[Show abstract][Hide abstract] ABSTRACT: Radial access for percutaneous coronary intervention (r-PCI) is associated with reduced vascular complications; however, previous reports have shown that <2% of percutaneous coronary intervention (PCI) procedures in the United States are performed via the radial approach. Our aims were to evaluate temporal trends in r-PCI and compare procedural outcomes between r-PCI and transfemoral PCI.
We conducted a retrospective cohort study from the CathPCI registry (n=2 820 874 procedures from 1381 sites) between January 2007 and September 2012. Multivariable logistic regression models were used to evaluate the adjusted association between r-PCI and bleeding, vascular complications, and procedural success, using transfemoral PCI as the reference. Outcomes in high-risk subgroups such as age ≥75 years, women, and patients with acute coronary syndrome were also examined. The proportion of r-PCI procedures increased from 1.2% in quarter 1 2007 to 16.1% in quarter 3 2012 and accounted for 6.3% of total procedures from 2007 to 2012 (n=178 643). After multivariable adjustment, r-PCI use in the studied cohort of patients was associated with lower risk of bleeding (adjusted odds ratio, 0.51; 95% confidence interval, 0.49-0.54) and lower risk of vascular complications (adjusted odds ratio, 0.39; 95% confidence interval, 0.31-0.50) in comparison with transfemoral PCI. The reduction in bleeding and vascular complications was consistent across important subgroups of age, sex, and clinical presentation.
There has been increasing adoption of r-PCI in the United States. Transradial PCI now accounts for 1 of 6 PCIs performed in contemporary clinical practice. In comparison with traditional femoral access, transradial PCI is associated with lower vascular and bleeding complication rates.
[Show abstract][Hide abstract] ABSTRACT: Objectives
The goal of this study was to characterize nonsystem reasons for delay in door-to-balloon time (D2BT) and the impact on in-hospital mortality.
Studies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographic characteristics. Limited data exist, however, for nonsystem reasons for delay in D2BT.
We analyzed nonsystem reasons for delay in D2BT among 82,678 ST-segment elevation myocardial infarction patients who underwent primary percutaneous coronary intervention within 24 h of symptom onset in the CathPCI Registry from January 1, 2009, to June 30, 2011.
Nonsystem delays occurred in 14.7% of patients (n = 12,146). Patients with nonsystem delays were more likely to be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without delay was 2.5% versus 15.1% for those with delay (p < 0.01). Nonsystem delay reasons included delays in providing consent (4.4%), difficult vascular access (8.4%), difficulty crossing the lesion (18.8%), “other” (31%), and cardiac arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the shortest time delay (median D2BT: 84 min; 25th to 75th percentile: 64 to 108 min); delays in providing consent had a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT: 100 min; 25th to 75th percentile: 80 to 131 min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and other was also higher (8.0%, 5.6%, and 5.9%, respectively) compared with nondelayed patients (p < 0.0001). After adjustment for baseline characteristics, in-hospital mortality remained higher for patients with nonsystem delays.
Nonsystem reasons for delay in D2BT in ST-segment elevation myocardial infarction patients presenting for primary percutaneous coronary intervention are common and associated with high in-hospital mortality.
Journal of the American College of Cardiology 04/2013; 61(16):1688–1695. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: The purpose of this study was to examine use and describe outcomes of radial access for percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Transradial PCI (TRI) is associated with reduced risk of bleeding and vascular complications, as compared with femoral access PCI (FPCI). Studies have suggested that TRI may reduce mortality among patients with STEMI. METHODS: We examined 294,769 patients undergoing PCI for STEMI at 1,204 hospitals in the CathPCI Registry between 2007 and 2011. Patients were grouped according to access site used for PCI. The temporal trend in the rate of radial versus femoral approach was determined. For minimization of confounding, an inverse probability weighting analysis incorporating propensity scores was used to compare procedural success, post-PCI bleeding, door-to-balloon times, and in-hospital mortality between radial and femoral access. RESULTS: Over the 5-year period, the use of TRI versus FPCI in STEMI increased from 0.9% to 6.4% (p < 0.0001). There was no difference in procedural success. TRI was associated with longer median door-to-balloon time (78 vs. 74 min; p < 0.0001) but lower adjusted risk of bleeding (odds ratio [OR]: 0.62; 95% CI: 0.53, 0.72; p < 0.0001) and lower adjusted risk of in-hospital mortality (OR: 0.76; 95% CI: 0.57, 0.99; p = 0.0455). CONCLUSIONS: In this large national database, use of radial access for PCI in STEMI increased over the study period. Despite longer door-to-balloon times, the radial approach was associated with lower bleeding rate and reduced in-hospital mortality. These data provide support to execute an adequately powered randomized controlled trial comparing radial and femoral approaches for PCI in STEMI.
Journal of the American College of Cardiology 12/2012; · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To examine the frequency and determinants of an assessment for rehabilitation during the hospitalization for acute stroke. DESIGN: Prospective cohort of patients admitted with acute stroke in the Get With The Guidelines (GWTG)-Stroke program from 01/08/2008 to 03/31/2011. SETTING: 1,532 acute hospitals in the United States participating in the GWTG-Stroke program. PARTICIPANTS: Adults with a stroke diagnosis from a GWTG-Stroke participating acute hospital (N=616,982). INTERVENTION: Not applicable MAIN OUTCOME MEASURE: Documentation of an assessment for rehabilitation services during the acute hospitalization. RESULTS: Overall almost 90% of stroke patients had documentation of an acute assessment for rehabilitation. In multivariable analysis, patients significantly more likely to be assessed for rehabilitation were younger, male, Black or of other non-White races (Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) when compared with White, independently ambulating prior to admission, and admitted from the community. Patients who received a stroke consult, cared for in a stroke unit, and treated in the Northeast region of the United States were also more likely to be assessed. CONCLUSION: There is evidence that rehabilitation was considered for 90% of acute stroke patients in this sample. Future research is needed to examine what assessments are conducted and by whom, and how these are used to determine the appropriate level of rehabilitation care for their needs.
Archives of physical medicine and rehabilitation 07/2012; · 2.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Limited data are available on the use of coronary computed tomographic angiography (CCTA) in patients who have received percutaneous coronary intervention (PCI). To evaluate patterns of cardiac testing including CCTA after PCI, we created a retrospective observational dataset linking National Cardiovascular Data Registry CathPCI Registry baseline data with longitudinal inpatient and outpatient Medicare claims data for patients who received coronary stenting from November 1, 2005 through December 31, 2007. In 192,009 patients with PCI (median age 74 years), the first test after coronary stenting was CCTA for 553 (0.3%), stress testing for 89,900 (46.8%), and coronary angiography for 22,308 (11.6%); 79,248 (41.3%) had no further testing. Patients referred to CCTA first generally had similar or lower baseline risk than those referred for stress testing or catheterization first. Compared to patients with stress testing first after PCI, patients who underwent CCTA first had higher unadjusted rates of subsequent noninvasive testing (10% vs 3%), catheterization (26% vs 15%), and revascularization (13% vs 8%) within 90 days of initial testing after PCI (p <0.0001 for all comparisons). In conclusion, despite similar or lesser-risk profiles, patients initially evaluated with CCTA after PCI had more downstream testing and revascularization than patients initially evaluated with stress testing. It is unclear whether these differences derive from patient selection, performance of CCTA compared to other testing strategies, or the association of early adoption of CCTA with distinct patterns of care.
The American journal of cardiology 05/2012; 110(6):776-83. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get with ehe Guidelines--Stroke.
Receipt of 8 guideline-recommended treatments (intravenous tissue-type plasminogen activator, antihypertensives, antithrombotics, anticoagulants for atrial fibrillation, deep vein thrombosis prophylaxis, lipid-lowering medications at discharge, smoking cessation counseling, weight loss education) and defect-free care were compared in 4 US regions among eligible patients with ischemic stroke and transient ischemic attack; there was adjustment for patient demographics, medical history, and hospital characteristics.
Among 991 995 admissions (South, 37%; Northeast, 27.6%; Midwest, 19.3%; West, 15.9%). Receipt varied regionally for tissue-type plasminogen activator (58.2%-67.8%), lipid-lowering medications (72.5%-75.7%), antihypertensives (80.1%-83.6%), antithrombotics (95.6%-96.8%), deep vein thrombosis prophylaxis (88.0%-91.4%), weight loss education (49.3%-54.7%), and defect-free care (72.1%-76.5%). In adjusted analyses, patients in the South had lower odds of use of intravenous tissue-type plasminogen activator (OR [95% CI]; 0.82 [0.69-0.97]), antihypertensives (0.82 [0.67-0.99]), and defect-free care (0.83 [0.75-0.92]); but, they were more likely to receive lipid-lowering medications (1.28 [1.05-1.54]) compared with those in the Northeast. Patients in the Midwest had lower odds of intravenous tissue-type plasminogen activator administration (0.82 [0.68-0.99]) and defect-free care (0.81 [0.72-0.92]). Those in the West had lower odds of antihypertensives (0.81 [0.67-0.99]), but had greater odds of receiving lipid-lowering medications (1.26 [1.03-1.53]).
Despite relatively high rates of adherence to stroke-related therapies in Get With The Guidelines-Stroke hospitals, regional variations exist, with over one quarter of patients receiving suboptimal care. Systematic improvements may lead to better patient outcomes.
[Show abstract][Hide abstract] ABSTRACT: The European Cooperative Acute Stroke Study (ECASS) III demonstrated benefit to expanding the intravenous tissue-type plasminogen activator (tPA) window from 3 to 4.5 hours for patients with acute ischemic stroke (AIS). We investigated how this trial influenced use of tPA in clinical practice.
Using the Get With The Guidelines-Stroke data set, we identified 217 692 patients who presented to the hospital within 4.5 hours of AIS from April 2003 to March 2011, 106 113 before and 111 579 after the publication of ECASS III in September 2008. The proportion of patients with AIS who presented within 4.5 hours and were treated with tPA in the 3- to 4.5-hour window increased from 1.2% before ECASS III to 3.5% after (P<0.0001). The proportion of eligible patients with AIS presenting within 3.5 hours and treated within 4.5 hours increased from 19% (18 484/96 208) to 35% (26 888/77 309) (P<0.0001). ECASS III appeared to have no adverse affect on the treatment of patients who presented early because the proportion of eligible patients with AIS presenting within 2 hours and treated within 3 hours increased after ECASS III from 57% to 75% (P<0.0001), whereas median door-to-needle times in patients treated within 3 hours decreased from 79 to 74 minutes (P<0.0001).
Following publication of ECASS III, there has been a significant increase in the use of tPA between 3 and 4.5 hours without adversely affecting treatment of patients in the <3-hour window. However, there remains substantial opportunity to further improve treatment rates in the later time window.
[Show abstract][Hide abstract] ABSTRACT: Nonadherence to cardiovascular medications is a significant public health problem. This randomized study evaluated the effect on medication adherence of linking hospital and community pharmacists.
Hospitalized patients with coronary artery disease discharged on aspirin, β-blocker, and statin who used a participating pharmacy were randomized to usual care or intervention. The usual care group received discharge counseling and a letter to the community physician; the intervention group received enhanced in-hospital counseling, attention to adherence barriers, communication of discharge medications to community pharmacists and physicians, and ongoing assessment of adherence by community pharmacists. The primary end point was self-reported use of aspirin, β-blocker, and statin at 6 months postdischarge; the secondary end point was a ≥ 75% proportion of days covered (PDC) for β-blocker and statin through 6 months postdischarge.
Of 143 enrolled patients, 108 (76%) completed 6-month follow-up, and 115 (80%) had 6-month refill records. There was no difference between intervention and control groups in self-reported adherence (91% vs 94%, respectively, P = .50). Using the PDC to determine adherence to β-blockers and statins, there was better adherence in the intervention versus control arm, but the difference was not statistically significant (53% vs 38%, respectively, P = .11). Adherence to β-blockers was statistically significantly better in intervention versus control (71% vs 49%, respectively, P = .03). Of 85 patients who self-reported adherence and had refill records, only 42 (49%) were also adherent by PDC.
The trend toward better adherence by refill records with the intervention should encourage further investigation of engaging pharmacists to improve continuity of care.
American heart journal 04/2012; 163(4):657-65.e1. · 4.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to describe differences in treatment and in-hospital mortality of early, late, and very late stent thrombosis (ST).
Early, late, and very late ST may differ in clinical presentation, management, and in-hospital outcomes.
We analyzed definite (angiographically documented) ST cases identified from February 2009 to June 2010 in the CathPCI Registry. We stratified events by timing of presentation: early (≤1 month), late (1 to 12 months), or very late (≥12 months) following stent implantation. Multivariable logistic regression modeling was performed to compare in-hospital mortality for each type of ST after adjusting for baseline comorbidities.
During the study period, 7,315 ST events were identified in 7,079 of 401,662 patients (1.8%) presenting with acute coronary syndromes. This ST cohort consisted of 1,391 patients with early ST (19.6%), 1,370 with late ST (19.4%), and 4,318 with very late ST (61.0%). Subjects with early ST had a higher prevalence of black race and diabetes, whereas subjects with very late ST had a higher prevalence of white race and a lower prevalence of prior myocardial infarction or diabetes. In-hospital mortality was significantly higher in early ST (7.9%) compared with late (3.8%) and very late ST (3.6%, p<0.001). This lower mortality for late and very late ST persisted after multivariable adjustment (odds ratio: 0.53 [95% confidence interval (CI): 0.36 to 0.79] and 0.58 [95% CI: 0.43 to 0.79], respectively).
Significant differences exist in the presentation and outcomes of early, late, and very late ST. Among patients with acute coronary syndromes who are undergoing percutaneous coronary intervention for angiographically documented ST, early ST is associated with the highest in-hospital mortality.
[Show abstract][Hide abstract] ABSTRACT: Asian-Americans represent an important United States minority population, yet there are limited data regarding the clinical care and outcomes of Asian-Americans following acute myocardial infarction (AMI). Using data from the American Heart Association Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program, we compared use of and trends in evidence-based care AMI processes and outcome in Asian-American versus white patients.
We analyzed 107,403 AMI patients (4412 Asian-Americans, 4.1%) from 382 United States centers participating in the Get With The Guidelines-Coronary Artery Disease program between 2003 and 2008. Use of 6 AMI performance measures, composite "defect-free" care (proportion receiving all eligible performance measures), door-to-balloon time, and in-hospital mortality were examined. Trends in care over this time period were explored. Compared with whites, Asian-American AMI patients were significantly older, more likely to be covered by Medicaid and recruited in the west region, and had a higher prevalence of diabetes, hypertension, heart failure, and smoking. In-hospital unadjusted mortality was higher among Asian-American patients. Overall, Asian-Americans were comparable with whites regarding the baseline quality of care, except that Asian-Americans were less likely to get smoking cessation counseling (65.6% versus 81.5%). Asian-American AMI patients experienced improvement in the 6 individual measures (P≤0.048), defect-free care (P<0.001), and door-to-balloon time (P<0.001). The improvement rates were similar for both Asian-Americans and whites. Compared with whites, the adjusted in-hospital mortality rate was higher for Asian-Americans (adjusted relative risk: 1.16; 95% confidence interval: 1.00-1.35; P=0.04).
Evidence-based care for AMI processes improved significantly over the period of 2003 to 2008 for Asian-American and white patients in the Get With The Guidelines-Coronary Artery Disease program. Differences in care between Asian-Americans and whites, when present, were reduced over time.
[Show abstract][Hide abstract] ABSTRACT: Patients undergoing elective percutaneous coronary intervention (PCI) are generally observed overnight in the hospital. The association between same-day discharge of older patients and death or readmission is unclear.
To evaluate the prevalence and outcomes of same-day discharge among older patients undergoing elective PCI in the United States.
Multicenter cohort study. Data were from 107,018 patients 65 years or older undergoing elective PCI procedures at 903 sites participating in the CathPCI Registry between November 2004 and December 2008 and were linked with Medicare Part A claims. Patients were divided into 2 groups based on their length of stay after PCI: same-day discharge or overnight stay.
Death or rehospitalization occurring within 2 days and by 30 days after PCI.
The prevalence of same-day discharge was 1.25% (95% CI, 1.19%-1.32%; n = 1339 patients) with significant variation across facilities. Patient characteristics were similar between the 2 groups, although same-day discharge patients underwent shorter procedures with less multivessel intervention. There were no significant differences in the rates of death or rehospitalization at 2 days (same-day discharge, 0.37% [95% CI, 0.16%-0.87%] vs overnight stay, 0.50% [95% CI, 0.46%-0.54%]; P = .51) or at 30 days (same-day discharge, 9.63% [95% CI, 8.17%-11.33%] vs overnight stay, 9.70% [95% CI, 9.52%-9.88%]; P = .94). Among patients with adverse outcomes, the median time to death or rehospitalization did not differ significantly between the groups (same-day discharge, 13 days [interquartile range, 7.0-21.0] vs overnight stay, 14 days [interquartile range, 7.0-21.0]; P = .96). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or rehospitalization (adjusted odds ratio, 0.95 [95% CI, 0.78-1.16]).
Among selected low-risk Medicare patients undergoing elective PCI, same-day discharge is rarely implemented but is not associated with death or rehospitalization compared with overnight observation.
JAMA The Journal of the American Medical Association 10/2011; 306(13):1461-7. · 29.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to describe hospital variability in the rate of finding obstructive coronary artery disease (CAD) at elective coronary angiography.
A recent national study found that obstructive CAD was found in less than one-half of patients undergoing elective coronary angiography.
We performed a retrospective analysis of 565,504 patients without prior myocardial infarction or revascularization undergoing elective coronary angiography using CathPCI Registry data from 2005 to 2008 to evaluate the rate of finding obstructive CAD (any major epicardial vessel stenosis ≥ 50%) at coronary angiography at 691 U.S. hospitals.
The rate of obstructive coronary disease found at elective coronary angiography varied from 23% to 100% among hospitals (median 45%; interquartile range: 39% to 52%), and were consistent from year to year and when alternative definitions of coronary stenosis were applied. Sites with lower rates of finding obstructive CAD were more likely to perform procedures on younger patients, those with low Framingham risk (33% in lowest yield quartile vs. 21% in highest yield quartile, p < 0.0001); with no or atypical symptoms (73% vs. 58%, p < 0.0001); and with a negative, equivocal, or unperformed functional status assessment. Hospitals with lower rates of finding obstructive CAD also less frequently prescribed aspirin, beta-blockers, platelet inhibitors, and statins (all p < 0.0001). The CAD rate was lower at facilities with small-volume catheterization laboratories and was not associated with hospital ownership or teaching program status.
The rate of finding obstructive CAD at elective coronary angiography varied considerably among reporting centers and was associated with patient selection and pre-procedure assessment strategies. This institutional variation suggests that an important opportunity may exist for quality improvement.
Journal of the American College of Cardiology 08/2011; 58(8):801-9. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hospitalized patients with heart failure and decreased ejection fraction are at substantial risk for mortality and rehospitalization, yet no acute therapies are proven to decrease this risk. Therefore, in-hospital use of medications proved to decrease long-term mortality is a critical strategy to improve outcomes. Although endorsed in guidelines, predictors of initiation and continuation of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β blockers, and aldosterone antagonists have not been well studied. We assessed noncontraindicated use patterns for the 3 medications using the Get With the Guidelines-Heart Failure (GWTG-HF) registry from February 2009 through March 2010. Medication continuation was defined as treatment on admission and discharge. Multivariable logistic regression using generalized estimating equations was used to determine factors associated with discharge use. In total 9,474 patients were enrolled during the study period. Of those treated before hospitalization, overall continuation rates were 88.5% for ACE inhibitors/ARBs, 91.6% for β blockers, and 71.9% for aldosterone-antagonists. Of patients untreated before admission, 87.4% had ACE inhibitors/ARBs and 90.1% had β blocker initiated during hospitalization or at discharge, whereas only 25.2% were started on an aldosterone antagonist. In multivariate analysis, admission therapy was most strongly associated with discharge use (adjusted odds ratios 7.4, 6.0, and 20.9 for ACE inhibitors/ARBs, β blockers, and aldosterone antagonists, respectively). Western region, younger age, and academic affiliation were also associated with higher discharge use. Although ACE inhibitor/ARB and β-blocker continuation rates were high, aldosterone antagonist use was lower despite potential eligibility. In conclusion, being admitted on evidence-based medications is the most powerful, independent predictor of discharge use.
The American journal of cardiology 06/2011; 107(12):1818-23. · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial.
To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial.
An observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin).
Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods.
Among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%-44.4%) before PCI and in 303,864 patients (65.0%; 95% CI, 64.9%-65.2%) at discharge following PCI (P < .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%-43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%-44.8%) after the COURAGE trial (P < .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%-63.7%) and 66.0% (95% CI, 65.8%-66.1%), respectively (P < .001).
Among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial.
JAMA The Journal of the American Medical Association 05/2011; 305(18):1882-9. · 29.98 Impact Factor