Faculty Bibliography

OBJECTIVE:To evaluate outcomes of routine invasive strategy (RIS) compared with selective invasive strategy (SIS) in elderly patients older than 75 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS:We systematically searched databases for randomized controlled trials (RCTs) between January 1, 1990, and October 1, 2016, comparing RIS with SIS for elderly patients (age>75 years) with NSTE-ACS. Random effects meta-analysis was conducted to estimate odds ratio (OR) with 95% CIs for composite of death or myocardial infarction (MI), and individual end points of all-cause death, cardiovascular (CV) death, MI, revascularization, and major bleeding. RESULTS:A total of 6 RCTs with 1887 patients were included in the final analysis. Compared with an SIS, RIS was associated with significantly decreased risk of the composite end point of death or MI (OR, 0.65; 95% CI, 0.51-0.83). Similarly, RIS led to a significant reduction in the risk of MI (OR, 0.51; 95% CI, 0.40-0.66) and need for revascularization (OR, 0.31; 95% CI, 0.11-0.91) compared with SIS. There were no significant differences between RIS and SIS in terms of all-cause death (OR, 0.85; 95% CI, 0.63-1.20), CV death (OR, 0.84; 95% CI, 0.61-1.15), and major bleeding (OR, 1.96; 95% CI, 0.97-3.97). CONCLUSION:In elderly patients older than 75 years with NSTE-ACS, RIS is superior to SIS for the composite end point (death or MI), primarily driven by reduced risk of MI.

BACKGROUND:Anemia may confer a poor prognosis among patients with the acute coronary syndrome. However, few data exist on the association of anemia with in-hospital outcomes, including bleeding, among ST-segment-elevation myocardial infarction patients receiving primary percutaneous coronary intervention. METHODS AND RESULTS:) and multivariate logistic regression were used to evaluate the relationship of anemia on admission with clinical outcomes. Compared with nonanemic patients, anemic patients were more likely to have preexisting hypertension, diabetes mellitus, and prior myocardial infarction. Anemic patients had higher unadjusted rates of in-hospital death (8.1% versus 3.7%; P<0.001), bleeding (18.2% versus 9.4%; P<0.001), and were more likely to develop heart failure (odds ratio [OR], 1.62; 95% CI, 1.19-2.22), shock (OR, 2.35; 95% CI, 1.62-3.40), or cardiac arrest (OR, 1.94; 95% CI, 1.10-3.40) during their hospital stay. Baseline anemia was independently associated with major bleeding (OR, 1.78; 95% CI, 1.25-2.56) but not all-cause mortality (OR, 0.99; 95% CI, 0.57-1.73). There was no significant correlation between anemia and overall reperfusion times (OR, 0.95; 95% CI, 0.74-1.22). CONCLUSIONS:In a contemporary ST-segment-elevation myocardial infarction cohort receiving primary percutaneous coronary intervention, nearly 1 in 5 patients were anemic. Anemia was associated with increased comorbidities and higher-risk features on presentation and was independently associated with subsequent major in-hospital bleeding but not all-cause mortality. These results suggest that anemic ST-segment-elevation myocardial infarction patients may safely receive timely primary percutaneous coronary intervention but with particular consideration for bleeding avoidance strategies.

Transcatheter aortic valve implantation is an important therapeutic option for patients with symptomatic, severe aortic stenosis at increased risk for open surgical aortic valve replacement. Although a number of alternative vascular access sites have been developed, transfemoral access is overwhelmingly the dominant access strategy for this procedure. Access was achieved in the initial clinical experience primarily via surgical cutdown, but more recently, there has been increasing use of a fully percutaneous approach. This is likely driven by improvements in technology, more experience with large bore vascular closure devices (VCDs), and pressures to reduce hospital length of stay. This review will describe temporal trends of percutaneous versus surgical transfemoral access, identify the advantages and disadvantages of each approach, and describe the best practices for achieving safe transfemoral percutaneous access.

OBJECTIVES:The aim of this study was to determine predictors and outcomes associated with staged percutaneous coronary intervention (PCI) versus one-time multivessel revascularization (OTMVR) in patients with multivessel coronary artery disease. BACKGROUND:Prior observational studies have not evaluated predictors and outcomes of staged PCI versus OTMVR in a heterogenous population of patients with multivessel coronary artery disease who undergo multivessel revascularization. METHODS:Data from the Veterans Affairs (VA) CART (Clinical Assessment, Reporting, and Tracking) Program were used to evaluate patients who underwent PCI of >2 vessels between October 1, 2007, and September 3, 2014. Associations between individual factors and the decision to perform staged PCI were assessed. Additionally, the impact of measured patient and procedural factors, site factors, and unmeasured site factors on the decision to perform staged PCI was compared. Cox proportional hazards models were used to determine the association between staged PCI and mortality. RESULTS:A total of 7,599 patients at 61 sites were included. The decision to perform staged PCI was driven by procedural characteristics and unmeasured site factors. Staged PCI was associated with lower risk-adjusted mortality compared with OTMVR (adjusted hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.72 to 0.84; p < 0.01). This mortality benefit was observed among the ST-segment elevation myocardial infarction (HR: 0.31; 95% CI: 0.21 to 0.47; p < 0.01), non-ST-segment elevation myocardial infarction (HR: 0.74; 95% CI: 0.64 to 0.87; p < 0.01), unstable angina (HR: 0.75; 95% CI: 0.64 to 0.89; p < 0.01) and stable angina (HR: 0.88; 95% CI: 0.77 to 1.00; p = 0.05) groups. CONCLUSIONS:The decision to pursue staged PCI was driven by procedural characteristics and unmeasured site variation and was associated with lower mortality compared with OTMVR. After adjustment, there was an association between staged PCI and reduced mortality. Given the observational nature of these findings, a randomized trial comparing the 2 is needed to guide practice.

OBJECTIVE:This study evaluated whether use of different spasmolytic regimens (nitroglycerin or verapamil) administered soon after sheath insertion affects postprocedure radial artery occlusion (RAO) in patients who underwent transradial catheterization. METHODS AND RESULTS:We performed a post hoc analysis of a randomized trial evaluating the use of 500 μg intra-arterial nitroglycerin just before sheath removal in 1706 patients undergoing transradial catheterization. Patients who received 200 μg or 300 μg nitroglycerin after sheath placement (group A; n = 688) were compared with patients who received 5 mg verapamil after sheath placement (group B; n = 1018). The primary endpoint was RAO diagnosed by Doppler ultrasound examination at 1 calendar day after the procedure. Logistic regression was used to determine predictors of RAO. RAO occurred in 16.0% of group A and 5.4% of group B. After adjustment for potential confounders, neither the use of verapamil nor nitroglycerin was associated with RAO (odds ratio [OR], 1.24; 95% confidence interval [CI], 0.51-3.02; P=.62). Radial artery compression >4 hours was the strongest predictor of RAO (OR, 5.41; 95% CI, 2.31-12.65; P<.001). CONCLUSIONS:In this study, the use of verapamil or nitroglycerin as a spasmolytic regimen was not associated with RAO. Given the strong association between duration of radial compression and RAO, further studies are needed to determine the interaction between vasodilator agents and compression protocols on RAO.

BACKROUND:In-stent restenosis (ISR) remains a common clinical problem associated with significant morbidity. We sought to evaluate the temporal trends in incidence and procedural management of coronary restenosis as well as evaluate the association between different treatment modalities and clinical outcomes. METHODS:We identified all patients treated for coronary ISR within the Veterans Affairs Healthcare System from October 1, 2006 to September 30, 2014. The temporal trends in incidence as well as intraprocedural management were assessed. Among patients treated for single vessel restenosis, a propensity matched cohort was created for those treated with drug-eluting stents (DES) or other treatment modalities. Target vessel revascularization (TVR) and mortality were compared between the two subpopulations. RESULTS:From 2006 to 2014, 65,443 patients underwent percutaneous coronary intervention and 6,872 patients (10.5%) with 8,921 lesions were treated for ISR. The proportion of patients undergoing revascularization for restenosis increased 0.28% per year (P = 0.055). Among a propensity-matched cohort of 6,231, the rates of TVR (subdistribution HR: 0.623, 95% CI: 0.511-0.760) and mortality (HR: 0.730, 95% CI: 0.641-0.830) were significantly lower among patients treated with a DES compared with other treatments. After adjustment for known risk factors, treatment with DES continued to be associated with a reduction in mortality rate (Adjusted HR: 0.802, 95% CI: 0.704-0.913). CONCLUSIONS:There is a trend toward an increasing proportion of coronary interventions for ISR in a national cohort of Veterans and treatment with a DES is associated with the lowest rate of TVR and overall mortality.

OBJECTIVES:This study sought to compare the appropriate use and outcomes of percutaneous coronary intervention (PCI) between top-ranked and nonranked hospitals. BACKGROUND:The U.S. News & World Report "Best Hospitals" rankings are an influential consumer-directed publication of hospital quality, and are commonly used in promotional campaigns by hospital systems. METHODS:Hospitals in the National Cardiovascular Data Registry CathPCI registry between July 1, 2014, and June 30, 2015, were classified as top-ranked if they were included in the 2015 U.S. News & World Report 50 best "Cardiology and Heart Surgery" hospitals. The remaining were classified as nonranked. We compared in-hospital mortality, post-procedural bleeding, post-procedural acute kidney injury, and the proportion of appropriate PCI procedures between top-ranked and nonranked hospitals. RESULTS:A total of 509,153 PCIs at 654 hospitals were included, of which 55,550 (10.9%) were performed at 44 top-ranked hospitals. After adjusting for patient case mix, PCIs performed at top-ranked hospitals had similar odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.96; 95% confidence interval [CI]: 0.83 to 1.12; p = 0.64), acute kidney injury (aOR: 1.10; 95% CI: 0.98 to 1.22; p = 0.099), and bleeding (aOR: 1.15; 95% CI: 0.99 to 1.31; p = 0.052). Top-ranked hospitals had a slightly lower proportion of appropriate PCI compared with nonranked hospitals (89.2% vs. 92.8%; OR: 0.56; 95% CI: 0.45 to 0.69; p < 0.001). CONCLUSIONS:PCI performed at top-ranked hospitals was not associated with superior outcomes compared with PCI at nonranked hospitals. The inclusion of metrics based on clinical data may be important for hospital quality rankings.