Devraj Sukul

Diagnostic performance of copeptin in patients with acute nontraumatic chest pain: BWH-TIMI ED chest pain study.

Arginine‐vasopressin (AVP) is an acute marker of physiologic stress. Copeptin is the C‐terminal fragment of vasopressin precursor hormone that is more easily measured than AVP. Studies assessing the utility of copeptin in the diagnosis of myocardial infarction (MI) have demonstrated mixed results.

Outcomes in patients undergoing percutaneous ventricular assist device implantation for cardiogenic shock

Background: Percutaneous ventricular assist devices (PVADs) offer an important but resource-intensive option for management of severe cardiogenic shock (CS). Optimal selection of patients for PVAD support remains undefined. We investigated outcomes, including characteristics associated with in-hospital survival, during PVAD support for CS. Methods: We established a prospective quality improvement program among patients undergoing TandemHeart PVAD implantation for CS at Brigham and Women’s Hospital (Boston, MA). We evaluated 65 consecutive patients between 2006 and 2014, analyzing demographic, clinical, laboratory, hemodynamic, and survival data. Results: Thirty-two patients (49.2%) survived to hospital discharge, of which 12 received destination surgical therapy. Baseline characteristics associated with survival included younger age (47 ± 15 years vs 61 ± 11 years; p<0.001), non-ischemic cardiomyopathy (NICMP) vs ischemic CMP (survival 70.4% vs 34.2%, p=0.004), and, paradoxically, lower presenting left ventricular ejection fraction (LVEF) (survival 66.7% for LVEF ⩽15%, 41.2% for LVEF 16–25%, 25.0% for LVEF >25%; p=0.010). Younger age (p=0.026) and NICMP (p=0.034) remained independent predictors of survival. Twenty-four hours after PVAD placement, a more modest increase in cardiac index (⩽0.75 L/min/m2) was associated with higher in-hospital mortality (OR 6.3, 95% CI 1.8–22.1), as was lack of improvement in serum anion gap (⩽2 mEq/L; OR 5.1, 95% CI 1.6–16.6). Conclusions: Despite intensive care and provision of circulatory support, survival is poor in severe CS. Patients in CS with younger age and NICMP were more likely to survive to hospital discharge. Less robust hemodynamic improvement and persistent acidosis after 24 hours of PVAD support also identified patients less likely to survive.

Identifying Important Gaps in Randomized Controlled Trials of Adult Cardiac Arrest Treatments A Systematic Review of the Published Literature

Background—Cardiac arrest is a major public health concern worldwide. The extent and types of randomized controlled trials (RCT)—our most reliable source of clinical evidence—conducted in these high-risk patients over recent years are largely unknown. Methods and Results—We performed a systematic review, identifying all RCTs published in PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library from 1995 to 2014 that focused on the acute treatment of nontraumatic cardiac arrest in adults. We then extracted data on the setting of study populations, types and timing of interventions studied, risk of bias, outcomes reported, and how these factors have changed over time. Over this 20-year period, 92 RCTs were published containing 64 309 patients (median, 225.5 per trial). Of these, 81 RCTs (88.0%) involved out-of-hospital cardiac arrest, whereas 4 (4.3%) involved in-hospital cardiac arrest and 7 (7.6%) included both. Eighteen RCTs (19.6%) were performed in the United States, 68 (73.9%) were performed outside the United States, and 6 (6.5%) were performed in both settings. Thirty-eight RCTs (41.3%) evaluated drug therapy, 39 (42.4%) evaluated device therapy, and 15 (16.3%) evaluated protocol improvements. Seventy-four RCTs (80.4%) examined interventions during the cardiac arrest, 15 (16.3%) examined post cardiac arrest treatment, and 3 (3.3%) studied both. Overall, reporting of the risk of bias was limited. The most common outcome reported was return of spontaneous circulation: 86 (93.5%) with only 22 (23.9%) reporting survival beyond 6 months. Fifty-three RCTs (57.6%) reported global ordinal outcomes, whereas 15 (16.3%) reported quality-of-life. RCTs in the past 5 years were more likely to be focused on protocol improvements and postcardiac arrest care. Conclusions—Important gaps in RCTs of cardiac arrest treatments exist, especially those examining in-hospital cardiac arrest, protocol improvement, postcardiac arrest care, and long-term or quality-of-life outcomes.

Ninety-Day Readmission and Long-Term Mortality in Medicare Patients (≥65 Years) Treated With Ticagrelor Versus Prasugrel After Percutaneous Coronary Intervention (from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium)

Ticagrelor and prasugrel were found to be superior to clopidogrel for the treatment of acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI); however, the comparative effectiveness of these 2 drugs remains unknown. We compared postdischarge outcomes among older patients treated with ticagrelor versus prasugrel after PCI for ACS. We linked clinical data from PCIs performed in older patients (age ≥65) for ACS at 47 Michigan hospitals to Medicare fee-for-service claims from January 1, 2013, to December 31, 2014, to ascertain rates of 90-day readmission and long-term mortality. We used propensity score matching to adjust for the nonrandom use of ticagrelor and prasugrel at discharge. Logistic regression and Cox proportional hazards models were used to compare rates of 90-day readmission and long-term mortality, respectively. Patients discharged on ticagrelor (n = 1,243) were more frequently older, female, had a history of cerebrovascular disease, and presented with ST- or non-ST-elevation myocardial infarction compared with prasugrel (n = 1,014). After matching (n = 756 per group), there were no significant differences in the rates of 90-day readmission (16.7% ticagrelor vs 14.6% prasugrel; adjusted odds ratio 1.15, 95% confidence interval 0.86 to 1.55, p = 0.35) or 1-year mortality (5.4% ticagrelor vs 3.7% prasugrel; hazard ratio 1.3, 95% confidence interval 0.8 to 2.2, p = 0.31). In conclusion, we found no significant differences in the rates of 90-day readmission or long-term mortality between older patients treated with ticagrelor and patients treated with prasugrel after PCI for ACS. In the absence of randomized data to the contrary, these 2 treatments appear similarly effective.

Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States

Background— Early reports suggest the number of cardiac intensive care unit (CICU) patients with primary noncardiac diagnoses is rising in the United States, but no national data currently exist. We examined changes in primary noncardiac diagnoses among elderly patients admitted to a CICU during the past decade. Methods and Results— Using 2003 to 2013 Medicare data, we grouped elderly patients admitted to CICUs into 2 categories based on principal diagnosis at discharge: (1) primary noncardiac diagnoses and (2) primary cardiac diagnoses. We examined changes in patient demographics, comorbidities, procedure use, and risk-adjusted in-hospital mortality. Among 3.4 million admissions with a CICU stay, primary noncardiac diagnoses rose in prevalence from 38.0% to 51.7% between 2003 and 2013. The fastest rising primary noncardiac diagnoses were infectious diseases (7.8%–15.1%) and respiratory diseases (6.0%–7.6%; P<0.001 for both), whereas the fastest declining primary cardiac diagnosis was coronary artery disease (32.3%–19.0%; P<0.001). Simultaneously, the prevalence of both cardiovascular and noncardiovascular comorbidities rose: heart failure (13.9%–34.4%), pulmonary vascular disease (1.2%–7.1%), valvular heart disease (5.0%–9.8%), and renal failure (7.1%–19.6%; P<0.001 for all). As compared with those with primary cardiac diagnoses, elderly CICU patients with primary noncardiac diagnoses had higher rates of noncardiac procedure use and risk-adjusted in-hospital mortality (P<0.001 for all). Risk-adjusted in-hospital mortality declined slightly in the overall cohort from 9.3% to 8.9% (P<0.001). Conclusions— More than half of all elderly patients with a CICU stay across the United States now have primary noncardiac diagnoses at discharge. These patients receive different types of care and have worse outcomes than patients with primary cardiac diagnoses. Our work has important implications for the development of appropriate training and staffing models for the future critical care workforce.

Readmissions after transcatheter aortic valve implantation.What are they doing right? How can we do better?

Readmissions represent an important outcome for patients and healthcare systems alike. From the patient’s perspective, recent hospitalizations are associated with a period of increased risk for adverse events. From the perspective of hospitals and healthcare systems, readmissions represent potentially preventable and costly events. For these reasons, there has been substantial research aimed at understanding the causes and consequences of readmission among a diverse array of conditions and procedures. Transcatheter aortic valve implantation (TAVI) is a first-line treatment option for symptomatic aortic stenosis in patients with prohibitive, high, or intermediate risk for surgical aortic valve replacement. By definition, most patients have significant co-morbid conditions putting them at increased risk for adverse events including readmission, leading to a recent focus on understanding readmissions after TAVI. In order to prevent readmissions, we must understand the causes and predictors of this costly event. In this issue of the journal, Franzone and colleagues have done just that by describing the rates, causes, and predictors of readmission within 1 year after TAVI at a single centre in Switzerland. The authors prospectively followed 900 consecutive patients with aortic stenosis who underwent TAVI between August 2007 and June 2014. Of those, 868 patients were discharged alive and at risk for readmission during the first year after TAVI. A total of 221 patients (25%) were readmitted within 1 year after discharge. Most readmissions were for noncardiovascular causes (54%), including non-cardiac surgery (12%), gastrointestinal disease (10%), and ‘other’ causes (17%) such as falls and immunological disorders. The most common cardiovascular reason for readmission was heart failure (39%), similar to other common cardiovascular discharge diagnoses including acute myocardial infarction and congestive heart failure. Notably, valve-related causes of readmission were rare in the current study, accounting for only 2.8% of cardiovascular readmissions and 1.3% of all readmissions. Using multivariable regression techniques that account for the competing risk of death, the authors identified male gender and inhospital acute kidney injury as independent risk factors for all-cause readmission, whereas a history of myocardial infarction and inhospital life-threatening bleeding were associated with an increased risk of cardiovascular-related readmission. Interestingly, postprocedural echocardiographic variables such as mean transprosthetic gradient, indexed aortic valve area, left ventricular ejection fraction, aortic regurgitation, and moderate or severe mitral regurgitation were not significantly associated with the risk of readmission. Finally, the authors discovered that early hospital readmission (within 30 days of discharge) was associated with significantly increased risks of all-cause and cardiovascular mortality, further highlighting the need to better understand the causes and effects of post-TAVI readmissions. The authors should be commended on this important study, providing detailed, clinically adjudicated outcomes on a large number of patients who underwent TAVI at a single centre. They used sophisticated statistical techniques to predict the risk of readmission while accounting for the competing risk of death, an issue that is often present and variably accounted for in many studies. They also provide a breakdown of the causes of readmissions not only for the initial readmission but for subsequent readmissions as well. This study also should be interpreted in the context of some limitations, the most significant of which may be related to the singlecentre setting of the study, limiting the generalizability of the findings. However, the authors disclose a 1-year readmission rate that, when placed in the context of other recent observations, is remarkable. In contrast, in a large observational study using the US STS/ACC Transcatheter Valve Registry, Holmes et al. reported a 1-year

The comparative safety of abciximab versus eptifibatide in patients on dialysis undergoing percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

OBJECTIVES We sought to evaluate the patterns of use and outcomes associated with eptifibatide and abciximab administration among dialysis patients who underwent percutaneous coronary intervention (PCI). BACKGROUND Contraindicated medications are frequently administered to dialysis patients undergoing PCI often resulting in adverse outcomes. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that is often used during PCI and is contraindicated in dialysis. METHODS We included dialysis patients who underwent PCI from January 2010 to September 2015 at 47 hospitals in Michigan. We compared outcomes between patients who received eptifibatide compared with abciximab. Both groups required concurrent treatment with unfractionated heparin only. In-hospital outcomes included repeat PCI, bleeding, major bleeding, need for transfusion, and death. Optimal full matching was used to adjust for non-random drug administration. RESULTS Of 177 963 patients who underwent PCI, 4303 (2.4%) were on dialysis. Among those, 384 (8.9%) received eptifibatide and 100 (2.3%) received abciximab. Prior to matching, patients who received eptifibatide had higher pre-procedural hemoglobin levels (11.3 g/dL vs. 10.7 g/dL; P < 0.001) and less frequently had a history of myocardial infarction (36.5% vs. 52.0%; P = 0.005). After matching, there were no significant differences in in-hospital outcomes between eptifibatide and abciximab including transfusion (aOR: 1.15; 95%CI: 0.55-2.40; P = 0.70), bleeding (1.47; 0.64-3.40; P = 0.36), major bleeding (4.68; 0.42-52.3; P = 0.21), repeat PCI (0.38; 0.03-4.23; P = 0.43), and death (1.53; 0.2-9.05; P = 0.64). CONCLUSIONS Despite being contraindicated in dialysis, eptifibatide was used approximately 3.5 times more frequently than abciximab among dialysis patients undergoing PCI but was associated with similar in-hospital outcomes.

The comparative safety and effectiveness of bivalirudin versus heparin monotherapy in patients on dialysis undergoing percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan cardiovascular consortium.

Dialysis patients are at a higher risk of bleeding after percutaneous coronary intervention (PCI); however, due to their exclusion from randomized clinical trials, the optimal antithrombotic regimen for this population remains unknown. We sought to evaluate the comparative safety and effectiveness of bivalirudin monotherapy versus unfractionated heparin (UFH) monotherapy in dialysis patients undergoing PCI.

THE SAFETY OF PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS TURNED DOWN FOR SURGICAL REVASCULARIZATION: INSIGHTS FROM THE BLUE CROSS BLUE SHIELD OF MICHIGAN CARDIOVASCULAR CONSORTIUM

Surgical ineligibility (SI) is associated with increased mortality after left main or multi vessel percutaneous coronary intervention (PCI). We compared outcomes after PCI between patients (pts) turned down and not turned down for surgery in a diverse cohort of pts and practices. We included

MAGNITUDE AND DETERMINANTS OF VARIATION IN PERCUTANEOUS CORONARY INTERVENTION PAYMENTS

Percutaneous coronary intervention (PCI) is a common and expensive procedure that has become a target for bundled payment initiatives. We sought to describe the magnitude and determinants of variation in 90-day PCI payments. We linked clinical registry data from PCIs performed at 33 Michigan