Edward McNulty

Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks

Objective To examine whether prospective bleeding risk estimates for patients undergoing percutaneous coronary intervention could improve the use of bleeding avoidance strategies and reduce bleeding. Design Prospective cohort study comparing the use of bleeding avoidance strategies and bleeding rates before and after implementation of prospective risk stratification for peri-procedural bleeding. Setting Nine hospitals in the United States. Participants All patients undergoing percutaneous coronary intervention for indications other than primary reperfusion for ST elevation myocardial infarction. Main outcome measures Use of bleeding avoidance strategies, including bivalirudin, radial approach, and vascular closure devices, and peri-procedural bleeding rates, stratified by bleeding risk. Observed changes were adjusted for changes observed in a pool of 1135 hospitals without access to pre-procedural risk stratification. Hospital level and physician level variability in use of bleeding avoidance strategies was examined. Results In a comparison of 7408 pre-intervention procedures with 3529 post-intervention procedures, use of bleeding avoidance strategies within intervention sites increased with pre-procedural risk stratification (odds ratio 1.81, 95% confidence interval 1.44 to 2.27), particularly among higher risk patients (2.03, 1.58 to 2.61; 1.41, 1.09 to 1.83 in low risk patients, after adjustment for control sites; P for interaction=0.05). Bleeding rates within intervention sites were significantly lower after implementation of risk stratification (1.0% v 1.7%; odds ratio 0.56, 0.40 to 0.78; 0.62, 0.44 to 0.87, after adjustment); the reduction in bleeding was greatest in high risk patients. Marked variability in use of bleeding avoidance strategies was observed across sites and physicians, both before and after implementation. Conclusions Prospective provision of individualized bleeding risk estimates was associated with increased use of bleeding avoidance strategies and lower bleeding rates. Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care. Study registration Clinicaltrials.gov NCT01383382.

A "grapple hook" technique using a deflectable tip catheter to facilitate complex proximal circumflex interventions.

We present two patients with angulated, proximal left circumflex lesions, one a chronic total occlusion and one an acute subtotal occlusion. In both cases, use of the deflectable tip Venture Catheter (Velocimed, Minneapolis, MN) facilitated guide wire passage and successful percutaneous coronary intervention (PCI) after prior attempts at guide wire passage with standard wires were unsuccessful.

The amplitude ratio of the first to second heart sound is reduced in left ventricular systolic dysfunction

In animal studies, the amplitude of the first heart sound (S1) is proportional to the rate of left ventricular pressure rise (LV dP/dt). To develop a clinical application for this property, we performed phono-electrocardiographic recordings using a digital hand-held device followed by an echocardiogram within 2 hours of a clinically indicated cardiac catheterization. Compared with the group with reduced dP/dt (<1000 mm Hg/s) or ejection fraction (EF) (<55%), the median S1/S2 detected at the cardiac base was higher in those with normal dP/dt or EF. On ROC analysis, S1/S2 significantly discriminated normal from reduced dP/dt and EF. This study demonstrated that S1, corrected for S2, is decreased in patients with impaired LV systolic function. Digital phonocardiography appears promising as an adjunctive bedside tool for evaluating left ventricular systolic function.

Finding Similar 2D X-Ray Coronary Angiograms

In clinical practice, physicians often exploit previously observed patterns in coronary angiograms from similar patients to quickly assess the state of the disease in a current patient. These assessments involve visually observed features such as the distance of a junction from the root and the tortuosity of the arteries. In this paper, we show how these visual features can be automatically extracted from coronary artery images and used for finding similar coronary angiograms from a database. Testing on a large collection has shown the method finds clinically similar coronary angiograms from patients with similar clinical history.

A brave new world? Measuring trends in percutaneous coronary intervention for stable angina after COURAGE.

More than 4 years have elapsed since the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial,1 which led to rampant speculation regarding its potential impact on clinical practice. As memories of the heated rhetoric that punctuated that debate fade, we are now in a position to look back with calmer heads and use observational data to see whether COURAGE was indeed associated with changes in the use of percutaneous coronary intervention (PCI). Given the importance of the issue (>600 000 patients underwent PCI in 2007),2 assessing the impact of COURAGE is an important test of the ability of these observational data resources to measure not only the presence of evidence-associated changes in practice, but also the pace and magnitude of those changes. Article see p 300 Perhaps the most straightforward approach to assess the effect COURAGE on practice is to determine whether there was a temporally associated change in the overall use of PCI. In a recent issue of Circulation: Cardiovascular Quality and Outcomes , Riley et al3 reported, using Medicare claims data, a 12.5% reduction in the use of PCI from 2004 through 2009, with most of the decline occurring in 2007. Although that drop may seem relatively modest, it occurred after a period of unprecedented growth in PCI during the preceding decade. It is tempting to attribute the observed decline to changes in the management of stable coronary artery disease (CAD), but this study left open the question of whether at least some of the reduction in PCI volumes could be a consequence of other factors. Foremost among these other factors were concerns regarding late thrombosis of drug-eluting stents (DES) that was initially brought to attention at the European Society of Cardiology Conference in September 2006 (6 months before the …

Cohort Study of ECG Left Ventricular Hypertrophy Trajectories: Ethnic Disparities, Associations With Cardiovascular Outcomes, and Clinical Utility

Background ECG left ventricular hypertrophy (LVH) is a well‐known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH (“ECG LVH trajectories”) across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories. Methods and Results We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1–9.3) years. ECG LVH was measured by Cornell voltage‐duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively. Conclusions ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility.