Hans Rickli

Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry

Background: Gender differences in management and outcomes have been reported in acute coronary syndrome (ACS). Objectives: To assess such gender differences in a Swiss national registry. Methods: 20 290 patients with ACS enrolled in the AMIS Plus Registry from January 1997 to March 2006 by 68 hospitals were included in a prospective observational study. Data on patients’ characteristics, diagnoses, procedures, complications and outcomes were recorded. Odds ratios (ORs) of in-hospital mortality were calculated using logistic regression models. Results: 5633 (28%) patients were female and 14 657 (72%) male. Female patients were older than men (mean (SD) age 70.9 (12.1) vs 63.4 (12.9) years; p<0.001), had more comorbidities and came to hospital later. They underwent percutaneous coronary intervention (PCI) less frequently (OR = 0.65; 95% CI 0.61 to 0.69) and their unadjusted in-hospital mortality was higher overall (10.7% vs 6.3%; p<0.001) and in those who underwent PCI (3.0% vs 4.2%; p = 0.018). Mortality differences between women and men disappeared after adjustments for other predictors (adjusted OR (aOR) for women vs men: 1.09; 95% CI 0.95 to 1.25), except in women aged 51–60 years (aOR = 1.78; 95% CI 1.04 to 3.04). However, even after adjustments, female gender remained significantly associated with a lower probability of undergoing PCI (OR = 0.70; 95% CI 0.64 to 0.76). Conclusions: The analysis showed gender differences in baseline characteristics and in the rate of PCI in patients admitted for ACS in Swiss hospitals between 1997 and 2006. Reasons for the significant underuse of PCI in women, and a slightly higher in-hospital mortality in the 51–60 year age group, need to be investigated further.

Raised cardiac troponins

Causes extend beyond acute coronary syndromes Cardiac troponins are regulatory proteins of the thin actin filaments of the cardiac muscle. Troponin T and troponin I are highly sensitive and specific markers of myocardial injury. Serial measurement of troponin I or troponin T has become an important tool for risk stratification of patients presenting with acute coronary syndromes. The joint committee of the European Society of Cardiology, the American College of Cardiology, and the American Heart Association has recently accepted their measurement in serum as the standard biomarker for the diagnosis of acute myocardial infarction and for diagnosis and management of acute coronary syndromes.1 2 Cardiac troponins, however, are raised in many patients presenting with conditions other than acute coronary syndromes (box). To ignore this fact will lead to unjustified, potentially harmful investigations and increases medical costs. In sepsis, for example, cardiac troponins are raised in up to 85% of patients in the absence of any acute coronary syndromes.3 Doctors need to be aware that troponins are biochemical markers that replace neither electrocardiograms nor clinical investigation. In the …

Comparison of Costs and Safety of a Suture-Mediated Closure Device With Conventional Manual Compression After Coronary Artery Interventions

The aim of this study was to assess costs and safety of immediate femoral sheath removal and closure with a suture‐mediated closure device (Perclose, Menlo Park, CA) in patients undergoing elective (PCI). A total of 193 patients was prospectively randomized to immediate arterial sheath removal and access site closure with a suture‐mediated closure device (SMC; n = 96) or sheath removal 4 hr after PCI followed by manual compression (MC; n = 97). In the SMC group, patients were ambulated 4 hr after elective PCI if hemostasis was achieved. In the MC group, patients were ambulated the day after the procedure. In addition to safety, total direct costs including physician and nursing time, infrastructure, and the device were assessed in both groups. Total direct costs were significantly (all P < 0.001) lower in the SMC group. Successful hemostasis without major complication was achieved in all patients. The time to achieve hemostasis was significantly shorter in the SMC group (7.1 ± 3.4 vs. 22.9 ± 14.0 min; P < 0.01) and 85% of SMC patients were ambulated on the day of intervention. Suture‐mediated closure allows a reduction in hospitalization time, leading to significant cost savings due to decreased personnel and infrastructural demands. In addition, the use of SMC is safe and convenient to the patients. Cathet Cardiovasc Intervent 2002;57:297–302.

Predictors of early readmission or death in elderly patients with heart failure

BACKGROUND Contemporary heart failure (HF) patients are elderly and have a high rate of early rehospitalization or death, resulting in a high burden for both the patients and the health care system. Prior studies were focused on younger and less well-characterized patients. We aimed to identify predictors of early hospital readmission and death in elderly patients with HF. METHODS Patients with chronic HF taking part in the TIME-CHF study (n = 614, age 77 +/- 8 years, 41% female, left ventricular ejection fraction 35% +/- 13%) were evaluated with respect to predictors of hospital readmission or death 30 and 90 days after inclusion. Demographic, clinical, laboratory, echocardiographic, and social variables were obtained at baseline and included in a multivariable logistic regression analysis to identify predictors of early events. RESULTS The rate of hospital readmission or death was high at 30 (11%) and 90 days (26%). The reason for hospitalization was HF in 33%, other cardiovascular in 32%, and noncardiovascular in 45% of the cases, respectively. Predictors of readmission or death at 30 days were angina, lower systolic blood pressure, anemia, more extensive edema, higher creatinine levels, and dry cough; and at 90 days were coronary artery disease, prior pacemaker implantation, high jugular venous pressure, pulmonary rales, prior abdominal surgery, older age, and depressive symptoms. CONCLUSIONS Early hospital readmission or death was frequent among elderly HF patients. A very large proportion of readmissions were due to noncardiovascular causes. In addition to clinical signs of HF, comorbidities are important predictors of early events in elderly HF patients.

Procedural complications following diagnostic coronary angiography are related to the operator's experience and the catheter size

Cardiac catheterization is performed routinely in hospitals all around the world. Extensive analysis of complications has been performed in the 1980s and early 1990s. However, because of the new therapeutic innovations based on advanced catheter technologies, these data may not apply to the present situation. Still, there are few data about procedural complications of diagnostic cardiac catheterization over the last 10 years. A total of 7,412 consecutive diagnostic cardiac catheterizations were performed between January 1990 and December 2000 and prospectively assessed in a registry. There were a total of 63 complications, of which 40 were minor and 23 major. Thus, the overall complication rate was 0.8%, with a mortality rate of 0%. Univariate analysis showed lower overall complication rate of senior physicians (> 500 coronary angiographies performed; OR = 0.58; 95% CI = 0.34–0.98; P = 0.04), smaller catheter size (< 6, 6, > 6 Fr: OR = 2.6; 95% CI = 1.53–4.41; P = 0.0004), and a higher rate in patients having left and right heart catheterization (OR = 2.62; 95% CI = 1.46–4.7; P = 0.003). Major complications were associated with larger catheters (< 6, 6, > 6 Fr: OR = 2.35; 95% CI = 1.0–5.51; P = 0.05), whereas vascular complications occurred more often with higher body weight (per 10 kg: OR = 1.4; 95% CI = 1.01–1.95; P = 0.04). Overall complication rate in diagnostic coronary angiography is very low and related to the experience of the performing cardiologist and catheter size. The only predicting risk factors for major complications in coronary angiography were catheter size and body weight. Cathet Cardiovasc Intervent 2003;59:13–18.

Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002–2012

Objective This study aimed to assess the impact of individual comorbid conditions as well as the weight assignment, predictive properties and discriminating power of the Charlson Comorbidity Index (CCI) on outcome in patients with acute coronary syndrome (ACS). Methods A prospective multicentre observational study (AMIS Plus Registry) from 69 Swiss hospitals with 29 620 ACS patients enrolled from 2002 to 2012. The main outcome measures were in-hospital and 1-year follow-up mortality. Results Of the patients, 27% were female (age 72.1±12.6 years) and 73% were male (64.2±12.9 years). 46.8% had comorbidities and they were less likely to receive guideline-recommended drug therapy and reperfusion. Heart failure (adjusted OR 1.88; 95% CI 1.57 to 2.25), metastatic tumours (OR 2.25; 95% CI 1.60 to 3.19), renal diseases (OR 1.84; 95% CI 1.60 to 2.11) and diabetes (OR 1.35; 95% CI 1.19 to 1.54) were strong predictors of in-hospital mortality. In this population, CCI weighted the history of prior myocardial infarction higher (1 instead of −0.4, 95% CI −1.2 to 0.3 points) but heart failure (1 instead of 3.7, 95% CI 2.6 to 4.7) and renal disease (2 instead of 3.5, 95% CI 2.7 to 4.4) lower than the benchmark, where all comorbidities, age and gender were used as predictors. However, the model with CCI and age has an identical discrimination to this benchmark (areas under the receiver operating characteristic curves were both 0.76). Conclusions Comorbidities greatly influenced clinical presentation, therapies received and the outcome of patients admitted with ACS. Heart failure, diabetes, renal disease or metastatic tumours had a major impact on mortality. CCI seems to be an appropriate prognostic indicator for in-hospital and 1-year outcomes in ACS patients. ClinicalTrials.gov Identifier NCT01305785

Impact of a lead glass screen on scatter radiation to eyes and hands in interventional cardiologists

The objective of this study was to assess the impact of a transparent lead glass screen (TLGS) on scatter radiation to the eyes and the hands in interventional cardiologists and to compare the results to the recommended annual threshold values of 150 and 500 mSv, respectively. Local radiation doses to the left eye and the ring finger of the left hand of three operators (A, B, C) were assessed by thermoluminiscence dosimeters during 813 coronary angiographies (CAs), including 190 ad hoc percutaneous coronary interventions (PCIs) either with a TLGS placed between patient and operator [615 CAs including 138 ad hoc PCIs; dose‐area product (DAP) = 84.9 ± 71.3 Gy·cm2], or without (198 CAs including 52 PCIs; DAP = 85.7 ± 61.5 Gy·cm2). To determine the efficacy of the TLGS, average DAP‐normalized local doses were calculated. Using a TLGS, operator A, B, and C performed 259 (in 9 months), 211 (in 8 months), and 145 CAs (in 8 months) with TLGS and acquired cumulative eye lens doses of 5.5, 1.5, and 1.0 mSv corresponding to extrapolated annual doses of 7.3, 2.3, and 1.5 mSv. The cumulative finger doses were 9.6, 10.3, and 6.4 mSv, resulting in extrapolated annual doses of 12.8, 15.5, and 9.6 mSv. Compared to 139 (in 5 months), 36 (in 2 months), and 23 CAs (in 2 months) without TLGS, the use of a TLGS reduced the DAP‐normalized eye dose by a factor of 19 (with TLGS 0.153 vs. without TLGS 2.924 μSv/Gy·cm2), whereas only a weak effect on the dose to the hands was observed (with TLGS 0.504 vs. without TLGS 0.578 μSv/Gy·cm2). The consequent use of a TLGS efficiently reduces scatter radiation to the operators eyes in daily practice, but has only minimal effects on the dose to the hands.

Oxygen uptake kinetics during low level exercise in patients with heart failure: relation to neurohormones, peak oxygen consumption, and clinical findings

Objective To investigate whether oxygen uptake (V˙o 2) kinetics during low intensity exercise are related to clinical signs, symptoms, and neurohumoral activation independently of peak oxygen consumption in chronic heart failure. Design Comparison ofV˙o 2 kinetics with peakV˙o 2, neurohormones, and clinical signs of chronic heart failure. Setting Tertiary care centre. Patients 48 patients with mild to moderate chronic heart failure. Interventions Treadmill exercise testing with “breath by breath” gas exchange monitoring. Measurement of atrial natriuretic factor (ANF), brain natriuretic peptide (BNP), and noradrenaline. Assessment of clinical findings by questionnaire. Main outcome measures O2 kinetics were defined as O2 deficit (time [rest to steady state] × ΔV˙o 2 − ∑V˙o 2 [rest to steady state]; normalised to body weight) and mean response time of oxygen consumption (MRT; O2 deficit/ΔV˙o 2). Results V˙o 2kinetics were weakly to moderately correlated to the peakV˙o 2 (O2 deficit,r = −0.37, p < 0.05; MRT,r = −0.49, p < 0.001). Natriuretic peptides were more closely correlated with MRT (ANF,r = 0.58; BNP,r = 0.53, p < 0.001) than with O2 deficit (ANF, r = 0.48, p = 0.001; BNP, r = 0.37, p < 0.01) or peak V˙o 2 (ANF,r = −0.40; BNP,r = −0.31, p < 0.05). Noradrenaline was correlated with MRT (r = 0.33, p < 0.05) and O2 deficit (r = 0.39, p < 0.01) but not with peakV˙o 2(r = −0.20, NS). Symptoms of chronic heart failure were correlated with all indices of oxygen consumption (MRT, r = 0.47, p < 0.01; O2 deficit, r = 0.39, p < 0.01; peak V˙o 2,r = −0.48, p < 0.01). Multivariate analysis showed that the correlation ofV˙o 2 kinetics with neurohormones and symptoms of chronic heart failure was independent of peakV˙o 2 and other variables. Conclusions Oxygen kinetics during low intensity exercise may provide additional information over peak V˙o 2 in patients with chronic heart failure, given the better correlation with neurohormones which represent an index of homeostasis of the cardiovascular system.

Long-Term Efficacy and Safety of Biodegradable-Polymer Biolimus-Eluting Stents: Main Results of the Basel Stent Kosten-Effektivitäts Trial- PROspective Validation Examination II (BASKET-PROVE II), A Randomized, Controlled Noninferiority 2-Year Outcome Trial

Background— Biodegradable-polymer drug-eluting stents (BP-DES) were developed to be as effective as second-generation durable-polymer drug-eluting stents (DP-DES) and as safe >1 year as bare-metal stents (BMS). Thus, very late stent thrombosis (VLST) attributable to durable polymers should no longer appear. Methods and Results— To address these early and late aspects, 2291 patients presenting with acute or stable coronary disease needing stents ≥3.0 mm in diameter between April 2010 and May 2012 were randomly assigned to biolimus-A9–eluting BP-DES, second-generation everolimus-eluting DP-DES, or thin-strut silicon-carbide–coated BMS in 8 European centers. All patients were treated with aspirin and risk-adjusted doses of prasugrel. The primary end point was combined cardiac death, myocardial infarction, and clinically indicated target-vessel revascularization within 2 years. The combined secondary safety end point was a composite of VLST, myocardial infarction, and cardiac death. The cumulative incidence of the primary end point was 7.6% with BP-DES, 6.8% with DP-DES, and 12.7% with BMS. By intention-to-treat BP-DES were noninferior (predefined margin, 3.80%) compared with DP-DES (absolute risk difference, 0.78%; −1.93% to 3.50%; P for noninferiority 0.042; per protocol P=0.09) and superior to BMS (absolute risk difference, −5.16; −8.32 to −2.01; P=0.0011). The 3 stent groups did not differ in the combined safety end point, with no decrease in events >1 year, particularly VLST with BP-DES. Conclusions— In large vessel stenting, BP-DES appeared barely noninferior compared with DP-DES and more effective than thin-strut BMS, but without evidence for better safety nor lower VLST rates >1 year. Findings challenge the concept that durable polymers are key in VLST formation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01166685.

Temporal trends in treatment of ST-elevation myocardial infarction among men and women in Switzerland between 1997 and 2011

Background: Few data are available concerning the impact of gender on temporal trends in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods: All STEMI patients consecutively enrolled in the AMIS (Acute Myocardial Infarction in Switzerland) Plus project from 1997–2011 were included. Temporal trends in presentation, treatment and outcomes were analyzed using multiple logistic regressions with generalized estimations. Results: Of 21,620 STEMI patients, 5786 were women and 15,834 men from 78 Swiss hospitals. Women were 8.6 years older, presented 48 minutes later with less pain, but more dyspnea, and more frequently had atrial fibrillation (5.5 vs. 3.9%, p<0.001), heart failure (Killip class >2) (9.7 vs. 7.3%, p<0.001), and moderate or severe comorbidities (24.8 vs. 18.2%, p<0.001). Women were less likely to undergo primary reperfusion treatment after adjustment for baseline characteristics and admission year (OR 0.80, 95% CI 0.71–0.90, p<0.001) or receive early and discharge drugs, such as thienopyridines, angiotensin-converting-enzyme inhibitors, angiotensin II receptor antagonists, and statins. In 1997, thrombolysis was performed in 51% of male and 39% of female patients; its use rapidly decreased during the 1990s and has now become negligible. Primary percutaneous coronary intervention increased from under 10% in both genders in 1997 to over 70% in females and over 80% in males since 2006. Patients admitted in cardiogenic shock increased by 8% per year in both genders. The incidence of both reinfarction and cardiogenic shock developing during hospitalization decreased significantly over 15 years while in-hospital mortality decreased from 10 to 5% in men and from 18 to 7% in women. This corresponds to a relative reduction of 5% per year for males (OR 0.95, 95% CI 0.92–0.99, p=0.006) and 6% per year for female STEMI patients (OR 0.94, 95% CI 0.91–0.97, p<0.001). Despite higher crude in-hospital mortality, female gender per se was not an independent predictor of in-hospital mortality (OR 1.07, 95% CI 0.84–1.35, p=0.59). Conclusion: Substantial changes have occurred in presentation, treatment, and outcome of men and women with STEMI in Switzerland over the past 15 years. Although parallel trends were seen in both groups, ongoing disparities in certain treatments remain. However, these did not translate into worse risk-adjusted in-hospital mortality, suggesting that the gender gap in STEMI care may be closing.