete outcome data were at a low risk of bias; however, data regarding binding of personnel were not conclusive. The rate of mortality was not different between the two groups (RR 0.64, 95% CI 0.15 to 2.80, P = 0.55). Regarding safety, the limited amount of evidence is inadequate to reach any conclusions regarding the safety of G-CSF therapy. Moreover, the results did not show any beneficial effects of G-CSF in patients with AMI regarding left ventricular function parameters, including left ventricular ejection fraction (RR 3.41, 95% CI -0.61 to 7.44, P = 0.1), end systolic volume (RR -1.35, 95% CI -4.68 to 1.99, P = 0.43) and end diastolic volume (RR -4.08, 95% CI -8.28 to 0.12, P = 0.06). It should also be noted that the study was limited since the trials included lacked long enough follow up durations.

AUTHORS' CONCLUSIONS

Limited evidence from small trials suggested a lack of benefit of G-CSF therapy in patients with AMI. Since data of the risk of bias regarding blinding of personnel were not conclusive, larger RCTs with appropriate power calculations and longer follow up durations are required in order to address current uncertainties regarding the clinical efficacy and therapy-related adverse events of G-CSF treatment.

Estimating the payoffs from cardiovascular disease research in Canada: an economic analysis

BACKGROUND

Investments in medical research can result in health improvements, reductions in health expenditures and secondary economic benefits. These "returns" have not been quantified in Canada. Our objective was to estimate the return on cardiovascular disease research funded by public or charitable organizations.

METHODS

Our primary outcome was the internal rate of return on cardiovascular disease research funded by public or charitable sources. The internal rate of return is the annual monetary benefit to the economy for each dollar invested in cardiovascular disease research. Calculation of the internal rate of return involved the following: measuring expenditures on cardiovascular disease research, estimating the health gains accrued from new treatments for cardiovascular disease, determining the proportion of health gains attributable to cardiovascular disease research and the time lag between research expenditures and health gains, and estimating the spillovers from public- or charitable-sector investments to other sectors of the economy.

RESULTS

Expenditures by public or charitable organizations on cardiovascular disease research from 1981 to 1992 amounted to $392 million (2005 dollars). Health gains associated with new treatments from 1994 to 2005 (13-yr lag) amounted to 2.2 million quality-adjusted life-years. We calculated an internal rate of return of 20.6%.

CONCLUSION

Canadians obtain relatively high health and economic gains from investments in cardiovascular disease research. Every $1 invested in cardiovascular disease research by public or charitable sources yields a stream of benefits of roughly $0.21 to the Canadian economy per year, in perpetuity.

Stem cell treatment for acute myocardial infarction

BACKGROUND

Stem cell therapy offers a promising approach to the regeneration of damaged vascular and cardiac tissue after acute myocardial infarction (AMI). This has resulted in multiple randomised controlled trials (RCTs) worldwide.

OBJECTIVES

To critically evaluate evidence from RCTs on the effectiveness of adult bone marrow-derived stem cells (BMSC) to treat acute myocardial infarction (AMI).

SEARCH METHODS

This Cochrane review is an update of a previous one (published in 2008). MEDLINE (1950 to January 2011), EMBASE (1974 to January 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1, 2011), CINAHL (1982 to January 2011) and the Transfusion Evidence Library (1980 to January 2011) were searched. In addition, several international and ongoing trial databases were searched and handsearching of relevant conference proceedings undertaken to January 2011.

SELECTION CRITERIA

RCTs comparing autologous stem/progenitor cells with no autologous stem/progenitor cells in patients diagnosed with AMI were eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently screened all references, assessed trial quality and extracted data. Meta-analyses using a random-effects model were conducted and heterogeneity was explored for the primary outcome using sub-group analyses.

MAIN RESULTS

Thirty-three RCTs (1765 participants) were eligible for inclusion. Stem/progenitor cell treatment was not associated with statistically significant changes in the incidence of mortality (RR 0.70, 95% CI 0.40 to 1.21) or morbidity (the latter measured by re-infarction, hospital re-admission, restenosis and target vessel revascularisation). A considerably high degree of heterogeneity has been observed among the included trials. In short-term follow up, stem cell treatment was observed to improve left ventricular ejection fraction (LVEF) significantly (WMD 2.87, 95% CI 2.00 to 3.73). This improvement in LVEF was maintained over long-term follow up of 12 to 61 months (WMD 3.75, 95% CI 2.57 to 4.93). With certain measurements and at certain times, stem cell treatment was observed to reduce left ventricular end systolic and end diastolic volumes (LVESV & LVEDV) and infarct size significantly in long-term follow up. There was a positive correlation between mononuclear cell dose infused and the effect on LVEF measured by magnetic resonance imaging. A correlation between timing of stem cell treatment and effect on LVEF measured by left ventricular angiography was also observed.

AUTHORS' CONCLUSIONS

Despite the high degree of heterogeneity observed, the results of this systematic review suggest that moderate improvement in global heart function is significant and sustained long-term. However, because mortality rates after successful revascularization of the culprit arteries are very low, larger number of participants would be required to assess the full clinical effect of this treatment. Standardisation of methodology, cell dosing and cell product formulation, timing of cell transplantation and patient selection may also be required in order to reduce the substantial heterogeneity observed among the included studies.

Identifying opportunities for a medical group to improve outcomes for patients with coronary artery disease and heart failure: an exploratory study

CONTEXT

A decision-support tool was created to identify opportunities to improve outcomes for patients with coronary artery disease and heart failure by delivering all efficacious interventions; that is, "optimizing" care. When national data were applied, nearly 75% of the deaths that could be prevented or postponed by optimizing care for patients with heart disease would occur among ambulatory patients.

OBJECTIVE

The purpose of this analysis is two-fold: 1) to determine whether medical group data are adequate to use in the decision-support tool, and 2) to determine whether the conclusions generated from the medical group data are similar to the conclusions generated from US data. DESIGN/MAIN OUTCOME MEASURE: The potential impact of optimizing care for patients age 40 to 75 years treated for coronary artery disease and heart failure by a multispecialty group between August 2007 and July 2008 was calculated using deaths that might be prevented or postponed if optimal care was achieved.

RESULTS

The greatest opportunity to prevent or postpone deaths-70% of the total opportunity-lies with optimizing care for ambulatory patients. Optimizing care for patients hospitalized for acute myocardial infarction with or without ST-segment elevation on electrocardiography would prevent or postpone only 2% of deaths.

CONCLUSIONS

This study demonstrates that 1) it is feasible to use the decision-support tool to analyze opportunities for improvement in a medical group, and 2) as concluded from national data analysis, optimizing ambulatory care presents the greatest opportunity to improve outcomes for patients with heart disease.

Geographic variations in percutaneous coronary interventions and coronary artery bypass graft surgery among Tennessee elders

OBJECTIVES

Coronary heart disease often presents with ST segment elevation acute myocardial infarction (STEMI). The American College of Cardiology/American Heart Association guidelines stress prompt reperfusion for STEMI. Examining geographic variations in treatment with PPCI (percutaneous primary coronary intervention) and CABG (coronary artery bypass graft) among metropolitan, micropolitan and non-micropolitan rural residents provides a descriptive basis for generating hypotheses concerning place and receipt of guidelines-based treatment.

METHODS

Using ICD-9 codes for STEMI and excluding beneficiaries with pre-existing MI in claims data, yielded a subset of 18,775 Tennessee Medicare beneficiaries experiencing STEMI from 1996 to 2002. The outcome variable is type of treatment, i.e., in accord (PPCI or CABG present) or not in accord (PPCI or CABG absent) with guidelines. Independent variables include type county residence, hospital volume, race, gender, and age. Analyses include cross-tabulation and logistic regression, estimating separate models by age and type of MI.

RESULTS

Micropolitan residents with STEMI have the lowest rates for PPCI (18.8%) versus 28.1% percent for metropolitan and 24.2% for non-micropolitan rural residents. CABG follows similar patterns at lower overall rates. Treatment at a heart center with high volume PPCI mediated the relationship between the likelihood of PPCI and place.

CONCLUSION

The correspondence between metropolitan and rural utilization suggests that access to a full range of treatment options and likelihood of "best practice" care is not dependent on metropolitan residence. This presents the possibility that with some policy changes, e.g., centralization of emergency heart care, the same may ultimately be true for micropolitan residents.

Management of acute coronary syndrome in a tertiary care general medical unit in Sri Lanka: how closely do we follow the guidelines?

BACKGROUND AND OBJECTIVES

Acute coronary syndrome (ACS) is a leading cause of death. Correct implementation of evidence-based guidelines should improve outcome. We conducted this study to determine to what extent management of ACS in a tertiary care medical ward in Sri Lanka adhered to current guidelines.

STUDY METHODS

This prospective observational study was carried out in the University Medical Unit of the National Hospital, Colombo, Sri Lanka, for a 5-month period commencing April 2008. All patients presenting with ACS to the unit were included.

RESULTS

During the period of study, there were 101 admissions of confirmed ACS. Thirty-one (30.6%) and 40 (39.6%) patients had not received the required correct loading dose of aspirin and clopidogrel, respectively. There were 34 cases of ST-elevation myocardial infarction (STEMI); 26 patients were eligible for thrombolysis and streptokinase was given to 22 (84.6%). The rest were treated with low-molecular-weight heparin (LMWH). Of the 67 patients who did not have STEMI, 66 received the correct dose of LMWH. Fifty-two patients (51.4%) were started on a b-blocker at presentation. None of the patients received intravenous b-blockers. Seventy-four patients (73.2%) were started on either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker on presentation. None of the patients underwent primary percutaneous intervention.

CONCLUSION

Adherence to guidelines is limited by lack of funds and resources in our setting; however, attention must be paid to non-costly easily correctable deficits.

Are adverse effects incorporated in economic models? A survey of current practice

Background: Clearly the benefits of a treatment must not be outweighed by the adverse effects. If researchers fail to incorporate adverse effects adequately in models, this could limit the validity of the results obtained. In the worst case, interventions that are cost-effective may be shown not to be. The aim of this research was to review current practice when incorporating adverse effects in economic models.

Methods: A survey of HTA reports commissioned by the National Institute for Health Research (NIHR) Health Technology Assessment programme, published between 2004 and 2007 was conducted. All reports which investigated the clinical and cost-effectiveness of a health technology using a systematic review and an economic model framework were included.

Results: A total of eighty reports met the inclusion criteria. Of the models including adverse effects (43/80), 67 percent used a clinical adverse effects parameter, 79 percent a cost of adverse effects parameter, 86 percent used one of these, and 60 percent used both. Of the thirty-seven models that did not include adverse effects, eighteen justified this omission, most commonly lack of data; nineteen appeared to make no explicit consideration of adverse effects in the model.

Conclusions: In many cases, poor reporting made it difficult to ascertain if there had been any consideration of adverse effects. We suggest that the findings of this survey support a call for much clearer and explicit reporting of adverse effects, or their exclusion, in decision models and for explicit recognition in future guidelines that “all relevant outcomes” should include some consideration of adverse events.

The comparative effectiveness of heart disease prevention and treatment strategies

BACKGROUND

Policymakers must be able to calculate the comparative effectiveness of interventions to control heart disease if they are to optimize the population impact of programmatic initiatives.

METHODS

A model was created to calculate the number of deaths that would be prevented or postponed if perfect care for heart disease prevention and treatment were achieved--that is, the elimination of risk factors and the prescription of all effective medications before and between acute events, and the delivery of all effective therapies to individuals suffering an acute heart disease event. The impact of perfect care was calculated for a hypothetic population aged 30-84 years with risk-factor levels, event rates, current patterns of behavior, levels of treatment, and mortality rates resembling those of the U.S. The analysis was performed in 2007 and 2008.

RESULTS

In this population, 44% of all deaths were due to heart disease. Perfect care before the first heart disease event would prevent or postpone 33% of all deaths. Perfect care between acute events would prevent or postpone 23% of all deaths. Perfect care during acute events would prevent or postpone 8% of all deaths.

CONCLUSIONS

This direct comparison of heart disease prevention and treatment strategies indicates that nearly 90% of the impact from perfect care for heart disease would accrue from interventions before and between acute events. The impact of risk-factor interventions before or between events is amplified by the fact that these interventions also reduce the risk of death from other chronic diseases.

Stem cell treatment for acute myocardial infarction

BACKGROUND

Stem cell therapy offers a promising approach to the regeneration of damaged vascular and cardiac tissue after myocardial infarction (MI). This has resulted in multiple randomised controlled trials (RCTs) worldwide.

OBJECTIVES

To critically evaluate evidence from RCTs on the effectiveness of adult bone marrow-derived stem cells (BMSC) to treat acute MI.

SEARCH STRATEGY

MEDLINE (1950 to August 2007), EMBASE (1974 to August 2007), The Cochrane Library (Issue 3 2007), and CINAHL (1982 to August 2007) were searched. In addition LILACS, KOREAMED, INMED, Current Controlled Trials Register, the UK National Research Register and other handsearching was undertaken to August 2007.

SELECTION CRITERIA

RCTs comparing autologous stem/progenitor cells with no autologous stem/progenitor cells in patients diagnosed with acute myocardial infarction (AMI) were eligible.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened all references, assessed trial quality and extracted data. Meta-analyses using a random-effects model were conducted and heterogeneity was explored using sub-group analyses.

MAIN RESULTS

Thirteen RCTs (811 participants) were included. There were insufficient events on clinical outcomes like mortality to draw clear conclusions. Stem/progenitor cell treatment does not appear to be associated with an increase in adverse events but again the data do not allow clear conclusions. Left ventricular ejection fraction (LVEF) was the outcome with most results and there was marked heterogeneity between trials. There was however a consistent pattern indicating that BMSC treatment generally improves short-term LVEF, with similar trends for left ventricular end systolic and end diastolic volumes (LVESV and LVEDV), infarct size or cardiac wall motion. There was a positive correlation between cell dose infused and the effect on LVEF measured by magnetic resonance imaging.

AUTHORS' CONCLUSIONS

The results of this systematic review suggest that there is little evidence to assess the clinical effects of this treatment. Larger trials using optimal dosing and more reliable, patient-centred outcomes are required. Several trials are ongoing but is unclear whether these will overcome the limitations of the current evidence base.

The cost-effectiveness of thrombolysis administered by paramedics

OBJECTIVE

The objective of this study is to estimate the expected health outcomes, costs and cost-effectiveness of changing from current practice, where thrombolytic therapy is given in hospital, to paramedic practice where thrombolytic therapy is administered by appropriately trained paramedics (pre-hospital) for STEMI patients.

METHODS

A decision-analysis microsimulation model was constructed with a 30-day component and a long-term health state transition component. A brief review of the literature was undertaken to obtain data on time-to-needle to populate the model. The primary health outcome was quality-adjusted life years (QALYs); secondary outcomes included cardiac events, procedures and survival. Costs to the Australian healthcare system for the rest of life were taken as the analytical perspective.

RESULTS

On average, STEMI patients gain 0.13 QALYs at an additional life-time cost of $343. The incremental cost-effectiveness ratios were $3428 per life-year gained and $2601 per QALY gained. These estimates were robust to changes in a range of assumptions and parameter values. The most important factor was the time-to-needle - the greater the difference between current practice times and paramedic practice times, the greater the health benefits and lower the cost per QALY (and life-year) gained. A key factor in the model was the substantially lower incidence of heart failure from earlier time-to-needle. Importantly, there was little change in the cost per QALY gained for a wide range of ages; thus, there is no argument to limit thrombolysis by paramedics to above or below an age threshold.

CONCLUSIONS

Paramedics administering thrombolysis can avert some STEMI deaths and the pre-hospital administration of thrombolysis is good value for money.

Costs of an early intervention versus a conservative strategy in acute coronary syndrome

BACKGROUND

The Randomised Intervention Treatment of unstable Angina (RITA-3) found that non-ST-elevation myocardial infarction and unstable angina patients randomised to routine early arteriography experienced a lower rate of death or myocardial infarction than patients randomised to conservative therapy over a five year period of follow up. This paper uses data from the RITA-3 trial to compare the health service costs of the two strategies.

METHODS

The resource use data included initial arteriography and revascularisation procedures in the early intervention group and subsequently in both groups; in-patient days in hospital for any reason in the first year of follow-up; incidence of myocardial infarction; and cardiac medication.

RESULTS

After five years, the early intervention arm accrued a total mean cost of pound sterling 11,340 (euro 15,592) and the conservative arm a mean of pound sterling 9749(euro 13,405), an additional mean cost in the intervention arm of pound sterling 1591 (95% CI pound sterling 851 to pound sterling 2276) (euro 2188; 95%CI euro 1160 to euro 3228). On average, costs increased with age and were higher in male patients and in patients with severe angina. However, the incremental cost of the intervention strategy was consistent across different patient sub-groups.

CONCLUSION

Over a period of 5 years, the initial additional cost of a strategy of early intervention is only partially offset by subsequent interventions in patients managed conservatively.

Is primary angioplasty cost effective in the UK? Results of a comprehensive decision analysis

OBJECTIVE

To assess the cost effectiveness of primary angioplasty, compared with medical management with thrombolytic drugs, to achieve reperfusion after acute myocardial infarction (AMI) from the perspective of the UK NHS.

DESIGN

Bayesian evidence synthesis and decision analytic model.

METHODS

A systematic review was conducted and Bayesian statistical methods used to synthesise evidence from 22 randomised control trials. Resource utilisation was based on UK registry data, published literature and national databases, with unit costs taken from routine NHS sources and published literature.

MAIN OUTCOME MEASURE

Costs from a health service perspective and outcomes measured as quality-adjusted life years (QALYs).

RESULTS

For the base case, the incremental cost-effectiveness ratio of primary angioplasty was 9241 pounds sterling for each additional QALY, with a probability of being cost effective of 0.90 for a cost-effectiveness threshold of 20,000 pounds sterling. Results were sensitive to variations in the additional time required to initiate treatment with primary angioplasty.

CONCLUSIONS

Primary angioplasty is cost effective for the treatment of AMI on the basis of threshold cost-effectiveness values used in the NHS and subject to a delay of up to about 80 minutes. These findings are mainly explained by the superior mortality benefit and the prevention of non-fatal outcomes associated with primary angioplasty for delays of up to this length.

Letalidade hospitalar nas angioplastias coronárias no Estado do Rio de Janeiro, Brasil, 1999-2003

O estudo analisa a letalidade hospitalar nas angioplastias coronárias, pagas pelo Sistema Único de Saúde (SUS), realizadas nos hospitais do Estado do Rio de Janeiro, Brasil, de 1999 até 2003. As informações sobre as angioplastias coronárias provieram do banco de Autorizações de Internações Hospitalares da Secretaria de Estado de Saúde do Estado do Rio de Janeiro. As taxas de letalidade foram estimadas segundo faixas etárias, sexo, diagnósticos e hospitais. A letalidade geral foi de 1,9% em 8.735 angioplastias coronárias. A taxa mais baixa ocorreu nas anginas (0,8%), as mais elevadas nos infartos agudos do miocárdio (6%) e em outros diagnósticos (7%). A letalidade foi menor nas mulheres na faixa etária entre 50 e 69 anos, e a partir dos setenta anos foi quase três vezes maior que a dos mais jovens (de 1,4 a 4%), em ambos os sexos. Ocorreu grande variabilidade entre as taxas de letalidade nas angioplastias coronárias nos diferentes hospitais (entre 0 e 6,5%). Portanto, é necessário acompanhar de modo contínuo a adequação da utilização da angioplastia coronária. Em conclusão, a performance deste procedimento no âmbito da modalidade de atenção pelo SUS nos hospitais, dentro do período estudado, não foi satisfatória.

Interventional cardiology in Israel at 2005 - state of practice

OBJECTIVE

To assess the current practice of interventional cardiology in Israel.

METHOD

Under the auspices of the 'Working group of interventional cardiology' of the 'Israel Heart Society,' a questionnaire regarding the practice of interventional cardiology sent to directors of interventional cardiology in all public hospitals.

RESULTS

Twenty centers received the questionnaires; however, complete data was obtained from 18. Most interventional cardiology units in Israel are merely engaged in percutaneous coronary interventions (PCIs). PCIs are executed mostly via the femoral artery, using almost exclusively stents, of which 36% were drug eluting. Noted was an infrequent use of other therapeutic, diagnostic devices, or femoral arteriotomy closure devices. Only 22% of the patients receive glycoprotein IIb/IIIa blockers (GPB). Most centers used conventional unfractionated heparin dosing (70 u/kg) and did not routinely monitor activated clotting time. Abciximab, bivalirudin or enoxaparine were rarely used. All laboratories performed both elective and emergency-PCI, although 12 facilities were not supported by on-site surgical backup.

CONCLUSION

Most cardiovascular intervention programs have restricted their activity to the coronary stenting, and are using a limited array of diagnostic and therapeutic devices, along with patient-tailored adjunctive pharmacotherapy, to sustain cost-effectiveness. Currently, ambulatory angiography and coronary interventions are not widely practiced in Israel.