Coronary artery disease performance measures and statin use in patients with recent percutaneous coronary intervention or recent coronary artery bypass grafting (from the NCDR PINNACLE registry)

The association between coronary revascularization strategy (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) and compliance with coronary artery disease (CAD) performance measures is not well studied. Our analysis studied patients enrolled in the Practice Innovation and Clinical Excellence registry, who underwent coronary revascularization using PCI or CABG in the 12 months before their most recent outpatient visit in 2011. We compared the attainment of CAD performance measures and statin use in eligible patients with PCI and CABG using hierarchical logistic regression models. Our study cohort consisted of 112,969 patients (80,753 with PCI and 32,216 with CABG). After adjustment for site and patient characteristics, performance measure compliance for tobacco use query (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.76 to 0.86), antiplatelet therapy (OR 0.9; 95% CI 0.86 to 0.94) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (OR 0.89; 95% CI 0.84 to 0.94) was lower in CABG compared with patients with PCI. Patients who underwent recent CABG had higher rates of β-blocker (OR 1.25; 95% CI 1.16 to 1.33) and statin treatment (OR 1.37; 95% CI 1.31 to 1.43) compared with patients with PCI. Of the 79 practice sites, 15 (19%) had ≥75% of their patients with CAD (CABG or PCI) meeting 75% to 100% of all eligible CAD performance measures. In conclusion, gaps persist in compliance with specific CAD performance measures in patients with recent PCI or CABG, and 1 in 5 practices had ≥75% compliance of eligible CAD performance measures in the most of their patients.

Relation between playing position and coronary artery calcium scores in retired National Football League players

Retired National Football League (NFL) linemen have an increased prevalence of risk factors for atherosclerosis and have an increased risk of cardiovascular death compared with nonlinemen and the general population. We evaluated whether playing in lineman position is independently associated with an increased risk of the presence and severity of subclinical atherosclerosis. Players were categorized as linemen if they reported playing on the offensive or defensive line during their careers. Subclinical atherosclerosis was assessed using coronary artery calcium (CAC) scores in 931 retired NFL players (310 linemen, 621 nonlinemen). CAC scores were evaluated for absence of subclinical atherosclerosis (CAC = 0), presence of mild subclinical atherosclerosis (CAC 1 to 100), and moderate to severe subclinical atherosclerosis (CAC ≥100). We performed multivariate logistic regression to determine whether the lineman position is independently associated with the presence and severity of subclinical atherosclerosis. Linemen were noted to have a lesser likelihood of absence of subclinical atherosclerosis (CAC = 0, 33.8% vs 41.7%, p = 0.02), a similar likelihood of mild subclinical atherosclerosis (CAC 1 to 100, 33.2% vs 31.8%, p = 0.7), and a greater likelihood of moderate to severe subclinical atherosclerosis (CAC >100, 32.9% vs 26.4%, p = 0.04) compared with nonlinemen. Adjusting for demographic and metabolic covariates, lineman status remained independently associated with mild subclinical atherosclerosis (CAC 1 to 100, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.05 to 2.2, p = 0.04) and moderate to severe subclinical atherosclerosis (CAC ≥100, OR 1.67, 95% CI 1.05 to 2.2). The association was attenuated after adjustment for race (CAC 1 to 100, OR 1.24, 95% CI 0.82 to 1.8; CAC >100, OR 1.59, 95% CI 1.01 to 2.49). In conclusion, lineman status in retired NFL players is associated with presence and severity of subclinical atherosclerosis, which is partly explained by race.

Novel therapies for treating familial hypercholesterolemia

Familial hypercholesterolemia is an inherited disorder associated with early accelerated atherosclerosis with morbidity and mortality resulting from premature cardiovascular disease. Affected individuals have extreme elevations in low-density lipoprotein cholesterol levels. Patients usually do not achieve target reductions in cholesterol levels with conventional antihyperlipidemic pharmacotherapy. This unmet need has resulted in the recent development and approval of novel therapies targeting different cholesterol pathways. This article briefly summarizes familial hypercholesterolemia and then discusses the newer pharmacotherapies available in the management of familial hypercholesterolemia.

Association between preoperative diuretic use and in-hospital outcomes after cardiac surgery

BACKGROUND

There is a paucity of evidence on the association between preoperative diuretics use and outcomes following cardiac surgery. We hypothesized that diuretic use prior to cardiac surgery will be associated with adverse in-hospital clinical outcomes.

METHODS

We evaluated patients undergoing cardiac surgery at a single institution between January 1, 2000, and December 31, 2011. Patients were grouped as follows: isolated coronary artery bypass grafting (CABG) (n = 8759), CABG plus valve surgery (n = 1188), and valve surgery only (n = 2646). A fourth group "All cardiac surgery" is comprised of patients from all three groups. Preoperative diuretic use was defined as patient on any diuretic till the day of surgery. Primary outcome was the incidence of major adverse events (MAEs) defined as the composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and new-onset atrial fibrillation (AF). Logistic regression analysis and propensity score matching were performed.

RESULTS

We included 12,593 patients [3546 on diuretic (28%)]. After logistic regression analyses, preoperative diuretic use was associated with an increased risk of the following: (1) MAE among all groups except the concomitant CABG and valve surgery group, (2) AF in "All cardiac surgery" and isolated CABG groups, (3) postoperative renal dysfunction in all groups. After propensity score matching (n = 3050 in each group), preoperative diuretic use was significantly associated with MAE (48% vs. 43%; P < 0.0001), postoperative renal dysfunction (19% vs. 14%; P < 0.0001), and AF (34% vs. 32%; P = 0.03) in the "All cardiac surgery" group.

CONCLUSION

Preoperative diuretics use is associated with an increased incidence of MAEs after cardiac surgery.

Comparison by meta-analysis of mortality after isolated coronary artery bypass grafting in women versus men

Short- and long-term mortality in women who undergo coronary artery bypass grafting (CABG) has been evaluated in multiple studies with conflicting results. The investigators conducted a meta-analysis of all existing studies to evaluate the impact of female gender on mortality in patients who undergo isolated CABG. A comprehensive search of studies published through May 31, 2012 identified 20 studies comparing men and women who underwent isolated CABG. All-cause mortality was evaluated at short-term (postoperative period and/or at 30 days), midterm (1-year), and long-term (5-year) follow-up. Odds ratios (ORs) and 95% confidence interval (CIs) were calculated using a random-effects model. A total of 966,492 patients (688,709 men [71%], 277,783 women [29%]) were included in this meta-analysis. Women were more likely to be older; had significantly greater co-morbidities, including hypertension, diabetes mellitus, hyperlipidemia, unstable angina, congestive heart failure, and peripheral vascular disease; and were more likely to undergo urgent CABG (51% vs 44%, p <0.01). Short-term mortality (OR 1.77, 95% CI 1.67 to 1.88) was significantly higher in women. At midterm and long-term follow-up, mortality remained high in women compared with men. Women remained at increased risk for short-term mortality in 2 subgroup analyses including prospective studies (n = 41,500, OR 1.83, 95% CI 1.59 to 2.12) and propensity score-matched studies (n = 11,522, OR 1.36, 95% CI 1.04 to 1.78). In conclusion, women who underwent isolated CABG experienced higher mortality at short-term, midterm, and long-term follow-up compared with men. Mortality remained independently associated with female gender despite propensity score-matched analysis of outcomes.

Abstract 328: Coronary Artery Disease Performance Measures And Statin Use Between Patients With Recent Percutaneous Coronary Intervention (PCI)and Patients With Recent Coronary Artery Bypass Grafting (CABG): An Analysis From The NCDR®

Background: Although rates of medication treatment for coronary artery disease (CAD) have improved, the association between coronary revascularization method and compliance with coronary artery disease (CAD) performance measures (PMs) is unknown.

Methods: Our analysis included patients enrolled in the Practice Innovation and Clinical Excellence (PINNACLE®) registry who underwent coronary revascularization in the 12 months prior to their index outpatient visit in 2011. Baseline characteristics between the two groups were compared. One-to-one propensity score matching was performed to control for differences between groups. Achievement of CAD PMs and statin use were compared between the propensity-matched groups.

Results (Table): Our study cohort consisted of 112,969 patients. Among these, 80,753 patients underwent PCI and 32,216 patients underwent CABG in the 12 months prior to their index visit. Successful propensity matching occurred in 43,484 patients (21,742 in each group). The resulting sample was well matched for all baseline characteristics except for age, peripheral arterial disease (PAD) and prior stroke. After conditionally adjusting for age, PAD, and prior stroke; a higher proportion of PCI patients, compared to CABG patients, met the CAD PMs for blood pressure control, tobacco use query and antiplatelet therapy. Statins were prescribed more often in CABG patients compared to PCI. CAD PMs of lipid control, symptom and activity assessment, beta-blocker therapy, ACE inhibitor/ARB therapy and smoking cessation intervention were not significantly different among the two groups. Only 23.7% CABG patients met between75-100% of all eligible PMs compared with 22% PCI patients; 50% met 50-74% of eligible PMs in CABG vs. 54.1% in the PCI group, and 25.8% met 0-49% of the eligible PMs in CABG group vs. 24% in the PCI group (p value for trend <0.0001).

Conclusion: Although overall compliance with CAD PMs between patients undergoing recent CABG compared to recent PCI is similar, only about one-fourth of patients in both groups met between 75-100% of eligible CAD PMs. Furthermore, distinct gaps were noted for specific PMs in the recent CABG group. Our study highlight areas for future quality improvement initiatives aimed at improving compliance in PMs in patients who have undergone recent revascularization.

Association between statins and infections after coronary artery bypass grafting

BACKGROUND

We determined whether pre-operative statin therapy is associated with a decrease in the incidence of infections after coronary artery bypass grafting (CABG).

METHODS

A retrospective cohort study of 6253 patients undergoing isolated CABG, from the Texas Heart Institute Database from January 1, 2000 to December 31, 2010 (3869 receiving statins and 2384 not receiving statins) was conducted. Primary outcome was the development of any postoperative infection (composite of deep-sternal wound infection, leg harvest-site infection, pneumonia, or sepsis) after CABG. Secondary outcome was the association between pre-operative statin use and individual incidence of each aforementioned infection. Logistic regression analyses were performed.

RESULTS

Incidence of any postoperative infection in patients who received statins pre-operatively was 6.5% compared to 8.3% in patients who did not receive statins. Pre-operative statin therapy was associated with a significant reduction in the primary outcome (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) in adjusted models. Among individual secondary outcomes, pre-operative statin therapy was associated with a reduced incidence of sternal wound infections (2.5% vs. 3.2%, OR 0.6, 95% CI 0.5-0.8) and leg harvest site infections (0.6% vs. 1.3%, OR 0.46, 95% CI 0.2-0.8). Pre-operative statin therapy was not associated with a reduced incidence of pneumonia or sepsis.

CONCLUSION

Pre-operative statin use is associated with a decrease in overall incidence of post-operative infections after CABG. We propose immunomodulatory effects of statins leading to a dampening of inflammatory cascade as the cause of our findings.

Outcomes of preoperative angiotensin-converting enzyme inhibitor therapy in patients undergoing isolated coronary artery bypass grafting

The association between preoperative use of angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass grafting (CABG) remain controversial. Our aim was to study in-hospital outcomes after isolated CABG in patients on preoperative ACE inhibitors. A retrospective analysis of 8,889 patients who underwent isolated CABG from 2000 through 2011 was conducted. The primary outcome of interest was the incidence of major adverse events (MAEs) defined as a composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and atrial fibrillation during index hospitalization. The secondary outcome was the incidence of individual outcomes included in MAEs. Logistic regression analyses were performed. Of 8,889 patients, 3,983 (45%) were on preoperative ACE inhibitors and 4,906 (55%) were not. Overall incidence of MAEs was 38.1% (n = 1,518) in the ACE inhibitor group compared to 33.6% (n = 1,649) in the no-ACE inhibitor group. Preoperative use of ACE inhibitors was independently associated with MAEs (odds ratio 1.13, 95% confidence interval 1.03 to 1.24), most of which was driven by a statistically significant increase in postoperative renal dysfunction (odds ratio 1.18, 95% confidence interval 1.03 to 1.36) and atrial fibrillation (odds ratio 1.15, 95% confidence interval 1.05 to 1.27). In-hospital mortality, postoperative myocardial infarction, and stroke were not significantly associated with preoperative ACE inhibitor use. Analyses performed after excluding patients with low ejection fractions yielded similar results. In conclusion, preoperative ACE inhibitor use was associated with an increased risk of MAEs after CABG, in particular postoperative renal dysfunction and atrial fibrillation.

Clinical outcomes of percutaneous interventions in saphenous vein grafts using drug-eluting stents compared to bare-metal stents: a comprehensive meta-analysisof all randomized clinical trials

BACKGROUND

Clinical outcomes of percutaneous coronary intervention (PCI) in patients with saphenous vein grafts (SVGs) remain poor despite the use of drug-eluting stents (DES). There is a disparity in clinical outcomes in SVG PCI based on various registries, and randomized clinical data remain scant. We conducted a meta-analysis of all existing randomized controlled trials (RCTS) comparing bare-metal stents (BMS) and DES in SVGPCIs.

HYPOTHESIS

PCI in patients with SVG disease using DES may reduce need for repeat revascularization without an excess mortality when compared to BMS.

METHODS

An aggregate data meta-analysis of clinical outcomes in RCTs comparing PCI with DES vs BMS for SVGs reporting at least 12 months of follow-up was performed. A literature search between Janurary 1, 2003 and September 30, 2011 identified 4 RCTs (812 patients; DES = 416, BMS = 396). Summary odds ratio (OR) and 95% confidence interval (CI) were calculated using the random-effects model. The primary endpoint was all-cause mortality. Secondary outcomes included nonfatal myocardial infarction (MI), repeat revascularization, and major adverse cardiac events (MACE). These outcomes were assessed in a cumulative fashion at 30 days, 18 months, and 36 months.

RESULTS

There were no intergroup differences in baseline clinical and sociodemographic characteristics. At a median follow-up of 25 months, patients in the DES and BMS group had similar rates of death (OR: 1.63, 95% CI: 0.45-5.92), MI (OR; 0.83, 95% CI: 0.27-2.60), and MACE (OR: 0.58, 95% CI: 0.25-1.32). Patients treated with DES had lower rates of repeat revascularization (OR: 0.40, 95% CI: 0.22-0.75).

CONCLUSIONS

In this comprehensive meta-analysis of all RCTs comparing clinical outcomes of PCI using DES vs BMS in patients with SVG disease, use of DES was associated with a reduction in rate of repeat revascularization and no difference in rates of all-cause death and MI. Clin. Cardiol. 2012 DOI: 10.1002/clc.21984 Dr. Virani is supported by a Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award (CDA-09-028), and has research support from Merck and National Football League Charities (all grants to the institution and not individual). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Abstract 303: Pre-operative Angiotensin Converting Enzyme Inhibitor use and outcomes in patients undergoing Isolated Coronary Artery Bypass Grafting

Background: The association between pre-operative use of angiotensin converting enzyme inhibitors (ACEI) and outcomes after coronary artery bypass grafting (CABG) remains controversial. Our aim was to study in-hospital outcomes after isolated CABG in patients on preoperative ACEI.

Methods: We performed a retrospective analysis of 8,889 patients who underwent isolated CABG from year 2000 to 2011. Primary outcome was the incidence of major adverse events (MAE) defined as a composite of in-hospital mortality, post-operative renal dysfunction, myocardial infarction, stroke, and atrial fibrillation during index hospitalization. Secondary outcomes studied were the incidence of individual components comprising MAE. Logistic regression analysis was performed.

Results (Table): Of the 8,889 patients, 3,983 (45%) were on pre-operative ACEI (“ACEI group”) and 4906 (55%) were not (“no ACEI group”). The overall incidence of MAE was 38.1% (n=1518) in the “ACEI group” versus 33.6% (n=1649) in “no ACEI group”. Pre-operative ACEI use was independently associated with increased risk of MAE (OR; 1.12, 95% CI; 1.02-1.23), most of which was driven by a statistically significant increase in post-operative renal dysfunction and atrial fibrillation. Pre-operative ACEI therapy was not associated with in-hospital mortality, post-operative myocardial infarction, or stroke.

Conclusion: Preoperative ACEI use was associated with an increased risk of MAE post CABG, in particular post-operative renal dysfunction and atrial fibrillation.

Abstract 304: The Outcomes of Pre-Procedural Angiotensin Converting Enzyme Inhibitor Therapy in patients undergoing Percutaneous Coronary Intervention

Background: Post-procedural outcomes associated with the use of angiotensin converting enzyme inhibitors (ACEI) in patients undergoing percutaneous coronary intervention (PCI) have not been studied. We aimed to determine the association between ACEI use and adverse cardiovascular/ renal outcomes in these patients.

Methods: We performed retrospective analysis of 15,485 consecutive patients who underwent percutaneous coronary intervention from January 1, 2000 to June 30, 2011. Primary outcome was the incidence of major adverse events (MAE) defined as a composite of mortality, post PCI renal dysfunction, myocardial infarction, and stroke during index hospitalization for PCI. Secondary outcome was the incidence of aforementioned components of MAE analyzed separately. Logistic regression and multivariate analyses were performed.

Results: Of the patients undergoing PCI, 6,600 (43%) received pre-PCI ACEI and 8,885 (57%) did not. Patients on ACEI were more likely to be older (64.6 ± 10.9 years vs. 63.6 ± 12.1 years; p<0.0001), have diabetes (41% vs. 26%; p<0.0001), prior renal insufficiency (19% vs. 15%; p<0.0001) and ejection fraction less than 35% (9.6% vs. 7%; p<0.0001). There were no significant associations between pre-operative ACEI use and primary and secondary outcomes (table).

Conclusion: Pre-operative ACEI use is not associated with major adverse events in patients undergoing PCI. Key Words: angiotensin converting enzyme inhibitor; percutaneous coronary intervention