Jamie Rankin

Predictive and protective factors associated with upper gastrointestinal bleeding after percutaneous coronary intervention: a case-control study.

BACKGROUND:Hemorrhagic complications of acute coronary syndromes and percutaneous coronary intervention (PCI) are associated with increased mortality. Upper gastrointestinal (UGI) bleeding after PCI is a potential target for preventative strategies.OBJECTIVE:To evaluate the risk factors for UGI bleeding in a large cohort of contemporary PCI patients and assess the outcomes of medical and endoscopic management.METHOD:A case-control study evaluating UGI bleeding in the 30 days following PCI for stable angina and acute coronary syndromes, at one institution between 1998 and 2005. Cases were identified and outcomes assessed using linkage analysis of data from institutional PCI and endoscopy databases, statewide vital statistics and hospital discharge registries, and a detailed review of medical notes for each case and three matched controls. Analysis of the case and control groups for risk and protective factors was performed using the χ2 test with Fishers exact P value and logistic regression.RESULTS:The incidence of UGI bleeding following PCI was 1.2% (70 of 5,673 patients). The etiologies of these bleeds were diverse. Risk factors for UGI bleeding were primary PCI (OR 27.80, 95% CI 6.28–123.05, P < 0.001), cardiac arrest (OR 6.17, 95% CI 1.82–20.84, P = 0.003), inotropic requirement (OR 5.85, 95% CI 1.98–17.27, P = 0.001), thienopyridine use before PCI (OR 2.40, 95% CI 1.04–5.53, P = 0.02), and advanced age (OR 1.08, 95% CI 1.04–1.12, P < 0.001). Proton pump inhibitor use after PCI (OR 0.08, 95% CI 0.02–0.40, P = 0.002) was accompanied by a reduced risk of UGI bleeding. Endoscopy provided therapeutic intervention in 33% of patients. There were no serious complications of endoscopy. The 30-day mortality for cases was 11.9% and 0.5% for controls (P = 0.001).CONCLUSION:UGI bleeding after PCI is relatively common and associated with increased mortality. Those undergoing PCI for acute myocardial infarction or in the presence hemodynamic instability are at highest risk. Proton pump inhibition following PCI may reduce the bleeding risk, though when UGI bleeding occurs, therapeutic endoscopy is safe.

Can we monitor heart attack in the troponin era: evidence from a population-based cohort study

BackgroundTroponins (highly sensitive biomarkers of myocardial damage) increase counts of myocardial infarction (MI) in clinical practice, but their impact on trends in admission rates for MI in National statistics is uncertain.MethodsCases coded as MI or other cardiac diagnoses in the Hospital Morbidity Data Collection (MI-HMDC) in Western Australia in 1998 and 2003 were classified using revised criteria for MI developed by an International panel convened by the American Heart Association (AHA criteria) using information on symptoms, ECGs and cardiac biomarkers abstracted from samples of medical notes. Age-sex standardized rates of MI-HMDC were compared with rates of MI based on AHA criteria including troponins (MI-AHA) or traditional biomarkers only (MI-AHAck).ResultsBetween 1998 and 2003, rates of MI-HMDC decreased by 3.5% whereas rates of MI-AHA increased by 17%, a difference largely due to increased false-negative cases in the HMDC associated with marked increased use of troponin tests in cardiac admissions generally, and progressively lower test thresholds. In contrast, rates of MI-AHAck declined by 18%.ConclusionsIncreasing misclassification of MI-AHA by the HMDC may be due to reluctance by clinicians to diagnose MI based on relatively small increases in troponin levels. These influences are likely to continue. Monitoring MI using AHA criteria will require calibration of commercially available troponin tests and agreement on lower diagnostic thresholds for epidemiological studies. Declining rates of MI-AHAck are consistent with long-standing trends in MI in Western Australia, suggesting that neither MI-HMDC nor MI-AHA reflect the true underlying population trends in MI.

Trends in coronary artery revascularisation procedures in Western Australia, 1980-2001

Objectives: To describe trends in the use of coronary artery revascularisation procedures (CARPs) and to determine whether or when CARP rates will stabilise. Setting: State of Western Australia. Patients: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001. Design: Descriptive study. Main outcome measures: Age standardised rates of first and total CARPs, CABGs, and PCIs. Results: Overall rates for both total and first CARPs among men and women rose steeply from 1980 to 1993, when they abruptly stabilised or actually started to decline. Rates in age groups under 65 years tended to rise earlier in the period and remained relatively flat, while rates for people over the age of 75 years started to rise later and were still increasing at the end of the study. Conclusions: Despite continuing increases in capacity to perform both CABG and PCI in Western Australia and evidence of continuing increases in the use of CARPs in the elderly population, rates appear to have stabilised for the first time since they were introduced.

Impact of acute and chronic risk factors on use of evidence-based treatments in patients in Australia with acute coronary syndromes

Objective: To determine whether acute risk factors (ARF) and chronic risk factors (CRF) contribute differently to the use of evidence-based treatments (EBT) for patients with acute coronary syndromes (ACS). Design: Data were collected through a prospective audit of patients with ACS. Management was analysed by the presence of acute myocardial risk factors and chronic comorbid risk factors at presentation. Setting: 39 hospitals across Australia. Patients: 2599 adults presenting with ACS. Interventions: None. Main outcome measures: Use of EBT, in-hospital and 12-month death, recurrent myocardial infarction and bleeding. Results: The number of ARF and CRF at presentation predicted in-hospital and 12-month death, recurrent myocardial infarction and bleeding. Patients with higher numbers of ARF were more likely to receive EBT (aspirin at presentation, 81.1% for zero ARF to 85.7% for ⩾3 ARF, p<0.001; angiography 45.9% to 67.5%, p<0.001; reperfusion for ST elevation 50% to 70%, p = 0.392; β blocker at discharge 66.5% to 74.4%, p<0.001). Patients with higher numbers of CRF were less likely to receive EBT (aspirin at presentation 90.4% for zero CRF to 68.8% for ⩾4 CRF, p<0.001; angiography 78.8% to 24.7%, p<0.001; reperfusion for ST elevation 73.4% to 30%; p<0.001, β blocker at discharge 75.2% to 55.6%; p<0.001). In multivariate regression analysis, ARF and CRF were the strongest predictors of receiving or failing to receive EBT, respectively. Conclusions: Patients presenting with many ARF are more likely to receive EBT, while patients presenting with many CRF are less likely to receive them. This has important implications for future quality-improvement efforts.

Randomized trial comparing 600- with 300-mg loading dose of clopidogrel in patients with non–ST elevation acute coronary syndrome undergoing percutaneous coronary intervention: Results of the Platelet Responsiveness to Aspirin and Clopidogrel and Troponin Increment after Coronary intervention in Acute coronary Lesions (PRACTICAL) Trial

BACKGROUND There is uncertainty about the benefit of a higher loading dose (LD) of clopidogrel in patients with non-ST elevation acute coronary syndrome (NSTEACS) undergoing early percutaneous coronary intervention (PCI). METHODS We compared the effects of a 600- versus a 300-mg LD of clopidogrel on inhibition of platelet aggregation, myonecrosis, and clinical outcomes in patients with NSTEACS undergoing an early invasive management strategy. Patients with NSTEACS (n = 256, mean age 63 years, 81.6% elevated troponin) without thienopyridine for at least 7 days were randomized to receive 600- or 300-mg LD of clopidogrel. Percutaneous coronary intervention was performed in 140 patients, with glycoprotein IIb/IIIa inhibitor use in 68.6%. Adenosine diphosphate (ADP)-induced platelet aggregation was measured by optical platelet aggregometry immediately before coronary angiography. RESULTS Post-PCI myonecrosis was defined as a next-day troponin I greater than 5 times the upper limit of reference range and greater than baseline levels. Clopidogrel 600-mg LD compared with 300-mg LD was associated with significantly reduced ADP-induced platelet aggregation (49.7% vs 55.7% with ADP 20 micromol/L) but did not reduce post-PCI myonecrosis or adverse clinical outcomes to 6 months. There was no association between preprocedural platelet aggregation and outcome. CONCLUSIONS These data confirm a modest incremental antiplatelet effect of a 600-mg clopidogrel LD compared with 300-mg LD but provide no support for a clinical benefit in patients with NSTEACS managed with an early invasive strategy including a high rate (69%) of glycoprotein IIb/IIIa inhibitor use during PCI.

Intra-aortic balloon pump: indications, efficacy, guidelines and future directions.

Purpose of review The intra-aortic balloon pump (IABP) has been used as a cardiac assist device in various clinical situations since 1968 on the basis of the physiological principles and observational data, with little randomized data until recently. Recent findings Recently published randomized controlled trials (RCTs) and meta-analyses have demonstrated acceptable safety for IABP but have raised doubt over efficacy in acute myocardial infarction (MI) both with and without cardiogenic shock. RCTs and meta-analyses have provided limited and qualified support for the efficacy of IABP in high-risk percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). There remains only observational data to support the efficacy of IABP in other niche indications, including mechanical complications of MI (acute severe mitral regurgitation and ventricular septal rupture) and refractory ventricular arrhythmia. Summary Current randomized trial data and meta-analyses support the safety of IABP, but provide limited or no support for its efficacy in the treatment of high-risk MI, MI complicated by cardiogenic shock or the use of prophylactic IABP in high-risk PCI and CABG. Further studies to inform optimal patient selection, timing and use of associated therapies are required to characterize the role of IABP in contemporary practice and optimize outcome in high-risk patient subsets.

Trends in two year risk of repeat revascularisation or death from cardiovascular disease after coronary artery bypass grafting or percutaneous coronary intervention in Western Australia, 1980–2001

Aims: To investigate whether, over the 21 year period 1980–2001, there had been a reduction in the risk of repeat revascularisation or death from cardiovascular disease in the cohort of all patients who were treated by coronary revascularisation in Western Australia. Setting: State of Western Australia. Patients: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001. Design: Cohort study. Main outcome measures: Risk of repeat coronary artery revascularisation procedures (CARP) and risk of death from cardiovascular disease after first CARP. Results: After a CABG procedure, the two year risk of repeat revascularisation remained low (less than 2%) across the period 1980–2001. For PCI, however, this risk declined significantly from 33.6% in 1985–9 to 12.4% in 2000–1. The risk of death from cardiovascular disease after a CARP declined by about 50% between 1985 and 2001. Conclusions: Outcomes such as the risk of repeat revascularisation and the risk of death from cardiovascular disease have improved significantly for patients who underwent CARPs across the period 1980–2001. This has occurred despite an increasing trend in first CARP rates among older people and those with a recent history of myocardial infarction.

Percutaneous coronary intervention in the Occluded Artery Trial: Procedural success, hazard, and outcomes over 5 years

BACKGROUND The Occluded Artery Trial (OAT) was a 2,201-patient randomized clinical trial comparing routine stent-based percutaneous coronary intervention (PCI) versus optimal medical therapy alone in stable myocardial infarction (MI) survivors with persistent infarct-related artery occlusion identified day 3 to 28 post MI. Intent-to-treat analysis showed no difference between strategies with respect to the incidence of new class IV congestive heart failure, MI, or death. The influence of PCI failure, procedural hazard, and crossover on trial results has not been reported. METHODS Study angiograms were analyzed and adjudicated centrally. Factors associated with PCI failure were examined. Time-to-event analysis using the OAT primary outcome was performed by PCI success status. Landmark analysis (up to and beyond 30 days) partitioned early hazard versus late outcome according to treatment received. RESULTS Percutaneous coronary intervention was adjudicated successful in >87%. Percutaneous coronary intervention failure rates were similar in US and non-US sites, and did not significantly influence outcome at 60 months (hazard ratio for success vs fail 0.79, 99% CI 0.45-1.40, P = .29). Partitioning of early procedural hazard revealed no late benefit for PCI (hazard ratio for PCI success vs medical therapy alone 1.06, 99% CI 0.75-1.50, P = .66). CONCLUSIONS Percutaneous coronary intervention failure and complication rates in the OAT were low. Neither PCI failure nor early procedural hazard substantively influenced the primary trial results.

An Invasive Management Strategy is Associated with Improved Outcomes in High-Risk Acute Coronary Syndromes in Patients with Chronic Kidney Disease

Introduction:  Chronic kidney disease (CKD) is associated with poor outcomes after acute coronary syndromes, yet selection for invasive investigation and management is low.

Long-term use and cost-effectiveness of secondary prevention drugs for heart disease in Western Australian seniors (WAMACH): a study protocol.

Introduction Secondary prevention drugs for cardiac disease have been demonstrated by clinical trials to be effective in reducing future cardiovascular and mortality events (WAMACH is the Western Australian Medication Adherence and Costs in Heart disease study). Hence, most countries have adopted health policies and guidelines for the use of these drugs, and included them in government subsidised drug lists to encourage their use. However, suboptimal prescribing and non-adherence to these drugs remains a universal problem. Our study will investigate trends in dispensing patterns of drugs for secondary prevention of cardiovascular events and will also identify factors influencing these patterns. It will also assess the clinical and economic consequences of non-adherence and the cost-effectiveness of using these drugs. Methods and analysis This population-based cohort study will use longitudinal data on almost 40 000 people aged 65 years or older who were hospitalised in Western Australia between 2003 and 2008 for coronary heart disease, heart failure or atrial fibrillation. Linking of several State and Federal government administrative data sets will provide person-based information on drugs dispensed precardiac and postcardiac event, reasons for hospital admission, emergency department visits, mortality and medical visits. Dispensed drug trends will be described, drug adherence measured and their association with future all-cause/cardiovascular events will be estimated. The cost-effectiveness of these long-term therapies for cardiac disease and the impact of adherence will be evaluated. Ethics and dissemination Human Research Ethics Committee (HREC) approvals have been obtained from the Department of Health (Western Australian #2011/62 and Federal) and the University of Western Australia (RA/4/1/1130), in addition to HREC approvals from all participating hospitals. Findings will be published in peer-reviewed medical journals and presented at local, national and international conferences. Results will also be disseminated to consumer groups.