Adam C. Salisbury

Predictors of Quality-of-Life Benefit After Percutaneous Coronary Intervention

Background—Improving patients’ quality of life is a primary indication for percutaneous coronary intervention (PCI), yet little is known about patient characteristics associated with greater quality-of-life improvement from the procedure. This study was conducted to identify patient characteristics associated with quality-of-life benefit after PCI. Methods and Results—A consecutive series of 1518 patients undergoing PCI in nonacute myocardial infarction settings were prospectively enrolled into an observational study documenting their postprocedural health status. We examined univariate and multivariable associations between baseline patient characteristics and quality of life 1 year after the procedure using the disease-specific Seattle Angina Questionnaire (SAQ) to quantify the impact of patients’ coronary disease on their quality of life. Baseline angina frequency and physical function were the strongest predictors of quality-of-life improvement 1 year after PCI. In comparing patients without angina to those experiencing monthly, weekly, and daily angina, the quality-of-life improvements (mean±SEM) were 21.4±2.1, 30.7±2.2, and 34.6±2.6 points greater (P<0.001). Patients with mild, moderate, and severe physical limitation improved 13.8±1.9, 20.0±2.1, and 13.5±3.5 points more than those with minimal baseline physical limitation (P<0.001). These findings were maintained in multivariable models correcting for baseline differences in demographic, clinical, disease-severity, and health-status variables. Conclusions—Preprocedural angina frequency is the most important prognostic indicator of quality-of-life improvement after PCI. Although substantial quality-of-life benefits are attained in most patients with preprocedural angina, more careful consideration of the potential benefits and risks of the procedure are needed in asymptomatic patients.

Trends in the incidence of acute kidney injury in patients hospitalized with acute myocardial infarction.

BACKGROUND Acute kidney injury (AKI) is common in patients with acute myocardial infarction (AMI) and is associated with permanent renal impairment and death. Although guidelines increasingly emphasize AKI prevention, whether increased awareness has translated into reduced AKI rates is unclear. METHODS Among 33,249 consecutive hospitalizations in 31,532 unselected patients with AMI across 56 US centers from Cerner Corporations Health Facts database, we examined the temporal trends in AKI incidence from 2000 to 2008. Acute kidney injury was defined as an absolute increase in creatinine level of at least 0.3 mg/dL or a relative increase of at least 50% during hospitalization. RESULTS From 2000 to 2008, the mean age of patients increased (from 66.5 to 68.6 years), as did the known AKI risk factors, including chronic kidney disease, cardiogenic shock, diabetes mellitus, heart failure, coronary angiography, and percutaneous coronary intervention. Despite this, AKI incidence declined from 26.6% in 2000 to 19.7% in 2008 (P < .001). After multivariate adjustment, the trend of decreasing AKI rates persisted (4.4% decline per year; P < .001). In addition, in-hospital mortality also declined over time among patients developing AKI, from 19.9% in 2000 to 13.8% in 2008 (P = .003). CONCLUSIONS In a large national study, AKI incidence in patients hospitalized with AMI declined significantly from 2000 to 2008 despite the aging population and rising prevalence of AKI risk factors. These findings may reflect increased clinician awareness, better risk stratification, or greater use of AKI prevention efforts during this time period.

Incidence, Correlates, and Outcomes of Acute, Hospital-Acquired Anemia in Patients With Acute Myocardial Infarction

Background— Anemia is common among patients hospitalized with acute myocardial infarction and is associated with poor outcomes. Less is known about the incidence, correlates, and prognostic implications of acute, hospital-acquired anemia (HAA). Methods and Results— We identified 2909 patients with acute myocardial infarction who had normal hemoglobin (Hgb) on admission in the multicenter TRIUMPH registry and defined HAA by criteria proposed by Beutler and Waalen. We used hierarchical Poisson regression to identify independent correlates of HAA and multivariable proportional hazards regression to identify the association of HAA with mortality and health status. At discharge, 1321 (45.4%) patients had HAA, of whom 348 (26.3%) developed moderate-severe HAA (Hgb <11 g/dL). The incidence of HAA varied significantly across hospitals (range, 33% to 69%; median rate ratio for HAA, 1.13; 95% confidence interval, 1.07 to 1.23, adjusting for patient characteristics). Although documented bleeding was more frequent with more severe HAA, fewer than half of the patients with moderate-severe HAA had any documented bleeding. Independent correlates of HAA included age, female sex, white race, chronic kidney disease, ST-segment elevation myocardial infarction, acute renal failure, use of glycoprotein IIb/IIIa inhibitors, in-hospital complications (cardiogenic shock, bleeding and bleeding severity), and length of stay. After adjustment for GRACE score and bleeding, patients with moderate-severe HAA had higher mortality rates (hazard ratio, 1.82; 95% confidence interval, 1.11 to 2.98 versus no HAA) and poorer health status at 1 year. Conclusions— HAA develops in nearly half of acute myocardial infarction hospitalizations among patients treated medically or with percutaneous coronary intervention, commonly in the absence of documented bleeding, and is associated with worse mortality and health status. Better understanding of how HAA can be prevented and whether its prevention can improve patient outcomes is needed.

Relation Between Red Blood Cell Omega-3 Fatty Acid Index and Bleeding During Acute Myocardial Infarction

Omega-3 fatty acids have multiple cardiovascular benefits but may also inhibit platelet aggregation and increase bleeding risk. If this platelet inhibition is clinically meaningful, patients with the highest omega-3 indexes (red blood cell eicosapentaenoic acid plus docosahexaenoic acid), which reflect long-term omega-3 fatty acid intake, should be at the risk for bleeding. In this study, 1,523 patients from 24 United States centers who had their omega-3 indexes assessed at the time of acute myocardial infarction were studied. The rates of serious bleeding (Thrombolysis In Myocardial Infarction [TIMI] major or minor) and mild to moderate bleeding (TIMI minimal) were identified in patients with low (<4%), intermediate (4% to 8%), and high (>8%) omega-3 indices. There were no differences in bleeding across omega-3 index categories. After multivariate adjustment, there remained no association between the omega-3 index and either serious (per 2% increase, relative risk 1.03, 95% confidence interval 0.90 to 1.19) or mild to moderate bleeding (per 2% increase, relative risk 1.02, 95% confidence interval 0.85 to 1.23). In conclusion, no relation was found between the omega-3 index and bleeding in this large, multicenter cohort of patients with acute myocardial infarction, suggesting that concerns about bleeding should not preclude the use of omega-3 supplements or increased fish consumption when clinically indicated.

Selecting Antiplatelet Therapy at the Time of Percutaneous Intervention for an Acute Coronary Syndrome Weighing the Benefits and Risks of Prasugrel Versus Clopidogrel

Background— On average, acute coronary syndrome patients treated with prasugrel experience fewer ischemic complications, but more bleeding, than those receiving clopidogrel. However, heterogeneity in treatment effects can alter the likelihood of benefits and risks of an individual patient. We developed predictive models of the benefits (reduced ischemic events) and risks (increased bleeding) to support targeting prasugrel to those who benefit most from treatment. Methods and Results— Using 12 579 patients from Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38), we fit risk models for ischemic events (cardiovascular death, spontaneous myocardial infarction, stroke) and bleeding (TIMI major/minor) over a 14.8-month follow-up and then calculated each patient’s predicted risk for major ischemia and bleeding with both prasugrel and clopidogrel. We found substantial heterogeneity of the treatment effect of prasugrel (mean absolute reduction in the ischemia risk with prasugrel=1.5±3.0%, ranging from an 8.4% increased risk to a 31.2% reduction in risk for ischemia compared with clopidogrel). The mean absolute increase in the bleeding risk with prasugrel versus clopidogrel was 1.3±1.4% and ranged from a 7.9% lower risk to an 11.2% higher risk with prasugrel. The ratio of the difference in predicted ischemia risk/difference in predicted bleeding risk between prasugrel and clopidogrel was calculated for each patient to identify the proportion likely to benefit from prasugrel. Considering both ischemia and bleeding risk, a large proportion of TRITON participants (42%) were predicted to experience net benefit with prasugrel, a rate that increased if patients more strongly preferred avoiding ischemic events than bleeding. Conclusions— The expected benefits and risks of prasugrel versus clopidogrel depend highly on patient characteristics. The use of risk models could support individualized thienopyridine selection to maximize the benefits and safety of these drugs.

Outcomes Associated with Anemia in Patients with Heart Failure

Over the past decade, a growing body of literature has led to a greater understanding of the relationship between anemia and the outcomes in patients with heart failure. This article reviews the current literature on the association between anemia and a broad range of clinical outcomes, including mortality, hospitalization, health status, and cost.

Realizing the Potential of Clinical Risk Prediction Models Where Are We Now and What Needs to Change to Better Personalize Delivery of Care

At the turn of the last century, physicians were largely guided by lessons passed down in training, their own personal experience, and the experiences of their colleagues. Although this approach produced thoughtful clinicians, a key limitation remained—even the busiest, most experienced providers could see only so many patients, experience only a limited number of outcomes, and often struggled to ascertain the accuracy of diagnoses or the effectiveness of treatment. These challenges to delivery of safe and effective patient care were subsequently addressed by a growing focus on progressively larger and better designed cohort studies and randomized clinical trials and later by distilling these insights into clinical practice guidelines and appropriate use criteria to help summarize the rapidly evolving medical literature. Article see p 368 Despite this exponential growth in well-conducted clinical research, a barrier in applying these studies into clinical care is that an individual patient may not obtain the average benefit observed in a clinical trial. It is well recognized that the heterogeneity of treatment effect across a population can be obscured by focusing only on the mean treatment effect in a population.1–3 Depending on a patient’s age, sex, comorbidities, and other characteristics, that patient may benefit greatly from the same treatment that poses a significant risk for another.4 Providers, after all, are concerned with delivering the safest and most effective treatment for a particular individual, rather than a population of patients. Accordingly, a growing focus has been placed on developing and implementing tools to identify which patients are likely to benefit from a particular treatment or strategy, those who may be harmed, and those for whom balanced risks and benefits exist that should prompt discussions between patients and providers about that patient’s goals and preferences for care. To address this need, there has been …

RED BLOOD CELL INDICES AND DEVELOPMENT OF HOSPITAL-ACQUIRED ANEMIA DURING ACUTE MYOCARDIAL INFARCTION

Hospital-acquired anemia (HAA) is common, associated with poor outcomes, and often develops in the absence of bleeding in acute myocardial infarction (AMI) patients. Unrecognized iron deficiency may be a risk factor for HAA, but routine screening of all AMI patients would be costly. Whether red cell

Diagnostic blood sampling: how much is too much?

In today’s hospital-based medicine, opportunities to reduce complications, improve patient safety and clinical outcomes, all without raising the cost of care, are rare. Preventing hospital-acquired anemia (HAA), or minimizing its severity, may be one such opportunity. HAA is not simply a transient, minor complication of hospital care: patients who develop new anemia during hospitalization have higher shortand long-term mortality and worse functional status, and for many patients anemia becomes a chronic problem [1–3]. Although a growing body of evidence links hospital-acquired anemia with poor shortand long-term prognosis, the question of whether treating anemia improves clinical outcomes remains highly controversial. For example, while blood transfusion for anemic patients with acute myocardial infarction (AMI) makes intuitive sense, transfusion may be associated with increased mortality in this patient population [4,5]. Similarly, erythropoietin analogs effectively raise hemoglobin concentrations and improve symptoms, but at the cost of greater risk for thromboembolic complications [6,7]. Due to the difficulties associated with treating anemia, minimizing in-hospital hemoglobin declines and preventing the development of hospital-acquired anemia is a particularly appealing approach that may improve outcomes while avoiding treatment-related risks. This common sense approach, however, has received little attention from the medical community, except for blood conservation efforts, which typically focus on perioperative management of a few high-risk patients unable to receive blood products. As evidence mounts that many patients experience significant blood loss from phlebotomy with a corresponding increase in risk of anemia [8], hospitals should now focus on broadening efforts to prevent in-hospital blood loss.

Predictors and variability of drug-eluting vs bare-metal stent selection in contemporary percutaneous coronary intervention: Insights from the PRISM study

Drug‐eluting stents (DES) reduce risk of in‐stent restenosis after percutaneous coronary intervention (PCI) but require dual antiplatelet therapy (DAPT) for a longer term than bare‐metal stents (BMS). Few studies have examined clinical predictors of DES vs BMS, and variability in provider selection between DES and BMS in clinical practice has not been well described. These insights can inform our understanding of current practice and may identify opportunities to improve decision‐making stent selection decinsion‐making. In a multicenter registry, 3295 consecutive patients underwent PCI by 158 interventional cardiologists across 10 US sites. Eighty percent of patients with treated with DES. Using hierarchical regression, diabetes mellitus, multivessel disease, health insurance, and white race were independently associated with greater DES use, whereas increasing age, history of hypertension, anticipated surgery, use of warfarin, lower hemoglobin, prior history of bleeding, and treatment of right coronary and left circumflex artery lesions as compared with PCI of left anterior descending artery were associated with lower likelihood of receiving DES. Adjusted rates of DES use across providers varied from 52.3% to 94.6%, and adjusted median odds ratio for DES selection was 1.69. DES selection appeared to reflect physicians’ attempts to balance benefits of DES against risks of prolonged DAPT. Nevertheless, marked residual variability in DES selection across providers persisted after adjusting for predictors of restenosis, bleeding, and other factors. Further studies are needed to better understand drivers of this variability and identify the impact of patient and provider preferences on stent selection at the time of PCI.