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Improving QOL With Coronary Interventions

Improving QOL With Coronary Interventions

For more than 30 years, research has indicated that PCI decreases mortality in STEMI and reduces recurrent ischemic events in patients with non-ST elevation acute coronary syndrome. The overriding goal in performing PCI for these patients is to reduce morbidity and mortality, but quality of life (QOL) is another important aspect to consider. Studies comparing QOL after PCI versus medical therapy or CABG generally report on angina, but this is only one symptom that is relieved by coronary interventions. PCI can also enhance the ability to function, exercise, and perform activities of daily living in many patients. Some comorbidities, however, can limit QOL before and after PCI and may minimize the chances of any improvement in QOL after undergoing the procedure. Individualizing Approaches for PCI & CABG The Society of Cardiovascular Angiography and Interventions (SCAI) released a consensus statement on the effect of PCI on QOL. Published in an issue of Catheterization and Cardiovascular Interventions, the document recommends that clinicians take into consideration that improvements in QOL due to PCI vary from patient to patient. For example, patients who are severely limited by angina will have dramatic improvements in QOL if PCI relieves the angina. However, patients who are severely limited by other medical problems may not experience much improvement in QOL after PCI. Investigations comparing CABG to PCI suggest that QOL is better in the first few months after PCI. At 3 to 5 months, QOL is similar for both PCI and CABG. After 1, 3, and even 5 years, however, QOL tends to be better for patients who receive CABG. When counseling patients on treatment decisions, SCAI...
Examining PCI Access Trends

Examining PCI Access Trends

Advances in medicine have enabled clinicians to use the radial and even ulnar arteries as alternative vascular access sites for PCI. Small studies have shown that transradial PCI is associated with lower rates of bleeding and vascular complications when compared with the femoral approach. Moreover, randomized trial data have demonstrated that both radial and femoral approaches are equally effective and safe in patients with acute coronary syndrome (ACS). “Despite the growing body of evidence supporting greater use of transradial approach to PCI, only 1.32% of PCIs from 2004 to 2007 in the United States were transradial,” says Dmitriy N. Feldman, MD, FACC, FSCAI. “One of the potential reasons for its less frequent use is the lack of operator experience, but multiple training programs have been implemented throughout the U.S. since 2007 to address this issue. The impact of these efforts, however, has not been evaluated.” Assessing More Recent Data In Circulation, Dr. Feldman and colleagues had a retrospective cohort study published that looked at 6 years of data from more than 2.8 million procedures in the CathPCI Registry. According to their results, radial access accounted for 6.3% of PCI procedures from 2007 to 2012. Importantly, transradial PCI was associated with a lower risk of bleeding (adjusted odds ratio [OR], 0.51) and vascular complications (adjusted OR, 0.39) when compared with transfemoral PCI. The reductions seen in bleeding and vascular complications were consistent across important subgroups of age, sex, and clinical presentation. “Since earlier reports have been released, there has been a 13-fold increase over a 6-year period in the use of transradial PCI,” says Dr. Feldman. “These findings are encouraging,...

A New Guide for Revascularizing Patients With CAD

In the December 6, 2011 Journal of the American College of Cardiology, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) published guidelines on the management of patients undergoing CABG, one of the most common operations performed in the United States. These guidelines were released at the same time that the ACCF and AHA published recommendations for PCI. According to L. David Hillis, MD, FACP, chair of the ACCF/AHA guidelines committee for CABG, the landscape regarding when surgeons should perform CABG or PCI has been continually changing, particularly in the past 5 to 10 years. “Several recent investigations have shown that PCI and CABG have comparable outcomes when used in patients with certain coronary arterial anatomic features,” he says. “The last guidelines were published in 2004, but clinical trials have continued to improve our understanding of how to optimize the management of patients with coronary artery disease (CAD).” A Collaborative Approach to Determine Revascularization Through a collaboration of two writing committees, the ACCF/AHA guideline update contains the most extensive examination of CABG and PCI use for coronary revascularization. “While one committee was re-writing the CABG guidelines, a separate committee was revising the PCI guidelines,” explains Dr. Hillis. “Our goal was then to develop a consensus between cardiologists and surgeons over patient selection for these two procedures. Busy practitioners have historically been challenged when deciding on which patients should undergo revascularization rather than being treated medically, and whether revascularization should be accomplished with CABG or PCI.” Dr. Hillis says a section of the guidelines has been established to address questions that clinicians may have when deciding...

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...

Keys to Transradial Access for Percutaneous Revascularization

Although the adoption of radial coronary angiography and radial PCI in the United States lags behind that of other countries, particularly those in Europe and Asia, transradial coronary intervention has seen an 8% to 10% increased utilization in the U.S., a trend that is expected to continue. The Society for Cardiovascular Angiography and Interventions (SCAI) published an executive summary on transradial access (TRA) for coronary and peripheral procedures in the November 2011 issue of Catheterization and Cardiovascular Interventions. The overview examined utility, utilization, and training aspects to consider when performing angioplasty via the radial artery. “Historically, the traditional route to access blocked coronary arteries has been through the larger femoral artery,” says Ronald P. Caputo, MD, FACC, FSCAI, lead author of the SCAI paper. “TRA is advantageous to transfemoral access because it’s less invasive and has been shown to decrease the risk of access site complications and bleeding.” TRA also is preferred by the vast majority of patients because, unlike the transfemoral approach, it causes less discomfort and allows them to stand up and ambulate immediately following the procedure. In addition, some patients undergoing TRA procedures can be discharged the same day. “These advantages ultimately can decrease length of stay and reduce hospitalization costs while still improving clinical outcomes,” adds Dr. Caputo. Avoiding Complications in Transradial Access Appropriate patient selection for TRA is the first important step in a successful procedure, says Dr. Caputo. Ideal patients for TRA include those with a palpably large radial artery with a strong pulse and a normal Allen’s test with no history of an ipsilateral brachial procedure. Contraindications include abnormal Allen’s test, a...
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