Joel A. Strom

Association of cardiac events with coronary artery disease detected by 64-slice or greater coronary CT angiography: A systematic review and meta-analysis ☆

BACKGROUND The value of ≥64-slice coronary CT angiography (CCTA) to determine odds of cardiac death or non-fatal myocardial infarction (MI) needs further clarification. METHODS We performed a systematic review and meta-analysis using publications reporting events/severity of coronary artery disease (CAD) in patients with suspected CAD undergoing CCTA. Patients were divided into: no CAD, non-obstructive CAD (maximal stenosis <50%), and obstructive CAD (≥50% stenosis). Odds ratios with 95% confidence intervals were calculated using a fixed or random effects model. Heterogeneity was assessed using the I(2) index. RESULTS We included thirty-two studies comprising 41,960 patients with 363 all-cause deaths (15.0%), 114 cardiac deaths (4.7%), 342 MI (14.2%), 69 unstable angina (2.8%), and 1527 late revascularizations (63.2%) over 1.96 (SD 0.77) years of follow-up. Cardiac death or MI occurred in 0.04% without, 1.29% with non-obstructive, and 6.53% with obstructive CAD. OR for cardiac death or MI was: 14.92 (95% CI, 6.78 to 32.85) for obstructive CAD, 6.41 (95% CI, 2.44 to 16.84) for non-obstructive CAD versus no CAD, and 3.19 (95% CI, 2.29 to 4.45) for non-obstructive versus obstructive CAD and 6.56 (95% CI, 3.07 to 14.02) for no versus any CAD. Similar trends were noted for all-cause mortality and composite major adverse cardiovascular events. CONCLUSIONS Increasing CAD severity detected by CCTA is associated with cardiac death or MI, all-cause mortality, and composite major adverse cardiovascular events. Absence of CAD is associated with very low odds of major adverse events, but non-obstructive disease significantly increases odds of cardiac adverse events in this follow-up period.

Candidates for transcatheter aortic valve replacement: fitting the PARTNERS criteria.

To determine an estimate patient volume with severe AS meeting PARTNER‐B criteria, with the objective of providing insights into the annual volume needed to sustain a TAVR program.

Transfer Travel Times for Primary Percutaneous Coronary Intervention From Low-Volume and Non–Percutaneous Coronary Intervention–Capable Hospitals to High-Volume Centers in Florida

STUDY OBJECTIVE Current guidelines recommend that ST-elevation myocardial infarction (STEMI) patients receive percutaneous coronary intervention less than or equal to 90 minutes from first medical contact, preferably at high-volume percutaneous coronary intervention centers (≥400 percutaneous coronary interventions annually). Because many patients present to low-volume or non-percutaneous coronary intervention-capable STEMI referral hospitals, timely percutaneous coronary intervention treatment requires effective transfer systems, which include interfacility transport times of less than 30 minutes. We investigate the geographic feasibility of achieving timely interfacility transport from STEMI referral hospitals to percutaneous coronary intervention hospitals in Florida. METHODS Using 2006 Florida hospital discharge data, we calculated driving times between STEMI referral hospitals and the nearest medium-/high-volume percutaneous coronary intervention centers. We plotted transfer travel time cumulative proportion survival curves for hospitals and patients to assess the feasibility of transfer within 30 minutes to higher-volume facilities. Differences by geographic location (rural versus urban) and patient race/ethnicity were examined. RESULTS In 2006, 77% of STEMI referral hospitals had transfer travel times within 30 minutes; 90th percentile for interhospital driving time was 56 minutes. For patients at STEMI referral hospitals, 85.6% were at facilities within a 30-minute drive of a high-/medium-volume percutaneous coronary intervention center; 90th percentile was 31 minutes. We found marked rural/urban disparities, with longer average driving times for patients in rural and small metropolitan counties. Significant racial/ethnic disparities in transfer travel times were not observed, although 90th percentile driving times were highest for blacks. CONCLUSION Driving times do not pose a major geographic barrier to transfer of STEMI patients in Florida. A majority of STEMI patients could be transferred from STEMI referral hospitals to high-volume percutaneous coronary intervention centers within 30 minutes.

De Facto regionalization of care for ST-elevation myocardial infarction in Florida, 2001–2009

ACC/AHA guidelines recommend STEMI patients receive percutaneous coronary intervention (PCI) at high volume hospitals performing ≥400 procedures/year. The objective of this study was to evaluate changes in the organization and implementation of care for STEMI patients in Florida. We assessed trends and predictors of STEMI patients first hospitalized at high PCI volume hospitals in Florida from 2001-2009. This is the first study to examine statewide trends in hospital admission for all STEMI patients. We classified Florida hospitals by PCI volume (high, medium, low, non-PCI) for each quarter from January, 2001 through June, 2009. Using hospital discharge data, we determined the percent of STEMI patients who went to each type of hospital and analyzed multiple predictors. From 2001-2009 the proportion of STEMI patients first hospitalized at high PCI volume hospitals rose from 62.4 to 89.7%, while admissions to non-PCI hospitals declined from 31% to 4.9%. Persistent barriers to high PCI volume hospital admission were age ≥85 years (OR 0.56, 95% CI 0.50-0.62), female gender (OR 0.85, 95% CI 0.79-0.91), and residence in a major metropolitan county. Through the efforts of local coalitions throughout Florida, by 2009 almost 90% of Florida STEMI patients were first admitted to high PCI volume hospitals. Greater hospital competition may explain lower admission rates to high PCI volume hospitals in major metropolitan counties. The age and gender disadvantage we observed requires further research to determine potential causes.

An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services

OBJECTIVE ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone. METHODS All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone. RESULTS ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%). CONCLUSIONS In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.

Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals

Objective To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, ‘STEMI referral hospitals’). Background Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact. Methods Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the ‘worst case’ scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients. Results PRLs were

Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital

0.33 for every

Valvular Heart Disease in Women

100 of patient revenue statewide for STEMI and

Optimizing Care for ST-elevation Myocardial Infarction Patients: Application of Systems Engineering

1.73 for ACS. At the individual hospital level, the 90th centile PRL was

Abstract 67: Retrospective Validation Of An Algorithm For Field Identification Of ST Elevation Myocardial Infarction Patients By Emergency Medicine Services Using A STEMI Alert Clinical Tool

0.74 for STEMI and