A quality framework for the role of invasive, non-interventional cardiologists in the present-day cardiac catheterization laboratory: A multidisciplinary SCAI/HFSA expert consensus statement.

The present-day cardiac catheterization laboratory (CCL) is home to varied practitioners who perform both diagnostic, interventional, and complex invasive procedures. Invasive, non-interventional cardiologists are performing a significant proportion of the work as the CCL environment has evolved. This not only includes those who perform diagnostic-only cardiac catheterization but also heart failure specialists who may be involved in hemodynamic assessment and in mechanical circulatory support and pulmonary hypertension specialists and transplant cardiologists. As such, the training background of those who work in the CCL is varied. While most quality metrics in the CCL are directed towards evaluation of patients who undergo traditional interventional procedures, there has not been a focus upon providing these invasive, noninterventional cardiologists, hospital/CCL administrators, and CCL directors a platform for quality metrics. This document focuses on benchmarking quality for the invasive, noninterventional practice, providing this physician community with guidance towards a patient-centered approach to care, and offering tools to the invasive, noninterventionalists to help their professional growth. This consensus statement aims to establish a foundation upon which the invasive, noninterventional cardiologists can thrive in the CCL environment and work collaboratively with their interventional colleagues while ensuring that the highest quality of care is being delivered to all patients.

Optimal use of left ventriculography at the time of cardiac catheterization: a consensus statement from the Society for Cardiovascular Angiography and Interventions.

The rationale to perform left ventriculography at the time of cardiac catheterization has been little studied. The technique and frequency of use of left ventriculography vary by geographic regions, institutions, and individuals. Despite the recent publication of guidelines and appropriate use criteria for coronary angiography, revascularization, and noninvasive imaging, to date there have been no specific guidelines on the performance of left ventriculography. When left ventriculography is performed, proper technique must be used to generate high quality data which can direct patient management. The decision to perform left ventriculography in place of, or in addition to, other forms of ventricular assessment should be made taking into account the clinical context and the type of information each study provides. This paper attempts to show the role of left ventriculography at the time of coronary angiography or left heart catheterization. The recommendations in this document are not formal guidelines but are based on the consensus of this writing group. These recommendations should be tested through clinical research studies. Until such studies are performed, the writing group believes that adoption of these recommendations will lead to a more standardized application of ventriculography and improve the quality of care provided to cardiac patients. © 2014 Wiley Periodicals, Inc.

Fractional flow reserve-guided coronary artery bypass grafting: can intraoperative physiologic imaging guide decision making?

OBJECTIVES: Fractional flow reserve-guided coronary artery bypass grafting is emerging in cardiac surgery, in which the nature (anatomic and functional characteristics) of the target vessel epicardial coronary artery stenosis is important in graft site selection. The nature of the stenosis might determine a different physiologic response to bypass grafting. We report our recent experience using near infrared fluorescence complex angiography and perfusion analysis to identify the nature of stenoses in the target vessel by imaging the physiologic response to grafting. METHODS: In 167 patients who underwent consecutive multivessel coronary artery bypass grafting cases (63% off-pump coronary artery bypass grafting) with traditional anatomy-based revascularization, we imaged and analyzed 359 grafts (53% arterial). This platform provides angiographic data of both the target vessel epicardial coronary artery and graft simultaneously (to assess the imaged competitive flow); and because a change in fluorescence intensity is proportional to the change in blood flow and perfusion, the quantified change (if any) in regional myocardial perfusion surrounding the grafted target vessel epicardial coronary artery. RESULTS: The patient outcomes in our series were excellent. All 359 grafts were widely patent by angiography, and 24% of the arterial and 22% of the saphenous vein grafts showed no regional myocardial perfusion change in response to bypass grafting. In 165 in situ internal mammary artery grafts to the left anterior descending artery (>70% stenosis), 40 had no change in regional myocardial perfusion, and 32 of the 40 had competitive flow imaged. CONCLUSIONS: An important number of angiographically patent bypass grafts demonstrated no change in regional myocardial perfusion, suggesting anatomic, but nonfunctional, stenoses in those target vessel epicardial coronary arteries. In in situ arterial grafts, imaged competitive flow is associated with nonfunctional stenoses in the target vessel epicardial coronary artery. Imaging these physiologic responses to target vessel revascularization might be useful in the emerging fractional flow reserve-guided era.

Fibrinolysis versus primary percutaneous intervention in ST-elevation myocardial infarction with long interhospital transfer distances.

BACKGROUND: Current guidelines recommend rapid initiation of reperfusion therapy for ST-elevation myocardial infarction (STEMI), with short-distance transfer for primary percutaneous coronary intervention (pPCI) preferred over fibrinolysis in non-pPCI-capable hospitals. Comparative outcomes in patients with longer transfer times are unclear. HYPOTHESIS: We designed this study to assess whether administering fibrinolytics prior to initiating longer-distance interhospital transfer in patients with STEMI leads to a delay in transfer or worse outcomes compared with transfer for pPCI. METHODS: We analyzed 259 STEMI patients transferred to a receiving pPCI-capable center in eastern North Carolina. The patients were divided into 2 groups, with 43 (16.6%) transferred for pPCI and the remaining 216 (83.4%) transferred following fibrinolysis. The primary endpoint was door-to-door time. We also compared stroke, death, significant bleeding, and combined outcomes between the 2 groups. RESULTS: The median door-to-door time was similar for pPCI and fibrinolysis patients (135 vs 128 minutes; P = 0.71). Median door-to-balloon time among pPCI patients was 182 minutes from the point of arrival at the referral hospital and 49 minutes from arrival at the receiving pPCI center. Median door-to-needle time in the fibrinolysis patients was 30 minutes, with rescue PCI eventually performed in 81 (37.5%) patients. In-hospital mortality was higher in patients with pPCI (9.3%) compared with fibrinolysis patients (1.9%; P = 0.03). Combined incidence of stroke, significant bleeding, and death was 14% in pPCI patients compared with 7% in fibrinolysis patients (P = 0.13). CONCLUSIONS: In settings with longer transfer distances, administering fibrinolytics prior to transfer to a pPCI-capable center did not cause any significant delay in transfer or worse outcomes.

Quartiles of peak troponin are associated with long-term risk of death in type 1 and STEMI, but not in type 2 or NSTEMI patients.

BACKGROUND: The prognostic value of peak cardiac troponin (cTn) in different types of acute myocardial infarction (AMI) under the universal clinical classification is unknown. HYPOTHESIS: We tested the hypothesis that the prognostic value of cTn varies with its peak level and type of AMI. METHODS: We studied 345 consecutive patients with AMI with mean follow-up of 30.6 months according to quartiles of peak cTn level (QPTL) and the type of AMI. The study outcomes were the major adverse cardiovascular events (MACE; composite of all causes of mortality and recurrent AMI) and the individual components of MACE. RESULTS: The study included patients with AMI Type 1 (n = 276), type 2 (n = 54), ST-segment elevation myocardial infarction (STEMI; n = 159), and non-ST-segment elevation myocardial infarction (NSTEMI; n = 186). Overall, peak cTn level was an independent predictor of MACE (hazard ratio [HR]: 1.001, 95% confidence interval [CI]: 1.000-1.003, P = 0.01) and death (HR: 1.002, 95% CI: 1.001-1.004, P = 0.003), but not of recurrent AMI. The highest risk of MACE and death was in the highest QPTL (61.6%, P = .016 and 66.3%, P = 0.021, respectively) while the highest risk of recurrent AMI was in the lowest QPTL (83.7%, P = 0.04). Quartiles of peak cTn level were significantly associated with increased risk of MACE and death in patients with Type 1 (all P = 0.01) and STEMI (P = 0.01 and P = 0.02, respectively), but no association existed in type 2 or NSTEMI patients. CONCLUSIONS: Overall, peak cTn predicts the risk of MACE and death but not the risk of AMI. While in Type 1 and STEMI patients, QPTL are associated with risk of MACE and death, no association exists in type 2 or NSTEMI patients.

A novel complication of bariatric surgery.

The incidence of obesity in the US is increasing. This has been associated with an increasing incidence and prevalence of diabetes, hypertension, and obstructive sleep apnea. Diet alone has generally been ineffective in attaining significant weight loss. Bariatric surgery is associated with significant weight loss and improvement in diabetes, hypertension, and obstructive sleep apnea. In this article we describe an unusual complication of bariatric surgery.

Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation.

Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.

Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction.

CONTEXT: Despite 2 decades of evidence demonstrating benefits from prompt coronary reperfusion, registries continue to show that many patients with ST-segment elevation myocardial infarction (STEMI) are treated too slowly or not at all. OBJECTIVE: To establish a statewide system for reperfusion, as exists for trauma care, to overcome systematic barriers. DESIGN AND SETTING: A quality improvement study that examined the change in speed and rate of coronary reperfusion after system implementation in 5 regions in North Carolina involving 65 hospitals and associated emergency medical systems (10 percutaneous coronary intervention [PCI] hospitals and 55 non-PCI hospitals). PATIENTS: A total of 1164 patients with STEMI (579 preintervention and 585 postintervention) eligible for reperfusion were treated at PCI hospitals (median age 61 years, 31% women, 4% Killip class III or IV). A total of 925 patients with STEMI (518 preintervention and 407 postintervention) were treated at non-PCI hospitals (median age 62 years, 32% women, 4% Killip class III or IV). INTERVENTIONS: Early diagnosis and the most expedient coronary reperfusion method at each point of care: emergency medical systems, emergency department, catheterization laboratory, and transfer. Within 5 regions, PCI hospitals agreed to provide single-call catheterization laboratory activation by emergency medical personnel, accept patients regardless of bed availability, and improve STEMI care for the entire region regardless of hospital affiliation. MAIN OUTCOME MEASURES: Reperfusion times and rates 3 months before (July to September 2005) and 3 months after (January to March 2007) a year-long implementation. RESULTS: Median reperfusion times significantly improved according to first door-to-device (presenting to PCI hospital 85 to 74 minutes, P < .001; transferred to PCI hospital 165 to 128 minutes, P < .001), door-to-needle in non-PCI hospitals (35 to 29 minutes, P = .002), and door-in to door-out for patients transferred from non-PCI hospitals (120 to 71 minutes, P < .001). Nonreperfusion rates were unchanged (15%) in non-PCI hospitals and decreased from 23% to 11% in the PCI hospitals. For patients presenting to or transferred to PCI hospitals, clinical outcomes including death, cardiac arrest, and cardiogenic shock did not significantly change following the intervention. CONCLUSIONS: A statewide program focused on regional systems for reperfusion for STEMI can significantly improve quality of care. Further research is needed to ensure that programs that result in improved application of reperfusion treatments will lead to reductions in mortality and morbidity from STEMI.

Reperfusion of acute myocardial infarction in North Carolina emergency departments (RACE): study design.

Despite the accumulation of almost 2 decades of data in support of rapid reperfusion therapy for ST-segment elevation myocardial infarction (STEMI), the United States healthcare system still faces serious challenges in providing reperfusion to all eligible patients in a timely fashion. American College of Cardiology/American Heart Association guidelines call for systematic interventions aimed at improving both the proportion of patients receiving reperfusion and the timeliness of treatment. We designed a project (RACE) that incorporates standardized protocols and integrated systems for treatment and timely transfer (when appropriate) of patients with STEMI in 5 geographic regions in North Carolina. The RACE project was created by an alliance between national and regional professional societies, a local payer, the pharmaceutical, and healthcare providers, including emergency medical services, emergency medicine, cardiology, and hospital administrations. The main outcomes of interest are rates of reperfusion and time to treatment. Collected data will also provide important insights into barriers to timely reperfusion. The goal of the RACE project is to provide a model for improving the care of patients with STEMI by identifying those features associated with significant improvement, as well as those imposing significant barriers to appropriate therapy.

Spontaneous coronary artery dissection.

Spontaneous coronary artery dissection (SCAD) should be considered as a cause of the acute coronary syndrome in young patients with few apparent risk factors for coronary artery disease, in females in the peripartum period, and in patients who are at a higher risk for this condition. SCAD can also present as sudden death and cardiogenic shock. Several mechanisms have been described in the pathophysiology of this condition. Urgent coronary angiography is indicated if SCAD is suspected. Percutaneous coronary artery stenting and coronary artery bypass grafting are the main treatment strategies.

Optimal management of hyperlipidemia in primary prevention of cardiovascular disease.

Cardiovascular disease (CVD) in the developed countries continues to grow at an epidemic proportion. There are a significant number of young adults with no clinical evidence of CVD, but who have two or more risk factors that predispose them to CV events and death. Many of these risk factors are modifiable, and by controlling these factors, the CVD burden can be decreased significantly. Recent statistics have shown that, if all major forms of CVD were eliminated, the life expectancy would rise by almost 7 years. Hence it is imperative that primary prevention efforts should be initiated at a young age to avert decades of unattended risk factors. Hyperlipidemia has been linked to CVD almost a century ago. Since then various clinical trials have not only supported this link, but have also shown the CV benefits in aggressively treating patients with hyperlipidemia. In this generation, we have various therapeutic agents that are capable of reducing the elevated lipid levels. With drugs like statins, we are able to reduce the risk of CVD by about 30% and avoid major adverse events. Newer drugs are being researched and introduced in the treatment of hyperlipidemia in humans. These can be used in combination therapy resulting in optimal levels of lipids. The new National Cholesterol Education Program (NCEP)/Adult Treatment Panel III (ATP III) guidelines have come as a wake-up call to clinicians about primary prevention of CVD through strict lipid management and multifaceted risk management approach in the prevention of CVD.