Balaji Pratap

Implementing a Pathway for the Management of Acute Coronary Syndrome Leads to Improved Compliance With Guidelines and a Decrease in Angina Symptoms

&NA; We describe our experience with the Advanced Cardiac Admission Program (ACAP) at our institution. The ACAP program is a hospital‐wide implementation of critical pathways‐based management of all cardiac patients. Data review of patients admitted for acute coronary syndromes from the ACAP–PAIN database and a comparative study of outcomes before and after implementation of the pathways‐based assessment and treatment protocols. In the pre‐ACAP and post‐ACAP patient groups, antiplatelet use at admission improved from 50% to 75% (p<.01), ACE‐I use improved from 32% to 54% (p<.0001), statins use increased from 35% to 62% (p<.0001), and smoking cessation awareness increased from 15% to 86% (p<.0001). At 1‐year follow‐up, 84% of patients with CAD were treated with statins, and 47% had LDL cholesterol <100 mg/dL, compared with 20% and 9%, respectively, with conventional treatment before ACAP implementation (p<.0001). Recurrent angina symptoms and nonfatal myocardial infarction rates decreased from 28.5% to 13% (p=.02), and 15% to 5% (p=0.03), respectively. Pathway‐based programs like ACAP significantly enhance administration of guidelines‐based cardioprotective medications both during hospital stay and at 1‐year follow‐up.

Strategies for the prevention and treatment of sudden cardiac death

Cardiovascular diseases account for 40% of all deaths in the West. Sudden cardiac death (SCD) is a major health problem affecting over 300,000 patients annually in the United States alone. Presence of coronary artery disease (CAD), usually in the setting of diminished left ventricular ejection fraction, is still the single major risk factor for SCD. Additionally, acute myocardial ischemia, structural cardiac defects, anomalous coronary arteries, cardiomyopathies, genetic mutations, and ventricular arrhythmias are all attributed to SCD, demonstrating the perplexity of this condition. With the recent advancements in cardiovascular medicine, the incidence of SCD is expected to increase steeply as the prevalence of CAD and heart failure is uprising in general population. Considering SCD, the major challenge confronting contemporary cardiology, multiple strategies for prevention against SCD have been developed. β-blockers have been shown to reduce the risk of SCD, whereas implantable cardioverter–defibrillator devices are found to be effective at terminating the malignant arrhythmias. In recent years, multiple clinical trials were carried out to identify patients who may benefit from preventive intervention, including medical therapy and automatic cardioverter–defibrillator implantations. This review article provides insight into the advanced strategies for the prevention and treatment of SCD based on the data available in medical literature to date.

FEMALE GENDER, LASER SHEATH USE AND OPERATOR SKILL DRIVE THE SUCCESS AND COMPLICATION RATES OF CARDIAC DEVICE LEAD EXTRACTION: AN ACAP REGISTRY ANALYSIS

As the prevalence of cardiac disease increases, the implantation of permanent pacemakers and implantable cardiac defibrillators is more common. Device complications and lead extractions have also increased. Factors influencing the complications and successes of lead extraction have not been well

Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: An updated review of literature

Recent trials have highlighted the comparable mortality benefits and durability of the results for patients with severe aortic stenosis (AS) and high surgical risk managed with either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (AVR). Various national guidelines and international regulatory bodies have approved TAVR, thereby leading to potential wide usage and dissemination of this technique worldwide. Quality-of-life outcomes, in spite of being an important measure of success and acceptability of the procedure, have not been publicized as extensively. For high risk patients with severe AS, implementation of TAVR has resulted in comparable survival, but different and novel adverse events compared with AVR. We present an updated review focusing on the quality-of-life outcomes and issues with this new and important procedural approach.

Success in implementing a hospital-wide evidence-based clinical pathways system for the management of cardiac patients: the ACAP program experience.

There is robust evidence to support the concept that critical pathways, derived from evidence-based guidelines, are an effective strategy for bridging the gap between published guidelines and clinical practice. It was with this idea in mind that in 2004 we developed an innovative novel program at our institution, that is, the Advanced Cardiac Admission Program. The Advanced Cardiac Admission program consists of tools and strategies for implementing American College of Cardiology or American Heart Association guidelines into daily clinical practice. The program is composed of 8 novel critical pathways for the management of cardiac patients. In this article, we describe our experience in successfully implementing this program at our institutions.

The presence of diastolic and systolic dysfunction in patients with impaired relaxation filling pattern

Impaired relaxation filling pattern in the presence of preserved left ventricular ejection fraction is a common finding which is ascribed to early diastolic dysfunction. We thought to determine the distribution of various markers of systolic and diastolic dysfunction in these patients.

EFFECT OF RACE ON LONGTERM OUTCOMES IN PATIENTS ADMITTED WITH ACUTE CORONARY SYNDROME: AN ACAP-PAIN REGISTRY ANALYSIS

Several studies have suggested that race might play a role in outcome of patients following acute coronary syndrome (ACS) admission.nnTo examine the association between patients’ race and long-term outcome after discharge following ACS admission from our hospital ACAP-PAIN registry.nnThe study

A MAJOR GAP EXISTS IN APPLYING PUBLISHED GUIDELINES FOR PRIMARY PREVENTION OF SUDDEN CARDIAC DEATH WITH UNDERUTILIZATION OF DEVICE IMPLANTATION; AN ESCAPE DATABASE ANALYSIS

Results: A total of 845 patients were included in this study; 546 (64%) males, mean age 66 ± 15 years, 75% with hypertension, 35% diabetics, and 30% with coronary artery disease. At the end of the follow-up period, astonishingly only 164 (19%) patients underwent ICD implantation; yet 236 (28%) patients had adverse outcomes, including 151 (18%) deaths and 111 (11%) HF readmissions. As expected patients with evidence-based device therapy had significantly lower adverse outcomes (Figure). Using Cox hazards regression, ICD implantation (OR=0.6), beta-blockers usage (OR=0.7), and ACEi usage (OR=0.8); p<0.0001, were the most effective tools in the reduction of adverse outcomes.