Bina Ahmed

Significantly Improved Vascular Complications Among Women Undergoing Percutaneous Coronary Intervention: A Report From the Northern New England Percutaneous Coronary Intervention Registry

Background— Women are at a higher risk for bleeding/vascular complications (VC) related to cardiovascular procedures. Although the overall incidence of percutaneous coronary intervention (PCI)-related bleeding/VC has declined, the impact of this decline, specifically in women, is unknown. Methods and Results— We studied 13 653 female and 32 334 male consecutive cases, from 2002 to 2007, in the Northern New England PCI Registry. We sought to (1) compare absolute rates of bleeding/VC in women and men over time, (2) define predictors of bleeding/VC in women and men undergoing PCI, and (3) trend the impact of female gender in predicting bleeding/VC over time. Bleeding/VC was defined as any access-site vessel injury requiring surgical intervention or bleeding requiring transfusion. The overall risk of bleeding/VC was significantly higher in women versus men (4.5±1.3% versus 1.6±0.5%; P <0.004). Over time, there was a significant ( P <0.001) 50% decrease in absolute bleeding/VC rates in both women and men. After adjustment for baseline differences, female gender remained a significant predictor of increased risk in 2007 (odds ratio, 2.6; 95% CI, 1.74 to 3.91). Independent predictors of increased risk of bleeding/VC in women included older age, shock, renal failure, presentation with non-ST-elevation myocardial infraction and larger sheath sizes, whereas the use of fluoroscopy-guided access, closure devices, history of dyslipidemia or prior PCI, and use of bivalirudin were protective. Conclusion— Women undergoing PCI have had a significant decline in bleeding/VC rates during the last 6 years. Despite the improvement in procedural safety, female gender continues to be associated with a >2-fold risk of bleeding/VC compared with men. Received February 24, 2009; accepted July 27, 2009.Background—Women are at a higher risk for bleeding/vascular complications (VC) related to cardiovascular procedures. Although the overall incidence of percutaneous coronary intervention (PCI)-related bleeding/VC has declined, the impact of this decline, specifically in women, is unknown. Methods and Results—We studied 13 653 female and 32 334 male consecutive cases, from 2002 to 2007, in the Northern New England PCI Registry. We sought to (1) compare absolute rates of bleeding/VC in women and men over time, (2) define predictors of bleeding/VC in women and men undergoing PCI, and (3) trend the impact of female gender in predicting bleeding/VC over time. Bleeding/VC was defined as any access-site vessel injury requiring surgical intervention or bleeding requiring transfusion. The overall risk of bleeding/VC was significantly higher in women versus men (4.5±1.3% versus 1.6±0.5%; P<0.004). Over time, there was a significant (P<0.001) 50% decrease in absolute bleeding/VC rates in both women and men. After adjustment for baseline differences, female gender remained a significant predictor of increased risk in 2007 (odds ratio, 2.6; 95% CI, 1.74 to 3.91). Independent predictors of increased risk of bleeding/VC in women included older age, shock, renal failure, presentation with non–ST-elevation myocardial infraction and larger sheath sizes, whereas the use of fluoroscopy-guided access, closure devices, history of dyslipidemia or prior PCI, and use of bivalirudin were protective. Conclusion—Women undergoing PCI have had a significant decline in bleeding/VC rates during the last 6 years. Despite the improvement in procedural safety, female gender continues to be associated with a >2-fold risk of bleeding/VC compared with men.

Significantly Improved Vascular Complications Among Women Undergoing Percutaneous Coronary Intervention

Background— Women are at a higher risk for bleeding/vascular complications (VC) related to cardiovascular procedures. Although the overall incidence of percutaneous coronary intervention (PCI)-related bleeding/VC has declined, the impact of this decline, specifically in women, is unknown. Methods and Results— We studied 13 653 female and 32 334 male consecutive cases, from 2002 to 2007, in the Northern New England PCI Registry. We sought to (1) compare absolute rates of bleeding/VC in women and men over time, (2) define predictors of bleeding/VC in women and men undergoing PCI, and (3) trend the impact of female gender in predicting bleeding/VC over time. Bleeding/VC was defined as any access-site vessel injury requiring surgical intervention or bleeding requiring transfusion. The overall risk of bleeding/VC was significantly higher in women versus men (4.5±1.3% versus 1.6±0.5%; P <0.004). Over time, there was a significant ( P <0.001) 50% decrease in absolute bleeding/VC rates in both women and men. After adjustment for baseline differences, female gender remained a significant predictor of increased risk in 2007 (odds ratio, 2.6; 95% CI, 1.74 to 3.91). Independent predictors of increased risk of bleeding/VC in women included older age, shock, renal failure, presentation with non-ST-elevation myocardial infraction and larger sheath sizes, whereas the use of fluoroscopy-guided access, closure devices, history of dyslipidemia or prior PCI, and use of bivalirudin were protective. Conclusion— Women undergoing PCI have had a significant decline in bleeding/VC rates during the last 6 years. Despite the improvement in procedural safety, female gender continues to be associated with a >2-fold risk of bleeding/VC compared with men. Received February 24, 2009; accepted July 27, 2009.Background—Women are at a higher risk for bleeding/vascular complications (VC) related to cardiovascular procedures. Although the overall incidence of percutaneous coronary intervention (PCI)-related bleeding/VC has declined, the impact of this decline, specifically in women, is unknown. Methods and Results—We studied 13 653 female and 32 334 male consecutive cases, from 2002 to 2007, in the Northern New England PCI Registry. We sought to (1) compare absolute rates of bleeding/VC in women and men over time, (2) define predictors of bleeding/VC in women and men undergoing PCI, and (3) trend the impact of female gender in predicting bleeding/VC over time. Bleeding/VC was defined as any access-site vessel injury requiring surgical intervention or bleeding requiring transfusion. The overall risk of bleeding/VC was significantly higher in women versus men (4.5±1.3% versus 1.6±0.5%; P<0.004). Over time, there was a significant (P<0.001) 50% decrease in absolute bleeding/VC rates in both women and men. After adjustment for baseline differences, female gender remained a significant predictor of increased risk in 2007 (odds ratio, 2.6; 95% CI, 1.74 to 3.91). Independent predictors of increased risk of bleeding/VC in women included older age, shock, renal failure, presentation with non–ST-elevation myocardial infraction and larger sheath sizes, whereas the use of fluoroscopy-guided access, closure devices, history of dyslipidemia or prior PCI, and use of bivalirudin were protective. Conclusion—Women undergoing PCI have had a significant decline in bleeding/VC rates during the last 6 years. Despite the improvement in procedural safety, female gender continues to be associated with a >2-fold risk of bleeding/VC compared with men.

Women, Bleeding, and Coronary Intervention

Bleeding initiates a cascade of events that increase morbidity and mortality among patients undergoing percutaneous coronary intervention (PCI).1–5 Acute loss of blood impacts circulatory volume and can potentiate and perpetuate shock. In addition, bleeding leads to anemia and transfusion of blood products, which promote inflammation and untoward cardiovascular effects, especially in the setting of acute coronary syndrome.6–8 Finally, bleeding results in cessation of dual antiplatelet therapy, which increases risk of recurrent ischemic events such as stent thrombosis and myocardial infarction.9,10 Registries and randomized trials have shown the impact of bleeding on outcomes. Patient in the Global Registry of Acute Coronary Events were noted to have a 4.0% incidence of major bleeding across the spectrum of acute coronary syndrome (ACS). Furthermore, major bleeding was an independent predictor of in-hospital mortality (adjusted odds ratio, 1.64 [95% confidence interval, 1.18-2.28]).11 Ndrepepa et al2 evaluated 4 randomized control trials of patients undergoing PCI and identified major bleeding as the strongest independent predictor of 1-year mortality. Similarly, Mehran et al12 performed a patient level pooled analysis of >17 000 patients in 3 ACS trials: the occurrence of a major bleed within 30 days of hospitalization was associated with a 4-fold higher risk of mortality at 1 year. Finally, in patients with ST segment elevation myocardial infarction enrolled in the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction trial, bleeding related to PCI was an independent predictor of mortality after 3 years of follow-up (hazard ratio, 2.80 [95% confidence interval, 1.89–4.16]).13 Increased focus on the morbidity and mortality associated with PCI-related bleeding has led to pharmacological, procedural, and technological advances,14 which have resulted in improvement in post-PCI bleeding rates over the past decade (Figure 1).15–18 The …

Recent Changes in Practice of Elective Percutaneous Coronary Intervention for Stable Angina

Background— The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to compare optimal medical therapy alone versus optimal medical therapy and percutaneous coronary intervention (PCI) for treatment of patients with stable coronary artery disease and showed equal efficacy for optimal medical therapy with or without PCI. The impact of results from the COURAGE trial on clinical practice is unknown. Methods and Results— We analyzed 26 388 consecutive patients from the Northern New England Cardiovascular Disease PCI Registry who underwent PCI between January 2006 and June 2009. We identified a COURAGE-like patient group as patients who were undergoing (1) an elective procedure; (2) for an indication of stable angina; and (3) on the day of admission (ie, the date of admission was the same as the procedure date). All other PCI patients were placed in an “other indications” cohort. We compared temporal trends in overall volume in PCI for stable angina and for other indications, comparing quarterly time periods before and after release of COURAGE in March 2007. Over the study period, there was a statistically significant decrease in total PCI volume from 2064 in Quarter 1 2006 (before COURAGE) to 1708 in Quarter 3 2007 (after COURAGE) (P<0.01). These trends were sustained through June 2009, with an approximate 16% peak relative reduction in all PCI compared with before COURAGE. As a percentage of all PCI, stable angina reached a high of 20.9% before COURAGE and began to decrease immediately after publication of COURAGE in Quarter 2 2007 to 16.1% (P<0.01). Among patients undergoing PCI for stable angina, there was a significant 26% peak decrease in post-COURAGE PCI volumes compared with pre-COURAGE Quarter 1 2006 (P trend, 0.01), which was maintained through the end of the study period. Conclusions— Publication of results from the COURAGE trial was temporally associated with a significant and sustained decline in the use of PCI to treat patients with stable angina. The long-term impact of this change in practice on patient outcomes remains to be determined.

In-Hospital Mortality Among Patients With Type 2 Diabetes Mellitus and Acute Myocardial Infarction: Results From the National Inpatient Sample, 2000–2010

Background Case‐fatality rates in acute myocardial infarction (AMI) have significantly decreased; however, the prevalence of diabetes mellitus (DM), a risk factor for AMI, has increased. The purposes of the present study were to assess the prevalence and clinical impact of DM among patients hospitalized with AMI and to estimate the impact of important clinical characteristics associated with in‐hospital mortality in patients with AMI and DM. Methods and Results We used the National Inpatient Sample to estimate trends in DM prevalence and in‐hospital mortality among 1.5 million patients with AMI from 2000 to 2010, using survey data‐analysis methods. Clinical characteristics associated with in‐hospital mortality were identified using multivariable logistic regression. There was a significant increase in DM prevalence among AMI patients (year 2000, 22.2%; year 2010, 29.6%, Ptrend<0.0001). AMI patients with DM tended to be older and female and to have more cardiovascular risk factors. However, age‐standardized mortality decreased significantly from 2000 (8.48%) to 2010 (4.95%) (Ptrend<0.0001). DM remained independently associated with mortality (adjusted odds ratio 1.069, 95% CI 1.051 to 1.087; P<0.0001). The adverse impact of DM on in‐hospital mortality was unchanged over time. Decreased death risk over time was greatest among women and elderly patients. Among younger patients of both sexes, there was a leveling off of this decrease in more recent years. Conclusions Despite increasing DM prevalence and disease burden among AMI patients, in‐hospital mortality declined significantly from 2000 to 2010. The adverse impact of DM on mortality remained unchanged overall over time but was age and sex dependent.

New insights into the pathophysiology, classification, and diagnosis of coronary microvascular dysfunction.

The coronary microvasculature plays a key role in determining and modulating coronary blood flow across the spectrum of myocardial demand. Our understanding of this complex system has been limited partly due to our inability to visualize the anatomy of an extensive microvascular bed and its complicated functional pathways. Nonetheless, research has led to the current belief that coronary microvascular dysfunction (CMVD) is a clinical entity that is an independent predictor of poor long-term outcomes in patients across a broad spectrum of cardiac diseases. CMVD exists in many clinical forms, in the presence and absence of epicardial coronary artery disease and structural heart disease. Both invasive and noninvasive tools have been used to assess the functional aspects of CMVD and both come with limitations. To date, invasive testing to assess coronary blood flow and microvascular resistance in response to provocative and hyperemic stimuli remains the gold standard. A recent clinical classification has been put forth to correctly categorize patients with CMVD. Despite the adverse outcomes associated with CMVD, proven targeted therapies remain elusive. Symptom relief and cardiovascular risk factor modification are the goals of current recommendations. There is a strong need for adequately powered trials to test specific management strategies and their effect on outcomes among patients with CMVD.

Entrapped devices after PCI.

In contemporary practice, entrapped devices are rarely encountered during percutaneous coronary intervention (PCI) but can be associated with serious morbidity and mortality. We present a case of a 62 y/o male who presented with an acute coronary syndrome. Revascularization was performed and complicated by guide wire entrapment and fracture. Cardiologists should be aware of this complication and the treatment options available.

Text Messaging Versus Paging: New Technology for the Next Generation

Of all the labels applied to my generation, the “millennials,” there is 1 for which we are fully deserving: we are the “digital generation.” Born roughly between 1980 and 2000, we are the first to grow up with computers and video games in our homes. Surveys have shown that millennials may

Tennis and Interventional Cardiology

The great game of tennis has origins that date back to 1,000 bc when French monks played ceremonial “je de paume,” or game of the hand. Initial tennis balls were wooden, and the first wooden racket used was laced with sheep gut. It was not until the invention of rubber and the bouncier tennis

Generational evolution of stents and sex-specific analyses.

Evolution – whether biological or technological – of the next generation depends on its capacity to build upon what already exists. The development of secondgeneration drug-eluting stents (DES) to treat coronary artery disease built upon and enhanced the safety and efficacy of first-generation DES. Second-generation DES are more deliverable, offer more reliable results, and are associated with improved outcomes.