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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...

Optimal Surgery Times After PCI

A Canadian investigation of more than 8,000 patients who underwent major elective non-cardiac surgery and received PCI within 10 years suggests that the earliest optimal time for their surgery is 46 to 180 days after bare-metal stent implantation and more than 180 days after drug-eluting stent implantation. Surgery at less than 45 days had 30-day event rates of 6.7% for bare-metal stents and 20.0% for drug-eluting stents. Surgery at 45 to 180 days had an event rate of 2.6% for bare-metal stents, but the rate increased with surgery past 180 days. Surgery after 180 days had an event rate of 1.2% for those who received drug-eluting stents within 10 years. Abstract: Circulation, August 14, 2012...

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...

Discharging Patients After Elective PCI

Among Medicare recipients, PCI is one of the most commonly performed cardiac procedures in the United States, with more than 1 million procedures being performed each year. Research has shown that the risks associated with PCI are highest within the first 24 to 48 hours after the procedure. Fortunately, both short- and long-term outcomes after PCI have improved substantially over the years because of the evolution of devices, technology, and pharmacotherapy. Despite recent advances, patients are usually observed overnight in the hospital after elective PCI to monitor for complications, sometimes in short-stay units and other times on traditional nursing floors as inpatients. This practice occurs even though some studies suggest that these patients can be discharged home safely on the same day of PCI without the need for overnight observation. The potential benefits of same-day discharge of patients include the elimination of an overnight hospital stay for patients, increased bed availability for the hospital, and cost savings. New Data on Discharge of PCI Patients Little is known about how often patients are discharged home the same day as their PCI. To shed light on the matter, my colleagues and I conducted a study using data from more than 107,000 patients aged 65 and older from the National Cardiovascular Data Registry CathPCI Registry and linked it with CMS claims data. Patients were either discharged the same day as their procedure or 24 or more hours after it. The investigation, published in the October 5, 2011 JAMA, examined trends in death or rehospitalization occurring within 2 days and by 30 days after PCI. “Same-day discharge was rarely implemented in low-risk Medicare...

Use of PCI & DES in Older Patients

Results of a large national study of older patients undergoing PCI suggests that those aged 85 or older appear most likely to decline use of drug-eluting stents (DES). However, the investigation showed that DES were associated with lower adverse event and mortality rates in all age groups when compared with bare-metal stents. Abstract: Journal of the American College of Cardiology, January 10,...
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