Abdul R. Halabi

Decreased Readmissions and Improved Quality of Care With the Use of an Inexpensive Checklist in Heart Failure

Providing effective discharge instructions, appropriate dose uptitration, education regarding heart failure (HF) monitoring, and strict follow-up have all been shown to decrease readmissions for HF but are all underutilized. The authors developed and evaluated the impact of a quality-improvement HF checklist as a tool to remind physicians to improve quality of care in HF patients. The checklist was used in randomly selected patients admitted with a primary diagnosis of acute decompensated HF. It included documentation regarding medications and dose uptitration, relevant counseling, and follow-up instructions at discharge. The checklist was used in 48 patients, and this checklist group was compared with 48 patients as a randomly selected control group. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs 23 of 48, P<.001). Compared with the controls, the rate of dose uptitration for β-blockers and/or ACE inhibitors/ARBs was more common in the checklist group (4 of 48 vs 21 of 48, P<.001). Both 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

The thrill is gone: catheter-based exclusion of a posttraumatic arteriovenous fistula with a covered stent graft.

Posttraumatic arteriovenous (AV) fistulae of the lower extremities may result from accidental trauma or iatrogenic surgical injuries. Large high‐flow fistulae are commonly associated with disabling localized symptoms and impaired wound healing. Therapeutic options are particularly challenging for AV fistulae involving the infrapopliteal circulation. Surgical repair may further delay healing and contribute to greater morbidity. Alternatively, percutaneous coil occlusion in large high‐flow fistulae mayenable coil embolization to the pulmonary circulation. Using a balloon‐expandable covered stent graft, we describe the percutaneous exclusion of a large posttraumatic infrapopliteal AV fistula with immediate clinical symptom improvement and resolution within 3 months following intervention. No clinical symptom recurrence was documented at a 9‐month follow‐up visit.

Impact of Internal Mammary Artery Conduit on Long-term Outcomes After Percutaneous Intervention of Saphenous Vein Graft

Background— The influence of an internal mammary artery (IMA) graft on long-term outcomes after percutaneous saphenous vein graft (SVG) intervention is currently unknown. Methods and Results— To examine the impact of IMA on outcomes in patients undergoing SVG interventions, we analyzed 2119 patients from the Duke Cardiovascular Disease Database (1986–2003) with prior coronary artery bypass surgery undergoing cardiac catheterization who had at least 1 SVG graft. Patients were categorized into 4 groups: group I, SVG intervention and patent IMA; group II, no SVG intervention and patent IMA; group III, SVG intervention without patent IMA; and group IV, no SVG intervention without patent IMA. At a median follow-up of 4.8 years (interquartile range, 2.1 to 8.8 years), adjusted survival rates in groups I, II, III, and IV were 72.8%, 72.3%, 64.5%, and 58.9%, respectively. Multivariate Cox proportional hazards modeling showed similar survival for groups I and II (P=0.63) and for groups III and IV (P=0.33). The presence of IMA graft was related to lower long-term mortality (adjusted hazard ratio [HR], 0.69; 95% CI, 0.58 to 0.82), whereas SVG intervention was not associated with long-term mortality (adjusted HR, 0.94; 95% CI, 0.81 to 1.10). In contrast, the adjusted event-free rates for nonfatal myocardial infarction were lower in the SVG intervention groups (groups I and III) than in the non-SVG intervention groups (groups II and IV) (HR for SVG intervention versus no SVG intervention, 3.19; 95% CI, 2.18 to 4.66), with the presence of patent IMA conferring no significant benefit on this outcome (HR, 1.37; 95% CI, 0.91 to 2.08). Conclusions— In patients undergoing SVG interventions, survival, but not nonfatal myocardial infarction, is favorably influenced by the presence of patent IMA. In contrast, SVG intervention had no measurable survival benefit but was associated with an increased risk of nonfatal myocardial infarction.

Periprocedural and long-term outcomes of endovascular abdominal aortic aneurysm repair in cardiology practice.

Endovascular repair of abdominal aortic aneurysm (AAA) has recently been made a class I indication in the treatment of AAA. In comparison to the conventional open surgical treatment, endovascular AAA repair (EVAR) is associated with equivalent long‐term morbidity and mortality rates. Vascular surgeons perform majority of EVAR. There are no reports for the long‐term results of this intervention performed by interventional cardiologists. We present one of the first reports of periprocedural and long‐term outcomes of EVAR performed by interventional cardiologists.

No Racial Disparities in the Treatment of ST Elevation Myocardial Infarction – A Community-based Experience

Whether racial disparities exist in the treatment of ST elevation myocardial infarction (STEMI) is not exactly known. We report a retrospective chart review of patients with first event of STEMI, in two groups separated by one decade. Results revealed that hospital mortality in the 2007 and 1997 groups for African Americans versus Caucasians was one of 22 versus 21 of 170, 95 % confidence interval (CI) -0.178 to 0.022, p=0.48 and four of 41 versus 39 of 402, 95 % CI -0.095 to 0.096, p=1.00, respectively. The mean length of stay (LOS) for African Americans and Caucasians in the 2007 and 1997 groups was 5.7 versus 4.1 days (p=0.09) and 7.3 versus 6.6 days (p=0.42), respectively. During follow-up, a total of 40 patients needed re-intervention in the 2007 group. The re-intervention rate in African American patients being 13.6 % (three of 22) versus 21.2 % (36 of 170) in Caucasians, 95 % CI -0.231 to 0.081, with p=0.57. In conclusion, there was no evidence of racial disparity in the treatment of STEMI in terms of hospital mortality, length of hospital stay and re-intervention rate.

Response to Letter Regarding Article, “Impact of Internal Mammary Artery Conduit on Long-Term Outcomes After Percutaneous Intervention of Saphenous Vein Graft”

We thank Drs Brilakis and Banerjee for their insightful comments concerning our recently published study.1 Our goal was to evaluate whether percutaneous interventions of saphenous vein graft (SVG) had any influence on long-term outcomes. In accordance with the retrospective and observational nature of our study, we used currently accepted methodology that included adjustments using a Cox proportional hazard model to account for differences in baseline confounders in the 4 groups. In …