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ABSTRACT: OBJECTIVE: We evaluated differences in outcome among women and men enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. BACKGROUND: Women and men with coronary artery disease (CAD) have different clinical presentations and outcomes that may be due to differences in management. METHODS: We compared baseline variables, study interventions and outcomes between women and men enrolled in the BARI 2D trial and randomized to aggressive medical therapy alone or aggressive medical therapy with prompt revascularization. RESULTS: At enrollment, women were more likely than men to have angina (67% vs 58% p<0.01) despite less disease on angiography (myocardial jeopardy index 41 ± 24 vs 46 ± 24, p<0.01; # of significant lesions 2.3 ± 1.7 vs 2.8 ± 1.8, p<0.01). Over 5 years, no sex differences were observed in BARI 2D study outcomes after adjustment for difference in baseline variables, (Death/MI/CVA: HR 1.11, 99% CI 0.85-1.44). However, women reported more angina than men (adjusted odds ratio = 1.51 99% CI 1.21 - 1.89, p < 0.0001) and had lower scores for the Duke Activity Status Index (DASI) (Adjusted β coefficient: -1.58, 99% CI -2.84, -0.32, p<0.01). CONCLUSIONS: There were no sex differences in death, MI or CVA among patients enrolled in the BARI 2D trial. However, compared with men, women had more symptoms and less anatomic disease at baseline, with persistence of higher angina rates and lower DASI scores following 5 years of medical therapy with or without prompt revascularization.
Journal of the American College of Cardiology 02/2013; · 14.16 Impact Factor
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ABSTRACT: BACKGROUND: THERE ARE EVIDENCE-BASED GUIDELINES FOR STAGING OF PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) UNDERGOING PERCUTANEOUS CORONARY INTERVENTION (PCI), BUT WE ARE NOT AWARE OF ANY EVIDENCE COMPARING THE STRATEGY OF COMPLETE REVASCULARIZATION (CR) WITH PCI IN THE INDEX ADMISSION VERSUS THE STRATEGY OF STAGING IN A SUBSEQUENT ADMISSION FOR PATIENTS WITH CORONARY ARTERY DISEASE WITHOUT STEMI.METHODS AND RESULTS: PCI PATIENTS WITHOUT STEMI UNDERGOING PCI IN NEW YORK BETWEEN 2007 AND 2009 WERE SEPARATED INTO 2 GROUPS: THOSE WITH ACUTE CORONARY SYNDROME BUT NO STEMI, AND THOSE WITHOUT ACUTE CORONARY SYNDROME. FOR EACH GROUP, PATIENTS WHO UNDERWENT CR IN THE INDEX ADMISSION WERE THEN PROPENSITY MATCHED TO PATIENTS STAGED WITHIN 60 DAYS TO OBTAIN CR BASED ON 17 PATIENT RISK FACTORS RELATED TO LONGER-TERM MORTALITY, AND 3-YEAR MORTALITY RATES WERE COMPARED FOR THE PROPENSITY-MATCHED GROUPS. OUTCOMES WERE ALSO COMPARED FOR PRESELECTED SUBGROUPS. FOR PROPENSITY-MATCHED PATIENTS WITHOUT ACUTE CORONARY SYNDROME, THE ALL-CAUSE MORTALITY RATES AT 3 YEARS FOR PATIENTS WHO UNDERWENT CR IN THE INDEX HOSPITALIZATION AND PATIENTS STAGED FOR CR WITHIN 60 DAYS OF DISCHARGE WERE 5.62% AND 5.97%, P=0.93, RESPECTIVELY. FOR PROPENSITY-MATCHED PATIENTS WITH ACUTE CORONARY SYNDROME BUT WITHOUT STEMI, THE ALL-CAUSE MORTALITY RATES AT 3 YEARS FOR PATIENTS WHO UNDERWENT CR IN THE INDEX HOSPITALIZATION AND PATIENTS STAGED FOR CR WITHIN 60 DAYS OF DISCHARGE WERE 6.59% AND 5.92%, P=0.41, RESPECTIVELY.CONCLUSIONS: Patients with coronary artery disease without STEMI do not have significantly lower 3-year mortality rates with staged PCI than when they undergo CR in the index admission.
Circulation Cardiovascular Interventions 01/2013; · 6.06 Impact Factor
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Thomas G Brott,
Jonathan L Halperin,
Suhny Abbara,
J Michael Bacharach,
John D Barr,
Ruth L Bush,
Christopher U Cates,
Mark A Creager,
Susan B Fowler,
Gary Friday, [......],
Harlan M Krumholz,
Frederick G Kushner,
Bruce W Lytle,
Rick A Nishimura,
E Magnus Ohman,
Richard L Page,
Barbara Riegel,
William G Stevenson,
Lynn G Tarkington,
Clyde W Yancy
Catheterization and Cardiovascular Interventions 01/2013; 81(1):E76-E123. · 2.29 Impact Factor
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Alice K Jacobs,
Frederick G Kushner,
Steven M Ettinger,
Robert A Guyton,
Jeffrey L Anderson,
E Magnus Ohman,
Nancy M Albert,
Elliott M Antman,
Donna K Arnett,
Marnie Bertolet, [......],
Sharon-Lise T Normand,
Eduardo Ortiz,
Eric D Peterson,
William H Roach,
Ralph L Sacco,
Sidney C Smith,
William G Stevenson,
Gordon F Tomaselli,
Clyde W Yancy,
William A Zoghbi
Circulation 12/2012; · 14.74 Impact Factor
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Alice K Jacobs,
Frederick G Kushner,
Steven M Ettinger,
Robert A Guyton,
Jeffrey L Anderson,
E Magnus Ohman,
Nancy M Albert,
Elliott M Antman,
Donna K Arnett,
Marnie Bertolet, [......],
William G Stevenson,
Gordon F Tomaselli,
Clyde W Yancy,
William A Zoghbi,
John G Harold,
Yulei He,
Pamela B Mangu,
Amir Qaseem,
Michael R Sayre,
Mark R Somerfield
Journal of the American College of Cardiology 12/2012; · 14.16 Impact Factor
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Cynthia M Tracy,
Andrew E Epstein,
Dawood Darbar,
John P Dimarco,
Sandra B Dunbar,
N A Mark Estes,
T Bruce Ferguson,
Stephen C Hammill,
Pamela E Karasik,
Mark S Link, [......],
Nancy M Albert,
Mark A Creager,
David Demets,
Steven M Ettinger,
Robert A Guyton,
Judith S Hochman,
Frederick G Kushner,
E Magnus Ohman,
William Stevenson,
Clyde W Yancy
The Journal of thoracic and cardiovascular surgery 12/2012; 144(6):e127-45. · 3.41 Impact Factor
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David R Holmes,
Michael J Mack,
Sanjay Kaul,
Arvind Agnihotri,
Karen P Alexander,
Steven R Bailey,
John H Calhoon,
Blase A Carabello,
Milind Y Desai,
Fred H Edwards, [......],
Deepak L Bhatt,
Victor A Ferrari,
John D Fisher,
Mario J Garcia,
Federico Gentile,
Michael F Gilson,
Adrian F Hernandez, Alice K Jacobs,
David J Moliterno,
Howard H Weitz
The Journal of thoracic and cardiovascular surgery 09/2012; 144(3):e29-84. · 3.41 Impact Factor
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Edward L Hannan,
Ye Zhong,
Chuntao Wu,
Gary Walford,
David R Holmes, Alice K Jacobs,
Nicholas J Stamato,
Ferdinand J Venditti,
Samin Sharma,
Icilma Fergus,
Spencer B King
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ABSTRACT: OBJECTIVES: To compare two-year outcomes (mortality, mortality/myocardial infarction (MI), target vessel PCI (TVPCI), and target lesion PCI (TLPCI)) for patients receiving EES and ZES. BACKGROUND: The utilization of drug-eluting coronary stents (DES) among patients undergoing percutaneous coronary interventions (PCI) has increased dramatically in the last decade. Everolimus-eluting stents (EES) and ENDEAVOR zotarolimus eluting stents (ZES) constitute the latest generation of approved DES in the United States, but little is known about their relative effectiveness. METHODS: New York patients undergoing EES and ZES revascularization without any other type of stent between 7/08 and 12/08 were propensity matched at the hospital level using multiple patient, operator, and hospital characteristics, and matched patients were followed through the end of 2010 to obtain comparative two-year outcomes. RESULTS: A total of 3,286 patients were propensity-matched. Patients receiving EES had a significantly lower TVPCI rate (9.0% vs. 11.9%, AHR = 1.31, 95% CI (1.04, 1.65)) and a significantly lower TLPCI rate (6.0% vs. 8.3%, AHR = 1.35, 95% CI (1.02, 1.79)). There was no significant difference between EES and ZES for mortality or MI/mortality. CONCLUSIONS: There were no significant differences in the hard endpoints of death or MI between patients who received EES versus those who received ZES (ENDEAVOR). Patients with EES experienced lower repeat revascularization rates than patients with ZES at 24 months. © 2012 Wiley Periodicals, Inc.
Catheterization and Cardiovascular Interventions 06/2012; · 2.29 Impact Factor
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Edward L Hannan,
Kimberly Cozzens,
Zaza Samadashvili,
Gary Walford, Alice K Jacobs,
David R Holmes,
Nicholas J Stamato,
Samin Sharma,
Ferdinand J Venditti,
Icilma Fergus,
Spencer B King
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ABSTRACT: The purpose of this study was to determine appropriateness of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery performed in New York for patients without acute coronary syndrome (ACS) or previous CABG surgery.
The American College of Cardiology Foundation (ACCF) and 6 other societies recently published joint appropriateness criteria for coronary revascularization.
Data from patients who underwent CABG surgery and PCI without acute coronary syndrome or previous CABG surgery in New York in 2009 and 2010 were used to assess appropriateness and to examine the variation across hospitals in inappropriateness ratings.
Of the 8,168 patients undergoing CABG surgery in New York without ACS/prior CABG who could be rated, 90.0% were appropriate for revascularization, 1.1% were inappropriate, and 8.6% were uncertain. Of the 33,970 PCI patients eligible for rating, 28% lacked sufficient information to be rated. Of the patients who could be rated, 36.1% were appropriate, 14.3% were inappropriate, and 49.6% were uncertain. A total of 91% of the patients undergoing PCI who were classified as inappropriate had 1- or 2-vessel disease without proximal left anterior descending artery disease and had no or minimal anti-ischemic medical therapy.
For patients without ACS/prior CABG, only 1% of patients undergoing CABG surgery who could be rated were found to be inappropriate for the procedure according to the ACCF appropriateness criteria, but 14% of the PCI patients who could be rated were found to be inappropriate, and 28% lacked enough noninvasive test information to be rated.
Journal of the American College of Cardiology 05/2012; 59(21):1870-6. · 14.16 Impact Factor
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James G Jollis,
Christopher B Granger,
Timothy D Henry,
Elliott M Antman,
Peter B Berger,
Peter H Moyer,
Franklin D Pratt,
Ivan C Rokos,
Anna R Acuña,
Mayme Lou Roettig, Alice K Jacobs
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ABSTRACT: National guidelines call for participation in systems to rapidly diagnose and treat ST-segment-elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States.
A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website. Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%).
This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.
Circulation Cardiovascular Quality and Outcomes 05/2012; 5(4):423-8. · 4.91 Impact Factor
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Thomas M Bashore,
Stephen Balter,
Ana Barac,
John G Byrne,
Jeffrey J Cavendish,
Charles E Chambers,
James Bernard Hermiller,
Scott Kinlay,
Joel S Landzberg,
Warren K Laskey, [......],
Timothy Gardner,
Federico Gentile,
Michael F Gilson,
Mark A Hlatky, Alice K Jacobs,
Sanjay Kaul,
Debabrata Mukherjee,
Robert S Rosenson,
Howard H Weitz,
Deborah J Wesley
Catheterization and Cardiovascular Interventions 05/2012; 80(3):E37-49. · 2.29 Impact Factor
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Edward L Hannan,
Zaza Samadashvili,
Kimberly Cozzens,
Gary Walford, Alice K Jacobs,
David R Holmes,
Nicholas J Stamato,
Jeffrey P Gold,
Samin Sharma,
Ferdinand J Venditti,
Tia Powell,
Spencer B King
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ABSTRACT: Little is known about what treatments patients receive after being diagnosed with stable coronary artery disease or what the comparative outcomes are for routine medical treatment (RMT) versus percutaneous coronary intervention (PCI) with RMT for patients in a setting apart from randomized controlled trials.
Patients with stable coronary artery disease undergoing cardiac catheterization in New York State between 2003 and 2008 were followed up to determine the treatment they received. Patients receiving RMT and patients receiving PCI with RMT were propensity matched through the use of 20 factors that could have a bearing on outcomes. The resulting cohort of 933 matched pairs was used to compare mortality/myocardial infarction (MI), mortality, MI, and subsequent revascularization rates. A total of 89% of all patients underwent PCI with RMT. PCI/RMT patients had significantly lower adverse outcome rates at 4 years for mortality/MI (16.5% versus 21.2%; P=0.003), mortality (10.2% versus 14.5%; P=0.02), MI (8.0% versus 11.3%; P=0.007), and subsequent revascularization (24.1% versus 29.1%; P=0.005). Adjusted RMT versus (PCI with RMT) hazard ratios were 1.49 (95% confidence interval, 1.16-1.93) for mortality/MI and 1.46 (95% confidence interval, 1.08-1.97) for mortality. There were no differences for patients ≤ 65 years of age or for patients with single-vessel disease.
Most patients with stable coronary artery disease in New York undergoing catheterization between 2003 and 2008 received PCI. Patients who received PCI experienced lower mortality, mortality/MI, and revascularization rates. The reasons for this finding need to be better understood, including the possible role of low medication adherence rates that have been found in other studies.
Circulation 03/2012; 125(15):1870-9. · 14.74 Impact Factor
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David R Holmes,
Michael J Mack,
Sanjay Kaul,
Arvind Agnihotri,
Karen P Alexander,
Steven R Bailey,
John H Calhoon,
Blase A Carabello,
Milind Y Desai,
Fred H Edwards, [......],
Deepak L Bhatt,
Victor A Ferrari,
John D Fisher,
Mario J Garcia,
Federico Gentile,
Michael F Gilson,
Adrian F Hernandez, Alice K Jacobs,
David J Moliterno,
Howard H Weitz
Catheterization and Cardiovascular Interventions 01/2012; 79(7):1023-82. · 2.29 Impact Factor
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L David Hillis,
Peter K Smith,
Jeffrey L Anderson,
John A Bittl,
Charles R Bridges,
John G Byrne,
Joaquin E Cigarroa,
Verdi J DiSesa,
Loren F Hiratzka,
Adolph M Hutter, [......],
Nancy Albert,
Mark A Creager,
Steven M Ettinger,
Robert A Guyton,
Jonathan L Halperin,
Judith S Hochman,
Frederick G Kushner,
E Magnus Ohman,
William Stevenson,
Clyde W Yancy
The Journal of thoracic and cardiovascular surgery 01/2012; 143(1):4-34. · 3.41 Impact Factor
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ABSTRACT: This study sought to report percutaneous coronary intervention (PCI) 30-day readmission rates, identify the impact of staged (planned) readmissions on overall readmission rates, determine the significant predictors of unstaged readmissions after PCI, and specify the reasons for readmissions.
Hospital readmissions occur frequently and incur substantial costs. PCI are among the most common and costly procedures, and little is known about the nature and extent of readmissions for PCI.
We retrospectively analyzed 30-day readmissions after PCI using the nation's largest statewide PCI registry to identify 40,093 New York State patients who underwent PCI between January 1, 2007, and November 30, 2007. Demographic variables, pre-procedural risk factors, complications of PCI, and length of stay were considered as potential predictors of readmission, and reasons for readmission were identified from New York's administrative database using principal diagnoses.
A total of 15.6% of all PCI patients were readmitted within 30 days, and 20.6% of these readmissions were staged. Among unstaged readmissions, the most common reasons for readmission were chronic ischemic heart disease (22.5%), chest pain (10.8%), and heart failure (8.2%). A total of 2,015 patients (32.2% of readmissions) underwent a repeat PCI. Thirteen demographic and diagnostic risk factors, as well as longer lengths of stay, were all associated with higher readmission rates.
Future efforts to reduce readmissions should be directed toward the recognition of patients most at risk, and the reasons they are readmitted. Staging also should be examined from a cost-effectiveness standpoint as a function of patients' unique risk factors.
12/2011; 4(12):1335-42. · 1.07 Impact Factor
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Glenn N Levine,
Eric R Bates,
James C Blankenship,
Steven R Bailey,
John A Bittl,
Bojan Cercek,
Charles E Chambers,
Stephen G Ellis,
Robert A Guyton,
Steven M Hollenberg, [......],
Jeffrey L Anderson,
Nancy Albert,
Mark A Creager,
Steven M Ettinger,
Jonathan L Halperin,
Judith S Hochman,
Frederick G Kushner,
E Magnus Ohman,
William Stevenson,
Clyde W Yancy
Catheterization and Cardiovascular Interventions 11/2011; · 2.29 Impact Factor
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Chuntao Wu,
Anne-Marie Dyer,
Spencer B King,
Gary Walford,
David R Holmes,
Nicholas J Stamato,
Ferdinand J Venditti,
Samin K Sharma,
Icilma Fergus, Alice K Jacobs,
Edward L Hannan
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ABSTRACT: The impact of incomplete revascularization (IR) on adverse outcomes after percutaneous coronary intervention remains inconclusive, and few studies have examined mortality during follow-ups longer than 5 years. The objective of this study is to test the hypothesis that IR is associated with higher risk of long-term (8-year) mortality after stenting for multivessel coronary disease.
A total of 13 016 patients with multivessel disease who had undergone stenting procedures with bare metal stents in 1999 to 2000 were identified in the New York State's Percutaneous Coronary Intervention Reporting System. A logistic regression model was fit to predict the probability of achieving complete revascularization (CR) in these patients using baseline risk factors; then, the CR patients were matched to the IR patients with similar likelihoods of achieving CR. Each patient's vital status was followed through 2007 using the National Death Index, and the difference in long-term mortality between IR and CR was compared. It was found that CR was achieved in 29.2% (3803) of the patients. For the 3803 pair-matched patients, the respective 8-year survival rates were 80.8% and 78.5% for CR and IR (P=0.04), respectively. The risk of death was marginally significantly higher for IR (hazard ratio=1.12; 95% confidence interval, 1.01-1.26, P=0.04). The 95% bootstrap confidence interval for the hazard ratio was 0.98 to 1.32.
IR may be associated with higher risk of long-term mortality after stenting with BMS in patients with multivessel disease. More prospective studies are needed to further test this association.
Circulation Cardiovascular Interventions 10/2011; 4(5):413-21. · 6.06 Impact Factor
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ABSTRACT: Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI. Door-in to door-out (DIDO) time, defined as the duration of time from arrival to discharge at the first or STEMI referral hospital, is a new clinical performance measure, and a DIDO time of 30 minutes or less is recommended to expedite reperfusion care.
To characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less.
Retrospective cohort of 14,821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry-Get With the Guidelines between January 2007 and March 2010.
Factors associated with a DIDO time greater than 30 minutes, overall DTB times, and risk-adjusted in-hospital mortality.
Median DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1627 patients (11%) had DIDO times of 30 minutes or less. Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and non-emergency medical services transport to the first hospital. Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60% [95% confidence interval {CI}, 57%-62%] vs 13% [95% CI, 12%-13%]; P < .001). Among patients with DIDO times greater than 30 minutes, only 0.6% (95% CI, 0.5%-0.8%) had an absolute contraindication to fibrinolysis. Observed in-hospital mortality was significantly higher among patients with DIDO times greater than 30 minutes vs patients with DIDO times of 30 minutes or less (5.9% [95% CI, 5.5%-6.3%] vs 2.7% [95% CI, 1.9%-3.5%]; P < .001; adjusted odds ratio for in-hospital mortality, 1.56 [95% CI, 1.15-2.12]).
A DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.
JAMA The Journal of the American Medical Association 06/2011; 305(24):2540-7. · 30.03 Impact Factor
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ABSTRACT: Activation of emergency medical services (EMS) is critical for the early triage and treatment of patients experiencing ST-segment-elevation myocardial infarction, yet data regarding EMS use and its association with subsequent clinical care are limited.
We performed an observational analysis of 37 634 ST-segment-elevation myocardial infarction patients treated at 372 US hospitals participating in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines between January 2007 and September 2009, and examined independent patient factors associated with EMS transportation versus patient self-transportation. We found that EMS transport was used in only 60% of ST-segment-elevation myocardial infarction patients. Older patients, those living farther from the hospital, and those with hemodynamic compromise were more likely to use EMS transport. In contrast, race, income, and education level did not appear to be associated with the mode of transport. Compared with self-transported patients, EMS-transported patients had significantly shorter delays in both symptom-onset-to-arrival time (median, 89 versus 120 minutes; P<0.0001) and door-to-reperfusion time (median door-to-balloon time, 63 versus 76 minutes; P<0.0001; median door-to-needle time, 23 versus 29 minutes; P<0.0001).
Emergency medical services transportation to the hospital is underused among contemporary ST-segment-elevation myocardial infarction patients. Nevertheless, use of EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Community education efforts are needed to improve the use of emergency transport as part of system-wide strategies to improve ST-segment-elevation myocardial infarction reperfusion care.
Circulation 06/2011; 124(2):154-63. · 14.74 Impact Factor
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William S Weintraub,
Ronald P Karlsberg,
James E Tcheng,
Jeffrey R Boris,
Alfred E Buxton,
James T Dove,
Gregg C Fonarow,
Lee R Goldberg,
Paul Heidenreich,
Robert C Hendel, Alice K Jacobs,
William Lewis,
Michael J Mirro,
David M Shahian,
Biykem Bozkurt,
Jeffrey P Jacobs,
Pamela N Peterson,
Véronique L Roger,
Eric E Smith,
Tracy Wang
Circulation 06/2011; 124(1):103-23. · 14.74 Impact Factor
