A Vogt

Klinikum Kassel, Cassel, Hesse, Germany

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Publications (52)242.66 Total impact

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    ABSTRACT: The formerly observed volume-outcome relation for percutaneous coronary interventions (PCIs) has recently been questioned. We analysed data of the PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte. In 2003 a total of 27 965 patients at 67 hospitals were included. The median PCI volume per hospital was 327. In-hospital mortality was 1.85% in hospitals belonging to the lowest PCI volume quartile and 1.21% in the highest quartile (p for trend <0.001). Two groups of patients were then compared according to their treatment at hospitals with either <325 PCIs (n = 5754) or >325 PCIs (n = 22 211) per year. Logistic regression analysis showed that a PCI performed at hospitals with a volume of >325 PCI/year was independently associated with a lower hospital mortality (OR = 0.67, 95% CI: 0.52 to 0.87; p = 0.002). If PCI was performed in patients with acute myocardial infarction there was a significant decline in mortality with increasing volume (p for trend = 0.004); however, there was no association in patients without a myocardial infarction. This analysis of contemporary PCI in clinical practice shows a small but significant volume-outcome relation for in-hospital mortality. However, this relation was only apparent in high-risk subgroups, such as patients presenting with acute myocardial infarction.
    Heart (British Cardiac Society) 03/2008; 94(3):329-35. · 5.01 Impact Factor
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    ABSTRACT: To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice. Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK). Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed. Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography" time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% > or = 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for > or = 20/year, p = 0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p = 0.397). In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.
    Heart (British Cardiac Society) 08/2005; 91(8):1041-6. · 5.01 Impact Factor
  • A Vogt, Ruth H Strasser
    Zeitschrift für Kardiologie 11/2004; 93(10):829-33. · 0.97 Impact Factor
  • ACC Current Journal Review 05/2004; 13(5):57.
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    ABSTRACT: Aims Acute myocardial infarction complicated by cardiogenic shock is associated with an exceedingly high mortality, even if patients are treated with early reperfusion therapy. The aim of this study was to evaluate predictors of in-hospital mortality of a large cohort of consecutive patients with cardiogenic shock treated with primary percutaneous coronary intervention (PCI). Methods and results Between July 1994 and March 2001 all interventions performed in 80 centres in Germany were prospectively entered into the primary PCI registry of the ALKK. A total of 9422 procedures were registered, of these 1333 (14.2%) were performed in patients with cardiogenic shock. Total in-hospital mortality was 46.1% and was dependent on TIMI flow grade after PCI, with mortality rates of 78.2%, 66.1% and 37.4% in patients with TIMI 0/1, TIMI 2 and TIMI 3 flow, respectively. In a multivariate analysis left main disease, TIMI <3 flow after PCI, older age, three-vessel disease and longer time-intervals between symptom onset and PCI were significant independent predictors of mortality. The relative number of PCIs performed in patients with cardiogenic shock did not change significantly from 1995-2000. There was a significant decrease in mortality over the years (P for trend 0.02). Conclusions In-hospital mortality in patients with acute myocardial infarction complicated by cardiogenic shock remains high, even with early interventional therapy. However, our data demonstrate that the PCI in these high-risk patients is feasible in a wide spectrum of community hospitals with acceptable success rates. Our results seen in connection with the results of the randomized SHOCK study advocate an early invasive approach in younger patients with cardiogenic shock, while the best strategy in elderly patients is still a matter of debate.
    European Heart Journal 03/2004; 25(4):322-8. · 14.72 Impact Factor
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    Zeitschrift für Kardiologie 01/2004; 93(10):829-833. · 0.97 Impact Factor
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    ABSTRACT: Percutaneous transluminal coronary angioplasty of the infarct-related artery in stable survivors of acute myocardial infarction is often performed, even in patients without any symptoms or residual ischemia. Despite the lack of randomized studies, it is widely believed that this intervention will improve the clinical outcome of these patients. Three hundred patients with single vessel disease of the infarct vessel and no or minor angina pectoris in the subacute phase (1 to 6 weeks) after an acute myocardial infarction were randomized to angioplasty (n=149) or medical therapy (n=151). Primary end point was the survival free of reinfarction, (re)intervention, coronary artery bypass surgery, or readmission for severe angina pectoris at 1 year. The event-free survival at 1 year was 82% in the medical group and 90% in the angioplasty group (P=0.06). This difference was mainly driven by the difference in the need for (re)interventions (20 versus 8, P=0.03). At long-term follow-up (mean, 56 months), survival was 89% and 96% (P=0.02). Survival free of reinfarction, (re)intervention, or coronary artery bypass surgery was 66% and 80% in the medically and interventionally treated patients, respectively (P=0.05). The use of nitrates was significantly lower in the angioplasty group, both at 1 year (38% versus 67%, P=0.001) and at long-term follow-up (36% versus 55%, P=0.006). Percutaneous revascularization of the infarct-related coronary artery in stable patients with single vessel disease improves clinical outcome at long-term follow-up and reduces the use of nitrates. The results of our study should be reproduced in a confirmatory study with a larger sample size before percutaneous coronary intervention in this low-risk patient subgroup, after myocardial infarction can be recommended as routine treatment in clinical practice.
    Circulation 10/2003; 108(11):1324-8. · 15.20 Impact Factor
  • The American Journal of Cardiology 12/2002; 90(9):1005-9. · 3.21 Impact Factor
  • The American Journal of Cardiology 10/2001; 88(5):565-7. · 3.21 Impact Factor
  • Zeitschrift für Kardiologie 07/2001; 90(6):449-52. · 0.97 Impact Factor
  • Zeitschrift für Kardiologie 10/2000; 89(9):838-40. · 0.97 Impact Factor
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    ABSTRACT: Mortality from cardiac surgery is an essential indicator of quality and forms the basis of treatment strategy decisions in eligible patients. No contemporary complete data on unselected adult cardiac surgery patients are available in Germany. A registry was started in June 1997 of all patients referred to surgery from 85 cardiology centres in Germany. The registry was intended to include 10 000 patients and this number was reached in March 1998. Follow-up of the patients was by simple questionnaire, reporting the date of surgery, major complications, and symptomatic improvement. If the questionnaire was not returned, a reminder letter was sent and, if necessary, further telephone investigations were performed. This resulted in 99.9% complete data. Of 10 525 patients operated on, 3.91% had died by 30 days after surgery. The overall operative mortality was 4.57%, which included 69 patients who died after more than 30 days from complications related to surgery. By multivariate analysis, the following predictors of mortality were identified: previous surgery, emergency or complex operation; age >75 years, female gender, cardiac failure, angina CCS class IV, and three-vessel coronary disease. An integral part of the registry was a pre-operative prediction of surgical risk in five categories. This risk estimate revealed a surprisingly correct prediction of the mortality observed. In a representative unselected group of cardiac surgery patients, operative mortality was 4.57%. Several procedural and clinical parameters were significantly correlated with mortality, but the risk increment by each of these factors was small. Unstructured clinical judgement reliably predicted the operative risk.
    European Heart Journal 01/2000; 21(1):28-32. · 14.72 Impact Factor
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    ABSTRACT: Background: Elective coronary stenting has hem shown to reduce the rate of recurrent stenoses after angioplasty but no firm data are available on its possible association with in-hospital ischemic complications. Methods: We analyzed the data of the registry of the German community hospitals covering approximately one quarter of all interventions in Germany. We included all angioplasty procedures performed in patients with stable coronary artery disease in 1996. Interventions with elective coronary stenting were compared to those with conventional balloon angioplasty. Interventions with bailout stenting were excluded. Results: Of 19,170 angioplasty procedures, 32.2% included elective coronary stenting. The immediate angiographic success rate (residual stenosis < 50%) was 90.6% of the procedures with stents versus 86.3% of those without stents (P < 0.001). The overall incidence of complications (death, myocardial infarction, bypass surgery, vessel closure, reintervention) was 3.9% and 3.8% (NS). Major events (death, myocardial infarction, bypass surgery) were more common in the stent-treated group (1.8% vs 1.4%, P = 0.027). In multivariate analysis, the following factors were significantly associated with complications: residual stenosis ≥ 50%, female gender, angioplasty of proximal left anterior descending coronary artery, morphological fype of lesion B2 or C, and multivessel disease. Angioplasty of restenoses after previous angioplasty was associated with significantly less risk than of de novo lesions. Stents were neutral with respect to the overall incidence of complications. Conclusions: Complications after elective coronary angioplasty remain largely unpredictable in individual patients despite the identification of several clinical and procedural risk factors. Elective coronary stenting is not associated with the immediate therapeutic risk of angioplasty in stable coronary artery disease.
    Journal of Interventional Cardiology 01/2000; 13(2):101-106. · 1.50 Impact Factor
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    ABSTRACT: 30-day mortality after operation is generally accepted as a central standard of quality, especially in regard to cardiac operations. The Working Party of Directors of Hospital Cardiology Departments (Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte, ALKK) in Germany set up a pilot project to analyse whether by direct communication with patients by a database centre the expenditure incurred in collecting complete data can be decisively reduced and full documentation of outcome can in this way be obtained even for a large multi-centre patient cohort. Between 1.6.1997 and 31.3.1998, data were consecutively collected by questionnaire on all patients registered for a cardiac operation at 85 of the 135 ALKK centres. The questionnaire included data about each patient and the indication for operation as well as the estimate of operative risk, assigned to one of five risk categories by the referring cardiologist either alone or in conjunction with the cardiac surgeon. Until 30.9.1998, the data were obtained on 11,349 patients who had given informed consent (response rate 99.99%), including survival figures. 824 (7.3%) patients had not undergone the planned cardiac surgery, 134 having died before the data of operation. The 30-day postoperative mortality, obtained in 99.99% of the 10,525 patients, was 3.92%. The operative mortality was lowest, at 3.73%, for aortocoronary bypass only (n = 7932), highest for aortocoronary bypass plus valvular operation (n = 785), at 8.04%. There was good agreement between the cardiologists' preoperative risk assessment and the observed mortality. The 30-day mortality after cardiac operation can be obtained almost completely and with reasonable expenditure even for a large patient cohort. The results confirm that hospital mortality data definitely understate the overall operative risk. The methodology used in this pilot project, namely the inclusion of information from the patients by questionnaire, can also be applied to clinical results in other areas.
    DMW - Deutsche Medizinische Wochenschrift 10/1999; 124(38):1090-4. · 0.65 Impact Factor
  • A Vogt, K L Neuhaus
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    ABSTRACT: Since reperfusion of the infarct-related coronary artery has been established as a mainstay in the treatment of acute myocardial infarction (AMI) mechanical recanalization by direct angioplasty has been used as an alternative to the standard treatment with thrombolysis. Direct PTCA is more efficient than thrombolysis in terms of reperfusion rates, whereas thrombolysis is more readily available. Thrombolysis reduces mortality from AMI by approximately 25%. The clinical efficacy is strongly time-dependent, and treatment within the first hour of AMI improves survival by nearly 50% by preventing transmural infarction in a significant proportion of the patients. The disadvantage of thrombolysis is its limited efficacy in terms of rapid, complete and sustained patency of the infarct vessel yielding optimal results in only 50% of the patients. Direct PTCA is generally agreed to be more efficient to recanalize the infarct vessel, but its clinical advantage remains controversial. The first randomized studies of direct PTCA in AMI from highly specialized centers in selected patients reported success rates of coronary reperfusion up to 97% resulting in a trend to less death and reinfarction, but the differences were significant only in a metaanalysis of these small studies. The real world of direct PTCA has been depicted by a large registry in Germany of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) now including more than 4,000 direct PTCA-procedures since 1994. In this registry, the success rate of direct PTCA was 87% as defined by a final TIMI-grade 3 perfusion of the infarct vessel which is close to the data of the MITI-registry and the GUSTO IIb study. Failed PTCA was associated with an exceptionally high mortality rate of 36% confirming earlier observational reports. The non-randomized comparison of thrombolysis and direct PTCA in the MITI-registry showed no differene in survival or reinfarction rates, and the randomized GUSTO IIb substudy of direct PTCA versus front-loaded alteplase showed a small advantage in death and reinfarction rates at 30 days which dissipated over time leaving no significant clinical advantage of direct PTCA over thrombolysis at 6 months. Thus, in myocardial infarction in general the advantage of direct PTCA over thrombolysis is at best minimal. The reason is very probably the longer time lag until the procedure is started, the lower success rate as compared to the first reports of some specialized centers, and the clearly negative impact of failed PTCA on survival. Moreover, the immediate success of direct PTCA seems to be overestimated by the operator as demonstrated by comparison of central and local estimates of the TIMI flow rates in GUSTO IIb. Improvements of direct PTCA in AMI might be possible by coronary stenting which has markedly increased to more than 60% during the last year in the ALKK-registry. This was accompanied by a slight decrease in death and reinfarction rates. Further improvements can be expected from GP IIb/IIIa platelet antagonists which are under clinical investigation. It has been claimed, that in cardiogenic shock direct PTCA is more effective than thrombolysis. This hypothesis is based on comparison of failed versus successful PTCA-attempts, but this comparison is not valid since failed procedures clearly increase mortality. In the GUSTO-1 study patients with cardiogenic shock had lower mortality with than without an early coronary angiogram. This survival advantage, however, was independent of revascularization since only half of the patients with an early angiogram had PTCA. The same was observed in the International Shock Registry, reflecting significant selection bias in that patients in relatively better condition will be taken to the cathlab whereas apparently hopeless cases will not. In the ALKK-registry half of the patients in cardiogenic shock died after direct PTCA casting doubt on the presumed high clinical efficacy of this strategy. (ABST
    Herz 09/1999; 24(5):363-8. · 0.78 Impact Factor
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    ABSTRACT: Beginning in October 1992, all PTCAs from more than 70 German hospitals were gathered in a central registry of the Working Group of the Leading Hospital Physicians in Cardiology in an intention to treat analysis. Each centre was visited twice a year and the local records were compared with the procedures entered into the registry to ensure completeness of the data. In selected patients, a quality control was performed by expert rating regarding the technical performance and the indication for the intervention. Additional registries about primary PTCA in patients with acute myocardial infarction and stent implantations were initiated in 1994 and 1995. Completeness of the registries was more than 98% and more than 150,000 PTCA procedures, more than 5,000 PTCAs in acute myocardial infarction and more than 35,000 stent implantations were entered into the specific registries until April 1998. These data demonstrate that a complete registration and monitoring of procedural outcome is feasible even in high volume procedures such as PTCA. A still unresolved problem is the determination of the appropriateness of the indication for an intervention. However, this part of quality control is very important in interventional cardiology and therefore methods to assess the quality of indications have to be elaborated.
    Zeitschrift für ärztliche Fortbildung und Qualitätssicherung. 07/1999; 93(4):281-6.
  • A Vogt, K L Neuhaus
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    ABSTRACT: From July 1994 to October 1998, 4280 primary PTCA procedures were entered into the registry of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte. The success rate of PTCA, as defined by TIMI-3 perfusion of the infarct-related artery was 87.1%, in-hospital mortality was 10.2% and 2.6% had reinfarction. The most powerful predictors of death were cardiogenic shock present in 14.6% of whom 47% died, and failed PTCA with a mortality of 32%. Stents were used in 4.1% in 1994 increasing to 64.5% in 1998 without significant changes in success rates, but associated with a slight decrease in mortality and reinfarction rates.
    Seminars in interventional cardiology: SIIC 04/1999; 4(1):43-6.
  • Deutsche Medizinische Wochenschrift - DEUT MED WOCHENSCHR. 01/1999; 124(38):1090-1094.
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    ABSTRACT: Direct percutaneous transluminal coronary angioplasty (PTCA) is widely accepted in the treatment of acute myocardial infarction since excellent results had been reported from several small randomized trials. Less favourable results were observed in large-scale registries. In particular, the use of stents in acute myocardial infarction has become common practice without documented evidence of clinical efficacy. Data were analysed from a registry of all consecutive percutaneous transluminal coronary angioplasty procedures from 62 centres in Germany, including 2331 direct percutaneous transluminal coronary angioplasty in acute myocardial infarction from July 1994 to April 1997. The overall angiographic success rate of percutaneous transluminal coronary angioplasty, defined as complete antegrade perfusion of the infarct vessel, was 87%. In-hospital mortality was 11.2%. The most important predictor of death was the presence of cardiogenic shock in 15% of patients, of whom 52% died. Mortality in patients without shock was 3.9%. Failed percutaneous transluminal coronary angioplasty was associated with a mortality of 36%. Further independent predictors of death were older age, multivessel disease, and anterior myocardial infarction. Stents were used in 4.1% of the procedures in 1994, increasing to 53% in 1997. However, this was not accompanied by improved clinical outcome. Mortality with coronary stenting was 9.9% vs 11.6% without stents (ns). Direct percutaneous transluminal coronary angioplasty is a valuable treatment strategy in acute myocardial infarction, although the results are less exceptional than reported from some highly specialized centres. Failed percutaneous transluminal coronary angioplasty seems to be harmful, thus outweighing much of the benefit from successful procedures. Stents did not improve the clinical outcome significantly, despite technically successful placement in 98%. Mortality from cardiogenic shock continues to be excessively high despite direct PTCA.
    European Heart Journal 07/1998; 19(6):917-21. · 14.72 Impact Factor
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    ABSTRACT: Wir berichten über die Ergebnisse der Ballondilatation beim akuten Myokardinfarkt (AMI) an großen kommunalen Kliniken zwischen 1992 und 1995. An 68 Zentren der ALKK wurden in diesem Zeitraum 4625 Dilatationen im Rahmen eines AMI durchgeführt. Das Alter der Patienten betrug 60,8 ± 11,3 Jahre, und es handelte sich in 75,1% der Fälle um Männer. Das Infarktgefäß war in 43% der Ramus interventricularis anterior, in 37% die Arteria coronaria dextra, in 16% die Arteria circumflexa, in 2,3% ein Bypassgefäß und in 1,4% der Hauptstamm der linken Koronararterie. Nach der Intervention wurde die Residualstenose in 86% der Fälle mit weniger als 50% beurteilt. In den verschiedenen Zentren wurden zwischen einer und 365 Infarktdilatationen durchgeführt, mit einem Median von 40 Infarktdilatationen pro Jahr und Zentrum. Der Anteil der Infarktdilatationen an allen durchgeführten Interventionen stieg von 5,2% 1992 auf 5,9% 1995 an (p = 0,01). Die Zahl der lokalen Komplikationen betrug 3,2%. Bei 1,1% der Untersuchungen erfolgte eine chirurgische Intervention am Gefäßzugang. Bei 273 (5,9%) der Patienten wurde während des Klinikaufenthaltes eine zweite Ballondilatation durchgeführt, eine aortokoronare Bypassoperation bei insgesamt 3% der Patienten. Während des Klinikaufenthaltes verstarben 438 (9,5%) der 4625 Patienten. Die Mortalitätsrate blieb über die Jahre hinweg konstant (1992: 10,6%; 1993: 8,6%; 1994: 9,7%; 1995: 9,8%: p = ns). Eine höhere Mortalität ergab sich bei älteren Patienten, bei Patienten mit einer Dreigefäßerkrankung, wenn das Infarktgefäß der Ramus interventricularis anterior oder ein Bypassgefäß war und bei schlechtem Ergebnis der Ballondilatation, d.h. einer Residualstenose über 50%. Krankenhäuser, an denen mehr als 40 Infarktdilatationen pro Jahr durchgeführt wurden, hatten eine niedrigere Mortalität. Im klinischen Alltag eines großen Spektrums interventionell tätiger kardiologischer Zentren lassen sich die Ergebnisse der Ballondilatation beim AMI bezüglich Mortalität, technischer Erfolgsrate und Komplikationen mit denen an hochspezialisierten Zentren vergleichen.
    Zeitschrift für Kardiologie 10/1997; 86(9). · 0.97 Impact Factor