1
|
O'Brien JM, Dinh D, Roberts L, Teh A, Brennan A, Duffy SJ, Clark D, Ajani A, Oqueli E, Sebastian M, Reid C, Econ CH, Freeman M, Chandrasekhar J. Associations Between Metabolic Syndrome and Long-Term Mortality in Patients who underwent Percutaneous Coronary Intervention: An Australian Cohort Analysis. Am J Cardiol 2024; 219:25-34. [PMID: 38447892 DOI: 10.1016/j.amjcard.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 02/06/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
Metabolic syndrome (MetS) provides significant risk for coronary disease, however long-term prognosis after percutaneous coronary intervention (PCI) has been understudied. We assessed the prevalence and outcomes of patients with MetS from an Australian PCI cohort. We retrospectively examined data from the Melbourne Interventional Group multicenter PCI registry using a modified definition for MetS including ≥3 of the following: hypertension, diabetes mellitus, dyslipidemia, and body mass index ≥30 kg/m2. Thirty-day outcomes and long-term mortality were compared with patients without MetS. Cox regression methods were used to assess the multivariable effect of MetS on long-term mortality. Of 41,146 patients, 12,228 (34%) had MetS. Patients with MetS experienced greater 30-day myocardial infarction (2.2% vs 1.8%, p = 0.013), whereas patients without MetS had a trend for greater 30-day mortality (3.0% vs 3.4%, p = 0.051) and greater in-hospital major bleeding (1.7% vs 2.4%, p <0.001). After a median follow-up of 5.62 years (Q1 2.03, Q3 8.89), patients with MetS experienced greater mortality (24% vs 19%, p <0.001). After adjustment, MetS was not an independent predictor of long-term mortality (hazard ratio 0.95 confidence interval 0.86 to 1.05, p = 0.35). In sensitivity analyses, MetS-Diabetic patients had the highest, and MetS-NonDiabetic obese patients had the lowest long-term mortality. One in 3 patients who underwent all-comer PCI presented with MetS and experienced greater long-term mortality compared with others. However, this association was lost after adjustment for baseline confounders, highlighting that MetS is a marker of risk after PCI. Our findings support the obesity paradox and confirm robust associations between diabetes mellitus and long-term mortality.
Collapse
Affiliation(s)
- Joseph M O'Brien
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Andrew Teh
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine
| | - Stephen J Duffy
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine
| | - David Clark
- Department of Cardiology, Austin Health, Heidelberg, Victoria Australia; Department of Cardiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Service, Ballarat, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, University Hospital Geelong, Geelong, Victoria Australia
| | - Christopher Reid
- Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Cert Health Econ
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine; Royal Melbourne Hospital, Curtin University, Perth, Western Australia, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Jaya Chandrasekhar
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Victoria, Australia.
| |
Collapse
|
2
|
Dagan M, Dinh DT, Stehli J, Nan Tie E, Brennan A, Ajani AE, Clark DJ, Freeman M, Reid CM, Hiew C, Oqueli E, Kaye DM, Duffy SJ. Sex Differences in Pharmacotherapy and Long-Term Outcomes in Patients With Ischaemic Heart Disease and Comorbid Left Ventricular Dysfunction. Heart Lung Circ 2023; 32:1457-1464. [PMID: 37945426 DOI: 10.1016/j.hlc.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 06/07/2023] [Accepted: 09/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) are common among women. However, women tend to present later and are less likely to receive guideline-directed medical therapy (GDMT) compared with men. METHODS We analysed prospectively collected data (2005-2018) from a multicentre registry on GDMT 30 days after percutaneous coronary intervention in 13,015 patients with LV ejection fraction <50%. Guideline-directed medical therapy was defined as beta blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker±mineralocorticoid receptor antagonist. Long-term mortality was determined by linkage with the Australian National Death Index. RESULTS Women represented 20% (2,634) of the total cohort. Mean age was 65±12 years. Women were on average >5 years, with higher body mass index and higher rates of hypertension, diabetes, renal dysfunction, prior stroke, and rheumatoid arthritis. Guideline-directed medical therapy was similar between sexes (73% vs 72%; p=0.58), although women were less likely to be on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80% vs 82%; p=0.02). Women were less likely to be on statin therapy (p<0.001) or a second antiplatelet agent (p=0.007). Women had higher unadjusted long-term mortality (25% vs 19%; p<0.001); however, there were no differences in long-term mortality between sexes on adjusted analysis (hazard ratio 0.99; 95% confidence interval 0.87-1.14; p=0.94). CONCLUSIONS Rates of GDMT for LV dysfunction were high and similar between sexes; however, women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality in women was attenuated in adjusted analysis, which highlights the need for optimisation of baseline risk to improve long-term outcomes of women with IHD and comorbid LV dysfunction.
Collapse
Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia. http://www.twitter.com/misha_dagan
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Emilia Nan Tie
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Andrew E Ajani
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Population Health, Curtin University, Perth, WA, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia; School of Medicine, Deakin University, Melbourne, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Melbourne, Vic, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Vic, Australia.
| |
Collapse
|
3
|
Stehli J, Johnston R, Duffy SJ, Zaman S, Gusberti TDH, Dagan M, Stub D, Walton A. Waiting times of women vs. men undergoing transcatheter aortic valve implantation. Eur Heart J Qual Care Clin Outcomes 2023; 9:691-698. [PMID: 36460051 DOI: 10.1093/ehjqcco/qcac081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/26/2022] [Accepted: 11/30/2022] [Indexed: 11/08/2023]
Abstract
AIMS Increasing transcatheter aortic valve implantation (TAVI) rates have resulted in prolonged waiting times. These have been associated with heart failure hospitalizations (HFH) and mortality yet sex differences have not yet been reported. METHODS AND RESULTS All patients who underwent TAVI for severe aortic stenosis at a tertiary referral hospital in Australia were prospectively included. Total waiting time was divided into 'work-up' waiting time (period from referral date until heart team approval) and, 'procedural' waiting time (period from heart team approval until procedure date). Patients were analysed according to sex. Cohorts were matched to correct for differences in baseline and procedural variables. The primary endpoints were waiting times. Secondary outcomes included a composite of 30-day mortality and HFH, quality of life, and mobility. A total of 407 patients (42% women) were included. After matching of the two cohorts (345 patients), women had significantly longer total waiting times than men: median 156 [interquartile range (IQR) 114-220] days in women vs. 147 [IQR 92-204] days in men (P = 0.037) including longer work-up (83 [IQR 50-128] vs. 71 [IQR 36-119], P = 0.15) and procedural waiting times (65 [IQR 44-100] vs. 58 [IQR 30-93], P = 0.042). Increasing waiting times were associated with higher 30-day mortality and HFH (P = 0.01 for work-up waiting time, P = 0.02 for procedural waiting time) and decreased 30-day mobility (P = 0.044 for procedural waiting time) in women, but not in men. CONCLUSION TAVI waiting times are significantly longer in women compared to men and are associated with increased mortality and HFH and reduced mobility at 30-days.
Collapse
Affiliation(s)
- Julia Stehli
- Monash University, Faculty of Medicine, Nursing and Health Sciences, Clayton, VIC 3800, Australia
| | - Rozanne Johnston
- Department of Cardiology, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Sarah Zaman
- Department of Cardiology, Westmead Hospital, Sydney, Westmead, NSW 2145, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, Westmead, NSW 2145, Australia
| | | | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Hospital, Melbourne, VIC 3004, Australia
| |
Collapse
|
4
|
Warren J, Dinh D, Brennan A, Tan C, Dagan M, Stehli J, Clark DJ, Ajani AE, Reid CM, Sebastian M, Oqueli E, Freeman M, Stub D, Duffy SJ. Impact of Preprocedural Diastolic Blood Pressure on Outcomes in Patients Undergoing Percutaneous Coronary Intervention. Hypertension 2023; 80:2447-2454. [PMID: 37655489 DOI: 10.1161/hypertensionaha.123.20963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Recent US guidelines recommend lower blood pressure (BP) targets in hypertension, but aggressive lowering of diastolic BP (DBP) can occur at the expense of myocardial perfusion, particularly in the presence of coronary artery disease. We sought to establish the long-term impact of low DBP on mortality among patients undergoing percutaneous coronary intervention with well-controlled systolic BP. METHODS We analyzed data from 12 965 patients undergoing percutaneous coronary intervention between 2009 and 2018 from the Melbourne Interventional Group registry who had a preprocedural systolic BP of ≤140 mm Hg. Patients with ST-elevation myocardial infarction, cardiogenic shock, and out-of-hospital arrest were excluded. Patients were stratified into 5 groups according to preprocedural DBP: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 mm Hg. The primary outcome was long-term, all-cause mortality. Mortality data were derived from the Australian National Death Index. RESULTS Patients with DBP<50 mm Hg were older with higher rates of diabetes, renal impairment, prior myocardial infarction, left ventricular dysfunction, peripheral and cerebrovascular disease (all P<0.001). Patients with DBP<50 mm Hg had higher 30-day (2.5% versus 0.7% for the other 4 quintiles; P<0.0001) and long-term mortality (median, 3.6 years; follow-up, 29% versus 11%; P<0.0001). Cox-regression analysis revealed that DBP<50 mm Hg was an independent predictor of long-term mortality (hazard ratio [HR], 1.55 [95% CI, 1.20-2.00]; P=0.001). CONCLUSIONS In patients with well-controlled systolic BP undergoing percutaneous coronary intervention, low DBP (<50 mm Hg) is an independent predictor of long-term mortality.
Collapse
Affiliation(s)
- Josephine Warren
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Christianne Tan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
| | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
- University Hospital, Zurich, Switzerland (J.S.)
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Australia (D.J.C.)
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia (A.E.A.)
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, Geelong, Australia (M.S.)
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health Ballarat, Australia (E.O.)
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia (E.O.)
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia (M.F.)
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (J.W., C.T., M.D., J.S., D.S.)
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (D.D., A.B., C.M.R., D.S., S.J.D.)
| |
Collapse
|
5
|
Rajakariar K, Andrianopoulos N, Gayed D, Liang D, Backhouse B, Ajani AE, Duffy SJ, Brennan A, Roberts L, Reid CM, Oqueli E, Clark D, Freeman M. Outcomes of thrombus aspiration during primary percutaneous coronary intervention for ST-elevation myocardial infarction. Intern Med J 2023; 53:1376-1382. [PMID: 35670161 DOI: 10.1111/imj.15828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). AIM To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI. METHODS We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality. RESULTS We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73). CONCLUSION The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.
Collapse
Affiliation(s)
- Kevin Rajakariar
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Nick Andrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel Gayed
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Danlu Liang
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Brendan Backhouse
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Noaman S, Kaye DM, Nanayakkara S, Dart AM, Yong ASC, Ng M, Vizi D, Duffy SJ, Cox N, Chan W. Haemodynamic and metabolic adaptations in coronary microvascular disease. Heart 2023; 109:1166-1174. [PMID: 36931716 DOI: 10.1136/heartjnl-2022-322156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/06/2023] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the microcirculatory resistance (MR) and myocardial metabolic adaptations at rest and in response to increased cardiac workload in patients with suspected coronary microvascular dysfunction (CMD). METHODS Patients with objective ischaemia and/or myocardial injury and non-obstructive coronary artery disease underwent thermodilution-derived microcirculatory assessment and transcardiac blood sampling during graded exercise with adenosine-mediated hyperaemia. We measured MR at rest and following supine cycle ergometry. Patients (n=24) were stratified by the resting index of MR (IMR) into normal-IMR (IMR<22U, n=12) and high-IMR groups (IMR≥22U, n=12). RESULTS The mean age was 57 years; 67% were males and 38% had hypertension. The normal-IMR group had increased IMR response to exercise (16±5 vs 23±12U, p=0.03) compared with the high-IMR group, who had persistently elevated IMR at rest and following exercise (38±19 vs 33±15U, p=0.39) despite similar exercise duration and rate-pressure product between the groups, both p>0.05. The normal-IMR group had augmented oxygen extraction ratio following exercise (53±18 vs 64±11%, p=0.03) compared with the high-IMR group (65±14 vs 59±11%, p=0.26). The postexercise lactate uptake was greater in the high-IMR (0.04±0.05 vs 0.11±0.07 mmol/L, p=0.004) compared with normal-IMR group (0.08±0.06 vs 0.09±0.09 mmol/L, p=0.67). The high-IMR group demonstrated greater troponin release following exercise compared with the normal-IMR group (0.13±0.12 vs 0.001±0.05 ng/L, p=0.03). CONCLUSIONS Patients with suspected CMD appear to have distinctive microcirculatory resistive and myocardial metabolic profiles at rest and in response to exercise. These differences in phenotypes may permit individualised therapies targeting microvascular responsiveness (normal-IMR group) and/or myocardial metabolic adaptations (normal-IMR and high-IMR groups).
Collapse
Affiliation(s)
- Samer Noaman
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Western Health, Footscray, Victoria, Australia
| | - David M Kaye
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Anthony M Dart
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Andy S C Yong
- Cardiology, Concord Hospital, Sydney, New South Wales, Australia
| | - Martin Ng
- Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Donna Vizi
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | | | | | - William Chan
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Nan Tie E, Dinh D, Chan W, Clark DJ, Ajani AE, Brennan A, Dagan M, Cohen N, Oqueli E, Freeman M, Hiew C, Shaw JA, Reid CM, Kaye DM, Stub D, Duffy SJ. Trends in Intra-Aortic Balloon Pump Use in Cardiogenic Shock After the SHOCK-II Trial. Am J Cardiol 2023; 191:125-132. [PMID: 36682080 DOI: 10.1016/j.amjcard.2022.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/10/2022] [Accepted: 12/18/2022] [Indexed: 01/21/2023]
Abstract
Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularization. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the IABP-SHOCK-II (Intra-aortic Balloon Pump in Cardiogenic Shock-II study) trial found no survival benefit. We aimed to determine the trends in IABP use in patients who underwent percutaneous intervention over time. Data were taken from patients in the Melbourne Interventional Group registry (2005 to 2018) with MI-CS who underwent percutaneous intervention. The primary outcome was the trend in IABP use over time. The secondary outcomes included 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCEs). Of the 1,110 patients with MI-CS, IABP was used in 478 patients (43%). IABP was used more in patients with left main/left anterior descending culprit lesions (62% vs 46%), lower ejection fraction (<35%; 18% vs 11%), and preprocedural inotrope use (81% vs 73%, all p <0.05). IABP use was associated with higher bleeding (18% vs 13%) and 30-day MACCE (58% vs 51%, both p <0.05). The rate of MI-CS per year increased over time; however, after 2012, there was a decrease in IABP use (p <0.001). IABP use was a predictor of 30-day MACCE (odds ratio 1.6, 95% confidence interval 1.18 to 2.29, p = 0.003). However, IABP was not associated with in-hospital, 30-day, or long-term mortality (45% vs 47%, p = 0.44; 46% vs 50%, p = 0.25; 60% vs 62%, p = 0.39). In conclusion, IABP was not associated with reduced short- or long-term mortality and was associated with increased short-term adverse events. IABP use is decreasing but is predominately used in sicker patients with greater myocardium at risk.
Collapse
Affiliation(s)
- Emilia Nan Tie
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - William Chan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Naomi Cohen
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat Central, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Box Hill, Australia
| | - Chin Hiew
- Department of Cardiology, Geelong Hospital, Geelong, Australia
| | - James A Shaw
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia.
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | | |
Collapse
|
8
|
Gao L, Nguyen D, Moodie M, Brennan A, Dinh D, Reid C, Duffy SJ, Clark DJ, Hiew C, Oqueli E, Stub D, Ajani A. Corrigendum to 'Temporal Change in the Remaining Life Expectancy in People Who Underwent Percutaneous Coronary Intervention' The American Journal of Cardiology Volume 187, 15 January 2023, Pages 154-161. Am J Cardiol 2023; 190:125. [PMID: 36634597 DOI: 10.1016/j.amjcard.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia.
| | - Dieu Nguyen
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Christopher Reid
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, the University of Melbourne, Melbourne, Victoria, Australia
| | - Chin Hiew
- University Hospital Geelong at Barwon Health, Geelong, Victoria, Australia; Deakin Medical School, Deakin University, Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Deakin Medical School, Deakin University, Geelong, Victoria, Australia; Cardiology Department, Ballarat Health Services, Ballarat, Victoria
| | - Dion Stub
- Alfred Hospital, Melbourne, Victoria, Australia; Monash University, Melbourne, Victoria, Australia; Baker IDI Heart Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Victorian Heart Institute Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Hamilton GW, Dinh D, Yeoh J, Brennan AL, Fulcher J, Koshy AN, Yudi MB, Reid CM, Hare DL, Freeman M, Stub D, Chan W, Duffy SJ, Ajani A, Raman J, Farouque O, Clark DJ. Characteristics of Radial Artery Coronary Bypass Graft Failure and Outcomes Following Subsequent Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:457-467. [PMID: 36858666 DOI: 10.1016/j.jcin.2022.11.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND When patients with prior coronary artery bypass grafting (CABG) undergo percutaneous coronary intervention (PCI), targeting the native vessel is preferred. Studies informing such recommendations are based predominantly on saphenous vein graft (SVG) PCI. There are few data regarding arterial graft intervention, particularly to a radial artery (RA) graft. OBJECTIVES The aim of this study was to report the characteristics of arterial graft stenoses and evaluate the feasibility of RA PCI. METHODS This study included 2,780 consecutive patients with prior CABG undergoing PCI between 2005 and 2018 who were prospectively enrolled in the MIG (Melbourne Interventional Group) registry. Data were stratified by PCI target vessel. RA graft PCI was compared with both native vessel (native PCI) and SVG PCI. Internal mammary graft PCI data were reported. The primary outcome was 3-year mortality. RESULTS Overall, 1,928 patients (69.4%) underwent native PCI, 716 (25.6%) SVG PCI, 86 (3.1%) RA PCI, and 50 (1.8%) internal mammary graft PCI. Compared with SVG PCI, the RA PCI cohort presented earlier after CABG, less frequently had acute coronary syndrome, and more commonly had ostial or distal anastomosis intervention (P < 0.005 for all). Compared with patients who underwent native PCI, those who underwent RA PCI were more likely to have diabetes and peripheral vascular disease (P < 0.001 for both) and to present with non-ST-segment elevation myocardial infarction (P = 0.010). The RA PCI group had no perforations or in-hospital myocardial infarctions, though no significant difference was found in periprocedural outcomes compared with either native or SVG PCI. No differences were found between RA PCI and either native or SVG PCI in 30-day outcomes or 3-year mortality. CONCLUSIONS Presenting and lesion characteristics differed between patients undergoing arterial compared with SVG PCI, implying a varied pathogenesis of graft stenosis. RA PCI appears feasible, safe, and where anatomically suitable, may be a viable alternative to native PCI.
Collapse
Affiliation(s)
- Garry W Hamilton
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia. https://twitter.com/GarryHamilton6
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Jordan Fulcher
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia; School of Population Health, Curtin University, Perth, Australia
| | - David L Hare
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - William Chan
- Department of Medicine, University of Melbourne, Melbourne, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Jaishankar Raman
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia.
| | | |
Collapse
|
10
|
Šeman M, Stephens AF, Walton A, Duffy SJ, McGiffin D, Nanayakkara S, Kaye DM, Gregory SD, Stub D. Impact of Concomitant Mitral Regurgitation on the Hemodynamic Indicators of Aortic Stenosis. J Am Heart Assoc 2023; 12:e025648. [PMID: 36789874 PMCID: PMC10111497 DOI: 10.1161/jaha.122.025648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background In patients with aortic stenosis (AS), the presence of mitral regurgitation (MR) can lead to underestimation of AS severity and worse clinical outcomes. The objective of this study was to characterize the magnitude of the effects of concomitant MR on hemodynamic indicators of AS severity using clinical data and a computational cardiovascular simulation. Methods and Results Echocardiographic data from 1427 patients with severe AS were used to inform a computational cardiovascular system model, and varying degrees of MR and AS were simulated. Hemodynamic data, including left ventricular and aortic pressure waveforms, were generated for all simulations. Simulated reduction in mean transaortic pressure gradient (MPG) associated with MR was then used to calculate the adjusted MPG in the clinical cohort. MR was present in 861 (60%) patients. Compared with patients without MR, patients with MR had a lower aortic-valve area (0.83±0.2 cm2 versus 0.75±0.2; P<0.001) and were more likely to have a low-gradient pattern (MPG <40 mm Hg) (45% versus 54%; P<0.001). Simulations showed that the presence of concomitant mild, moderate, and severe MR with AS was accompanied by a mean reduction in MPG of 10%, 29%, and 40%, respectively. For patients with MR, their calculated adjusted MPG was on average 24% higher than their MPG (52±22 versus 42±16 mm Hg). Of the 467 patients with low-gradient AS and MR, 240 (51%) would reclassify as high gradient based on their adjusted MPG. Conclusions Concomitant MR results in lower MPG and reduced forward flow compared with isolated AS. Careful quantitation of MR should be factored into the assessment of AS severity to mitigate for potential underestimation.
Collapse
Affiliation(s)
- Michael Šeman
- School of Public Health and Preventative Medicine Monash University Melbourne Australia.,Cardio-Respiratory Engineering and Technology Laboratory Baker Heart and Diabetes Institute Melbourne Australia.,Department of Cardiology - Alfred Health Melbourne Australia
| | - Andrew F Stephens
- Cardio-Respiratory Engineering and Technology Laboratory Baker Heart and Diabetes Institute Melbourne Australia.,Department of Mechanical and Aerospace Engineering Monash University Melbourne Australia
| | - Antony Walton
- Department of Cardiology - Alfred Health Melbourne Australia.,Baker IDI Heart and Diabetes Institute and Alfred Hospital Melbourne Australia.,School of Medicine, Monash University Melbourne Australia
| | - Stephen J Duffy
- School of Public Health and Preventative Medicine Monash University Melbourne Australia.,Department of Cardiology - Alfred Health Melbourne Australia.,Baker IDI Heart and Diabetes Institute and Alfred Hospital Melbourne Australia
| | - David McGiffin
- Cardio-Respiratory Engineering and Technology Laboratory Baker Heart and Diabetes Institute Melbourne Australia.,School of Medicine, Monash University Melbourne Australia.,Department of Cardiothoracic Surgery - Alfred Health Melbourne Australia
| | - Shane Nanayakkara
- Department of Cardiology - Alfred Health Melbourne Australia.,Baker IDI Heart and Diabetes Institute and Alfred Hospital Melbourne Australia.,School of Medicine, Monash University Melbourne Australia
| | - David M Kaye
- Cardio-Respiratory Engineering and Technology Laboratory Baker Heart and Diabetes Institute Melbourne Australia.,Department of Cardiology - Alfred Health Melbourne Australia.,Baker IDI Heart and Diabetes Institute and Alfred Hospital Melbourne Australia.,School of Medicine, Monash University Melbourne Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory Baker Heart and Diabetes Institute Melbourne Australia.,Department of Mechanical and Aerospace Engineering Monash University Melbourne Australia
| | - Dion Stub
- School of Public Health and Preventative Medicine Monash University Melbourne Australia.,Cardio-Respiratory Engineering and Technology Laboratory Baker Heart and Diabetes Institute Melbourne Australia.,Department of Cardiology - Alfred Health Melbourne Australia.,Baker IDI Heart and Diabetes Institute and Alfred Hospital Melbourne Australia
| |
Collapse
|
11
|
Stehli J, Dagan M, Duffy SJ, Morisset S, Vriesendorp P, Nanayakkara S, Samuel Koh JQ, Quine E, Htun NM, Stub D, Dick R, Walton AS. Long-Term Valve Durability in Patients Undergoing Transcatheter Aortic Valve Implantation. Heart Lung Circ 2023; 32:240-246. [PMID: 36376193 DOI: 10.1016/j.hlc.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 08/20/2022] [Accepted: 10/09/2022] [Indexed: 11/13/2022]
Abstract
AIMS To evaluate the long-term incidence of structural valve deterioration (SVD) in patients who underwent transcatheter aortic valve implantation (TAVI). METHOD AND RESULTS Between 2008 and 2018, 693 underwent TAVI at two centres. Four hundred and twenty-one (421) patients (mean age 83.6±6.0 yrs) survived for ≥2 years post TAVI and had at least two consecutive transthoracic echocardiographies (TTEs) with the latest TTE no less than 2 years after TAVI, and were therefore included in the analysis for SVD. Median follow-up was 4.7 (3.6-6.0) years and median echocardiography follow-up 3 (3.0-4.0) years. All-cause mortality was 30.9% (130) with a median time to death of 4.1 (3.0-5.6) years. The cumulative incidence of SVD increased from 1.7% (95% CI, 0.4-2.9) at 3 years to 3.5% (95% CI, 1.5-5.8) at 5 years and 4.7% (95% CI, 1.6-7.9) at 10 years. The overall median time to SVD was 3 (2-4) years. Twelve (12) patients demonstrated SVD stage 2, and 1 patient stage 3. No SVD required re-intervention. All other patients showed no significant changes in valve parameters over time. CONCLUSIONS Structural valve deterioration is an uncommon event, occurring in 5% over a total follow-up of 10 years. Most patients show stable valve parameters. However, the analysis is limited by the loss of follow-up (owing to patient mortality), which renders extrapolation of the data to a younger patient population difficult.
Collapse
Affiliation(s)
- Julia Stehli
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Cardiovascular Institute, Epworth Healthcare, Melbourne, Vic, Australia; School of Clinical Sciences at Monash Health, Monash Cardiovascular Research Centre, Monash University, Melbourne, Vic, Australia
| | - Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia
| | | | | | - Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia
| | | | - Edward Quine
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Nay M Htun
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Ron Dick
- Cardiovascular Institute, Epworth Healthcare, Melbourne, Vic, Australia
| | - Antony S Walton
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Cardiovascular Institute, Epworth Healthcare, Melbourne, Vic, Australia.
| |
Collapse
|
12
|
Reid CM, Chih H, Duffy SJ, Brennan AL, Ajani AE, Beltrame J, Tavella R, Yan BP, Dinh D, Chin CT, Do LD, Nguyen QN, Nguyen HTT, Wijaya IP, Yamin M, Rusdi L, Alwi I, Sim KH, Yip Fong AY, Wan Ahmad WA, Yeo KK. Harmonising Individual Patient Level Cardiac Registry Data Across the Asia Pacific Region-A Feasibility Study of In-Hospital Outcomes of STEMI Patients From the Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) Network. Heart Lung Circ 2023; 32:166-174. [PMID: 36272954 DOI: 10.1016/j.hlc.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 03/04/2023]
Abstract
OBJECTIVE The Asia-Pacific Evaluation of Cardiovascular Therapies (ASPECT) collaboration was established to inform on percutaneous coronary intervention (PCI) in the Asia-Pacific Region. Our aims were to (i) determine the operational requirements to assemble an international individual patient dataset and validate the processes of governance, data quality and data security, and subsequently (ii) describe the characteristics and outcomes for ST-elevation myocardial infarction (STEMI) patients undergoing PCI in the ASPECT registry. METHODS Seven (7) ASPECT members were approached to provide a harmonised anonymised dataset from their local registry. Patient characteristics were summarised and associations between the characteristics and in-hospital outcomes for STEMI patients were analysed. RESULTS Six (6) participating sites (86%) provided governance approvals for the collation of individual anonymised patient data from 2015 to 2017. Five (5) sites (83%) provided >90% of agreed data elements and 68% of the collated elements had <10% missingness. From the registry (n=12,620), 84% were male. The mean age was 59.2±12.3 years. The Malaysian cohort had a high prevalence of previous myocardial infarction (34%), almost twice that of any other sites (p<0.001). Adverse in-hospital outcomes were the lowest in Hong Kong whilst in-hospital mortality varied from 2.7% in Vietnam to 7.9% in Singapore. CONCLUSIONS Governance approvals for the collation of individual patient anonymised data was achieved with a high level of data alignment. Secure data transfer process and repository were established. Patient characteristics and presentation varied significantly across the Asia-Pacific region with this likely to be a major predictor of variations in the clinical outcomes observed across the region.
Collapse
Affiliation(s)
- Christopher M Reid
- School of Population Health, Curtin University, Perth, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia.
| | - HuiJun Chih
- School of Population Health, Curtin University, Perth, WA, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Andrew E Ajani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - John Beltrame
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Rosanna Tavella
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong SAR, China
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Chee Tang Chin
- National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | - Loi Doan Do
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Hoai T T Nguyen
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | - Ika Prasetya Wijaya
- Cipto Mangunkusumo National General Hospital, Universitas Indonesia Medical School, Jalan Pangeran Diponegoro, Jakarta, Indonesia
| | - Muhammad Yamin
- Cipto Mangunkusumo National General Hospital, Universitas Indonesia Medical School, Jalan Pangeran Diponegoro, Jakarta, Indonesia
| | - Lusiani Rusdi
- Cipto Mangunkusumo National General Hospital, Universitas Indonesia Medical School, Jalan Pangeran Diponegoro, Jakarta, Indonesia
| | - Idrus Alwi
- Cipto Mangunkusumo National General Hospital, Universitas Indonesia Medical School, Jalan Pangeran Diponegoro, Jakarta, Indonesia
| | - Kui Hian Sim
- Sarawak Heart Centre, Sarawak, Malaysia; National Heart Association of Malaysia, Kuala Lumpur, Malaysia
| | - Alan Yean Yip Fong
- Sarawak Heart Centre, Sarawak, Malaysia; National Heart Association of Malaysia, Kuala Lumpur, Malaysia
| | - Wan Azman Wan Ahmad
- National Heart Association of Malaysia, Kuala Lumpur, Malaysia; University of Malaya Medical Centre, Jalan Universiti, Selangor, Malaysia
| | - Khung Keong Yeo
- National Heart Centre Singapore, Singapore; Duke-NUS Medical School, Singapore
| | | |
Collapse
|
13
|
Noaman S, Neil C, O'Brien J, Frenneaux M, Hare J, Wang B, Yee Tai T, Theuerle J, Shaw J, Stub D, Bloom J, Walton A, Duffy SJ, Peter KH, Cox N, Kaye DM, Taylor A, Chan W. UpStreAm doxycycline in ST-eLeVation myocArdial infarction - targetinG infarct hEaling and ModulatIon (SALVAGE-MI trial). Eur Heart J Acute Cardiovasc Care 2022; 12:143-152. [PMID: 36567466 DOI: 10.1093/ehjacc/zuac161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/03/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Experimental studies demonstrate protective effects of doxycycline on myocardial ischemia-reperfusion injury. The trial investigated whether doxycycline administered prior to reperfusion in patients presenting with ST-elevation myocardial infarction (STEMI) reduces infarct size (IS) and ameliorates adverse left ventricular (LV) remodeling. METHODS In this randomized, double-blind, placebo-controlled trial, patients presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI) were randomized to either intravenous doxycycline or placebo prior to reperfusion followed by 7-days of oral doxycycline or placebo. The primary outcome was final IS adjusted for area-at-risk (fIS/AAR) measured on two cardiac magnetic resonance scans ∼6 months apart. RESULTS Of 103 participants, 50 were randomized to doxycycline and 53 to placebo and were matched for age (59 ± 12 vs. 60 ± 10 years), male sex (92% vs. 79%), diabetes mellitus (26% vs. 11%) and left anterior descending artery occlusion (50% vs. 49%), all p > 0.05. Patients treated with doxycycline had a trend for larger fIS/AAR (0.79 [0.5-0.9] vs. 0.61 [0.47-0.76], p = 0.06), larger fIS at 6 months (18.8% [12-26] vs. 13.6% [11-21], p = 0.08), but similar acute IS (21.7% [17-34] vs. 19.4% [14-27], p = 0.19) and AAR (26% [20-36] vs. 24.7% [16-31], p = 0.22) compared to placebo. Doxycycline did not ameliorate adverse LV remodeling (%Δend-diastolic volume index, 1.1% [-3.8-8.4] vs. -1.34% [-6.1-5.8], p = 0.42) and was independently associated with larger fIS (regression coefficient = 0.175, p = 0.03). CONCLUSION Doxycycline prior to PPCI neither reduced IS acutely or at 6 months nor attenuated adverse LV remodeling. These data raise safety concerns regarding doxycycline use in STEMI for infarct modulation and healing.
Collapse
Affiliation(s)
- Samer Noaman
- Department of Cardiology, Western Health, Victoria, Australia.,Department of Cardiology, Alfred Health, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Christopher Neil
- Department of Cardiology, Western Health, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia
| | - Jessica O'Brien
- Department of Cardiology, Alfred Health, Victoria, Australia
| | | | - James Hare
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Bing Wang
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Tsin Yee Tai
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - James Theuerle
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Victoria, Australia.,Department of Cardiology, Western Health, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Victoria, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRET), School of Public Health and Preventive Medicine, Monash University, Melbourne
| | - Karl-Heinz Peter
- Department of Cardiology, Alfred Health, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew Taylor
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Victoria, Australia.,Department of Cardiology, Alfred Health, Victoria, Australia.,Department of Medicine, University of Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
14
|
Hamilton GW, Yeoh J, Dinh D, Reid CM, Yudi MB, Freeman M, Brennan A, Stub D, Oqueli E, Sebastian M, Duffy SJ, Horrigan M, Farouque O, Ajani A, Clark DJ. Trends and Real-World Safety of Patients Undergoing Percutaneous Coronary Intervention for Symptomatic Stable Ischaemic Heart Disease in Australia. Heart Lung Circ 2022; 31:1619-1629. [PMID: 36856290 DOI: 10.1016/j.hlc.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) in stable ischaemic heart disease (SIHD) has not been shown to improve prognosis but can alleviate symptoms and improve quality of life. Appropriately selected patients with symptoms refractory to medical therapy therefore stand to benefit, provided safety is proven. METHODS Consecutive patients undergoing PCI for SIHD between 2005-2018 in a prospective registry were included. Yearly comparisons evaluated trends, and a sub-analysis was performed comparing proximal left anterior descending artery (prox-LAD) to other-than-proximal LAD (non-pLAD) PCI. Outcomes included peri-procedural characteristics, in-hospital and 30-day event rates including MACE, and 5-year National Death Index (NDI) linked mortality. RESULTS There were 9,421 procedures included. Over time, patients were increasingly co-morbid and had higher rates of AHA/ACC class B2/C lesions, ostial stenoses, bifurcation lesions, and chronic total occlusions (all p-for-trend ≤0.001). Over 14 years, major bleeding reduced (1.05% in 2005/06 vs 0.29% in 2017/18, p-for-trend <0.001), while other in-hospital and 30-day event rates were stably low. There were only seven (0.07%) in hospital deaths and 5-year mortality was 10.3%. No differences were found in outcomes between patients who underwent prox-LAD compared to non-pLAD PCI. Major independent predictors of NDI linked all-cause mortality included an eGFR <30 mL/min/1.73 m2 (HR 4.06, 95% CI 3.26-5.06), chronic obstructive pulmonary disease (COPD) (HR 2.25, 95% CI 1.89-2.67) and LVEF <30% (HR 2.13, 95% CI 1.57-2.89). CONCLUSIONS Although patient and procedural complexity increased over time, a high degree of procedural success and safety was maintained, including in those undergoing prox-LAD PCI. These real-world data can enhance shared decision making discussions regarding whether PCI should be pursued in patients with symptomatic SIHD refractory to medical therapy.
Collapse
Affiliation(s)
- Garry W Hamilton
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Vic, Australia
| | - Martin Sebastian
- Department of Cardiology, University Hospital Geelong, Vic, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia.
| |
Collapse
|
15
|
Wong N, Dinh DT, Brennan A, Batchelor R, Duffy SJ, Shaw JA, Chan W, Layland J, van Gaal WJ, Reid CM, Liew D, Stub D. Incidence, predictors and clinical implications of new renal impairment following percutaneous coronary intervention. Open Heart 2022; 9:openhrt-2021-001876. [PMID: 36220310 PMCID: PMC9558795 DOI: 10.1136/openhrt-2021-001876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 09/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background Renal impairment post-percutaneous coronary intervention (post-PCI) is a well-described adverse effect following the administration of contrast media. Within a large cohort of registry patients, we aimed to explore the incidence, predictors and clinical outcomes of renal impairment post-PCI. Methods The Victorian Cardiac Outcomes Registry is an Australian state-based clinical quality registry focusing on collecting data from all PCI capable centres. Data from 36 970 consecutive PCI cases performed between 2014 and 2018 were analysed. Patients were separated into three groups based on post-procedure creatinine levels (new renal impairment (NRI), defined as an absolute rise in serum creatinine>44.2 µmol/L or>25% of baseline creatinine; new renal impairment requiring dialysis (NDR), defined as worsening renal failure that necessitated a new requirement for renal dialysis; no NRI). Multivariate logistic regression analysis was performed to investigate the impact of NRI and NDR on clinical outcomes. Results 3.1% (n=1134) of patients developed NRI, with an additional 0.6% (n=225) requiring dialysis. 96.3% (n=35 611) of patients did not develop NRI. Those who developed renal impairment were more comorbid, with higher rates of diabetes (22% vs 38% vs 38%, p<0.001), peripheral vascular disease (3.4% vs 8.2% vs 11%, p<0.001), chronic kidney disease (19% vs 49.7% vs 54.2%) and severe left ventricular dysfunction (5% vs 22% vs 40%, p<0.001). Multivariable analysis found that when compared with the no NRI group, those in the combined NRI/NDR group were at a greater risk of 30-day mortality (OR 4.77; 95% CI 3.89 to 5.86, p<0.001) and 30-day major adverse cardiac events (OR 3.72; 95% CI 3.15 to 4.39, p<0.001). Conclusions NRI post-PCI remains a common occurrence, especially among comorbid patients, and is associated with a significantly increased morbidity and mortality risk.
Collapse
Affiliation(s)
- Nathan Wong
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | - James A Shaw
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - William Chan
- Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jamie Layland
- Cardiology, Frankston Hospital, Frankston, Victoria, Australia,St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
| | | | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia,School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Cardiology, Alfred Health, Melbourne, Victoria, Australia,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Wexler NZ, Vogrin S, Brennan AL, Noaman S, Al-Mukhtar O, Haji K, Bloom JE, Dinh DT, Zheng WC, Shaw JA, Duffy SJ, Lefkovits J, Reid CM, Stub D, Kaye DM, Cox N, Chan W. Adverse Impact of Peri-Procedural Stroke in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2022; 181:18-24. [PMID: 35999069 DOI: 10.1016/j.amjcard.2022.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
Peri-procedural stroke (PPS) is an important complication in patients who underwent percutaneous coronary intervention (PCI). The extent to which PPS impacts mortality and outcomes remains to be defined. Consecutive patients who underwent PCI enrolled in the Victorian Cardiac Outcomes Registry (2014 to 2018) were categorized into PPS and no PPS groups. The primary outcome was 30-day major adverse cardiovascular events (MACEs) (composite of mortality, myocardial infarction, stent thrombosis, and unplanned revascularization). Of 50,300 patients, PPS occurred in 0.26% patients (n = 133) (71% ischemic, and 29% hemorrhagic etiology). Patients who developed PPS were older (69 vs 66 years) compared with patients with no PPS, and more likely to have pre-existing heart failure (59% vs 29%), chronic kidney disease (33% vs 20%), and previous cerebrovascular disease (13% vs 3.6%), p <0.01. Among those with PPS, there was a higher frequency of presentation with ST-elevation myocardial infarction (49% vs 18%) and out-of-hospital cardiac arrest (14% vs 2.2%), PCI by way of femoral access (59% vs 46%), and adjunctive thrombus aspiration (12% vs 3.6%), all p = <0.001. PPS was associated with incident 30-day MACE (odds ratio [OR] 2.97, 95% confidence intervals [CIs] 1.86 to 4.74, p <0.001) after multivariable adjustment. Utilizing inverse probability of treatment weighting analysis, PPS remained predictive of 30-day MACE (OR 1.91, 95% CI 1.31 to 2.80, p = 0.001) driven by higher 30-day mortality (OR 2.0, 95% CI 1.35 to 2.96, p = 0.001). In conclusion, in this large, multi-center registry, the incidence of PPS was low; however, its clinical sequelae were significant, with a twofold increased risk of 30-day MACE and all-cause death.
Collapse
Affiliation(s)
- Noah Z Wexler
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - James A Shaw
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Curtain School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.
| |
Collapse
|
17
|
Zheng WC, Noaman S, Batchelor RJ, Hanson L, Bloom J, Kaye D, Duffy SJ, Walton A, Pellegrino V, Shaw J, Yang Y, French C, Stub D, Cox N, Chan W. Determinants of Undertaking Coronary Angiography and Adverse Prognostic Predictors Among Patients Presenting With Out-of-Hospital Cardiac Arrest and a Shockable Rhythm. Am J Cardiol 2022; 171:75-83. [PMID: 35296378 DOI: 10.1016/j.amjcard.2022.01.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 12/22/2022]
Abstract
Characteristics of patients presenting with out-of-hospital cardiac arrest (OHCA) selected for coronary angiography (CA) and factors predicting in-hospital mortality remain unclear. We assessed clinical characteristics associated with undertaking CA in patients presenting with OHCA and shockable rhythm (CA group). Predictors of in-hospital mortality were evaluated with multivariable analysis. Of 1,552 patients presenting with cardiac arrest between 2014 and 2018 to 2 health services in Victoria, Australia, 213 patients with OHCA and shockable rhythm were stratified according to CA status. The CA group had shorter cardiopulmonary resuscitation duration (17 vs 25 minutes) and time to return of spontaneous circulation (17 vs 26 minutes) but higher proportion of ST-elevation on electrocardiogram (48% vs 24%) (all p <0.01). In-hospital mortality was 38% (n = 81) for the overall cohort, 32% (n = 54) in the CA group, and 61% (n = 27) in the no-CA group. Predictors of in-hospital mortality included non-selection for CA (odds ratio 4.5, 95% confidence interval 1.5 to 14), adrenaline support (3.9, 1.3 to 12), arrest at home (2.7, 1.1 to 6.6), longer time to defibrillation (2.5, 1.5 to 4.2 per 5-minute increase), lower blood pH (2.1, 1.4 to 3.2 per 0.1 decrease), lower albumin (2.0, 1.2 to 3.3 per 5 g/L decrease), higher Acute Physiology and Chronic Health Evaluation II score (1.7, 1.0 to 3.0 per 5-point increase), and advanced age (1.4, 1.0 to 2.0 per 10-year increase) (all p ≤0.05). In conclusion, non-selection for CA, concomitant cardiogenic shock requiring inotropic support, poor initial resuscitation (arrest at home, longer time to defibrillation and lower pH), greater burden of co-morbidities (higher Acute Physiology and Chronic Health Evaluation II score and lower albumin), and advanced age were key adverse prognostic indicators among patients with OHCA and shockable rhythm.
Collapse
|
18
|
Zhou JY, Tie EN, Liew D, Duffy SJ, Shaw J, Walton A, Chan W, Stub D. Sex-Specific Outcomes Following Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Disease: A Systematic Review and Meta-Analysis. Heart Lung Circ 2022; 31:658-665. [PMID: 35033432 DOI: 10.1016/j.hlc.2021.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/27/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess whether outcomes following percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease differ between men and women. BACKGROUND Current guidelines recommend either PCI or CABG for patients with unprotected LMCA disease and low-to-intermediate anatomical complexity. However, it is unclear whether these guidelines apply to women, who are underrepresented in clinical trials. METHODS An electronic search was performed to identify studies reporting sex-specific outcomes after PCI versus CABG in patients with LMCA disease. Trial level hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by random-effects modelling. RESULTS Eight (8) studies met inclusion criteria, comprising 13,066 patients (24.3% women). In both sexes, there was no difference between PCI and CABG with respect to the primary composite endpoint of death, myocardial infarction or stroke (HR in women: 1.03, 95% CI 0.76-1.40; HR in men: 1.04, 95% CI 0.92-1.17). However, both sexes were more likely to require repeat revascularisation after PCI. There was no interaction between sex and treatment effect for the primary composite endpoint nor for the individual outcomes of death, stroke and repeat revascularisation. However, in women the risk of myocardial infarction was higher after PCI compared with CABG (HR 1.84, 95% CI 1.06-3.18), with a trend toward the opposite in men (HR 0.78, 95% CI 0.54-1.13; p-interaction=0.01). CONCLUSION Percutaneous coronary intervention and CABG have a comparable risk of the composite outcome of death, stroke or myocardial infarction in patients undergoing revascularisation for LMCA disease, with no significant interaction between sex and treatment effect.
Collapse
Affiliation(s)
- Jennifer Y Zhou
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Emilia Nan Tie
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Danny Liew
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - James Shaw
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; Western Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Western Health, Melbourne, Vic, Australia.
| |
Collapse
|
19
|
Batchelor RJ, Dinh D, Noaman S, Brennan A, Clark D, Ajani A, Freeman M, Stub D, Reid CM, Oqueli E, Yip T, Shaw J, Walton A, Duffy SJ, Chan W. Adverse 30-Day Clinical Outcomes and Long-Term Mortality Among Patients With Preprocedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Heart Lung Circ 2022; 31:638-646. [PMID: 35125322 DOI: 10.1016/j.hlc.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined. METHODS We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index. RESULTS 13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3±1.5 years. CONCLUSIONS Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.
Collapse
Affiliation(s)
- Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Diem Dinh
- Monash University, Melbourne, Vic, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | | | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Christopher M Reid
- Monash University, Melbourne, Vic, Australia; Curtin University, Perth, WA, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Vic, Australia
| | - Thomas Yip
- Deakin University, Geelong, Vic, Australia; Department of Cardiology, Barwon Health, Geelong, Vic, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.
| |
Collapse
|
20
|
Noaman S, Vogrin S, Dinh D, Lefkovits J, Brennan AL, Reid CM, Walton A, Kaye D, Bloom JE, Stub D, Yang Y, French C, Duffy SJ, Cox N, Chan W. Percutaneous Coronary Intervention Volume and Cardiac Surgery Availability Effect on Acute Coronary Syndrome-Related Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:876-886. [PMID: 35450687 DOI: 10.1016/j.jcin.2022.01.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/30/2021] [Accepted: 01/11/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study sought to assess the association between cardiac surgery availability and percutaneous coronary intervention (PCI) volume with clinical outcomes of cardiogenic shock (CS) complicating acute coronary syndrome (ACS). BACKGROUND CS remains a grave complication of ACS with high mortality rates despite timely reperfusion and improved heart failure therapies. METHODS The study analyzed data from consecutive patients with CS complicating ACS who underwent PCI and were prospectively enrolled in the VCOR (Victorian Cardiac Outcomes Registry) from 26 hospitals in Victoria. We compared patients treated at cardiac surgical centers (CSCs) versus non-CSCs as well as the annual CS PCI volume (stratified into tiers of <10, 10-25, and >25 cases) for in-hospital major adverse cardiac and cerebrovascular events (MACCE) and long-term mortality. RESULTS Of 1,179 patients with CS, the mean age of patients was 65 years; males comprised 74%, and 22% had diabetes mellitus. Cardiac arrest occurred in 38% of patients, while 90% presented with ST-segment elevation myocardial infarction and 26% received intra-aortic balloon pump support. Overall, in-hospital and long-term mortality were 42% and 51%, respectively. There was no difference among patients treated non-CSCs compared with a CSCs for in-hospital MACCE and mortality (both P > 0.05). Similarly, there was no association between tiers of annual CS PCI volume with in-hospital MACCE and mortality (both P > 0.05). CONCLUSIONS Comparable short- and long-term mortality rates among patients with ACS complicated by CS treated by PCI irrespective of cardiac surgery availability and CS PCI volume support the emergent treatment of these gravely ill patients at their presenting PCI-capable hospital.
Collapse
Affiliation(s)
- Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yang Yang
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.
| | | |
Collapse
|
21
|
Hanson L, Vogrin S, Noaman S, Dinh D, Zheng W, Lefkovits J, Brennan A, Reid C, Stub D, Duffy SJ, Layland J, Freeman M, van Gaal W, Cox N, Chan W. Long-Term Outcomes of Unprotected Left Main Percutaneous Coronary Intervention in Centers Without Onsite Cardiac Surgery. Am J Cardiol 2022; 168:39-46. [PMID: 35115134 DOI: 10.1016/j.amjcard.2021.12.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 11/01/2022]
Abstract
Unprotected left main (LM) percutaneous coronary intervention (PCI) at centers without onsite cardiac surgery remains controversial. We aimed to evaluate the effect of onsite cardiac surgery on short-term and long-term outcomes in patients who had unprotected LM PCI. We analyzed Victorian Cardiac Outcomes Registry data on consecutive patients who had unprotected LM PCI at cardiac surgical centers (SCs) and non-SCs (NSCs) between January 2014 to December 2018. Compared with the SC group (n = 594, 81%), the NSC group (n = 136) were younger (69 vs 72 years) and presented with more ST-elevation myocardial infarction (35% vs 16%) and cardiogenic shock (25% vs 15%), with higher rates of preprocedural intubation (17% vs 11%) and mechanical circulatory support (20% vs 9.3%), all p <0.01. Unadjusted in-hospital mortality (23% vs 11.4%), and 30-day major adverse cardiac events (composite of mortality, myocardial infarction, stent thrombosis, or unplanned revascularization) (26% vs 16%) were higher in NSC patients, all p <0.01. However, following multivariable adjustment, SC was neither a predictor of in-hospital mortality (odds ratio 0.68, 95% confidence interval [CI] 0.32 to 1.43, p = 0.31), 30-day mortality (odds ratio 0.70, 95% CI 0.33 to 1.48, p = 0.35) nor long-term survival at 60 months (hazard ratio 0.88, 95% CI 0.62 to 1.27, p = 0.51). Propensity score analysis confirmed the neutral effect of onsite cardiac surgery on long-term survival (hazard ratio 0.99, 95% CI 0.66 to 1.50, p = 0.97). In conclusion, patients who underwent unprotected LM PCI at NSCs presented with greater acuity of illness. Despite this, the availability of onsite cardiac surgical support was not associated with in-hospital, 30-day, or long-term outcomes underscoring the safety of LM PCI in NSCs.
Collapse
|
22
|
Stehli J, Dinh D, Dagan M, Dick R, Oxley S, Brennan A, Lefkovits J, Duffy SJ, Zaman S. Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction. Clin Cardiol 2022; 45:427-434. [PMID: 35253228 PMCID: PMC9019891 DOI: 10.1002/clc.23797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND HYPOTHESIS Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients. METHODS Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models. RESULTS A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13). CONCLUSIONS In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.
Collapse
Affiliation(s)
- Julia Stehli
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Epworth HealthCareRichmondVictoriaAustralia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Misha Dagan
- Department of General MedicineThe Alfred HospitalMelbourneVictoriaAustralia
| | - Ron Dick
- Epworth HealthCareRichmondVictoriaAustralia
| | | | - Angela Brennan
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Jeffrey Lefkovits
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Stephen J. Duffy
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Sarah Zaman
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
| |
Collapse
|
23
|
Stehli J, Dagan M, Dinh DT, Lefkovits J, Dick R, Oxley S, Brennan AL, Duffy SJ, Zaman S. Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis. BMJ Open 2022; 12:e052000. [PMID: 35256441 PMCID: PMC8905957 DOI: 10.1136/bmjopen-2021-052000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Patients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital ('in-hospital STEMI') face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI. DESIGN, SETTING AND PARTICIPANTS Consecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013-2018). PRIMARY AND SECONDARY OUTCOMES Patients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding. RESULTS Of 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001). CONCLUSIONS Patients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.
Collapse
Affiliation(s)
- Julia Stehli
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Misha Dagan
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ron Dick
- Epworth HealthCare, Richmond, Victoria, Australia
| | | | - Angela L Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Stephen J Duffy
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sarah Zaman
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIctoria, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia
| |
Collapse
|
24
|
Koshy AN, Dinh DT, Fulcher J, Brennan AL, Murphy AC, Duffy SJ, Reid CM, Ajani AE, Freeman M, Hiew C, Oqueli E, Farouque O, Yudi MB, Clark DJ. Long-term mortality in asymptomatic patients with stable ischemic heart disease undergoing percutaneous coronary intervention. Am Heart J 2022; 244:77-85. [PMID: 34780716 DOI: 10.1016/j.ahj.2021.10.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/27/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Patients with stable ischemic heart disease (SIHD) may present with a variety of symptoms including typical angina, angina equivalents such as dyspnea or no symptoms. We sought to determine whether symptom status affects periprocedural safety and long-term mortality in patients undergoing PCI. METHODS Prospectively enrolled consecutive patients undergoing PCI for SIHD at six hospitals in Australia between 2005 to 2018 as part of the Melbourne Interventional Group registry. Symptom status was recorded at the time of PCI and patients undergoing staged PCI were excluded. RESULTS Overall, 11,730 patients with SIHD were followed up for a median period of 5 years (maximum 14.0 years, interquartile range 2.2-9.0 years) with 1,317 (11.2%) being asymptomatic. Asymptomatic patients were older, and more likely to be male, have triple-vessel disease, with multiple comorbidities including renal failure, diabetes and heart failure (all P < .01). These patients had significantly higher rates of periprocedural complications and major adverse cardiovascular events at 30-days. Long-term mortality was significantly higher in asymptomatic patients (27.2% vs 18.0%, P < .001). On cox regression for long-term mortality, after adjustment for more important clinical variables, asymptomatic status was an independent predictor (Hazard ratio (HR) 1.39 95% CI 1.16-1.66, P < .001). CONCLUSIONS In a real-world cohort of patients undergoing revascularization for SIHD, absence of symptoms was associated with higher rates of periprocedural complications and, after adjustment for more important clinical variables, was an independent predictor of long-term mortality. As the primary goal of revascularization in SIHD remains angina relief, the appropriateness of PCI in the absence of symptoms warrants justification.
Collapse
Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Diem T Dinh
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Jordan Fulcher
- Department of Cardiology, Austin Health, Melbourne, Australia
| | - Angela L Brennan
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Stephen J Duffy
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- The University of Melbourne, Parkville, Victoria; Center of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Australia; The University of Melbourne, Parkville, Victoria; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
| |
Collapse
|
25
|
Navani RV, Quine EJ, Duffy SJ, Htun NM, Nanayakkara S, Walton AS, Stub D. Relation of Preprocedure Platelet-to-Lymphocyte Ratio and Major Adverse Cardiovascular Events Following Transcatheter Aortic Valve Implantation for Aortic Stenosis. Am J Cardiol 2022; 163:65-70. [PMID: 34776120 DOI: 10.1016/j.amjcard.2021.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 11/01/2022]
Abstract
The platelet-to-lymphocyte ratio (PLR) is a novel inflammatory biomarker that has prognostic value in patients presenting with acute coronary syndrome. Transcatheter aortic valve implantation (TAVI) treats the inflammatory disease of aortic stenosis. However, the utility of preprocedure PLR in predicting major adverse cardiovascular events (MACE) after TAVI is not clear. Our study population included 470 patients who underwent TAVI at The Alfred Hospital in Melbourne, Australia from August 2008, to January 2019. Patients were divided into 4 groups based on PLR quartiles. The incidence of 30-day MACE (a composite of stroke, myocardial infarction, and death) was then compared. Outcomes were reported according to the Valve Academic Research Consortium-2 criteria. Of 470 patients, median age 84 years, 54% men, and median Society of Thoracic Surgeons score of 3.5%, 14 (3%) suffered a MACE within 30 days. Rates of MACE were low in all 4 groups (1.7%, 2.5%, 2.6%, 5.1%, respectively) with no statistically significant difference in the different PLR groups (p = 0.46). This nonsignificant association was supported by univariate logistic regression analysis of PLR as a continuous variable (odds ratio 1.01, p = 0.55). Using multivariable logistic regression analysis accounting for age, gender, self-expanding valve, and procedural risk, a higher PLR did not correlate with MACE (odds ratio 1.01, p = 0.60). In this study of a large cohort of TAVI patients, elevated preprocedure PLR was not independently associated with MACE after TAVI. This is a novel finding in comparison with previous studies.
Collapse
|
26
|
Dawson LP, Dinh DT, Stub D, Ahern S, Bloom JE, Duffy SJ, Lefkovits J, Brennan A, Reid CM, Oqueli E. Health-related quality of life following percutaneous coronary intervention during the COVID-19 pandemic. Qual Life Res 2022; 31:2375-2385. [PMID: 34978043 PMCID: PMC8720546 DOI: 10.1007/s11136-021-03056-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 12/02/2022]
Abstract
Purpose During the COVID-19 pandemic, widespread public health measures were implemented to control community transmission. The association between these measures and health-related quality of life (HRQOL) among patients following percutaneous coronary intervention has not been studied. Methods We included consecutive patients undergoing percutaneous coronary intervention (PCI) in the state-wide Victorian Cardiac Outcomes Registry between 1/3/2020 and 30/9/2020 (COVID-19 period; n = 5024), with a historical control group from the identical period one year prior (control period; n = 5041). HRQOL assessment was performed via telephone follow-up 30 days following PCI using the 3-level EQ-5D questionnaire and Australian-specific index values. Results Baseline characteristics were similar between groups, but during the COVID-19 period indication for PCI was more common for acute coronary syndromes. No patients undergoing PCI were infected with COVID-19 at the time of their procedure. EQ-5D visual analogue score (VAS), index score, and individual components were higher at 30 days following PCI during the COVID-19 period (all P < 0.01). In multivariable analysis, the COVID-19 period was independently associated with higher VAS and index scores. No differences were observed between regions or stage of restrictions in categorical analysis. Similarly, in subgroup analysis, no significant interactions were observed. Conclusion Measures of HRQOL following PCI were higher during the COVID-19 pandemic compared to the previous year. These data suggest that challenging community circumstances may not always be associated with poor patient quality of life. Supplementary Information The online version contains supplementary material available at 10.1007/s11136-021-03056-0.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Susannah Ahern
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jason E Bloom
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Jeffrey Lefkovits
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, WA, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, 1 Drummond St North, Ballarat, VIC, 3350, Australia. .,School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia.
| | | |
Collapse
|
27
|
Dagan M, Dinh DT, Stehli J, Zaman S, Brennan A, Tan C, Liew D, Reid CM, Stub D, Kaye DM, Lefkovits J, Duffy SJ. Impact of Age and Sex on Treatment and Outcomes Following Myocardial Infarction. J Am Coll Cardiol 2021; 78:1934-1936. [PMID: 34736569 DOI: 10.1016/j.jacc.2021.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/12/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022]
|
28
|
Dawson LP, Chen D, Dagan M, Bloom J, Taylor A, Duffy SJ, Shaw J, Lefkovits J, Stub D. Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2134322. [PMID: 34797371 PMCID: PMC8605486 DOI: 10.1001/jamanetworkopen.2021.34322] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The practice of pretreatment with oral P2Y12 inhibitors in non-ST elevation acute coronary syndromes (NSTEACS) remains common; however, its association with improved cardiovascular outcomes is unclear. OBJECTIVE To assess the association between oral P2Y12 inhibitor pretreatment and cardiovascular and bleeding outcomes in patients with NSTEACS. DATA SOURCES On March 20, 2021, PubMed, MEDLINE, Embase, Scopus, Web of Science, Science Direct, clinicaltrials.gov, and the Cochrane Central Register for Controlled Trials were searched from database inception. STUDY SELECTION Randomized clinical trials of patients with NSTEACS randomized to either oral P2Y12 inhibitor pretreatment (defined as prior to angiography) or no pretreatment (defined as following angiography, once coronary anatomy was known) among patients undergoing an invasive strategy. DATA EXTRACTION AND SYNTHESIS This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data on publication year, sample size, clinical characteristics, revascularization strategy, P2Y12 inhibitor type and dosage, time from pretreatment to angiography, and end point data were independently extracted by 2 authors. A random-effects model was used, including stratification by (1) P2Y12 inhibitor type, (2) revascularization strategy, and (3) access site. MAIN OUTCOMES AND MEASURES The primary end point was 30-day major adverse cardiac events (MACEs). Secondary end points were 30-day myocardial infarction (MI) and cardiovascular death. The primary safety end point was 30-day major bleeding (defined according to individual studies). RESULTS A total of 7 trials randomizing 13 226 patients to either pretreatment (6603 patients) or no pretreatment (6623 patients) were included. The mean age of patients was 64 years and 3598 (27.2%) were female individuals. Indication for P2Y12 inhibitors was non-ST elevation myocardial infarction in 7430 patients (61.7%), radial access was used in 4295 (32.6%), and 10 945 (82.8%) underwent percutaneous coronary intervention. Pretreatment was not associated with a reduction in 30-day MACE (odds ratio [OR], 0.95; 95% CI, 0.78-1.15; I2 = 28%), 30-day MI (OR, 0.90; 95% CI, 0.72-1.12; I2 = 19%), or 30-day cardiovascular death (OR, 0.79; 95% CI, 0.49-1.27; I2 = 0%). The risk of 30-day major bleeding was increased among patients who underwent pretreatment (OR, 1.51; 95% CI, 1.16-1.97; I2 = 41%). The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients. CONCLUSIONS AND RELEVANCE In this study, pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography, compared with treatment once coronary anatomy is known, was associated with increased bleeding risk and no difference in cardiovascular outcomes. Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.
Collapse
Affiliation(s)
- Luke P. Dawson
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David Chen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Misha Dagan
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Andrew Taylor
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen J. Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Fernando H, Duong T, Huynh K, Noonan J, Shaw J, Duffy SJ, Nehme Z, Smith K, Myles PS, Meikle PJ, Peter K, Stub D. Effects of lignocaine vs. opioids on antiplatelet activity of ticagrelor: the LOCAL trial. Eur Heart J 2021; 42:4025-4036. [PMID: 34423354 DOI: 10.1093/eurheartj/ehab557] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/09/2021] [Accepted: 08/02/2021] [Indexed: 12/12/2022] Open
Abstract
AIMS We assessed the impact of intravenous fentanyl and lignocaine on the pharmacokinetics and pharmacodynamics of ticagrelor in patients with unstable angina and non-ST-elevation myocardial infarction and their procedural analgesic efficacy and safety. METHODS AND RESULTS Seventy patients undergoing coronary angiography with ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analyses of this randomized trial. Plasma ticagrelor levels 2 h post-loading dose were significantly lower in the fentanyl arm than in the lignocaine treatment arm (598 vs. 1008 ng/mL, P = 0.014). The area under the plasma-time curves for ticagrelor (1228 vs. 2753 ng h/mL, P < 0.001) and its active metabolite (201 vs. 447 ng h/mL, P = 0.001) were both significantly lower in the fentanyl arm. Expression of activated platelet glycoprotein IIb/IIIa receptor (2829 vs. 1426 mean fluorescence intensity, P = 0.006) and P-selectin (439 vs. 211 mean fluorescence intensity, P = 0.001) was significantly higher at 60 min in the fentanyl arm. A higher proportion of patients had high on-treatment platelet reactivity in the fentanyl arm at 60 min using the Multiplate Analyzer (41% vs. 9%, P = 0.002) and 120 min using the VerifyNow (30% vs. 3%, P = 0.003) and VASP (37% vs. 6%, P = 0.002) assays. Both drugs were well tolerated with a high level of patient satisfaction. CONCLUSIONS Unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective with a high level of patient satisfaction for procedural analgesia. Routine procedural analgesia during percutaneous coronary intervention should be reconsidered and if performed, lignocaine is a beneficial alternative to fentanyl.
Collapse
Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Cardiology, Bendigo Health, 100 Barnard St, Bendigo, Victoria 3550, Australia
| | - Thy Duong
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia
| | - Kevin Huynh
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia
| | - Jonathan Noonan
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Department of Cardiometabolic Health, University of Melbourne, 75 Commercial Road, Melbourne, Victoria 3004, Australia
| | - James Shaw
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road Melbourne, Melbourne, Victoria 3004, Australia
| | - Ziad Nehme
- Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Centre for Research and Evaluation, Ambulance Victoria, PO Box 2000, Doncaster, Victoria 3108, Australia
| | - Karen Smith
- Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Centre for Research and Evaluation, Ambulance Victoria, PO Box 2000, Doncaster, Victoria 3108, Australia
| | - Paul S Myles
- Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred and Monash University, 55 Commercial Road Melbourne, Melbourne, Victoria 3004, Australia
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Cardiometabolic Health, University of Melbourne, 75 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Department of Cardiometabolic Health, University of Melbourne, 75 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Victoria 3004, Australia.,Monash University, Wellington Road, Melbourne, Victoria 3800, Australia.,Department of Cardiology, Western Health, 176 Furlong Rd, St Albans, Victoria 3021, Australia
| |
Collapse
|
30
|
Cohen NS, Dinh D, Ajani A, Clark D, Brennan A, Nan Tie E, Dagan M, Hamilton G, Sebastian M, Shaw J, Oqueli E, Freeman M, Reid C, Stub D, Duffy SJ. Outcomes after percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (cabg). Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In patients with prior CABG requiring subsequent PCI there is uncertainty whether bypass grafts or native coronary arteries should be targeted.
Methods
We analysed data from 2,764 patients with prior CABG in the Melbourne Interventional Group registry (2005–2018), divided into two groups: those undergoing PCI to a native vessel (n=1,928) and those with PCI to a graft vessel (n=836).
Results
Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (prior MI, heart failure, ejection fraction <50%, renal impairment, peripheral and cerebrovascular disease), and high-risk procedural features (ACC/AHA types B2/C lesions). However, patients in the native vessel group were more likely to have PCI to a chronic total occlusion. The majority of graft PCI were to saphenous vein grafts (84%), with 10% to radial and 6% to LIMA/RIMA grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3% vs. 1.5%; p<0.001), coronary perforation (p=0.016) and inpatient stent thrombosis (p=0.028). However, 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCE) were similar. Unadjusted long-term mortality (median follow up 4.8 years) was higher in patients who had undergone a graft PCI (44% vs. 32%, p<0.001), but following Cox proportional hazards modelling, PCI vessel type was not a predictor of long-term mortality (HR 1.13; 95% CI 0.96–1.33, p=0.14).
Conclusions
Early clinical outcomes and risk-adjusted long-term mortality are similar for patients with prior CABG undergoing PCI to a native vessel or a bypass graft.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): The Alfred Hospital
Collapse
Affiliation(s)
- N S Cohen
- The Alfred Hospital, Melbourne, Australia
| | - D Dinh
- Monash University, Melbourne, Australia
| | - A Ajani
- Royal Melbourne Hospital, Melbourne, Australia
| | - D Clark
- Austin Hospital, Melbourne, Australia
| | - A Brennan
- Monash University, Melbourne, Australia
| | - E Nan Tie
- The Alfred Hospital, Melbourne, Australia
| | - M Dagan
- The Alfred Hospital, Melbourne, Australia
| | | | | | - J Shaw
- The Alfred Hospital, Melbourne, Australia
| | - E Oqueli
- Ballarat Health Services, Ballarat, Australia
| | - M Freeman
- Eastern Health, Melbourne, Australia
| | - C Reid
- Monash University, Melbourne, Australia
| | - D Stub
- The Alfred Hospital, Melbourne, Australia
| | - S J Duffy
- The Alfred Hospital, Melbourne, Australia
| |
Collapse
|
31
|
Nan Tie E, Fernando H, Nehme Z, Dinh D, Andrew E, Brennan A, Zaman S, Liew D, Stephenson M, Lefkovits J, Peter K, Duffy SJ, Shaw J, Smith K, Stub D. Sex differences in pre-hospital analgesia and outcomes in patients presenting with acute coronary syndromes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Opioid analgesia remains the mainstay of pain management in acute coronary syndromes (ACS). Significant sex differences persist in ACS presentation, management and outcomes, but the impact of sex-differences on pre-hospital pain management of ACS with opioids is unknown. There is increasing awareness of the importance of pre-hospital factors in ACS, as well as emerging concerns with opioid use impairing the gastrointestinal absorption of oral P2Y12 inhibitors.
Purpose
This study examined if sex-differences in pre-hospital pain scores, opioid administration and clinical outcomes exist in ACS patients.
Methods
Patients presenting with ACS via ambulance (2014–2018) that underwent percutaneous coronary intervention (PCI) were prospectively collected via the Victorian Cardiac Outcomes Registry (VCOR), the Melbourne Interventional Group (MIG), and linked to the Ambulance Victoria database. The primary outcome was 30-day major adverse cardiac events (MACE). Secondary outcomes were descriptive analyses of pre-hospital pain score, intravenous morphine equivalent analgesic dosing, plus predictors of MACE and Thrombolysis In Myocardial Infarction (TIMI) 0–1 flow pre-PCI using logistic regression.
Results
10,547 patients were included (female: 2,775 [26.3%]). Opioids were administered to 1,585 (57%) females and 5,068 (65%) males (p<0.001). Adjusted 30-day MACE was similar between opioid groups in both sexes (female: OR 1.21, CI 0.82–1.79, p=0.34; male: OR 0.89, 0.68–1.16, p=0.40). Median pain score at presentation was 6 (IQR 4,8) for both sexes. Median opioid dose was 2.5 mg (IQR 0,10) in females and 5 mg (IQR 0,10) in males (p<0.001), with similar pain relief achieved. Adjusted rates of TIMI 0–1 pre-PCI were higher in patients administered opioids (female: OR 2.83, CI 2.14–3.56, p<0.001; male: OR 2.95, CI 2.49–3.49, p<0.001).
Conclusions
Female patients undergoing PCI received less opioid analgesia, but no sex-differences in pre-hospital pain scores were seen. Opioid administration was associated with impaired antegrade flow in the culprit artery in both sexes, but not short-term MACE. Randomised trials evaluating the clinical implications of opioid administration in ACS with sex subgroup analyses are needed to guide clinical practice.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Melbourne Interventional GroupVictorian Cardiac Outcomes Registry
Collapse
Affiliation(s)
- E Nan Tie
- Monash University, Melbourne, Australia
| | - H Fernando
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - Z Nehme
- Monash University, Melbourne, Australia
| | - D Dinh
- Monash University, Melbourne, Australia
| | - E Andrew
- Monash University, Melbourne, Australia
| | - A Brennan
- Monash University, Melbourne, Australia
| | - S Zaman
- Westmead Hospital, Sydney, Australia
| | - D Liew
- Monash University, Melbourne, Australia
| | | | - J Lefkovits
- Royal Melbourne Hospital, Melbourne, Australia
| | - K Peter
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - S J Duffy
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - J Shaw
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - K Smith
- Monash University, Melbourne, Australia
| | - D Stub
- The Alfred Hospital, Cardiology, Melbourne, Australia
| |
Collapse
|
32
|
Nan Tie E, Dinh D, Clark D, Ajani AE, Brennan A, Cohen N, Dagan M, Shaw J, Sebastian M, Freeman M, Oqueli E, Reid C, Kaye D, Stub D, Duffy SJ. Trends in intra-aortic balloon pump use in cardiogenic shock in the post-SHOCK II trial era. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit.
Purpose
This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use.
Methods
Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression.
Results
Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction (<35%; 18% vs. 11%), and pre-procedural inotrope use (81% vs. 73%), all p<0.05. IABP use was associated with higher inpatient bleeding (18% vs. 13%) and 30-day MACCE (58% vs. 51%), both p<0.05. The rate of MI-CS increased over time, but after 2012 there was a decline in IABP use (Figure 1). IABP use was a predictor of 30-day MACCE (OR 1.6, 95% CI 1.18–2.29, p=0.003). However, IABP was not associated with in-hospital, 30-day or long-term mortality (45% vs. 47%, p=0.44; 46% vs. 50%, p=0.25; 60% vs. 62%, p=0.39).
Conclusions
Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group
Collapse
Affiliation(s)
- E Nan Tie
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - D Dinh
- Monash University, Melbourne, Australia
| | - D Clark
- Austin Hospital, Melbourne, Australia
| | - A E Ajani
- Royal Melbourne Hospital, Melbourne, Australia
| | - A Brennan
- Monash University, Melbourne, Australia
| | - N Cohen
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - M Dagan
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - J Shaw
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | | | - M Freeman
- Eastern Health, Melbourne, Australia
| | - E Oqueli
- Ballarat Health Services, Ballarat, Australia
| | - C Reid
- Monash University, Melbourne, Australia
| | - D Kaye
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - D Stub
- The Alfred Hospital, Cardiology, Melbourne, Australia
| | - S J Duffy
- The Alfred Hospital, Cardiology, Melbourne, Australia
| |
Collapse
|
33
|
Dawson LP, Dinh D, Duffy SJ, Clark D, Reid CM, Brennan A, Andrianopoulos N, Hiew C, Freeman M, Oqueli E, Chan W, Ajani AE. Temporal Trends in Patient Risk Profile and Clinical Outcomes Following Percutaneous Coronary Intervention. Cardiovascular Revascularization Medicine 2021; 31:10-16. [DOI: 10.1016/j.carrev.2020.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022]
|
34
|
Fernando H, Duffy SJ, Low A, Dinh D, Adrianopoulos N, Sharma A, Peter K, Stub D, Leong K, Ajani A, Clark D, Freeman M, Sebastian M, Brennan A, Selkrig L, Reid CM, Kaye D, Oqueli E. Totally Occluded Culprit Coronary Artery in Patients with Non-ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2021; 156:52-57. [PMID: 34362552 DOI: 10.1016/j.amjcard.2021.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/17/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022]
Abstract
The short- and long-term implications of identifying totally occluded culprit coronary arteries (TOCCA) in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) have not been well studied. This study compares clinical characteristics, short- and long-term outcomes of patients with NSTEMI identified with TOCCA to that of patients with non-TOCCA undergoing percutaneous coronary intervention (PCI). We analyzed data from patients with NSTEMI undergoing single-vessel PCI within the Melbourne Interventional Group multi-center registry between 2005 and 2017. Those with TOCCA were compared to those with non-TOCCA. The primary endpoint was 30-day major adverse cardiac events (MACE). Secondary endpoints included 12-month MACE and long-term mortality. A total of 6,829 patients with NSTEMI had single-vessel PCI of which 954 (14%) had TOCCA. Most TOCCA were non-left anterior descending (right coronary artery 39% versus circumflex 33% versus left anterior descending 26%; p <0.001). Cardiogenic shock and left ventricular dysfunction were higher in the TOCCA group, but non-TOCCA patients had more baseline comorbidities. Thirty-day MACE was higher in the TOCCA group (6.7% versus 3.8%; p <0.001). Long-term mortality with an average follow-up of 4.9 years was higher in the non-TOCCA group (12% versus 18%, p <0.01). Multivariable Cox-proportional hazards regression identified TOCCA as an independent predictor of 30-day MACE (HR = 1.93; 95%CI: 1.4-2.6), but not long-term mortality, which was predicted by baseline comorbidities. In conclusion, while patients with NSTEMI with TOCCA undergoing PCI represent a more unstable subgroup early on, long-term outcomes appear more dependent on baseline comorbidities.
Collapse
Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ashlea Low
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nick Adrianopoulos
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anand Sharma
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Kai'En Leong
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology Austin Health, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Laura Selkrig
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Christopher M Reid
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - David Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
| |
Collapse
|
35
|
Noaman S, Dinh D, Reid CM, Brennan AL, Clark D, Shaw J, Freeman M, Sebastian M, Oqueli E, Ajani A, Walton A, Bloom J, Biswas S, Stub D, Duffy SJ, Chan W. Comparison of Outcomes of Coronary Artery Disease Treated by Percutaneous Coronary Intervention in 3 Different Age Groups (<45, 46-65, and >65 Years). Am J Cardiol 2021; 152:19-26. [PMID: 34147208 DOI: 10.1016/j.amjcard.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/15/2022]
Abstract
There is paucity of data examining long-term outcomes of premature coronary artery disease (CAD). We aimed to investigate the short- and long-term clinical outcomes of patients with premature CAD treated by percutaneous coronary intervention (PCI) compared to older cohorts. We analyzed data from 27,869 patients who underwent PCI from 2005-2017 enrolled in a multicenter PCI registry. Patients were divided into three age groups: young group (≤ 45 years), middle-age group (46-65 years) and older group (>65 years). There were higher rates of current smokers in the young (n = 1,711) compared to the middle-age (n = 12,830) and older groups (n = 13,328) (54.2% vs 34.6% vs 11%) and the young presented more frequently with acute coronary syndrome (ACS) (78% vs 66% vs 62%), all p <0.05. There were also greater rates of cardiogenic shock (CS), out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) in the young, all p <0.05. The young cohort with STEMI had higher rates of in-hospital, 30-day death, and long-term mortality (3.8% vs 0.2%, 4.3% vs 0.2% and 8.6% vs 3.1%, all p <0.05, respectively) compared to the non-STEMI subgroup. There was a stepwise increase in long-term mortality from the young, to middle-age, to the older group (6.1% vs 9.9% vs 26.8%, p <0.001). Younger age was an independent predictor of lower long-term mortality (HR 0.66, 95% CI 0.52-0.84, p = 0.001). In conclusion, younger patients presenting with STEMI had worse prognosis compared to those presenting with non-STEMI. Despite higher risk presentations among young patients, their overall prognosis was favorable compared to older age groups.
Collapse
Affiliation(s)
- Samer Noaman
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia; BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia; School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Angela L Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Victoria, Australia; BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Martin Sebastian
- Department of Cardiology, Geelong University Hospital, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Jason Bloom
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Sinjini Biswas
- Department of Cardiology, Alfred Health, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University, Victoria, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia; BakerIDI Heart and Diabetes Institute, Melbourne, Victoria, Australia; Monash University, Victoria, Australia.
| |
Collapse
|
36
|
Biswas S, Dinh D, Duffy SJ, Brennan A, Liew D, Chan W, Cox N, Reid CM, Lefkovits J, Stub D. Characteristics and outcomes of unsuccessful percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 99:609-616. [PMID: 34331500 DOI: 10.1002/ccd.29886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/12/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To examine predictors and outcomes of unsuccessful percutaneous coronary intervention (PCI) cases in a contemporary Australian registry cohort. BACKGROUND With improvements in techniques and pharmacotherapy in PCI, more complex lesions in older patients are now being attempted. In the context of PCI performance assessment, there are limited data regarding the characteristics and outcomes of unsuccessful PCI. METHOD We prospectively collected data on patients undergoing single-lesion PCI between 2013 and 2017 who were enrolled in the multi-center Victorian Cardiac Outcomes Registry. Procedures were divided into two groups by whether or not PCI was deemed successful at the end of the procedure using a pre-specified definition. RESULTS There were 34,383 single-lesion PCI performed, of which 18,644 (54.2%) were for acute coronary syndromes. Of the study cohort, 2080 patients (6.0%) had an unsuccessful PCI - these patients were older, more likely to have previous stroke, PCI, severe left ventricular dysfunction and chronic kidney disease (all p < 0.001). The procedure was also more likely to be performed for stable angina (p < 0.001). Chronic total occlusion PCI made up 31% of unsuccessful PCI cases. Unsuccessful PCI was itself associated with higher in-hospital and 30-day mortality and MACE (all p < 0.001). 4.9% of unsuccessful PCIs led to unplanned in-hospital bypass surgery (compared to 0.2% in successful PCIs, p < 0.001). CONCLUSION Our study highlights that even in contemporary PCI practice, more than 1 in 20 PCI attempts are unsuccessful. Lack of procedural success has a strong influence on patient outcomes. Monitoring rates of unsuccessful cases is an important quality assurance tool.
Collapse
Affiliation(s)
- Sinjini Biswas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of General Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Cardiology, Western Health, Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
37
|
Dawson LP, Burchill L, O'Brien J, Dinh D, Duffy SJ, Stub D, Brennan A, Clark D, Oqueli E, Hiew C, Freeman M, Reid CM, Ajani AE. Differences in outcome of percutaneous coronary intervention between Indigenous and non-Indigenous people in Victoria, Australia: a multicentre, prospective, observational, cohort study. Lancet Glob Health 2021; 9:e1296-e1304. [PMID: 34274040 DOI: 10.1016/s2214-109x(21)00224-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/02/2021] [Accepted: 05/05/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Data on the patient characteristics and health outcomes of Indigenous Australians having revascularisation for treatment of coronary artery disease are scarce. The aim of this study was to assess differences in patient characteristics, presentations, and outcomes among Indigenous and non-Indigenous Australians having percutaneous coronary intervention (PCI) in urban and larger regional centres in Victoria, Australia. METHODS In this multicentre, prospective, observational cohort study, data were prospectively collected from six government-funded tertiary hospitals in the state of Victoria, Australia. The Melbourne Interventional Group PCI registry was used to identify patients having PCI at Victorian metropolitan and large regional hospitals between Jan 1, 2005, and Dec 31, 2018. The primary outcome was long-term mortality. Secondary outcomes were 30 day mortality and 30 day major adverse cardiovascular events (MACE), defined as a composite endpoint of death, myocardial infarction, and target-vessel revascularisation. Regression analyses, adjusted for clinically relevant covariates and geographical and socioeconomic indices, were used to establish the influence of Indigenous status on these study outcomes. FINDINGS 41 146 patient procedures were entered into the registry, of whom 179 (0·4%) were recorded as identifying as Indigenous Australian, 39 855 (96·9%) were not Indigenous Australian, and 1112 (2·7%) had incomplete data regarding ethnicity and were excluded. Compared with their non-Indigenous counterparts, Indigenous patients were younger, more often women, and more likely to have comorbidities. Indigenous Australians were also more likely to live in a regional community and areas of socioeconomic disadvantage. Procedural success and complication rates were similar for Indigenous and non-Indigenous patients having PCI. At 30 day follow-up, Indigenous Australians were more likely to be taking optimal medical therapy, although overall follow-up rates were lower and prevalence of persistent smoking was higher. Multivariable analysis showed that Indigenous status was independently associated with increased risk of long-term mortality (hazard ratio 2·49, 95% CI 1·79-3·48; p<0·0001), 30 day mortality (odds ratio 2·78, 95% CI 1·09-7·12; p=0·033), and 30-day MACE (odds ratio 1·87, 95% CI 1·03-3·39; p=0·039). INTERPRETATION Indigenous Australians having PCI in urban and larger regional centres are at increased risk of mortality and adverse cardiac events. Clinically effective and culturally safe care pathways are urgently needed to improve health outcomes among Indigenous Australians who are having PCI. FUNDING National Health and Medical Research Council, National Heart Foundation.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Luke Burchill
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Medicine, Melbourne University, Melbourne, VIC, Australia
| | - Jessica O'Brien
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Dion Stub
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, VIC, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, VIC, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital, Geelong, VIC, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, VIC, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Centre of Clinical Research and Education, School of Public Health, Curtin University, Perth, WA, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Medicine, Melbourne University, Melbourne, VIC, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia.
| | | |
Collapse
|
38
|
Vriesendorp PA, Nanayakkara S, Bowditch J, Htun NM, Stub D, Dagan M, Stehli J, Dick R, Duffy SJ, Walton AS. Short- and Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Public and Private Hospital Settings: A Propensity-Matched Analysis. Heart Lung Circ 2021; 30:1910-1917. [PMID: 34244066 DOI: 10.1016/j.hlc.2021.05.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/20/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare short- and long-term outcomes after transcatheter aortic valve implantation (TAVI) in the public and private hospital setting. DESIGN Propensity-matched, retrospective analysis of a prospective registry. SETTING AND PARTICIPANTS Patients with severe aortic stenosis who underwent TAVI at a tertiary public hospital (n=507) and an experienced private hospital (n=436). MAIN OUTCOME MEASURES The primary endpoint was all-cause mortality. RESULTS Patients that underwent TAVI in the public hospital were younger than patients in the private hospital (82±8 years vs 84±6 years, p<0.001), with lower estimated short-term mortality risk (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] score >4.0%: 43% vs 56%, p<0.001). There was no difference between public and private hospitals in 30-day mortality (1.5% vs 1.2%, p=1.0), and the rate of complications was similar. Long-term survival was similar in propensity-matched public (n=344) and private (n=344) patient cohorts. The 1-year, 2-year, 5-year and 7-year survival rates were 95%, 90%, 67% and 47% in public patients, and 92%, 86%, 67% and 51% in private patients (p=0.94). In multivariable analysis, the hospital setting was not a predictor of mortality. CONCLUSION Despite increased age and predicted mortality in private hospital patients, short- and long-term outcomes after TAVI were comparable between public and private hospital settings. This study demonstrates the feasibility of performing TAVI in a private hospital with a dedicated and experienced team and questions the current restricted access to TAVI in the private sector.
Collapse
Affiliation(s)
- Pieter A Vriesendorp
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Epworth Healthcare, Melbourne, Vic, Australia.
| | - Shane Nanayakkara
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Joshua Bowditch
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia
| | - Nay M Htun
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia
| | - Dion Stub
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; The School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Misha Dagan
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia
| | - Julia Stehli
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Epworth Healthcare, Melbourne, Vic, Australia
| | - Ronald Dick
- Department of Cardiology, Epworth Healthcare, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; The School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Antony S Walton
- Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Epworth Healthcare, Melbourne, Vic, Australia
| |
Collapse
|
39
|
Biswas S, Dinh D, Lucas M, Duffy SJ, Brennan A, Liew D, Cox N, Smith K, Andrew E, Nehme Z, Reid CM, Lefkovits J, Stub D. Impact of limited English proficiency on presentation and clinical outcomes of patients undergoing primary percutaneous coronary intervention. Eur Heart J Qual Care Clin Outcomes 2021; 6:254-262. [PMID: 31782766 DOI: 10.1093/ehjqcco/qcz061] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/06/2019] [Accepted: 11/26/2019] [Indexed: 11/13/2022]
Abstract
AIMS To evaluate the association of limited English proficiency (LEP) with reperfusion times and outcomes in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS This cohort study included 5385 patients who underwent PPCI in 2013-2017 and were prospectively enrolled in the Victorian Cardiac Outcomes Registry. Data linkage to government administrative datasets was performed to identify patients' preferred spoken language, socioeconomic status, and ambulance utilization data. Patients who had a preferred spoken language other than English were defined as having LEP. Of the study cohort, 430 patients (8.0%) had LEP. They had longer mean symptom-to-door time (STDT) [164 (95% confidence interval, CI 149-181) vs. 136 (95% CI 132-140) min, P < 0.001] but similar mean door-to-balloon time [79 (95% CI 72-87) vs. 76 (95% CI 74-78) min, P = 0.41]. They also had higher major adverse cardiovascular and cerebrovascular events (MACCE; 13.5% vs. 9.9%; P = 0.02), severe left ventricular dysfunction (11.0% vs. 8.4%, P = 0.02), and heart failure (HF) hospitalizations within 30 days of PPCI (5.1% vs. 2.0%, P < 0.001). On multivariable analysis, LEP did not independently predict 30-day MACCE [odds ratio (OR) 1.16, 95% CI 0.79-1.69; P = 0.45] but was an independent predictor of both prolonged STDT ≥ 120 min (OR 1.25, 95% CI 1.02-1.52; P = 0.03) and 30-day HF hospitalizations (OR 2.01, 95% CI 1.21-3.36; P = 0.008). CONCLUSION Patients with LEP undergoing PPCI present later and are more likely to have HF readmissions within 30 days of percutaneous coronary intervention, but with similar short-term MACCE. More effort to provide education in varied languages on early presentation in STEMI is required.
Collapse
Affiliation(s)
- Sinjini Biswas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark Lucas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of General Medicine, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Gordon Street, Footscray, VIC 3011, Australia.,Department of Medicine, Melbourne Medical School-Western Precinct, The University of Melbourne, Furlong Road, St Albans, VIC 3021, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Manningham Road, Doncaster, VIC 3108, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Manningham Road, Doncaster, VIC 3108, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Manningham Road, Doncaster, VIC 3108, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Kent Street, Perth, WA 6102, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Cardiology, Royal Melbourne Hospital, Grattan Street, Melbourne, VIC 3050, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Cardiology, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia.,Department of Cardiology, Western Health, Gordon Street, Footscray, VIC 3011, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Manningham Road, Doncaster, VIC 3108, Australia.,Baker Heart and Diabetes Institute, Commercial Road, Melbourne, VIC 3004, Australia
| |
Collapse
|
40
|
Bloom JE, Andrew E, Nehme Z, Dinh DT, Fernando H, Shi WY, Vriesendorp P, Nanayakarra S, Dawson LP, Brennan A, Noaman S, Layland J, William J, Al-Fiadh A, Brooks M, Freeman M, Hutchinson A, McGaw D, Van Gaal W, Willson W, White A, Prakash R, Reid C, Lefkovits J, Duffy SJ, Chan W, Kaye DM, Stephenson M, Bernard S, Smith K, Stub D. Pre-hospital heparin use for ST-elevation myocardial infarction is safe and improves angiographic outcomes. Eur Heart J Acute Cardiovasc Care 2021; 10:1140-1147. [PMID: 34189566 DOI: 10.1093/ehjacc/zuab032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 11/12/2022]
Abstract
AIMS This study aims to evaluate if pre-hospital heparin administration by paramedics is safe and improves clinical outcomes. METHODS AND RESULTS Using the multicentre Victorian Cardiac Outcomes Registry, linked with state-wide ambulance records, we identified consecutive patients undergoing primary percutaneous coronary intervention for STEMI between January 2014 and December 2018. Information on thrombolysis in myocardial infarction (TIMI) flow at angiography was available in a subset of cases. Patients receiving pre-hospital heparin were compared to those who did not receive heparin. Findings at coronary angiography and 30-day clinical outcomes were compared between groups. Propensity-score matching was performed for risk adjustment. We identified a total of 4720 patients. Of these, 1967 patients had TIMI flow data available. Propensity-score matching in the entire cohort yielded 1373 matched pairs. In the matched cohort, there was no observed difference in 30-day mortality (no-heparin 3.5% vs. heparin 3.0%, P = 0.25), MACCE (no-heparin 7% vs. heparin 6.2%, P = 0.44), and major bleeding (no-heparin 1.9% vs. heparin 1.4%, P = 0.64) between groups. Propensity-score analysis amongst those with TIMI data produced 552 matched pairs. The proportion of cases with TIMI 0 or 1 flow in the infarct-related artery (IRA) was lower among those receiving pre-hospital heparin (66% vs. 76%, P < 0.001) compared to those who did not. CONCLUSION In this multicentre, propensity-score matched study, the use of pre-hospital heparin by paramedics was safe and is associated with fewer occluded IRAs in patients presenting with STEMI.
Collapse
Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - William Y Shi
- Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Pieter Vriesendorp
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shane Nanayakarra
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - Jamie Layland
- Department of Cardiology, Peninsula Health, 2 Hastings Road, Frankston, VIC 3199, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Matthew Brooks
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia
| | - Adam Hutchinson
- Department of Cardiology, Geelong University Hospital, Bellerine Street, Geelong, VIC 3220, Australia
| | - David McGaw
- Department of Cardiology, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, 185 Cooper Street, Epping, VIC 3076, Australia
| | - William Willson
- Department of Cardiology, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia
| | - Anthony White
- Curtain University, Kent Street, Bentley, WA 6102, Australia
| | - Roshan Prakash
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Christopher Reid
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Curtain University, Kent Street, Bentley, WA 6102, Australia
| | - Jeffrey Lefkovits
- Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Michael Stephenson
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Stephen Bernard
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| |
Collapse
|
41
|
Stehli J, Dinh D, Dagan M, Duffy SJ, Brennan A, Smith K, Andrew E, Nehme Z, Reid CM, Lefkovits J, Stub D, Zaman S. Sex Differences in Prehospital Delays in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention. J Am Heart Assoc 2021; 10:e019938. [PMID: 34155902 PMCID: PMC8403281 DOI: 10.1161/jaha.120.019938] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Women with ST‐segment–elevation myocardial infarction experience delays in reperfusion compared with men with little data on each time component from symptom onset to reperfusion. This study analyzed sex discrepancies in patient delays, prehospital system delays, and hospital delays. Methods and Results Consecutive patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention across 30 hospitals in the Victorian Cardiac Outcomes Registry (2013–2018) were analyzed. Data from the Ambulance Victoria Data warehouse were used to perform linkage to the Victorian Cardiac Outcomes Registry for all patients transported via emergency medical services (EMS). The primary end point was EMS call‐to‐door time (prehospital system delay). Secondary end points included symptom‐to‐EMS call time (patient delay), door‐to‐device time (hospital delay), 30‐day mortality, major adverse cardiovascular events, and major bleeding. End points were analyzed according to sex and adjusted for age, comorbidities, cardiogenic shock, cardiac arrest, and symptom onset time. A total of 6330 (21% women) patients with ST‐segment–elevation myocardial infarction were transported by EMS. Compared with men, women had longer adjusted geometric mean symptom‐to‐EMS call times (47.0 versus 44.0 minutes; P<0.001), EMS call‐to‐door times (58.1 versus 55.7 minutes; P<0.001), and door‐to‐device times (58.5 versus 54.9 minutes; P=0.006). Compared with men, women had higher 30‐day mortality (odds ratio [OR], 1.38; 95% CI, 1.06–1.79; P=0.02) and major bleeding (OR, 1.54; 95% CI, 1.08–2.20; P=0.02). Conclusions Female patients with ST‐segment–elevation myocardial infarction experienced excess delays in patient delays, prehospital system delays, and hospital delays, even after adjustment for confounders. Prehospital system and hospital delays resulted in an adjusted excess delay of 10 minutes compared with men.
Collapse
Affiliation(s)
- Julia Stehli
- School of Clinical Sciences at Monash Health Monash Cardiovascular Research Centre Monash University Melbourne Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics School of Public Health and Preventive Medicine Monash University Melbourne Australia
| | - Misha Dagan
- Department of General Medicine The Alfred Hospital Melbourne Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics School of Public Health and Preventive Medicine Monash University Melbourne Australia.,Department of Cardiology The Alfred Hospital Melbourne Australia.,Baker Heart and Diabetes Institute Melbourne Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics School of Public Health and Preventive Medicine Monash University Melbourne Australia
| | - Karen Smith
- Centre for Research and Evaluation Ambulance Victoria Melbourne Australia.,Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
| | - Emily Andrew
- Centre for Research and Evaluation Ambulance Victoria Melbourne Australia.,Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
| | - Ziad Nehme
- Centre for Research and Evaluation Ambulance Victoria Melbourne Australia.,Department of Epidemiology and Preventive Medicine Monash University Melbourne Australia
| | - Christopher M Reid
- Centre for Research and Evaluation Ambulance Victoria Melbourne Australia.,School of Public Health Curtin University Perth Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics School of Public Health and Preventive Medicine Monash University Melbourne Australia.,Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics School of Public Health and Preventive Medicine Monash University Melbourne Australia.,Department of Cardiology The Alfred Hospital Melbourne Australia.,Centre for Research and Evaluation Ambulance Victoria Melbourne Australia.,Baker Heart and Diabetes Institute Melbourne Australia
| | - Sarah Zaman
- School of Clinical Sciences at Monash Health Monash Cardiovascular Research Centre Monash University Melbourne Australia.,Department of Cardiology Westmead Hospital Sydney Australia.,Westmead Applied Research Centre University of Sydney Australia
| |
Collapse
|
42
|
Parfrey S, Teh AW, Roberts L, Brennan A, Clark D, Duffy SJ, Ajani AE, Reid CM, Freeman M. The role of CHA2DS2-VASc score in evaluating patients with atrial fibrillation undergoing percutaneous coronary intervention. Coron Artery Dis 2021; 32:288-294. [PMID: 33394696 DOI: 10.1097/mca.0000000000000987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the review was to assess whether CHA2DS2-VASc score is predictive of mortality in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI). BACKGROUND The CHA2DS2-VASc score is validated in predicting stroke risk in atrial fibrillation. The optimum management strategy for these patients undergoing PCI is still debated. METHODS The CHA2DS2-VASc score was calculated in consecutive patients with atrial fibrillation undergoing PCI in a large Australian registry between 2007 and 2013. Patients were divided into low (1-2), intermediate (3-4) and high (≥5) groups. Clinical and procedural data, 30-day, 1-year and long-term outcomes were compared between the groups. RESULTS A total of 564 patients were included in our analysis. Patients with high CHA2DS2-VASc scores had higher mortality rates at 1-year (2, 8, 15; P = 0.002) and long-term (6, 20, 37; P < 0.001). High-risk patients were more likely to have renal impairment and multivessel disease. Increasing CHA2DS2-VASc score was associated with increased risk of stroke (0, 2, 6; P = 0.03). However, only 41.9% received anticoagulation, with no difference across the risk groups. When compared to low-risk, intermediate [HR 3.57; 95% confidence interval (CI), 1.28-9.92; P = 0.015] and high (hazard ratio 7.82; 95% CI, 2.88-21.24; P < 0.001) CHA2DS2-VASc scores were significant predictors of long-term mortality. CONCLUSIONS Higher CHA2DS2-VASc scores in patients with atrial fibrillation undergoing PCI are associated with significantly worse outcomes. Despite being high-risk, the patients in this cohort are likely undertreated with anticoagulation. Close clinical follow-up with greater utilization of anticoagulation and optimal medical therapy has the potential to improve long-term outcomes.
Collapse
Affiliation(s)
| | - Andrew W Teh
- Department of Cardiology, Box Hill Hospital
- Department of Cardiology, Austin Hospital
| | | | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
| | - David Clark
- Department of Cardiology, Austin Hospital
- University of Melbourne
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- Department of Cardiovascular Medicine, Alfred Hospital
| | - Andrew E Ajani
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- University of Melbourne
- Department of Cardiology, Royal Melbourne Hospital
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- John Curtain Distinguished Professor Director, Centre for Clinical Research and Education Director, WAHTN Clinical Trials and Data Management Centre, Curtain University, Perth, Western Australia, Australia
| | | |
Collapse
|
43
|
Biswas S, Dinh D, Andrianopoulos N, Lefkovits J, Ajani A, Duffy SJ, Chan W, Walton A, Brennan A, Clark DJ, Hiew C, Oqueli E, Reid CM, Stub D, Eccleston D. Comparison of Long-Term Outcomes After Percutaneous Coronary Intervention in Patients With Insulin-Treated Versus Non-Insulin Treated Diabetes Mellitus. Am J Cardiol 2021; 148:36-43. [PMID: 33667454 DOI: 10.1016/j.amjcard.2021.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
There are conflicting data on whether patients with insulin-treated diabetes mellitus (ITDM) have poorer outcomes compared with non-insulin treated diabetic (non-ITDM) patients following percutaneous coronary intervention (PCI). We therefore compared clinical outcomes following PCI in ITDM versus non-ITDM patients. We prospectively collected data on 4,579 patients with diabetes underwent PCI between 2005 and 2014 in a large multicenter registry and dichotomized them as having ITDM (n = 1,111) or non-ITDM (n = 3,468). The non-ITDM group was further divided into diet control only (diet-DM; n = 786) and those taking oral hypoglycemic agents (OHG-DM; n = 2,639), and clinical outcomes were compared with ITDM patients. Median follow-up for long-term mortality was 4.2 years (IQR 2.0 to 6.6 years). ITDM patients were more likely to be female, obese, and have severe renal impairment (all p <0.001). Procedural characteristics were similar other than a greater use of drug-eluting stents in ITDM patients. On multivariable analysis, ITDM was an independent predictor of 12-month major adverse cardiovascular and cerebrovascular events (MACCE; OR 1.26, 95% CI 1.02 to1.55, p = 0.03). Dividing the non-ITDM group further by treatment, a progressively higher rate of 12-month MACCE across the 3 groups was observed (13.5% vs 17.9% vs 21.8%; p <0.001). Long-term mortality was similar in the diet-DM and OHG-DM groups, but significantly higher in the ITDM group on Kaplan-Meier analysis (log-rank p <0.001). In conclusion, there is a clear gradient of adverse outcomes with escalation of therapy from diet control to OHGs to insulin.
Collapse
|
44
|
Dawson LP, Duffy SJ, Dinh D, Clark D, Brennan A, Ajani AE. Difference in a decade: percutaneous coronary interventions in Australia. Intern Med J 2021; 51:138-139. [PMID: 33572022 DOI: 10.1111/imj.15150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/11/2020] [Accepted: 02/25/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia
| |
Collapse
|
45
|
Zhou J, Liew D, Duffy SJ, Shaw J, Walton A, Chan W, Gerber R, Stub D. Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: A Health Economic Analysis. Circ Cardiovasc Qual Outcomes 2021; 14:e006789. [PMID: 34003686 DOI: 10.1161/circoutcomes.120.006789] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is increasing evidence that use of intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography guidance alone. However, concern regarding the cost-effectiveness of IVUS has limited use of this technology worldwide. In this study, we aimed to evaluate the cost-effectiveness of IVUS-guided PCI compared with angiography-guided PCI in patients undergoing drug-eluting stent implantation. METHODS A decision-analytic Markov model was constructed to compare the cost-effectiveness of IVUS to angiography guidance from the Australian healthcare system perspective. Procedure-related morbidity and mortality were estimated from the literature. Costs were obtained from Australian sources. The population of interest was all-comers undergoing PCI with drug-eluting stent. Outcomes of interest included costs, life-expectancy, and quality-adjusted life years (QALYs) for both treatment groups. RESULTS In the base case, IVUS guidance was cost-effective compared with angiography guidance alone. With 5% annual discounting, IVUS was associated with increased lifetime costs of Australian dollars (AUD) $823 (USD $597) per person and benefits of 0.04 life years and 0.05 QALYs compared with angiography, yielding an incremental cost-effectiveness ratio of AUD $17 539 (USD $12 730) per QALY gained. Results were robust to sensitivity analyses, with IVUS being cost-effective in 99% of 10 000 Monte Carlo iterations assuming a willingness-to-pay threshold of AUD $50 000 per QALY gained. In a worst-case scenario analysis, IVUS remained the cost-effective option, with an ICER of AUD $36 651 (USD $26 601) per QALY gained. Exploratory subgroup analysis revealed that cost-effectiveness may be greatest among patients with left main and complex coronary lesions. CONCLUSIONS Use of IVUS guidance during PCI is likely to be cost-effective compared with angiography guidance alone among patients undergoing drug-eluting stent implantation.
Collapse
Affiliation(s)
- Jennifer Zhou
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.)
| | - Danny Liew
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (D.L., S.J.D., D.S.)
| | - Stephen J Duffy
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (D.L., S.J.D., D.S.)
| | - James Shaw
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.)
| | - Antony Walton
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.)
| | - William Chan
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,Western Health, Melbourne, Australia (W.C., D.S.)
| | | | - Dion Stub
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (D.L., S.J.D., D.S.).,Western Health, Melbourne, Australia (W.C., D.S.)
| |
Collapse
|
46
|
Sarkies MN, Robinson S, Briffa T, Duffy SJ, Nelson M, Beltrame J, Cullen L, Chew D, Smith J, Brieger D, Macdonald P, Liew D, Reid C. Applying a framework to assess the impact of cardiovascular outcomes improvement research. Health Res Policy Syst 2021; 19:67. [PMID: 33882947 PMCID: PMC8059028 DOI: 10.1186/s12961-021-00710-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 03/21/2021] [Indexed: 01/06/2023] Open
Abstract
Background Health and medical research funding agencies are increasingly interested in measuring the impact of funded research. We present a research impact case study for the first four years of an Australian National Health and Medical Research Council funded Centre of Research Excellence in Cardiovascular Outcomes Improvement (2016–2020). The primary aim of this paper was to explore the application of a research impact matrix to assess the impact of cardiovascular outcomes improvement research. Methods We applied a research impact matrix developed from a systematic review of existing methodological frameworks used to measure research impact. This impact matrix was used as a bespoke tool to identify and understand various research impacts over different time frames. Data sources included a review of existing internal documentation from the research centre and publicly available information sources, informal iterative discussions with 10 centre investigators, and confirmation of information from centre grant and scholarship recipients. Results By July 2019, the impact on the short-term research domain category included over 41 direct publications, which were cited over 87 times (median journal impact factor of 2.84). There were over 61 conference presentations, seven PhD candidacies, five new academic collaborations, and six new database linkages conducted. The impact on the mid-term research domain category involved contributions towards the development of a national cardiac registry, cardiovascular guidelines, application for a Medicare Benefits Schedule reimbursement item number, introduction of patient-reported outcome measures into several databases, and the establishment of nine new industry collaborations. Evidence of long-term impacts were described as the development and use of contemporary management for aortic stenosis, a cardiovascular risk prediction model and prevention targets in several data registries, and the establishment of cost-effectiveness for stenting compared to surgery. Conclusions We considered the research impact matrix a feasible tool to identify evidence of academic and policy impact in the short- to midterm; however, we experienced challenges in capturing long-term impacts. Cost containment and broader economic impacts represented another difficult area of impact to measure. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-021-00710-4.
Collapse
Affiliation(s)
- Mitchell N Sarkies
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, 75 Talavera Road, Sydney, NSW, 2109, Australia. .,Health Systems and Health Economics Group, Health Research and Data Analytics Hub, School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Australia.
| | - Suzanne Robinson
- Health Systems and Health Economics Group, Health Research and Data Analytics Hub, School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Tom Briffa
- Faculty of Health and Medical Sciences, Population and Public Health, The University of Western Australia, Perth, Australia
| | - Stephen J Duffy
- Department of General Cardiology, Alfred Health, Melbourne, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Mark Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - John Beltrame
- Discipline of Medicine, University of Adelaide, Adelaide, Australia.,Cardiology Department, Central Adelaide Local Health Network, Adelaide, Australia.,Cardiology Department, Lyell McEwin Hospital, Adelaide, Australia
| | - Louise Cullen
- Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Australia.,School of Medicine, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Australia
| | - Derek Chew
- Department of Cardiovascular Medicine, Flinders University, Adelaide, Adelaide, Australia
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences At Monash Health), Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - David Brieger
- Division of Cardiology, Concord Hospital and University of Sydney, Sydney, Australia
| | - Peter Macdonald
- St Vincent's Hospital, Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Danny Liew
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Chris Reid
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia.,NHMRC Centre for Research Excellence in Cardiovascular Outcomes Improvement, Health Research and Data Analytics Hub, School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| |
Collapse
|
47
|
Dagan M, Dawson LP, Stehli J, Koh JQS, Quine E, Stub D, Htun NM, Walton A, Duffy SJ. Periprocedural myocardial injury and coronary artery disease in patients undergoing transcatheter aortic valve replacement. Cardiovasc Revasc Med 2021; 35:8-15. [PMID: 33863658 DOI: 10.1016/j.carrev.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND/PURPOSE PPMI and CAD are common in patients undergoing TAVR. Despite several studies evaluating their interaction as well as the influence these factors play on outcomes, there remains no consensus. We sought to evaluate the impact of peri-procedural myocardial injury (PPMI) and incidental coronary artery disease (iCAD) on outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS/MATERIALS We analyzed prospective data from 400 patients undergoing TAVI for severe aortic stenosis between 2008 and 2018 to determine rates of PPMI (troponin 15× the upper limit of normal) and iCAD (≥50% stenosis) and their impact on long-term mortality. RESULTS Mean age was 83 ± 6 years; 45% were female. PPMI was observed in 65% (254/400). On multivariable logistic regression analysis, higher left ventricular ejection fraction (LVEF) (OR 1.04, 95%CI 1.01-1.06, p = 0.002), and first generation valves (OR 3.00, 95%CI 1.75-5.15, p < 0.001) were independently associated with PPMI, while oral anticoagulation was inversely associated (OR 0.48, 95%CI 0.28-0.82, p = 0.007). PPMI was not associated with 30-day, 1-year or long-term mortality. After excluding previous bypass grafting, iCAD was observed in 40% (129/324). In patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management in adjusted analysis (OR 0.37, 95%CI 0.16-0.88, p = 0.03). CONCLUSIONS PPMI and iCAD in patients undergoing TAVR are common. PPMI is associated with older generation valves and higher LVEF rather than traditional cardiovascular risk factors. In our study, PPMI was not associated with long-term mortality. However, in patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management.
Collapse
Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | | | - Edward Quine
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nay M Htun
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| |
Collapse
|
48
|
Fernando H, Dinh D, Duffy SJ, Brennan A, Sharma A, Clark D, Ajani A, Freeman M, Peter K, Stub D, Hiew C, Reid CM, Oqueli E. Rescue PCI in the management of STEMI: Contemporary results from the Melbourne Interventional Group registry. Int J Cardiol Heart Vasc 2021; 33:100745. [PMID: 33786363 PMCID: PMC7988313 DOI: 10.1016/j.ijcha.2021.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/12/2021] [Accepted: 02/19/2021] [Indexed: 12/01/2022]
Abstract
Background Fibrinolysis is an important reperfusion strategy in the management of ST-elevation myocardial infarction (STEMI) when timely access to primary percutaneous coronary intervention (PPCI) is unavailable. Rescue PCI is generally thought to have worse outcomes than PPCI in STEMI. We aimed to determine short- and long-term outcomes of patients with rescue PCI versus PPCI for treatment of STEMI. Methods and results Patients admitted with STEMI (excluding out-of-hospital cardiac arrest) within the Melbourne Interventional Group (MIG) registry between 2005 and 2018 treated with either rescue PCI or PPCI were included in this retrospective cohort analysis. Comparison of 30-day major adverse cardiac events (MACE) and long-term mortality between the two groups was performed. There were 558 patients (7.1%) with rescue PCI and 7271 with PPCI. 30-day all-cause mortality (rescue PCI 6% vs. PPCI 5%, p = 0.47) and MACE (rescue PCI 10.3% vs. PPCI 8.9%, p = 0.26) rates were similar between the two groups. Rates of in-hospital major bleeding (rescue PCI 6% vs. PPCI 3.4%, p = 0.002) and 30-day stroke (rescue PCI 2.2% vs. PPCI 0.8%, p < 0.001) were higher following rescue PCI. The odds ratio for haemorrhagic stroke in the rescue PCI group was 10.3. Long-term mortality was not significantly different between the groups (rescue PCI 20% vs. PPCI 19%, p = 0.33). Conclusions With contemporary interventional techniques and medical therapy, rescue PCI remains a valuable strategy for treating patients with failed fibrinolysis where PPCI is unavailable and it has been suggested in extenuating circumstances where alternative revascularisation strategies are considered.
Collapse
Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anand Sharma
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - David Clark
- Department of Cardiology Austin Health, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Chin Hiew
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| |
Collapse
|
49
|
Dagan M, Dinh DT, Stehli J, Tan C, Brennan A, Warren J, Ajani AE, Freeman M, Murphy A, Reid CM, Hiew C, Oqueli E, Clark DJ, Duffy SJ. Sex Disparity In Secondary Prevention Pharmacotherapy And Clinical Outcomes Following Acute Coronary Syndrome. Eur Heart J Qual Care Clin Outcomes 2021; 8:420-428. [PMID: 33537698 DOI: 10.1093/ehjqcco/qcab007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/30/2020] [Accepted: 01/29/2021] [Indexed: 12/11/2022]
Abstract
Abstract
Aims
We sought to investigate if sex disparity exists for secondary prevention pharmacotherapy following acute coronary syndrome (ACS) and impact on long-term clinical outcomes.
Methods and results
We analysed data on medical management 30-day post-percutaneous coronary intervention (PCI) for ACS in 20 976 patients within the multicentre Melbourne Interventional Group registry (2005–2017). Optimal medical therapy (OMT) was defined as five guideline-recommended medications, near-optimal medical therapy (NMT) as four medications, sub-optimal medical therapy (SMT) as ≤3 medications. Overall, 65% of patients received OMT, 27% NMT and 8% SMT. Mean age was 64 ± 12 years; 24% (4931) were female. Women were older (68 ± 12 vs. 62 ± 12 years) and had more comorbidities. Women were less likely to receive OMT (61% vs. 66%) and more likely to receive SMT (10% vs. 8%) compared to men, P < 0.001. On long-term follow-up (median 5 years, interquartile range 2–8 years), women had higher unadjusted mortality (20% vs. 13%, P < 0.001). However, after adjusting for medical therapy and baseline risk, women had lower long-term mortality [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.79–0.98; P = 0.02]. NMT (HR 1.17, 95% CI 1.05–1.31; P = 0.004) and SMT (HR 1.79, 95% CI 1.55–2.07; P < 0.001) were found to be independent predictors of long-term mortality.
Conclusion
Women are less likely to be prescribed optimal secondary prevention medications following PCI for ACS. Lower adjusted long-term mortality amongst women suggests that as well as baseline differences between gender, optimization of secondary prevention medical therapy amongst women can lead to improved outcomes. This highlights the need to focus on minimizing the gap in secondary prevention pharmacotherapy between sexes following ACS.
Collapse
Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Diem T Dinh
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Christianne Tan
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | | | - Andrew E Ajani
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | | | - Christopher M Reid
- Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Chin Hiew
- Department of Cardiology, Geelong Hospital, Geelong, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Victoria, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Victoria, Australia.,Centre of Cardiovascular Research & Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
50
|
Dawson LP, Dinh D, O'Brien J, Duffy SJ, Guymer E, Brennan A, Clark D, Oqueli E, Hiew C, Freeman M, Reid CM, Ajani AE. Outcomes of Percutaneous Coronary Intervention in Patients With Rheumatoid Arthritis. Am J Cardiol 2021; 140:39-46. [PMID: 33144158 DOI: 10.1016/j.amjcard.2020.10.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022]
Abstract
Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p <0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p <0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (hazard ratio 1.53, 95% confidence interval 1.30 to 1.80; median follow-up 5.0 years), whereas 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery, and target vessel revascularization were similar. In subgroup analysis, patients with RA and lower BMI (Pfor interaction < 0.001) and/or acute coronary syndromes (Pfor interaction = 0.05) had disproportionately higher risk of long-term mortality compared with patients without RA. In conclusion, patients with RA who underwent PCI had more co-morbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes was similar, whereas risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower body mass index.
Collapse
Affiliation(s)
- Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Jessica O'Brien
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Emma Guymer
- Department of Rheumatology, Monash Medical Centre, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia; School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital, Geelong, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Andrew E Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Medicine, Melbourne University, Victoria, Australia.
| |
Collapse
|