Cause and preventability of in-hospital mortality after PCI: A statewide root-cause analysis of 1,163 deaths.

BACKGROUND: Mortality is the most devastating complication of percutaneous coronary interventions (PCI). Identifying the most common causes and mechanisms of death after PCI in contemporary practice is an important step in further reducing periprocedural mortality. OBJECTIVES: To systematically analyze the cause and circumstances of in-hospital mortality in a large, multi-center, statewide cohort. METHODS: In-hospital deaths after PCI occurring at 39 hospitals included in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) between 2012 and 2014 were retrospectively reviewed using validated methods. A priori PCI-related mortality risk was estimated using the validated BMC2 model. RESULTS: A total of 1,163 deaths after PCI were included in the study. Mean age was 71±13 years, and 507 (44%) were women. Left ventricular failure was the most common cause of death (52% of cases). The circumstance of death was most commonly related to prior acute cardiovascular condition (61% of cases). Procedural complications were considered contributing to mortality in 235 (20%) cases. Death was rated as not preventable or slightly preventable in 1,045 (89.9%) cases. The majority of the deaths occurred in intermediate or high-risk patients, but 328 (28.2%) deaths occurred in low-risk patients (<5% predicted risk of mortality). PCI was considered rarely appropriate in 30% of preventable deaths. CONCLUSIONS: In-hospital mortality after PCI is rare, and primarily related to pre-existing critical acute cardiovascular condition. However, approximately 10% of deaths were preventable. Further research is needed to characterize preventable deaths, in order to develop strategies to improve procedural safety.

Strategic Deployment of Cardiology Fellows in Training Using the Accreditation Council for Graduate Medical Education Coronavirus Disease 2019 Framework.

Coronavirus disease 2019 is a global pandemic affecting >3 million people in >170 countries, resulting in >200 000 deaths; 35% to 40% of patients and deaths are in the United States. The coronavirus disease 2019 crisis is placing an enormous burden on health care in the United States, including residency and fellowship training programs. The balance between mitigation, training and education, and patient care is the ultimate determinant of the role of cardiology fellows in training during the coronavirus disease 2019 crisis. On March 24, 2020, the Accreditation Council for Graduate Medical Education issued a formal response to the pandemic crisis and described a framework for operation of graduate medical education programs. Guidance for deployment of cardiology fellows in training during the coronavirus disease 2019 crisis is based on the principles of a medical mission, and adherence to preparation, protection, and support of our fellows in training. The purpose of this review is to describe our departmental strategic deployment of cardiology fellows in training using the Accreditation Council for Graduate Medical Education framework for pandemic preparedness.

Hospital process intervals, not EMS time intervals, are the most important predictors of rapid reperfusion in EMS Patients with ST-segment elevation myocardial infarction.

OBJECTIVE: To assess the relationship of emergency medical services (EMS) intervals and internal hospital intervals to the rapid reperfusion of patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We performed a secondary analysis of a prospectively collected database of STEMI patients transported to a large academic community hospital between January 1, 2004, and December 31, 2009. EMS and hospital data intervals included EMS scene time, transport time, hospital arrival to myocardial infarction (MI) team activation (D2Page), page to catheterization laboratory arrival (P2Lab), and catheterization laboratory arrival to reperfusion (L2B). We used two outcomes: EMS scene arrival to reperfusion (S2B) ≤90 minutes and hospital arrival to reperfusion (D2B) ≤90 minutes. Means and proportions are reported. Pearson chi-square and multivariate regression were used for analysis. RESULTS: During the study period, we included 313 EMS-transported STEMI patients with 298 (95.2%) MI team activations. Of these STEMI patients, 295 (94.2%) were taken to the cardiac catheterization laboratory and 244 (78.0%) underwent percutaneous coronary intervention (PCI). For the patients who underwent PCI, 127 (52.5%) had prehospital EMS activation, 202 (82.8%) had D2B ≤90 minutes, and 72 (39%) had S2B ≤90 minutes. In a multivariate analysis, hospital processes EMS activation (OR 7.1, 95% CI 2.7, 18.4], Page to Lab [6.7, 95% CI 2.3, 19.2] and Lab arrival to Reperfusion [18.5, 95% CI 6.1, 55.6]) were the most important predictors of Scene to Balloon ≤ 90 minutes. EMS scene and transport intervals also had a modest association with rapid reperfusion (OR 0.85, 95% CI 0.78, 0.93 and OR 0.89, 95% CI 0.83, 0.95, respectively). In a secondary analysis, Hospital processes (Door to Page [OR 44.8, 95% CI 8.6, 234.4], Page 2 Lab [OR 5.4, 95% CI 1.9, 15.3], and Lab arrival to Reperfusion [OR 14.6 95% CI 2.5, 84.3]), but not EMS scene and transport intervals were the most important predictors D2B ≤90 minutes. CONCLUSIONS: In our study, hospital process intervals (EMS activation, door to page, page to laboratory, and laboratory to reperfusion) are key covariates of rapid reperfusion for EMS STEMI patients and should be used when assessing STEMI care.

Determinants of markedly increased B-type natriuretic peptide in patients with ST-segment elevation myocardial infarction.

BACKGROUND: A modestly increased plasma B-type natriuretic peptide (BNP) level of greater than 80 pg/mL has been associated with increased mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, the prognostic significance of larger increases in BNP during STEMI has not been reported. METHODS: A total of 420 patients with STEMI were identified from an administrative database, and 91 were found to have a BNP level measured within 24 hours of hospitalization. All patients underwent detailed angiographic and echocardiographic evaluation. Charts were abstracted in a blinded fashion to the BNP results. RESULTS: The mean ± SD age of the participants was 64 ± 13 years, and 53 (58%) of the participants were men. The median, 25th percentile, and 75th percentile of the BNP value were 366, 142, and 1011 pg/mL, respectively. The BNP level increased progressively in 1-, 2-, and 3-vessel coronary disease with medians of 253, 351, and 818 pg/mL, respectively (P = .009). Patients with grade 3/4 diastolic dysfunction had significantly increased median BNP values vs all others, 786 vs 306 pg/mL (P = .03). Eight (9%) patients died during their hospitalization. The median BNP values for 83 (91%) survivors and 8 (9%) nonsurvivors were 344 and 1420 pg/mL, respectively (P = .007). By multiple logistic regression, BNP level more than 500 pg/mL was independently associated with female sex, increased number of vessels diseased (>75% stenosis), lower ejection fraction, higher creatine kinase level, and lower body mass index. CONCLUSION: In patients with STEMI, markedly increased BNP level seems to reflect the extent of coronary disease, the degree of associated systolic and diastolic dysfunction, and a higher risk of in-hospital mortality.

Obesity and age of first non-ST-segment elevation myocardial infarction.

OBJECTIVES: Because excess adiposity is one of the most important determinants of adipokines and inflammatory factors associated with coronary plaque rupture, we hypothesized that obesity was associated with myocardial infarction at earlier ages. BACKGROUND: The developing obesity pandemic of the past 50 years has gained considerable attention as a major public health threat. METHODS: The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) registry was a voluntary observational data collection and quality improvement initiative that began in November 2001, with retrospective data collection from January 2001 to January 2007. The CRUSADE initiative included high-risk patients with unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). We retrospectively examined, among 189,065 patients with acute coronary syndrome (between January 2001 and September 2006) in the CRUSADE initiative, the relationship of body mass index (BMI) with patient age of first NSTEMI. RESULTS: A total of 111,847 patients with NSTEMI were included in the final analysis. There was a strong, inverse linear relationship between BMI and earlier age of first NSTEMI. The mean patient ages (+/- SD) of first NSTEMI were 74.6 +/- 14.3 years and 58.7 +/- 12.5 years for the leanest (BMI 40.0 kg/m(2)) cohorts, respectively (p < 0.0001). After adjustment for baseline demographic data, cardiac risk factors, and medications, the age of first NSTEMI occurred 3.5, 6.8, 9.4, and 12.0 years earlier with ascending levels of adiposity (BMI 25.1 to 30.0, 30.1 to 35.0, 35.1 to 40.0, and >40.0 kg/m(2), respectively; referent 18.6 to 25.0 kg/m(2)) (p < 0.0001 for each estimate). CONCLUSIONS: Excess adiposity is strongly related to first NSTEMI occurring prematurely.

Body weight limitations of United States cardiac catheterization laboratories including restricted access for the morbidly obese.

A telephone survey was performed to determine the current weight limits of cardiovascular catheterization laboratories (n = 94) in the United States. The minimum, mean, and maximum weight limits of the catheterization laboratories in this survey were 160, 198.9, and 250 kg (350, 437.5, and 550 lb), respectively. Twenty-two percent of respondents (n = 21) referred to other institutions when asked what they did when patients were too heavy, and 70% of respondents (n = 66) could not provide an answer. In this population, 5.2 +/- 3.4 patients/hospital/year were rejected for being over the weight limit. In conclusion, these results provide useful information for the future management of this growing population.

Percutaneous coronary interventions in the high-risk renal patient: strategies for renal protection and vascular protection.

CKD is the most important factor in predict-ing adverse short- and long-term outcomes after PCI. Hence, the rationale for renal end-organ protection is based on chronic renal protection,avoidance of additive renal insults, and a comprehensive CIN prophylaxis. The pathogenesis of CIN goes beyond serum creatinine and involves a unique vascular pathobiology in which interrelates renal and CVD outcomes are interrelated. Attempts at PCI in patients with CKD and ESRD are high-risk procedures, but the risks involved seem to be warranted given comparative outcomes in conservatively treated patients. The benefits of short- and long-term vascular protective therapies in CKD patients have been confirmed, and these therapies are an important component of PCI care.

Impact of interventionalist volume, experience, and board certification on coronary angioplasty outcomes in the era of stenting.

It has been suggested that percutaneous coronary intervention (PCI) by high-volume operators may be associated with better outcomes. However, the relation between operator and outcome is confounded by hospital caseloads of PCI, with busier hospitals generally having better outcomes. We assessed the effect of operator characteristics (volume of PCI, years in practice, and board certification status) on contemporary outcomes of PCI in a busy center with high-volume operators. Between 1999 and 2001, 12,293 PCIs were performed at our center by 28 interventionalists. Patients' clinical risk was assessed with the previously validated Beaumont PCI Risk Score. Operators were classified as producing low, medium, or high volume (tertiles of annual PCI volume < or =92, 93 to 140, or >140, respectively), as less, medium, or great experience (tertiles of years in practice < or =8, 9 to 14, or >14 years, respectively), and board certified (68%) or not. In-hospital death rate and a composite end point (death, coronary artery bypass graft surgery, myocardial infarction, or stroke) occurred in 0.99% and 2.59% of patients, respectively. Operator volume, experience, and board certification showed no univariate or multivariate relation with the study end points. The Beaumont PCI Risk Score showed a strong independent relation with in-hospital death rate (adjusted odds ratio 1.37, 95% confidence interval 1.31 to 1.43, p <0.0001) and composite end point (odds ratio 1.19, 95% confidence interval 1.16 to 1.22, p <0.0001). We conclude that, in contemporary PCI practice at a large center with high-volume operators, in-hospital outcomes are not affected by operator volume, experience, or board certification. Rather, patients' clinical risk score is the overriding determinant of clinical outcomes. Our findings emphasize the power of a well-organized high-volume system to minimize the impact of operator factors on outcomes of PCI.

Effectiveness of primary angioplasty for acute myocardial infarction in patients on dialysis.

We sought to characterize the outcome in patients who were on long-term dialysis and who underwent primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction. Of 2,831 consecutive patients who underwent primary PTCA for acute myocardial infarction from 1993 to 2001, 15 patients on long-term dialysis were identified. This small cohort had a 40% incidence of cardiogenic shock on admission. Despite the angiographic success rate for primary PTCA of 80%, in-hospital mortality was 53%.