A CHIP fellow's transition into practice: Building a complex coronary therapeutics program.

BACKGROUND: Both the prevalence and complexity of coronary artery disease are on the rise in the United States, leading to a resurgence in novel techniques and equipment utilized to treat complex coronary disease. However, declining percutaneous coronary intervention (PCI) volumes and lack of formal post-graduate education opportunities have created a gap in treatment delivery for this patient population. Several complex, high-risk, and indicated PCI (CHIP) fellowships have been developed in an attempt to bridge this disparity. We present data from the first year of practice from a former CHIP fellow during development of a formal complex coronary therapeutics program. METHODS: Data was prospectively collected for PCIs performed during the first 12 months of practice for the lead author and compared to procedures performed in the 12 months prior to the study period. RESULTS: Out of 371 PCIs performed during the study period, 53.4% (198/371) were considered complex, including 126 chronic total occlusion (CTO) procedures. Compared to the previous 12 months, there was a significant increase in the number and complexity (median J-CTO score 2.1 vs. 1.3, p .04) of CTOs performed during the study period. CTO procedural characteristics and complication rates were similar to those previously published in large U.S. registries, with technical success in 93.4% (118/126) and procedural success in 85.7% (108/126). CONCLUSION: Following dedicated CHIP fellowship training and establishment of a formal CHIP program, procedural success and complication rates were achieved similar to those published in prior studies evaluating CTO PCI at high volume centers.

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.

Intensive treatment of hypertension decreases the risk of hyperperfusion and intracerebral hemorrhage following carotid artery stenting.

OBJECTIVES: To assess the efficacy of a comprehensive blood pressure (BP) management protocol in reducing intracerebral hemorrhage (ICH) following carotid artery stenting (CAS). BACKGROUND: Following CAS hyperperfusion syndrome (HPS) can lead to significant morbidity and mortality. Hypertension plays an essential role in its development. METHODS: We instituted a comprehensive BP protocol following the last case of ICH complicating a CAS procedure. All patients received comprehensive monitoring of BP and treatment to a BP < 140/90 mm Hg; those with a treated stenosis >or=90%, contralateral stenosis >or=80%, and hypertension (i.e., risk factors for HPS) were treated to a BP < 120/80 mm Hg. Patients who developed HPS received parenteral beta-blockers or nitrates titrated to resolution of symptoms and discharged when asymptomatic and normotensive. Patients and families were instructed to measure BP twice daily for 2 weeks and to call if hypertension or headache developed. RESULTS: A total of 836 patients had CAS, 266 prior to the comprehensive BP management program and 570 subsequently. The incidence of HPS/ICH was 5/266 (1.9%) patients prior to comprehensive BP management and 3/570 (0.5%) patients afterwards, P = 0.12. The incidence of ICH was 3/266 (1.1%) and 0/570, respectively, P = 0.032. In high-risk patients both HPS and ICH were significantly reduced from 29.4 to 4.2% (P = 0.006) and 17.6-0% (P = 0.006), respectively. There were no complications attributable to the comprehensive program and lengths of hospitalization were similar (2.6 vs. 2.1 days, P = 0.18). CONCLUSIONS: Comprehensive management of arterial hypertension can lower the incidence of ICH and HPS in high-risk patients following CAS, without additional complications or prolonged hospitalizations.

The challenge of valvular heart disease: when is it time to operate?

In patients with valve disease, operating too soon exposes them to unnecessary surgical risk, but waiting too long may lead to cardiac damage and poor outcome. When to refer a patient for surgery depends on which valve is involved, the type of defect (stenosis or regurgitation), the degree of the defect, and the degree of symptoms or functional impairment.

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment.

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS). BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS. METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH. RESULTS: The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH. CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.

Point-of-care ecarin clotting time versus activated clotting time in correlation with bivalirudin concentration.

INTRODUCTION: A thrombin inhibitor management (TIM) point-of-care test based upon the ecarin clotting time (ECT) has been developed. The ECT has been suggested to more accurately reflect the anti-coagulant effect of direct thrombin inhibitors compared with the activated clotting time (ACT). We sought to examine the correlation of the TIM-ECT test with bivalirudin concentration in patients undergoing percutaneous coronary intervention (PCI), and to compare the performance of this test with the current standard (i.e., ACT). MATERIALS AND METHODS: In a multicenter study, blood samples were obtained at six pre-defined time-points in 170 consecutive patients undergoing PCI using bivalirudin. For each sample, the TIM-ECT (citrated and non-citrated), ACT, and bivalirudin concentration was determined. RESULTS: Considering samples from all time-points (n=784), the correlations of TIM-ECT citrated, TIM-ECT non-citrated, and ACT with bivalirudin concentration were 0.96, 0.93, and 0.90, respectively. For samples collected at therapeutic levels of bivalirudin (n=353), the correlations of TIM-ECT citrated, TIM-ECT non-citrated, and ACT with bivalirudin concentration were lower, and showed a greater disparity between methods, with correlation coefficients of 0.75, 0.59, and 0.37, respectively. Prediction models based on the measured bivalirudin concentration were developed for TIM-ECT and ACT, and the coefficients of determination (r(2)) of actual versus predicted TIM-ECT and ACT were 0.91 and 0.81, respectively. CONCLUSIONS: In this PCI population, the TIM-ECT point-of-care test and ACT demonstrated a strong correlation with bivalirudin concentration. The TIM-ECT test had a higher correlation with bivalirudin concentration at therapeutic levels of the drug, and for individual samples appears to more consistently reflect the bivalirudin concentration compared with the ACT.

Severe bilateral carotid stenosis: the impact of ipsilateral stenting on Doppler-defined contralateral stenosis.

OBJECTIVES: The study examined the effect of carotid stenting (CS) on contralateral carotid Doppler-defined degree of stenosis. BACKGROUND: Patients with carotid disease are frequently referred for carotid revascularization (carotid endarterectomy [CEA] or CS) based on the results of carotid duplex studies. Although a drop in flow velocities in the contralateral carotid has been described after CEA, the effect of ipsilateral stenting on contralateral velocities has not been defined. METHODS: A total of 104 consecutive patients underwent CS and were divided into two cohorts, those with unilateral stenosis, and those with bilateral stenosis. Doppler-defined pre-procedural peak systolic velocities (PSV) and end-diastolic velocities (EDV) in the contralateral carotid were compared with the post-procedural velocities. Post-procedural angiographic stenoses were compared with post-procedural duplex-defined stenoses. RESULTS: Among patients with bilateral stenosis, after ipsilateral stenting there was a drop in the contralateral PSV and EDV of 60.3 cm/s (p = 0.005) and 15.1 cm/s (p = 0.03), respectively. There was no change in the contralateral velocities in patients with unilateral stenosis. Among patients with > or =60% stenosis by duplex in the contralateral carotid, 20% dropped to a lower classification of contralateral stenosis after ipsilateral stenting. Furthermore, 71% of patients with significant contralateral stenosis by duplex pre-stenting did not have significant stenosis by angiography. CONCLUSIONS: Patients with bilateral carotid disease may have elevated Doppler flow velocities in the contralateral carotid resulting in an artifactually high grade of stenosis. After ipsilateral carotid revascularization, such patients should have a repeat Doppler of the contralateral carotid to assess the true grade of stenosis.

Relation of inflammation and benefit of statins after percutaneous coronary interventions.

BACKGROUND: Beyond lipid lowering, statins are known to possess antiinflammatory and antithrombotic properties. Recent studies suggested an association between statins and early reduction in death or myocardial infarction (MI) after percutaneous coronary interventions (PCIs). We sought to examine the interrelationship between inflammation, statin use, and PCI outcomes. METHODS AND RESULTS: In the year 2000, 1552 consecutive United States residents underwent elective or urgent PCI at the Cleveland Clinic and were prospectively followed for 1 year. Preprocedural serum high-sensitivity C-reactive protein (hsCRP) levels were routinely measured. Patients who had statins initiated before the procedure (39.6%) had a lower median hsCRP level (0.40 versus 0.50 mg/dL, P=0.012) independent of the baseline cholesterol levels and had less frequent periprocedural MI (defined by CKMB > or =3x upper limit of normal, 5.7% versus 8.1%, P=0.038). At 1 year, statin pretreatment was predictive of survival predominantly among patients within the highest hsCRP quartile (mortality rate with statin pretreatment versus no pretreatment when hsCRP > or =1.11 mg/dL, 5.7% versus 14.8%, P=0.009). Using multivariate analysis, preprocedural hsCRP level remained an independent predictor for 1-year death or MI only in patients without statin therapy (hazard ratio, 1.32/quartile; P=0.001). After adjusting for the propensity of receiving statins, statin pretreatment was an independent predictor for 1-year survival within the highest hsCRP quartile (hazard ratio, 0.44; P=0.039). CONCLUSIONS: Statin therapy before PCI is associated with a marked reduction in mortality among patients with high hsCRP levels. A hsCRP-guided strategy may improve targeting of statin therapy and clinical outcome among patients undergoing PCI.

Why diabetics are at risk in percutaneous coronary intervention and the appropriate management of diabetics in interventional cardiology.

The increasing prevalence of diabetes mellitus in the U.S., particularly among younger patients, will place significant additional demands on an already strained healthcare delivery system. The metabolic and hormonal milieu created by diabetes mellitus fosters the development of systemic atherosclerosis, and mortality in these patients is driven largely by complications of cardiovascular disease. Unfortunately, diabetic pathophysiology poses unique challenges to attaining successful coronary revascularization, whether it is by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). In determining the optimal treatment strategy for a diabetic patient with coronary atherosclerotic disease, it is imperative that the treating physician fully understands the following: the inherent limitations to revascularization in diabetics, the pharmacologic therapies of proven benefit in diabetics with atherosclerotic disease, the currently available comparative data of CABG versus PCI in diabetics, and the ongoing medical, surgical, and interventional advances which may render earlier data obsolete.