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The Impact of Chronic Lung Disease in MI

The Impact of Chronic Lung Disease in MI

Chronic lung disease (CLD)—including COPD, chronic bronchitis, and emphysema—is common, presenting in approximately one in seven patients presenting with myocardial infarction (MI). Patients with CLD are more likely to die or be hospitalized from cardiovascular disease than from any other disease. Despite this knowledge, few studies have explored the influence of CLD on patient management and outcomes following MI. Gaining a better understanding of this relationship could lead to opportunities for improving quality of care and outcomes for CLD patients. Treatments & Mortality for Chronic Lung Disease In a study published in the American Heart Journal, my colleagues and I utilized the National Cardiovascular Data Registry to determine the association of CLD with treatments and adverse events after MI. Our results showed that CLD patients presenting with non-STEMI had a 20% increased risk for in-hospital death when compared with those who did not have CLD. No such link, however, was found among CLD patients with STEMI. In addition, CLD patients with non-STEMI were markedly less likely to receive invasive procedures, such as cardiac catheterization, PCI, or CABG surgery. They were also slightly less likely to receive evidence-based medical therapies, including thienopyridines, β-blockers, and statins. Conversely, differences in treatment of STEMI patients with CLD were not clinically significant, according to findings in our investigation. Taking a Closer Look at Bleeding Risks This is also the first study to our knowledge indicating that, independent of other factors, CLD patients had a 20% to 25% higher risk of bleeding when compared with those without CLD. Major bleeding is one of the most common in-hospital complications following acute coronary syndromes and is associated...
The Costs & Benefits of Radial Catheterization

The Costs & Benefits of Radial Catheterization

Most patients in the United States undergo femoral artery access for cardiac catheterization procedures despite research demonstrating that radial access can reduce vascular complications and increase patients’ ability to become mobile more quickly after their procedure. It has been speculated that lower adoption of radial artery access could be the result of concerns about increases in procedure time, radiation exposure, and access failure for patients who undergo this procedure. Support for Radial Access for Cardiac Catheterization In Circulation: Cardiovascular Quality and Outcomes, my colleagues and I published a cost-benefit analysis of cardiac catheterization approaches based on results from a systematic review of published randomized controlled trials (RCTs). The analysis combined find­ings from 14 published RCTs, comparing outcomes from coronary angiograms and stenting procedures that were performed via the radial artery versus the femoral artery. These combined findings were inserted into a cost-benefit simulation model that estimated the average cost of care for patients receiving these procedures. The model took into account procedure and hemostasis time, the costs of repeating cath­eterization at alternate sites if a first catheterization failed, and inpatient hospital costs associated with complications from the procedure. We found that radial catheterization significantly lowered the risk for major complications (odds ratio [OR], 0.32), major bleeding (OR, 0.39), and hematoma (OR, 0.36), when compared with femoral catheterization. Regarding procedure time, the radial approach took only 1.4 minutes longer than the femoral approach and reduced hemostasis time by approximately 13.0 minutes, on average. Radial cath­eterization increased the potential for catheterization failure (OR, 4.92), but there were no differences in procedure success rates or major adverse cardiovas­cular events. Potential Cost Savings...
Strategies to Lower Death Risk After AMI

Strategies to Lower Death Risk After AMI

Research has shown that the risk of dying from an acute myocardial infarction (AMI) has been steadily decreasing across the United States in recent years. Despite this improvement, there is still substantial variation in 30-day risk-standardized mortality rates (RSMRs) from hospital to hospital. To investigate the causes of variation with RSMRs in these patients, my colleagues and I conducted a cross-sectional survey of 537 hospitals to see what strategies they employed. Published in the May 1, 2012 Annals of Internal Medicine, our findings were combined with data from CMS to determine the links between hospital strategies and mortality rates. 5 Key Hospital Strategies for AMI According to our analysis, five hospital strategies were associated with a clinically important reduced risk of death for patients hospitalized with an AMI: 1) Monthly meetings: Holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital was associated with a 0.70 percentage-point decrease in the RSMR. 2) Cardiologists on site: Always having cardiologists on site lowered the RSMR by 0.54 percentage points. 3) Problem-solving culture: Fostering an organizational environment in which clinicians are encouraged to solve problems creatively lowered the RSMR by 0.84 percentage points. 4) Cross-training nurses: Avoiding cross-training nurses from ICUs for the cardiac catheterization laboratory lowered the RSMR by 0.44 percentage points. 5) Dual champions: Having both physician and nurse champions lowered the RSMR by 0.88 percentage points. Using all five of these strategies was associated with more than a 1% decrease in 30-day RSMRs when compared with hospitals that used none of the strategies. Only six of the hospitals reviewed in our...

Revascularizing Occluded Arteries: Assessing the Influence of Guidelines

The Occluded Artery Trial (OAT) was a large, randomized controlled study funded by the National Heart, Lung, and Blood Institute that tested routine percutaneous recanalization of persistently totally occluded infarct-related arteries identified a minimum of 24 hours after myocardial infarction (MI) in stable patients who did not have triple vessel disease or severe inducible ischemia. In 2006, results from OAT were released, showing that there appears to be no benefit to routinely using PCI for persistently totally occluded infarct-related arteries in this patient population. Routine PCI for these arteries did not reduce mortality, reinfarction, or class IV heart failure. These results subsequently led to updates of guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) on unstable angina/non-STEMI, STEMI, and PCI in 2007. The revised guidelines recommended that PCI not be performed in this context. Prior to OAT data being released, clinicians tended to favor using PCI for persistent infarct-related artery occlusions largely because of experimental and observational data. “OAT results demonstrated that use of PCI did not lead to a reduction in clinical events,” explains Judith S. Hochman, MD. “The beneficial effect on angina and quality of life was small and not durable. OAT also suggested that PCI was more costly than optimal medical therapy alone. As a result, these findings should have discouraged routine PCI in this setting.” Assessing the Impact of the OAT Study In the October 10, 2011 Archives of Internal Medicine, Dr. Hochman and colleagues had a study published in which they examined whether PCI use for treating occluded infarct-related arteries after an MI decreased following the publication of OAT...

American College of Cardiology 2010 Scientific Sessions

The American College of Cardiology (ACC) held its 2010 annual scientific sessions from March 14 to 16 in Atlanta. The features below highlight some of the news emerging from the ACC scientific sessions. For more information on these items and other research that was presented, go to www.acc.org. Gender Differences in Cardiac Catheterization The Particulars: In previous research data, men have been consistently more likely than women to be sent to the cardiac catheterization laboratory after noninvasive cardiovascular imaging tests. In the past, symptoms of suspected heart disease in women have often been dismissed as false positives or misinterpreted. More recently, there has been increased publicity about the underrecognition of heart disease in women, and campaigns have been launched to raise awareness. Data Breakdown: A study of 1,700 patients recruited from the Study of Myocardial Perfusion and Coronary Anatomy Imaging Roles in Coronary Artery Disease registry was conducted. Patients had no history of heart disease, presented with chest pain, and underwent cardiovascular imaging tests. Tests were abnormal in 30% of women and 22% of men. Overall, 10% of patients in the study cohort were referred to cardiac catheterization within 90 days, with higher rates in women (13%) than men (6%). Take Home Pearls: Women appear to be twice as likely as men to be referred for cardiac catheterization. Whether the difference in referrals by gender is due to excessive referrals to cardiac catheterization in women or underutilization in men requires further investigation. Promising New Data on Mitral-Clip Device The Particulars: Only about 20% of patients with significant mitral regurgitation undergo surgery, and most are managed medically. While drugs may...
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