Long-term efficacy and safety of drug-coated balloons versus drug-eluting stents for small coronary artery disease (BASKET-SMALL 2): 3-year follow-up of a randomised, non-inferiority trial

BACKGROUND

In the treatment of de-novo coronary small vessel disease, drug-coated balloons (DCBs) are non-inferior to drug-eluting stents (DESs) regarding clinical outcome up to 12 months, but data beyond 1 year is sparse. We aimed to test the long-term efficacy and safety of DCBs regarding clinical endpoints in an all-comer population undergoing percutaneous coronary intervention.

METHODS

In this prespecified long-term follow-up of a multicentre, randomised, open-label, non-inferiority trial, patients from 14 clinical sites in Germany, Switzerland, and Austria with de-novo lesions in coronary vessels <3 mm and an indication for percutaneous coronary intervention were randomly assigned 1:1 to DCB or second-generation DES and followed over 3 years for major adverse cardiac events (ie, cardiac death, non-fatal myocardial infarction, and target-vessel revascularisation [TVR]), all-cause death, probable or definite stent thrombosis, and major bleeding (Bleeding Academic Research Consortium bleeding type 3-5). Analyses were performed on the full analysis set according to the modified intention-to-treat principle. Dual antiplatelet therapy was recommended for 1 month after DCB and 6 months after DES with stable symptoms, but 12 months with acute coronary syndromes. The study is registered with ClinicalTrials.gov, NCT01574534 and is ongoing.

FINDINGS

Between April 10, 2012, and Feb 1, 2017, of 883 patients assessed, 758 (86%) patients were randomly assigned to the DCB group (n=382) or the DES group (n=376). The Kaplan-Meier estimate of the rate of major adverse cardiac events was 15% in both the DCB and DES groups (hazard ratio [HR] 0·99, 95% CI 0·68-1·45; p=0·95). The two groups were also very similar concerning the single components of adverse cardiac events: cardiac death (Kaplan-Meier estimate 5% vs 4%, HR 1·29, 95% CI 0·63-2·66; p=0·49), non-fatal myocardial infarction (both Kaplan-Meier estimate 6%, HR 0·82, 95% CI 0·45-1·51; p=0·52), and TVR (both Kaplan-Meier estimate 9%, HR 0·95, 95% CI 0·58-1·56; p=0·83). Rates of all-cause death were very similar in DCB versus DES patients (both Kaplan-Meier estimate 8%, HR 1·05, 95% CI 0·62-1·77; p=0·87). Rates of probable or definite stent thrombosis (Kaplan-Meier estimate 1% vs 2%; HR 0·33, 95% CI 0·07-1·64; p=0·18) and major bleeding (Kaplan-Meier estimate 2% vs 4%, HR 0·43, 95% CI 0·17-1·13; p=0·088) were numerically lower in DCB versus DES, however without reaching significance.

INTERPRETATION

There is maintained efficacy and safety of DCB versus DES in the treatment of de-novo coronary small vessel disease up to 3 years.

FUNDING

Swiss National Science Foundation, Basel Cardiovascular Research Foundation, and B Braun Medical.

Coronary angioplasty in spontaneous coronary artery dissection-Strategy and outcomes

OBJECTIVE

To study the clinical, angiographic and technical characteristics of patients with spontaneous coronary artery dissection (SCAD) undergoing percutaneous coronary intervention (PCI).

METHODS

This was a retrospective single center study where patients with angiographically confirmed SCAD undergoing PCI over a period of 4 years (2013-2017) were analyzed. We also sought to identify the clinical and angiographic predictors of procedural failure during PCI.

RESULTS

There were a total of 42 patients with angiographically confirmed SCAD during the study period of which 16 patients (38.1%) underwent PCI. 14 out of the 16 patients (87.5%) taken up for PCI had technical success. In all patients the lesion was initially attempted to cross with a floppy wire and if unsuccessful it was escalated to a hydrophilic wire and finally to a stiff wire The SCAD lesion was crossed with a floppy wire in 71.4% of patients, with a hydrophilic wire in 14.2% and a stiff wire in 7.1% of patients. Wire escalation was required in 5 patients (31.3%) and in 60% of cases there was a technical success after wire escalation. Presence of diabetes mellitus, hypertension, dyslipidemia, smoking, coexisting atherosclerosis, diffuse nature of the lesion, and baseline Thrombolysis in Myocardial Infarction (TIMI)≤2 flow did not predict procedural failure during PCI.

CONCLUSION

PCI in SCAD is associated with a fair rate of technical success in our population. Choosing an initial floppy wire and then escalating to a hydrophilic wire followed by a stiff wire is an optimal revascularization strategy.

The impact on long term health outcomes for STEMI patients during a period of process change to reduce door to balloon time

BACKGROUND

Guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend a 'door to balloon time' (DTBT) within 90 minutes. It is unclear whether strategies to reduce DTBT translate to improved longer-term health outcomes for STEMI patients.

AIMS

This study sought to determine whether implemented strategies to improve timely management of STEMI reduced DTBT and impacted upon health outcomes such as length of stay, unplanned readmission and 12-month mortality. Predictors of timely management for STEMI were also examined.

METHODS

A five-year review was undertaken on primary percutaneous coronary intervention for STEMI in one tertiary hospital. Comparisons were made between process change groups and DTBT. Logistic regression identified predictors of timely management.

RESULTS

470 STEMI patients underwent immediate primary percutaneous coronary intervention. Process change improved the median DTBT (109 min vs. 72 min, p<0.001) with no significant effect on length of stay (p=0.83), unplanned cardiac readmissions (p=0.68) or 12-month mortality (9.0% vs. 8.6%, p=0.64). Those receiving timely treatment (i.e. DTBT< 90 min) were younger (p<0.05), male (p<0.03), presented via ambulance (p<0.004), during business hours (p<0.0001) and had a lower Thrombolysis In Myocardial Infarction score (p<0.006). Timely treatment was associated with lower 12-month mortality (3.7% vs. 15.7%, p<0.0001) and increased uptake of inpatient cardiac rehabilitation (p<0.005), with length of stay and unplanned readmission similar between groups (p=NS).

CONCLUSIONS

Process changes improved DTBT but had no effect on length of stay, readmission rate or 12-month mortality. Yet, timely management was critical to 12-month outcomes. Further studies are required to explore the barriers to timely treatment.

The importance of audit to monitor applications of procedures and improve primary angioplasty results

Although clinical trials have demonstrated that primary percutaneous coronary intervention (PPCI) provides better outcomes than thrombolysis for STEMI, it cannot be assumed that similar results can be obtained in day-to-day practice. To determine whether standards are being met, continuous audit of PPCI programmes is necessary, with appropriate feedback to participating centres and operators. Both the MINAP and BCIS national audit projects allow central electronic collection of data on consecutive patients presenting to every hospital involved in the acute management of these patients. Regular programmed feedback is provided to centres performing primary PCI that attempts to take account of statistical variation and differences in case mix between units by making use of funnel plots, statistical process control graphs and risk adjustment models. This reporting of "process" and "outcome" data, both confidentially and within the public domain, has been used to drive up clinical performance and has been associated with steady improvements and reduced inequalities of care.

Door-to-balloon time and mortality among patients undergoing primary PCI

BACKGROUND

Current guidelines for the treatment of ST-segment elevation myocardial infarction recommend a door-to-balloon time of 90 minutes or less for patients undergoing primary percutaneous coronary intervention (PCI). Door-to-balloon time has become a performance measure and is the focus of regional and national quality-improvement initiatives. However, it is not known whether national improvements in door-to-balloon times have been accompanied by a decline in mortality.

METHODS

We analyzed annual trends in door-to-balloon times and in-hospital mortality using data from 96,738 admissions for patients undergoing primary PCI for ST-segment elevation myocardial infarction from July 2005 through June 2009 at 515 hospitals participating in the CathPCI Registry. In a subgroup analysis using a linked Medicare data set, we assessed 30-day mortality.

RESULTS

Median door-to-balloon times declined significantly, from 83 minutes in the 12 months from July 2005 through June 2006 to 67 minutes in the 12 months from July 2008 through June 2009 (P<0.001). Similarly, the percentage of patients for whom the door-to-balloon time was 90 minutes or less increased from 59.7% in the first year to 83.1% in the last year (P<0.001). Despite improvements in door-to-balloon times, there was no significant overall change in unadjusted in-hospital mortality (4.8% in 2005-2006 and 4.7% in 2008-2009, P=0.43 for trend) or in risk-adjusted in-hospital mortality (5.0% in 2005-2006 and 4.7% in 2008-2009, P=0.34), nor was a significant difference observed in unadjusted 30-day mortality (P=0.64).

CONCLUSIONS

Although national door-to-balloon times have improved significantly for patients undergoing primary PCI for ST-segment elevation myocardial infarction, in-hospital mortality has remained virtually unchanged. These data suggest that additional strategies are needed to reduce in-hospital mortality in this population. (Funded by the National Cardiovascular Data Registry of the American College of Cardiology Foundation.).

Nonemergency PCI at hospitals with or without on-site cardiac surgery

BACKGROUND

Emergency surgery has become a rare event after percutaneous coronary intervention (PCI). Whether having cardiac-surgery services available on-site is essential for ensuring the best possible outcomes during and after PCI remains uncertain.

METHODS

We enrolled patients with indications for nonemergency PCI who presented at hospitals in Massachusetts without on-site cardiac surgery and randomly assigned these patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that had cardiac surgery services available. A total of 10 hospitals without on-site cardiac surgery and 7 with on-site cardiac surgery participated. The coprimary end points were the rates of major adverse cardiac events--a composite of death, myocardial infarction, repeat revascularization, or stroke--at 30 days (safety end point) and at 12 months (effectiveness end point). The primary end points were analyzed according to the intention-to-treat principle and were tested with the use of multiplicative noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness).

RESULTS

A total of 3691 patients were randomly assigned to undergo PCI at a hospital without on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery (917 patients). The rates of major adverse cardiac events were 9.5% in hospitals without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at 30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98; 95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of death, myocardial infarction, repeat revascularization, and stroke (the components of the primary end point) did not differ significantly between the groups at either time point.

CONCLUSIONS

Nonemergency PCI procedures performed at hospitals in Massachusetts without on-site surgical services were noninferior to procedures performed at hospitals with on-site surgical services with respect to the 30-day and 1-year rates of clinical events. (Funded by the participating hospitals without on-site cardiac surgery; MASS COM ClinicalTrials.gov number, NCT01116882.).

[Primary percutaneous coronary intervention as a national Danish reperfusion strategy of ST-elevation myocardial infarction]

The use of primary percutaneous coronary intervention (PCI) as the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI) requires optimal systems-of-care and logistics in order to enable rapid treatment of all patients. In Denmark, this has been achieved through prehospital electrocardiogram diagnosis, field triage and dedicated PCI centres 24/7. Today, primary PCI is an option for all Danish patients with STEMI, regardless of the distance to a PCI centre. This has led to a decline in both mortality and morbidity.

Door-to-balloon time in acute ST segment elevation myocardial infarction--further experience

Early coronary reperfusion has been established as the optimal treatment for acute ST segment elevation myocardial infarction. A treatment protocol, previously described, has been designed to reduce delay in achieving recanalization of the culprit coronary artery. Over a period of about 4 years, Door-to-Balloon time has been analyzed for patients arriving in the Emergency Department with this condition. During that time the process was enhanced by the ability of ambulance personnel to transmit 12 lead EKG's from the field. Door-to-Balloon times have been analyzed and compared to the American College of Cardiology target of 90 minutes. After just over one year of gradually improving results, 100% compliance was achieved. From that time on, this was achieved during the period under consideration in 97% of cases.

[Use of drug-eluting balloons for coronary interventions: current indications and perspectives]

The paclitaxel-eluting balloon is an emerging percutaneous coronary angioplasty tool which aim is to prevent restenosis by delivering a high intravessel paclitaxel dose during balloon inflation. It has been already approved in the treatment of bare metal stent restenosis and is being investigated in drug-eluting stent restenosis. For the treatment of de novo lesions, it could be used alone or in combination with bare metal stent implantation. Most interesting results were obtained by a drug-eluting balloon alone strategy in small vessels angioplasty. Current and upcoming results of this evolving technology are reviewed.

Analysis on outcome of 5284 patients with coronary artery disease: the role of integrative medicine

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese Medicine (TCM) has a history of thousands of years and has made great contributions to the health and well-being of the people. Integrative medicine (IM) treatment, combing TCM and conventional medicine, has been the most representative characteristic for coronary artery disease (CAD) patients in China, especially those in IM hospitals. However, the secondary prevention status of CAD and the potential benefit of IM therapy in improving CAD prognosis remains unclear.

MATERIALS AND METHODS

By means of a unified clinical and research information platform, we collected clinical information of hospitalized patients with CAD in cardiovascular department of 9 IM hospitals in Beijing and Tianjin from January 2003 to September 2006. The primary endpoints were major adverse cardiac events (MACEs) which include all-cause death in hospital and during one-year follow-up, acute myocardial infarction (AMI), percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). The diagnostic and therapeutic status of CAD patients was evaluated based on the latest available clinical guidelines. Meanwhile, a logistic stepwise regression analysis was also used to identify independent prognostic factors.

RESULTS

5284 hospitalized patients with CAD were registered. The top five TCM patterns were in turn blood stasis 79.3%, Qi deficiency 56.5%, phlegm-turbidness 41.1%, Yin deficiency 24.8%, Yang deficiency 11.3%. The standard-reaching rate of CAD patients with hyperlipidemia was 85.6% for total cholesterol, 31.2% for triglyceride, 21.4% for low-density lipoprotein cholesterol, 52.5% for high-density lipoprotein cholesterol, while it was 61.9% and 80.9% in systolic and diastolic blood pressure of CAD with hypertension respectively. The top five commonly used herbs by functions were Qi-tonifying agents 89.25%, blood-activating agents 86.04%, Qi-regulating agents 77.60%, heat-clearing agents 67.50%, dampness-draining agents 65.95%. The herbs commonly used were Salvia miltiorrhiza Bunge 63.10%, Poria 59.99%, Raidx Astragali 49.67%, Radix Paeoniae Rubra 48.71%, peach seed 47.32%, angelica 46.82%, Radix Ligustici Chuanxiong 46.36%, safflower 45.40%, Pinellia 45.30%, glycyrrhiza 41.36%. 90 patients (1.7%) died in hospital, and the overall incidence of endpoints was 6.1% (322/5284). The logistic stepwise regress analysis showed that AMI (OR, 5.62, 95% CI=2.56-12.33), heart failure (OR, 2.68, 95% CI=1.67-4.29), age≥60 years (OR, 2.01, 95% CI=1.22-3.30), and medication of phosphodiesterase inhibitors (OR, 1.67, 95% CI=1.15-2.42) were independent risk factors for in-hospital mortality and one-year follow-up MACEs, while statins (OR, 0.23, 95% CI=0.06-0.91) and IM therapy (OR, 0.69, 95% CI=0.49-0.97) were protective factors.

CONCLUSION

There was still certain gap between the usage of conventional medicine and clinical guideline in IM hospitals of China. Integrative Medicine might have potential benefit for CAD patients in reducing MACEs. However, the scheme of IM intervention and the mechanism of action are still needed to be further determined.

New era of left main coronary artery treatment strategy

For several decades of medical history, coronary-artery bypass grafting (CABG) has been regarded as the best treatment option for patients with unprotected left main coronary artery (LMCA) disease, considering lesion priority and its clinical consequences. Over the time, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with DES implantation has appeared to be new and alternative option for optimal revascularization therapy for these patients. The available cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction and stroke are similar among PCI and CABG for patients with LMCA disease, the only difference was the rate of repeat revascularization. Current evidence and ongoing large clinical trials may encourage interventional cardiologists to choose PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease in future. Finally, this evidence will change the current clinical practice and the guideline of optimal revascularization strategy for unprotected LMCA disease.

[Myocardial infarction due to left main occlusion in a patient with Leriche's syndrome]

We present the case of a 55 year-old male admitted to Malopolskie Centrum Sercowo-Naczyniowe PAKS in Chrzanów with diagnosis of anterior wall myocardial infarction (STEMI). We decided to treat the patient invasively because of presence of chest pain, persistent ST elevation and signs of haemodinamical instability. As it revealed later patient needed combination of PCI of left main/left anterior descending artery with PTA of iliac artery.

Primary percutaneous angioplasty, thrombolysis and conservative treatment in low-risk patients with ST-elevation myocardial infarction: effects on short- and long-term mortality

BACKGROUND

Although primary coronary intervention (PCI) is currently regarded as the preferred reperfusion strategy in ST- -elevation myocardial infarction (STEMI), its superiority over thrombolysis has been documented mainly in high-risk patients. In low-risk patients, the difference seems to be not so significant.

AIM

To evaluate the early and late mortality in low-risk STEMI patients treated with thrombolysis, PCI, or conservatively.

METHODS

From a total of 3,780 consecutive STEMI patients presenting within 24 h from symptom onset, 990 low-risk patients (age < 70 years old, Killip-Kimball class 1 at admission, non-anterior STEMI) were selected. The median follow-up duration was 18.3 (14.2-25.0) months. The patients were subdivided into three groups: group A (n = 465) - treated with PCI; group B (n = 289) - treated with thrombolysis; and group C (n = 236) - treated conservatively.

RESULTS

In the whole study group 12 (1.21%) patients died; 30-day mortality in group A was 0.65%. In group B five out of 289 (1.73%) patients died, and in group C four out of 236 (1.69%) patients died. No significant differences in 30-day mortality between these three groups were found (p = 0.3). During the long-term follow-up, 37 (3.7%) of 990 patients died. In group A 18 (3.9%) patients died, in group B ten (3.4%) patients died, and in group C nine (3.8%) patients died (p = 0.96).

CONCLUSIONS

No significant differences in 30-day or long-term mortality rates between conservative therapy, PCI or thrombolysis groups in low-risk STEMI patients were observed.

Reduced door-to-balloon times in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

BACKGROUND

Primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity, particularly when door-to-balloon (D2B) time is < 90 min. We sought to minimize preventable delays by instituting an on-site cardiology team-based approach in the emergency department (ED).

METHODS

The on-site group comprised 146 consecutive patients with STEMI undergoing primary PCI after implementation of the on-site strategy. This new patient care model was compared with the conventional care administered before instituting the on-site cardiology team-based strategy in ED, which included 90 patients (interim group) receiving primary PCI at a catheterization room in the same building as the ED, and 147 patients (pre-on-site group) undergoing primary PCI at a catheterization room two blocks away from the ED.

RESULTS

Median D2B time decreased from 107 min in the pre-on-site group to 72 min in the interim group, and to 47 min in the on-site group, respectively (p < 0.001). The percentage of D2B times < 90 min increased from 34% to 78% and 96%, respectively among the three groups (p < 0.001). Hospitalization costs were significantly reduced in the on-site and interim vs. pre-on-site groups ($5944, $5999, and $6581, respectively; p = 0.008). In-hospital mortality did not differ significantly among the three groups (4.8%, 2.2%, and 6.1%, respectively; p = 0.387).

CONCLUSIONS

Institution of an on-site cardiology team-based approach in the ED significantly reduces D2B time in STEMI patients eligible for primary PCI.

[The efficiency of cutting balloon angioplasty in the treatment of in-stent restenosis]

OBJECTIVE

Although stents reduce the restenosis rate, stent restenosis continues to be a major problem and the optimal treatment of stent restenosis is still controversial. In this study, we aimed to investigate the angiographic recurrent stent restenosis rate at 6-12 months after successful cutting balloon angioplasty (CBA) for the bare metal stent restenosis.

METHODS

Thirty patients (mean age: 57.9 ± 11.6, 22 males) undergoing successful CBA for the treatment of in-stent restenosis at our hospital were prospectively included in this study. Control coronary angiography was performed at 6-12 months after CBA. Lesion length, minimal lumen diameter (MLD), and reference vessel diameter were analyzed by computerized digital angiographic analysis. Recurrent restenosis was defined as the lesions obstructing the lumen more than 50%. We described the lesions shorter than 10 mm as to be focal and those longer than 10 mm as to be diffuse. We used Student t, Chi-square, and Mann-Whitney U tests for statistical analysis.

RESULTS

Two patients had two distinct lesions; therefore, 32 lesions were assessed. There were 9 (28.1%) recurrent restenosis on the control coronary angiography. Recurrent restenosis developed in 3/21 (14.3%) of focal type lesions and 6/11(54.5%) of diffuse type lesions (p=0.035). Pre-procedural MLD was lower in the restenotic group compared to non-restenotic group (0.41 ± 0.29 vs. 0.64 ± 0.17 mm, p=0.048) while percent of stenosis was higher in the restenotic group (76.8 ± 12 vs. 69.6 ± 5.37%, p=0.029).

CONCLUSION

In the selected patients, CBA is an effective and a safe method for the treatment of bare metal stent restenosis. CBA might be considered as a first-line treatment method in patients with focal type lesions.

[Percutaneous coronary interventions in patients with acute myocardial infarction after unsuccessful thrombolysis]

In 176 patients with acute myocardial infarction admitted to N.V. Sklifosofsky institute of urgent aid in 2003-20007 we compared efficacy of 3 strategies of treatment after unsuccessful thrombolytic therapy (TLT): percutaneous coronary intervention (PCI) during first 24 hours (n = 30), PCI on days 2 or 3 (n = 38); conservative treatment (n = 108). The data obtained show that it is expedient to consider absence of 50% reduction of STAsegment elevations in 90 min after start of TLT as indication to urgent late PCI when possibilities for immediate intervention after unsuccessful thrombolysis are lacking. Alternative reperfusion is the only type of effective treatment of patients with failed pharmacological reperfusion. Necessity to perform PCI during first 12 hours after unsuccessful TLT does not exclude possibility of its later fulfillment in acute period of myocardial infarction. Efficacy of the latter is comparable with success rate of rescue PCI. The use of both invasive strategies has allowed to lessen rate of complications and prevent lethal outcomes. Success of late urgent interventions in acute period of infarction after failed thrombolysis opens possibilities for their active use in patients transferred from other hospitals.

Quality measure study: progress in reducing the door-to-balloon time in patients with ST-segment elevation myocardial infarction

BACKGROUND

Reperfusion therapy improves both mortality and morbidity in patients with ST-elevation myocardial infarction (STEMI). Timeliness of such reperfusion is an important factor in improving patient survival. For percutaneous coronary intervention (PCI), the American College of Cardiology has recommended a goal of <90 minutes from initial hospital contact to first balloon inflation.

METHODS

The authors retrospectively reviewed 131 patients with a diagnosis of STEMI seen at a PCI capable hospital between January, 2006 and September, 2008, a period of time before and after implementation of a protocol aimed at reducing door-to-balloon time. Sixty-one percent of study population was Asian or Pacific Islander. This protocol was largely based on the identification by Bradley et al. of factors whose modification could shorten this time interval.

RESULTS

Time to reperfusion was compared between groups before (n=57), and after (n=58) protocol implementation. Median door-to-balloon time for the former group was 133 minutes, interquartile range (IQRs), (25th, 75th percentile; 104.5, 147), and for the latter group 67 minutes, IQRs (56, 80) respectively (p<0.001). Prior to implementation of the protocol, a door-to-balloon time of <90 minutes was achieved in 17% of cases. By the third quarter of 2008, this goal was being met in 100%.

CONCLUSION

This observational study provides support for the use of the strategies described as a key for reduction in door-to-balloon time.

The relationship between the emergent primary percutaneous coronary intervention quality measure and inpatient myocardial infarction mortality

BACKGROUND

In the setting of acute ST-segment elevation myocardial infarction (STEMI), reperfusion therapy with emergent primary percutaneous coronary intervention (PCI) significantly reduces mortality. It is unknown whether a hospital's performance on the Centers for Medicare & Medicaid Services (CMS) quality metric for time from patient arrival to angioplasty is associated with its overall hospital acute myocardial infarction (AMI) mortality rate.

OBJECTIVES

The objective of this study was to evaluate if hospitals with higher performance on the time-to-PCI quality measure are more likely to achieve lower mortality for patients admitted for any type of AMI.

METHODS

Using merged 2006 data from the Nationwide Inpatient Sample (NIS), the American Hospital Association (AHA) annual survey, and CMS Hospital Compare quality indicator data, we examined 69,101 admissions with an International Classification of Diseases, Ninth Revision (ICD-9)-coded principal diagnosis of AMI in the 116 hospitals that reported more than 24 emergent primary PCI admissions in that year. Hospitals were categorized into quartiles according to percentage of admissions in 2006 that achieved the primary PCI timeliness threshold (time-to-PCI quality measure). Using a random effects logistic regression model of inpatient mortality, we examined the significance of the hospital time-to-PCI quality measure after adjustment for other hospital and individual patient sociodemographic and clinical characteristics.

RESULTS

The unadjusted inpatient AMI mortality rate at the 27 top quartile hospitals was 4.3%, compared to 5.1% at the 32 bottom quartile (worst performing) hospitals. The risk-adjusted odds ratio (OR) of inpatient death was 0.83 (95% confidence interval [CI] = 0.72 to 0.95), or 17% lower odds of inpatient death, among patients admitted to hospitals in the top quartile for the time-to-PCI quality measure compared to the case if the hospitals were in the bottom 25th percentile.

CONCLUSIONS

Hospitals with the highest and second highest quartiles of time-to-PCI quality measure had a significantly lower overall AMI mortality rate than the lowest quartile hospitals. Despite the fact that a minority of all patients with AMI get an emergent primary PCI, hospitals that perform this more efficiently also had a significantly lower mortality rate for all their patients admitted with AMI. The time-to-PCI quality measure in 2006 was a potentially important proxy measure for overall AMI quality of care.

[Short and long-term results of endovascular treatment of bifurcational coronary stenosis]

Short and long-term results of endovascular treatment of true bifurcational coronary stenosis were analyzed in 229 patients. 68 patients received a "provisional-T" stenting on the first stage of the study. On the next stage 40 patients received the same "provisional-T" stenting, a total bifurcational stenting was conducted in 37 patients. Only coated stents were used. Independent risk factors of "provisional-T" stenting conversion to total bifurcational stenting were revealed. There were no differences between "provisional-T" and total bifurcational stenting considering the short-term treatment results. Long-term results (12-18 months) were analyzed in 70 patients. There were no restenosis of the main artery, whereas restenosis of the lateral branch was noticed in 5.5 and 2.94%, respectively, in the groups of "provisional-T" and total bifurcational stenting. Late thrombosis was registered in 1 case from the group of total bifurcational stenting.

Association of hospital primary angioplasty volume in ST-segment elevation myocardial infarction with quality and outcomes

CONTEXT

Earlier studies indicate an inverse relationship between hospital volume and mortality after primary angioplasty for patients presenting with ST-segment elevation myocardial infarction (STEMI). However, contemporary data are lacking.

OBJECTIVE

To assess the relationship between hospital primary angioplasty volume and outcomes and quality of care measures in patients presenting with STEMI.

DESIGN, SETTING, AND PATIENTS

An observational analysis of data on 29,513 patients presenting with STEMI and undergoing primary angioplasty in the American Heart Association's Get With the Guidelines registry. Patients were treated between July 5, 2001, and December 31, 2007, at 166 angioplasty-capable hospitals across the United States. Hospitals were divided into tertiles (<36 procedures per year, 36-70 procedures per year, and >70 procedures per year) based on their annual primary angioplasty volume.

MAIN OUTCOME MEASURES

Door-to-balloon (DTB) times, length of hospital stay, adherence with evidence-based quality of care measures, and in-hospital mortality.

RESULTS

Compared with low- and medium-volume centers, high-volume centers had better median DTB times (98 vs 90 vs 88 minutes, respectively; P for trend < .001). High-volume centers were more likely than low-volume centers to follow evidence-based guidelines at discharge. Length of stay was similar between the 3 groups (P for trend = .13). There was no significant difference in the crude mortality between the tertiles of volume (incidence rate, 3.9% vs 3.2% vs 3.0% for low-, medium-, and high-volume centers, respectively; P = .26 and P = .99 for low- and medium- vs high-volume hospitals, respectively). Sequential multivariable modeling using generalized estimating equations revealed no significant association between hospital primary angioplasty volume and in-hospital mortality (adjusted odds ratio [OR], 1.22; 95% confidence interval [CI], 0.78-1.91; P = .38 and adjusted OR, 1.14; 95% CI, 0.78-1.66; P = .49 for low- and medium- vs high-volume hospitals, respectively).

CONCLUSION

In a contemporary registry of patients with STEMI, higher-volume primary angioplasty centers vs lower-volume centers were associated with shorter DTB times and more use of evidence-based therapies, but not with adjusted in-hospital mortality or length of hospital stay.

Novel design of drug delivery in stented arteries: a numerical comparative study

Implantation of drug eluting stents following percutaneous transluminal angioplasty has revealed a well established technique for treating occlusions caused by the atherosclerotic plaque. However, due to the risk of vascular re-occlusion, other alternative therapeutic strategies of drug delivery are currently being investigated. Polymeric endoluminal pave stenting is an emerging technology for preventing blood erosion and for optimizing drug release. The classical and novel methodologies are compared through a mathematical model able to predict the evolution of the drug concentration in a cross-section of the wall. Though limited to an idealized configuration, the present model is shown to catch most of the relevant aspects of the drug dynamics in a delivery system. Results of numerical simulations shows that a bi-layer gel paved stenting guarantees a uniform drug elution and a prolonged perfusion of the tissues, and remains a promising and effective technique in drug delivery.

[Transportation of two patients with acute myocardial infarction for primary percutaneous coronary intervention by a helicopter ambulance]

Air ambulance system has been established throughout the country by the Ministry of Health of Turkey. Fifteen provinces are determined as centers of the system so that all the country is covered within at the most one-hour flight distance. As part of this nationwide system, two helicopter ambulances have been deployed in our hospital since October 2008. Prompt use of reperfusion therapy improves survival of patients sustaining acute myocardial infarction (AMI). Two components of delay from the onset of AMI to reperfusion therapy are prehospital and interhospital transportations. We presented the first two cases of AMI whose transfers were made by a helicopter ambulance for primary percutaneous coronary intervention. One patient (age 58 years, male) presented to a state hospital 47 km away from Ankara about an hour after the onset of chest pain. Time to reach the patient by a helicopter ambulance was 28 minutes and transfer to our center was 14 minutes. The other patient (age 76 years, male) was admitted within 15 minutes of the onset of chest pain to a state hospital 58 km away from Ankara. Reaching the patient by a helicopter ambulance and transferring him to our center took 30 minutes and 16 minutes, respectively. Door-to-balloon times were 16 minutes and 18 minutes, respectively. Infarct-related coronary artery patency was achieved in both cases.

Different treatment options in chronic coronary artery disease: when is it the time for medical treatment, percutaneous coronary intervention or aortocoronary bypass surgery?

BACKGROUND

3% to 4% of the population suffers from chronic coronary artery disease (CAD). Primary care physicians, internists, cardiologists, and cardiac surgeons are involved in their long-term care. This article presents a complementary care pathway that integrates two apparently competing treatment options, aortocoronary bypass surgery (ACB) and percutaneous coronary intervention (PCI). Together with lifestyle changes and medical therapy, these treatments reduce morbidity and mortality and improve quality of life.

METHODS

This article was written by cardiac surgeons and cardiologists on the basis of the current treatment guidelines for coronary artery disease, a selective review of the literature (randomized, controlled trials and registry data), and a process of interdisciplinary consensus building.

RESULTS AND CONCLUSIONS

Lifestyle changes can reduce cardiovascular risk factors, improve quality of life, and lower cardiovascular morbidity and mortality. They provide additional benefit over and above medical therapy and/or revascularization procedures and should be strongly recommended to all patients. Revascularization is not indicated for patients who are asymptomatic on medical therapy or who have only a small area of myocardial ischemia. With either PCI or ACB, the symptoms of angina pectoris can be markedly improved, or even eliminated. Both of these revascularization procedures should be accompanied by optimized medical treatment. Revascularization is indicated when the area of myocardial ischemia is large, whether or not symptomatic angina is present. ACB is the treatment of choice for 3-vessel disease and/or left main stenosis. For all other constellations of coronary findings, ACB and PCI are equally good therapeutic options. The treating physician should take the patient's expectations into account and present the short- and long-term benefits and drawbacks of each proposed treatment to the patient so that an informed decision can be made.

An emergency physician activated protocol, 'Code STEMI' reduces door-to-balloon time and length of stay of patients presenting with ST-segment elevation myocardial infarction

INTRODUCTION

National consensus guidelines recommend that ST-segment elevation myocardial infarction (STEMI) patients achieve a door-to-balloon time of < 90 min. We sought to determine if emergency physician initiated simultaneous activation of the cardiac catheterisation laboratory team and the on-call interventional cardiologist has any impact on reducing door-to-balloon-times at our hospital.

METHODS

A total of 72 consecutive STEMI patients were evaluated from January 2007 to December 2007. The emergency physician activated Code STEMI required concurrent activation of cardiac catheterisation personnel and the on-call interventional cardiologist by the emergency physician. These patients were compared with our staff cardiologist activated primary angioplasty protocol from January 2006 to December 2006 for 51 consecutive STEMI patients. The primary outcome was to measure median door-to-balloon time between both groups. Secondary end-points included the individual components of door-to-balloon times (i.e. door-to-ECG time), peak troponin-I level within 24 h, length of stay and all-cause in-hospital mortality.

RESULTS

Median door-to-balloon time decreased overall (112 vs. 74 min, p < 0.001). Of the three components of door-to-balloon time analysed, the ECG to cardiac catheterization laboratory time exhibited the largest area of improvement with 16 min absolute reduction in median door-to-balloon time. Median peak troponin levels (50 vs. 25 ng/ml, p < 0.001), and hospital length of stay (4 vs. 3 days, p < 0.01) decreased. We did not see any statistically significant difference in all-cause in-hospital mortality (p = 0.6).

CONCLUSIONS

Emergency physician activation of the Code STEMI significantly reduces door-to-balloon time to within national standards of care, and length of stay in STEMI patients.

Individual quality improvement in acute coronary syndromes: a performance improvement initiative

Although treatment guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) have been published and widely accepted, barriers to the optimal management of patients with acute coronary syndromes (ACS) still exist. Adherence to guidelines has been correlated with improvements in patient outcomes in ACS, including reduced mortality, yet data demonstrate that 25% of opportunities to provide guideline-recommended care are missed. This article describes a performance improvement (PI) initiative designed to address gaps in process-related ACS care and improve patient outcomes. PI is an American Medical Association-approved, standardized continuing medical education format in which physicians can earn up to 20 American Medical Association PRA category 1 credits by completing 2 phases of self-assessment and developing and implementing a PI plan to address self-identified areas in which patient care can be improved. In this ACS PI initiative, physicians will assess their practice using performance measures defined by the 2007 ACC/AHA ST-segment elevation myocardial infarction and unstable angina or non-ST-segment elevation myocardial infarction guideline updates within 3 general benchmark areas: (1) patient risk assessment, (2) initial pharmacologic management, and (3) time-to-treatment (ie, "door-to-needle," "door-to-balloon," and "door-in-door-out" times). After completing a self-assessment and identifying 1 or more areas of improvement, participants can complete educational interventions and access benchmark-specific tools that provide guidance on improving adherence with the ACC/AHA guidelines. This PI initiative supplements other ongoing quality improvement initiatives in ACS, but is unique in that it is the first to use individual physician self-assessment, benchmark-focused continuing medical education, and self-developed PI plans to improve process-related ACS care.

On acquiring decision making skills for endovascular interventions

To improve interventional training we propose a staged rational approach for decision making and skill acquisition. Education and training for endovascular interventions should start to develop the learners' decision-making skills by learning from explicit representations of master interventionist's tacit decision-making knowledge through implementation of the notions of generic interventional modules, interventional strategic and tactical designs. We hope that these suggestions will encourage action, stimulate dialogue and advance the precision of our learning, procedures, practice and patient care.