Craig Strauss

Correlates of Delayed Recognition and Treatment of Acute Type A Aortic Dissection The International Registry of Acute Aortic Dissection (IRAD)

Background— In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. Methods and Results— Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1–3, 1.5–24 hours; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1–3, 2.4–24 hours; n=751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital (all P<0.05). The largest relative DTRs were for fever (DTR=5.11; P<0.001) and transfer from nontertiary hospital (DTR=3.34; P<0.001). Delay in time from diagnosis to surgery was associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital (all P<0.001). The strongest factors associated with operative delay were prolonged time from presentation to diagnosis (DTR=1.35; P<0.001), race other than white (DTR=2.25; P<0.001), and history of coronary artery bypass surgery (DTR=2.81; P<0.001). Conclusions— Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.

Multidisciplinary Standardized Care for Acute Aortic Dissection Design and Initial Outcomes of a Regional Care Model

> “No physician can diagnose a condition he never thinks about.” > > — Michael DeBakey Patients with acute aortic dissection (AAD) have an in-hospital mortality of 26%, and for those patients with type A AAD, the mortality risk is 1% to 2% per hour until emergency surgical repair is performed.1,2 It is therefore critical that AAD be recognized promptly and that surgical care be provided expeditiously. Data from the International Registry of Acute Aortic Dissection (IRAD) indicate that the median time from emergency department (ED) presentation to definitive diagnosis of AAD is 4.3 hours, with an additional 4 hours between diagnosis and surgical intervention for type A patients.2,3 A portion of the delay to surgery is often the result of the patients presenting to smaller community hospitals underequipped to manage emergent AAD. Transfer to high-volume aortic care centers with highly specialized facilities and expertise is routine, but even at such centers, current surgical mortality is 25%.4 In an effort to address factors that delay AAD recognition and optimal management, a standardized, quality-improvement protocol for the regional treatment of AAD was developed and implemented with the goal of providing consistent, integrated, and coordinated care for patients with AAD throughout all phases of care. Modeled, in part, after a successful regional program for ST-segment elevation myocardial infarction,5, the specific aims of the program were to decrease the time from hospital arrival to diagnosis and treatment and to improve clinical outcomes for patients with AAD. A collaborative team designed program elements directed at (1) increasing awareness and knowledge of AAD among emergency care providers, (2) standardizing optimal care for AAD through the use of a formal protocol, (3) improving care coordination and communication across disciplines, and (4) providing …

Has the Time Come for a National Cardiovascular Emergency Care System

In 2007, there were ≈4 million visits to emergency departments in the United States with a primary diagnosis of cardiovascular disease.1 Current forecasts estimate that the direct medical costs for cardiovascular disease in the United States will triple by 2030 to

Sex‐related differences in outcomes among men and women under 55 years of age with acute coronary syndrome undergoing percutaneous coronary intervention: Results from the PROMETHEUS Study

800 billion dollars.2 Acute cardiovascular emergencies, including ST-segment–elevation myocardial infarction (STEMI), non-STEMI/unstable angina, out-of-hospital cardiac arrest (OHCA), acute aortic dissection (AAD), abdominal aortic aneurysm (AAA), stroke, and acute decompensated heart failure/cardiogenic shock, require rapid, complex, and resource-intensive care and confer a high risk of mortality. Regionalized systems of care enable patients with complex and urgent medical needs to be systematically directed to hospitals that can provide the highest level of clinical expertise and resources (ie, designated centers). Historically, trauma systems have used this paradigm with improved outcomes. There is a growing focus on regionalized medical care as a strategy to leverage limited resources, to manage cost, and to improve outcomes for other medical emergencies. National cardiovascular organizations have already published recommendations for the establishment of centers and regional systems of care for STEMI,3–6 cardiac arrest,7–9 and stroke.10,11 The purpose of this article is to propose the concept of a cardiovascular emergency system, ie, a comprehensive regional system of care for cardiovascular emergencies led by a designated cardiovascular emergency receiving center. Over the past decade, the Minneapolis Heart Institute at Abbott Northwestern Hospital (MHI-ANW) has implemented regional systems of care for STEMI,12 OHCA,13 AAD,14 non-STEMI, and AAA. These initiatives provide a demonstration of the clinical programs and supportive network that reflect the burgeoning framework of a cardiovascular emergency system. Informed by this work, we discuss the historical perspective of, rationale for, and proposed principal elements of a cardiovascular emergency system. Trauma systems are the prototype for …

Correlates of Delayed Recognition and Treatment of Acute Type A Aortic Dissection

Young women undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) experience greater adverse events than men, potentially due to under‐treatment. We sought to compare the 1‐year outcomes by sex in patients ≤55 years of age from a contemporary PCI cohort.

Use of prasugrel vs clopidogrel and outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention in contemporary clinical practice: Results from the PROMETHEUS study.

Background— In acute aortic dissection, delays exist between presentation and diagnosis and, once diagnosed, definitive treatment. This study aimed to define the variables associated with these delays. Methods and Results— Acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and January 2007 were evaluated for factors contributing to delays in presentation to diagnosis and in diagnosis to surgery. Multiple linear regression was performed to determine relative delay time ratios (DTRs) for individual correlates. The median time from arrival at the emergency department to diagnosis was 4.3 hours (quartile 1–3, 1.5–24 hours; n=894 patients) and from diagnosis to surgery was 4.3 hours (quartile 1–3, 2.4–24 hours; n=751). Delays in acute aortic dissection diagnosis occurred in female patients; those with atypical symptoms that were not abrupt or did not include chest, back, or any pain; patients with an absence of pulse deficit or hypotension; or those who initially presented to a nontertiary care hospital (all P<0.05). The largest relative DTRs were for fever (DTR=5.11; P<0.001) and transfer from nontertiary hospital (DTR=3.34; P<0.001). Delay in time from diagnosis to surgery was associated with a history of previous cardiac surgery, presentation without abrupt or any pain, and initial presentation to a nontertiary care hospital (all P<0.001). The strongest factors associated with operative delay were prolonged time from presentation to diagnosis (DTR=1.35; P<0.001), race other than white (DTR=2.25; P<0.001), and history of coronary artery bypass surgery (DTR=2.81; P<0.001). Conclusions— Improved physician awareness of atypical presentations and prompt transport of acute aortic dissection patients could reduce crucial time variables.

Real-Time Decision Support to Guide Percutaneous Coronary Intervention Bleeding Avoidance Strategies Effectively Changes Practice Patterns

Background and objectives We sought to determine the frequency of use and association between prasugrel and outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI) in clinical practice. Methods PROMETHEUS was a multicenter observational registry of acute coronary syndrome patients undergoing PCI from 8 centers in the United States that maintained a prospective PCI registry for patient outcomes. The primary end points were major adverse cardiovascular events at 90 days, a composite of all‐cause death, nonfatal myocardial infarction, stroke, or unplanned revascularization. Major bleeding was defined as any bleeding requiring hospitalization or blood transfusion. Hazard ratios (HRs) were generated using multivariable Cox regression and stratified by the propensity to treat with prasugrel. Results Of 19,914 patients (mean age 64.4 years, 32% female), 4,058 received prasugrel (20%) and 15,856 received clopidogrel (80%). Prasugrel‐treated patients were younger with fewer comorbid risk factors compared with their counterparts receiving clopidogrel. At 90 days, there was a significant association between prasugrel use and lower major adverse cardiovascular event (5.7% vs 9.6%, HR 0.58, 95% CI 0.50‐0.67, P < .0001) and bleeding (1.9% vs 2.9%, HR 0.65, 95% CI 0.51‐0.83, P < .001). After propensity stratification, associations were attenuated and no longer significant for either outcome. Results remained consistent using different approaches to adjusting for potential confounders. Conclusions In contemporary clinical practice, patients receiving prasugrel tend to have a lower‐risk profile compared with those receiving clopidogrel. The lower ischemic and bleeding events associated with prasugrel use were no longer evident after accounting for these baseline differences.

Familial hypercholesterolemia in a large ambulatory population: Statin use, optimal treatment, and identification for advanced medical therapies

Approximately 600 000 percutaneous coronary interventions (PCIs) are performed annually in the United States.1 Periprocedural bleeding is a common complication of PCI,2–6 occurring in 2% to 6% of cases.6–12 Bleeding is associated with major adverse events, including short- and long-term mortality,4,8–11,13 as well as prolonged hospital length of stay (LOS)7–10,14 and higher hospital costs.6,7,15,16 Periprocedural bleeding seems to be predictable and modifiable.4 A validated risk prediction algorithm may help clinicians estimate bleeding risk in patients undergoing PCI, and established bleeding avoidance strategies (BAS), such as bivalirudin, radial artery access, and vascular closure devices, have been demonstrated to reduce bleeding.2,16–24 However, recent studies have reported that patients at highest risk for bleeding are least likely to receive treatment with BAS.2,5 Accurate preprocedure bleeding risk assessment scoring may provide a significant opportunity for physicians to selectively use effective preventative tactics in patients most likely to benefit and improve PCI safety, care quality, and subsequently hospitalization costs. Bleeding events after cardiovascular procedures have been identified by the Centers for Medicare and Medicaid Services to be quality indicators among centers participating in its Acute Care Episode demonstration.2 However, data on the impact of pre-PCI bleeding risk assessment on physician practice patterns, BAS use, and quality outcomes are sparse. We developed a quality improvement program for PCI patients using a preprocedure bleeding risk score to stimulate the use of consensus BAS in high-risk, high-cost patients. The specific aims of the program were to improve patient safety and care quality and to decrease LOS and hospital costs by reducing bleeding events and associated complications in PCI patients. An interdisciplinary team …

Chest compression injuries detected via routine post-arrest care in patients who survive to admission after out-of-hospital cardiac arrest

BACKGROUND Familial hypercholesterolemia (FH) is an autosomal dominant genetic disease resulting in elevated serum low-density lipoprotein cholesterol (LDL-C) levels. Patients with FH have a very high lifetime risk of cardiovascular disease, but FH often goes unrecognized in clinical care. New treatments including PCSK9 inhibitors are now available for this population, and the use of the electronic record may be able to help identify potential patients for therapy. OBJECTIVES The goal of this study was to determine the period prevalence of FH in a large ambulatory care population, including the homozygous form. In addition, use of cholesterol lowering therapy in individuals with FH was characterized. METHODS A retrospective analysis was carried out among patients seen in an upper Midwest health care system between 2009 and 2012. In a search of electronic health records (EHR) and using the current National Lipid Association guidelines, FH patients (including homozygous cases) were identified based on age and highest LDL-C. Statin therapy was characterized according to current FH treatment guidelines. RESULTS There were 391,166 individuals with available measures during the study timeframe. Of these, 841 were identified as having probable HeFH, representing a prevalence of 0.21% (about 1 in 470 patients) in this population. HoFH was identified as probable in 6 patients. For the total group, two-thirds of FH patients were on a statin, but only half were treated adequately. The remaining one-third of FH patients were not on statin therapy, with only 27% of those not on statin therapy having a documented statin intolerance. CONCLUSIONS FH is often underdiagnosed and suboptimally treated in clinical practice. Statin therapy in this population rarely went beyond low-moderate doses. These findings support EHR-based population health efforts to initiate an FH cascade-screening model and ensure higher quality care for this high-risk population and identify those who may benefit from advanced therapy.

Usefulness of Lipid Apheresis in the Treatment of Familial Hypercholesterolemia

Abstract Objective. To examine injuries produced by chest compressions in out-of-hospital cardiac arrest (OHCA) patients who survive to hospital admission. Methods. A retrospective cohort study was conducted among 235 consecutive patients who were hospitalized after nontraumatic OHCA in Minnesota between January 2009 and May 2012 (117 survived to discharge; 118 died during hospitalization). Cases were eligible if the patient had received prehospital compressions from an emergency medical services (EMS) provider. One EMS provider in the area was using a mechanical compression device (LUCASTM) as standard equipment, so the association between injury and use of mechanical compression was also examined. Prehospital care information was abstracted from EMS run sheets, and hospital records were reviewed for injuries documented during the post-arrest hospitalization that likely resulted from compressions. Results. Injuries were identified in 31 patients (13%), the most common being rib fracture (9%) and intrathoracic hemorrhage (3%). Among those who survived to discharge, the mean length of stay was not statistically significantly different between those with injuries (13.5 days) and those without (10.8 days; p = 0.23). Crude injury prevalence was higher in those who died prior to discharge, had received compressions for >10 minutes (versus ≤10 minutes) and underwent computer tomography (CT) imaging, but did not differ by bystander compressions or use of mechanical compression. After multivariable adjustment, only compression time > 10 min and CT imaging during hospitalization were positively associated with detected injury (OR = 7.86 [95% CI = 1.7–35.9] and 6.30 [95% CI = 2.6–15.5], respectively). Conclusion. In patients who survived OHCA to admission, longer duration of compressions and use of CT during the post-arrest course were associated positively with documented compression injury. Compression-induced injuries detected via routine post-arrest care are likely to be largely insignificant in terms of length of recovery.