Joseph D. Babb

ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents

This document has been developed as an Expert Consensus Document (ECD) by the American College of Cardiology Foundation (ACCF), American Association for Clinical Chemistry (AACC), American College of Chest Physicians (ACCP), American College of Emergency Physicians (ACEP), American College of

Late stent thrombosis: Considerations and practical advice for the use of drug‐eluting stents: A report from the Society for Cardiovascular Angiography and Interventions drug‐eluting stent task force

Recent analyses have suggested that implantation of drug-eluting stents (DES) is associated with a higher rate of very late stent thrombosis when compared with bare metal stents. This complication is evident with both sirolimus-eluting stents as well as polymer-based paclitaxel-eluting stents, but the precise magnitude of this risk and whether this applies to all patients or only a subset of those who have received DES is incompletely characterized. This alert is designed to provide the practicing interventional cardiologist with practical advice in light of this new information. It is not the purpose of this document to provide an exhaustive review of the literature on DES and the risk of stent thrombosis; however a brief summary is appropriate. While exact definitions have been variable in different trials, late stent thrombosis generally refers to stent thrombosis occurring at least 1 month following stent implantation, while very late stent thrombosis refers to events occurring more than 12 months following stent placement. Following bare metal stent implantation, stent thrombosis is rare after 2 weeks, and dual antiplatelet therapy (aspirin and a thienopyridine) was typically prescribed for 3–6 weeks. In contrast, sporadic reports of late stent thrombosis in patients receiving DES have occurred over the past few years. These events often (but not always) occurred in the setting of premature discontinuation of dual antiplatelet therapy. In March 2006, the BASKET-LATE trial was reported, describing a significantly greater composite occurrence of cardiac death and non-fatal myocardial infarction in patients treated with DES when compared with bare-metal stents after clopidogrel had been discontinued at 6 months [1]. Other meta-analyses of the existing DES trials also showed an increase in late events in the DES cohort although these analyses were limited by incomplete data in publications, abstracts, and Internet sources [2,3]. In October 2006, an independent patient-level meta analysis of the four pivotal randomized Cypher stent trials and the five pivotal randomized Taxus stent trials was publicly presented. These analyses demonstrated an increased rate of stent thrombosis with both sirolimus-eluting and paclitaxelJ_ID: Z7V Customer A_ID: 06-0418 Cadmus Art: CCI 21093 Date: 5-JANUARY-07 Stage: I Page: 1

A simplified lesion classification for predicting success and complications of coronary angioplasty

In 1988, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures presented a classification of coronary lesions utilizing 26 lesion features to predict the success and complications of balloon angioplasty. Using data from the Registry of the Society for Cardiac Angiography and Interventions (SCAI) we evaluated the ability of this classification to predict success and complications. Lesion success, death in hospital, emergency cardiac bypass surgery, and major adverse events were evaluated in 41,071 patients who underwent single-vessel angioplasty from January 1993 to June 1996. Logistic models using the ACC/AHA lesion classification, vessel patency, or both, were compared. A new classification based on the interaction of the ACC/AHA classification plus lesion patency was compared with the existing ACC/AHA classification. Vessel patency, added to the ACC/AHA classification, improved prediction of lesion success (p </=0.0001). Class A and patent B lesions had similar success and complication rates, so a simplified classification (SCAI) using only 7 lesion characteristics could be created. This system (I: non-C patent, II: C patent, III: non-C occluded, and IV: C occluded) improved prediction of lesion success compared with the ACC/AHA classification (Bayesian Information Criterion statistic: ACC/AHA 16539, SCAI 15956; and area under the receiver- operating characteristics curve 0.659, 0.693, respectively). The SCAI classification was preferred for predicting major complications and in-hospital death and was similar to the ACC/AHA classification for predicting emergency bypass surgery.

Defining the length of stay following percutaneous coronary intervention: an expert consensus document from the Society for Cardiovascular Angiography and Interventions. Endorsed by the American College of Cardiology Foundation.

Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same‐day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention.

Task force 3: training in diagnostic and interventional cardiac catheterization endorsed by the Society for Cardiovascular Angiography and Interventions.

Since the second edition of Task Force 3 of the American College of Cardiology (ACC) Core Cardiology Training Symposium (COCATS) guidelines was published ([1][1]), both the cognitive knowledge and technical skill required of the invasive and interventional cardiologist have continued to grow.

Society of Cardiac Angiography and Interventions: Suggested Management of the No-Reflow Phenomenon in the Cardiac Catheterization Laboratory

The interventional cardiologist makes a provisional diagnosis of the no-reflow phenomenon in the presence of an acute reduction in coronary flow despite a widely patent epicardial vessel during percutaneous coronary intervention (PCI). Its occurrence is recognized as a column of contrast arising distal to the original target stenosis that does not rapidly clear [1–3]. The precise pathophysiologic mechanisms are uncertain, although flow-limiting spasm of the distal microvasculature, distal thromboembolism, and microembolization of atherosclerotic debris are believed to be operative, in some combination, in most cases [4,5]. No-reflow as a cardiac phenomenon was originally identified in experimental models of acute myocardial infarction and described as the failure to restore normal myocardial blood flow despite subsequent removal of the coronary arterial obstruction, attributable to microvascular damage related to irreversible ischemic changes and local edema. It has been recognized for over a decade clinically [6,7] as an uncommon (0.6–2.0%) complication of PCI [1,2,6]. It occurs frequently following thrombolytic or mechanical reperfusion for acute myocardial infarction and in the setting of unstable angina [3,7,8]. It is most common during use of rotational atherectomy [9,10] and during PCI in saphenous vein grafts [2]. The purpose of this review is to define the angiographic appearance and clinical outcomes of no-reflow and to summarize the various treatment and prevention options currently available to the interventional cardiologist.

ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting

2007;49;126-170 J. Am. Coll. Cardiol. H. Stein, Cynthia M. Tracy, Robert A. Vogel, and Deborah J. Wesley Lindner, Gerald M. Pohost, Richard S. Schofield, Samuel J. Shubrooks, JR, James Eisenberg, Cindy L. Grines, Mark A. Hlatky, Robert C. Lichtenberg, Jonathan R. Harrington, Jonathan Abrams, Jeffrey L. Anderson, Eric R. Bates, Mark J. Rundback, Robert D. Safian, Michael A. Sloan, Christopher J. White, Robert A. William A. Gray, Kenneth Ouriel, Eric D. Peterson, Kenneth Rosenfield, John H. Donald E. Casey, Jr, Christopher U. Cates, Gary R. Duckwiler, Ted E. Feldman, Biology, Society of Interventional Radiology, Eric R. Bates, Joseph D. Babb, Cardiovascular Angiography and Interventions, Society for Vascular Medicine and American Society of Interventional & Therapeutic Neuroradiology, Society for Committee on Carotid Stenting) (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus Document Task Force on Clinical Expert Consensus Documents Carotid Stenting: A Report of the American College of Cardiology Foundation ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on This information is current as of January 4, 2011 http://content.onlinejacc.org/cgi/content/full/49/1/126 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Evaluation of the Society for Coronary Angiography and Interventions' lesion classification system in 14,133 patients with percutaneous coronary interventions in the current stent era

We recently showed that the ACC/AHA coronary lesion classification could be simplified with no loss of predictive value (SCAI I = patent/non‐C; SCAI II = patent/C; SCAI III = occluded/non‐C; SCAI IV = occluded/C). We now test this system in a database reflecting current stent usage. Data from 14,133 patients with single‐native‐vessel interventions recorded in the Society for Coronary Angiography and Interventions (SCAI) Registry from July 1996 to July 1999 were analyzed. Stents were used in 60.2% of procedures. Logistic models predicting angiographic success suggested a slight, clinically insignificant preference for the SCAI classification (c‐statistic = 0.692 vs. 0.670). Models using clinical variables to predict major complications were superior to models using only lesion classification. Lesion characteristics were related to outcomes primarily in elective (not acute myocardial infarction) patients. In the current PCI device era, the simpler SCAI classification using 7 variables predicted interventional success and complications as well as or better than the ACC/AHA system requiring 26. Cathet Cardiovasc Intervent 2002;55:1–7.

Scai statement on drug-eluting stents: Practice and health care delivery implications

Coronary artery disease remains a major health problem throughout the world. Since the inception of percutaneous transluminal coronary angioplasty in 1978 and the addition of stents in the early 1990s, much progress has been made in the treatment of atherosclerotic obstructive coronary artery disease. Percutaneous coronary intervention (PCI) has eclipsed coronary artery bypass grafting surgery as the treatment of choice for many patients with obstructive coronary lesions. PCI, however, has been limited by restenosis, the incidence of which is highly variable, ranging from less than 5% to over 50% in certain clinical and anatomic subgroups. While restenosis rates have fallen consistently over the past 10 years due to stent use, ancillary guidance techniques, and possibly adjunctive pharmacology, the recent development of antiproliferative drug-eluting stents (DES) is a major breakthrough in preventing restenosis after initial PCI. The use of DES in the treatment of obstructive coronary disease will have major beneficial medical impact on the care of patients, but also will create additional medicolegal, financial, and programmatic ramifications. This statement will provide a preliminary framework to address the multifactorial issues surrounding the introduction of DES into widespread practice.

Quartiles of Peak Troponin Are Associated with Long‐term Risk of Death in Type 1 and STEMI, but Not in Type 2 or NSTEMI Patients

The prognostic value of peak cardiac troponin (cTn) in different types of acute myocardial infarction (AMI) under the universal clinical classification is unknown.