Kevin P. Jennings

Obesity paradox in a cohort of 4880 consecutive patients undergoing percutaneous coronary intervention.

AIMS We sought to investigate the impact of body mass index (BMI) on long-term all-cause mortality in patients following first-time elective percutaneous coronary intervention (PCI). METHODS AND RESULTS We used the Scottish Coronary Revascularisation Register to undertake a cohort study of all patients undergoing elective PCI in Scotland between April 1997 and March 2006 inclusive. We excluded patients who had previously undergone revascularization. There were 219 deaths within 5 years of 4880 procedures. Compared with normal weight individuals, those with a BMI > or =27.5 and <30 were at reduced risk of dying (HR 0.59, 95% CI 0.39-0.90, 95%, P = 0.014). There was no attenuation of the association after adjustment for potential confounders, including age, hypertension, diabetes, and left ventricular function (adjusted HR 0.59, 95% CI 0.39-0.90, P = 0.015), and there were no statistically significant interactions. The results were unaltered by restricting the analysis to events beyond 30 days of follow-up. CONCLUSION Among patients undergoing percutaneous intervention for coronary artery disease, increased BMI was associated with improved 5 year survival. Among those with established coronary disease, the adverse effects of excess adipose tissue may be offset by beneficial vasoactive properties.

Time of occurrence, duration, and ventricular rate of paroxysmal atrial fibrillation: the effect of digoxin.

One hundred and thirty nine episodes of atrial fibrillation were identified from Holter recordings in 72 patients with paroxysmal atrial fibrillation. Paroxysms occurred more often by day than by night, suggesting that attacks are more closely associated with sympathetic than with vagal activity. In 41 patients who were not taking digoxin there were 79 episodes, and in 31 patients who were taking digoxin there were 60 episodes. Significantly more of the episodes that lasted for 30 minutes or more occurred in patients taking digoxin (13/17); the relative risk of a prolonged paroxysm associated with taking digoxin was 4.3 (95% confidence intervals 1.6-11.9). The mean (SD) ventricular rate at the onset of the paroxysms was not significantly different in those taking digoxin (140 (25) beats/min) and in those who were not (134 (22) beats/min). In paroxysmal atrial fibrillation, pretreatment with digoxin does not seem to reduce the frequency of paroxysms, or the ventricular rate when paroxysms occur, but it is associated with longer attacks.

Percutaneous Coronary Intervention in the Elderly Changes in Case-Mix and Periprocedural Outcomes in 31 758 Patients Treated Between 2000 and 2007

Background— The elderly account for an increasing proportion of the population and have a high prevalence of coronary heart disease. Percutaneous coronary intervention (PCI) is the most common method of revascularization in the elderly. We examined whether the risk of periprocedural complications after PCI was higher among elderly (age ≥75 years) patients and whether it has changed over time. Methods and Results— The Scottish Coronary Revascularization Register was used to undertake a retrospective cohort study on all 31 758 patients undergoing nonemergency PCI in Scotland between April 2000 and March 2007, inclusive. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (χ2 tests, all P <0.001). The elderly had a higher risk of major adverse cardiovascular events within 30 days of PCI (4.5% versus 2.7%, χ2 test P <0.001). Over the 7 years, there was a significant increase in the proportion of elderly patients who had multiple comorbidity (χ2 test for trend, P <0.001). Despite this, the underlying risk of complications did not change significantly over time either among the elderly (χ2 test for trend, P =0.142) or overall (χ2 test for trend, P =0.083). Conclusions— Elderly patients have a higher risk of periprocedural complications and account for an increasing proportion of PCIs. Despite this, the risk of complications after PCI has not increased over time.Background—The elderly account for an increasing proportion of the population and have a high prevalence of coronary heart disease. Percutaneous coronary intervention (PCI) is the most common method of revascularization in the elderly. We examined whether the risk of periprocedural complications after PCI was higher among elderly (age ≥75 years) patients and whether it has changed over time. Methods and Results—The Scottish Coronary Revascularization Register was used to undertake a retrospective cohort study on all 31 758 patients undergoing nonemergency PCI in Scotland between April 2000 and March 2007, inclusive. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (&khgr;2 tests, all P<0.001). The elderly had a higher risk of major adverse cardiovascular events within 30 days of PCI (4.5% versus 2.7%, &khgr;2 test P<0.001). Over the 7 years, there was a significant increase in the proportion of elderly patients who had multiple comorbidity (&khgr;2 test for trend, P<0.001). Despite this, the underlying risk of complications did not change significantly over time either among the elderly (&khgr;2 test for trend, P=0.142) or overall (&khgr;2 test for trend, P=0.083). Conclusions—Elderly patients have a higher risk of periprocedural complications and account for an increasing proportion of PCIs. Despite this, the risk of complications after PCI has not increased over time.

Comparison of survival following coronary artery bypass grafting vs. percutaneous coronary intervention in diabetic and non-diabetic patients: retrospective cohort study of 6320 procedures.

Aim  To determine whether mortality following percutaneous coronary intervention vs. coronary bypass grafting varies according to whether or not patients have diabetes.

Outcomes following coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in the stent era: a prospective study of all 9890 consecutive patients operated on in Scotland over a two year period

OBJECTIVE To determine current outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). DESIGN The Scottish coronary revascularisation register provided prospectively collected data on case mix and in-hospital complications for all revascularisation procedures between April 1997 and March 1999 (4775 PTCA; 5115 CABG). Linkage to routine hospital discharge and death data provided follow up information on survival and repeat revascularisation. RESULTS Stents were used in 51% of PTCA procedures. CABG patients were older, had more severe coronary disease, and had greater comorbidity. PTCA was more likely to be undertaken as an urgent or emergency procedure. Perioperative death and urgent surgery followed 0.3% and 0.6% of PTCA procedures, respectively. Case fatality rates were higher following CABG, with 6.7% dead within two years compared with 3.4% following PTCA. PTCA was more often followed by readmission for ischaemic heart disease, repeat angiography, or revascularisation: 22.8% of patients had repeat revascularisation within two years, compared with 1.8% following CABG. CONCLUSIONS The severity of coronary heart disease was greater than in previously published registry studies and randomised trials. Despite this, overall survival figures were comparable and repeat revascularisation rates lower, particularly following PTCA. Perioperative death and urgent surgery following PTCA were also lower. These favourable outcomes may be attributable, in part, to increased use of bail out and elective stenting.

Women and myocardial infarction: agism rather than sexism?

OBJECTIVE--To determine whether women with myocardial infarction are treated differently from men of the same age and to assess the effect of changes in the coronary care unit admission policy. DESIGN--Clinical audit. SETTING--The coronary care unit and general medical wards of a teaching hospital. In 1990 the age limit for admission to coronary care was 65 years. This age limit was removed in 1991. PATIENTS--539 female and 977 male patients admitted with myocardial infarction between 1990 and 1992. MAIN OUTCOMES--Admission to the coronary care unit, administration of thrombolysis, and in-hospital mortality. RESULTS--409 men and 254 women were admitted with myocardial infarction in 1990 and 568 men and 285 women in 1992. Removal of the age limit for admission to the coronary care unit resulted in an increase in the numbers of both sexes admitted with myocardial infarction. In both years, however, proportionately more men with infarction were admitted to coronary care: 226 men (55%) and 96 women (38%) (P < 0.01) (95% CI 7 to 28) in 1990 and 459 men (81%) and 200 women (70%) (P < 0.01) (%CI 2 to 19) in 1992. Some 246 men (60%) and 133 women (52%) with infarction (P < 0.01) received thrombolytic treatment in 1990 compared with 319 men (56%) and 130 women (46%) (P < 0.01) in 1992. The mean age of women sustaining a myocardial infarction was significantly greater in both years studied. In 1992 a total of 78 men (7%) and 34 women (4%) (P < 0.05) admitted with chest pain underwent cardiac catheterisation before discharge from hospital. CONCLUSIONS--Differences in admission rates to the coronary care unit and the rate of thrombolysis between the sexes can be explained by the older age of women sustaining infarction. The application of age limits for admission to coronary care or administration of thrombolysis places elderly patients at a disadvantage. As women sustain myocardial infarctions at an older age they are placed at a greater disadvantage.

Hospital volume of throughput and periprocedural and medium-term adverse events after percutaneous coronary intervention: retrospective cohort study of all 17 417 procedures undertaken in Scotland, 1997–2003

Objective: To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix. Design: Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period. Methods: All PCIs in Scotland during 1997–2003 were examined. Linkage to administrative databases identified events over two years’ follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Results: Of the 17 417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p  =  0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p  =  0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Conclusion: Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Percutaneous Coronary Intervention in the ElderlyClinical Perspective

Background— The elderly account for an increasing proportion of the population and have a high prevalence of coronary heart disease. Percutaneous coronary intervention (PCI) is the most common method of revascularization in the elderly. We examined whether the risk of periprocedural complications after PCI was higher among elderly (age ≥75 years) patients and whether it has changed over time. Methods and Results— The Scottish Coronary Revascularization Register was used to undertake a retrospective cohort study on all 31 758 patients undergoing nonemergency PCI in Scotland between April 2000 and March 2007, inclusive. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (χ2 tests, all P <0.001). The elderly had a higher risk of major adverse cardiovascular events within 30 days of PCI (4.5% versus 2.7%, χ2 test P <0.001). Over the 7 years, there was a significant increase in the proportion of elderly patients who had multiple comorbidity (χ2 test for trend, P <0.001). Despite this, the underlying risk of complications did not change significantly over time either among the elderly (χ2 test for trend, P =0.142) or overall (χ2 test for trend, P =0.083). Conclusions— Elderly patients have a higher risk of periprocedural complications and account for an increasing proportion of PCIs. Despite this, the risk of complications after PCI has not increased over time.Background—The elderly account for an increasing proportion of the population and have a high prevalence of coronary heart disease. Percutaneous coronary intervention (PCI) is the most common method of revascularization in the elderly. We examined whether the risk of periprocedural complications after PCI was higher among elderly (age ≥75 years) patients and whether it has changed over time. Methods and Results—The Scottish Coronary Revascularization Register was used to undertake a retrospective cohort study on all 31 758 patients undergoing nonemergency PCI in Scotland between April 2000 and March 2007, inclusive. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (&khgr;2 tests, all P<0.001). The elderly had a higher risk of major adverse cardiovascular events within 30 days of PCI (4.5% versus 2.7%, &khgr;2 test P<0.001). Over the 7 years, there was a significant increase in the proportion of elderly patients who had multiple comorbidity (&khgr;2 test for trend, P<0.001). Despite this, the underlying risk of complications did not change significantly over time either among the elderly (&khgr;2 test for trend, P=0.142) or overall (&khgr;2 test for trend, P=0.083). Conclusions—Elderly patients have a higher risk of periprocedural complications and account for an increasing proportion of PCIs. Despite this, the risk of complications after PCI has not increased over time.

Delay between the onset of symptoms of acute myocardial infarction and seeking medical assistance is influenced by left ventricular function at presentation.

OBJECTIVE--To determine whether the interval between the onset of symptoms of acute myocardial infarction and the patients call for medical assistance (patient delay) is related to left ventricular function at the time of presentation. DESIGN--Prospective observational study. SETTING--Coronary care unit of Aberdeen Royal Infirmary. PATIENTS--93 consecutive patients with acute myocardial infarction. MAIN OUTCOME MEASURES--Left ventricular stroke distance, expressed as a percentage of the age predicted normal value, measured first on admission, and then daily for 10 days or until discharge. Patients were questioned at admission to determine the time of onset of symptoms and the time of their call for medical assistance. RESULTS--Median (range) patient delay was 30 (1-360) min. Mean (SD) stroke distance on admission was 70(18)%, rising to 77(19)% on the second recording, and to 84(18)% on the day of discharge. Linear regression of log(e)(patient delay) against first, second, and last measurements of stroke distance gave correlation coefficients of 0.28 (P < 0.01), 0.18 (not significant), and 0.11 (not significant), respectively. CONCLUSIONS--Patient delay within the first 4 h after the onset of symptoms of acute myocardial infarction is positively related to left ventricular function on admission. A possible explanation is that deteriorating left ventricular function influences the patients decision to call for help. This tendency for patients with more severe infarction to call for help sooner is an added reason for giving thrombolytic treatment at the first opportunity: those who call early have most to gain from prompt management.

Audit of prehospital thrombolysis by general practitioners in peripheral practices in Grampian

Background In the Grampian region early anistreplase trial (GREAT), domiciliary thrombolysis by general practitioners was associated with a halving of one year mortality compared with hospital administration. However, after completion of the trial and publication of the results, the use of this treatment by general practitioners declined sharply. Objective To increase the proportion of eligible patients receiving timely thrombolytic treatment from their general practitioners. Setting Practices in Grampian located ⩾ 30 minutes’ travelling time from Aberdeen Royal Infirmary, where patients with suspected acute myocardial infarction were referred after being seen by general practitioners. Audit standard A call-to-needle time of 90 minutes, as proposed by the British Heart Foundation (BHF). Methods Findings of this audit of prehospital management of acute myocardial infarction were periodically fed back to the participating doctors, when practice case reviews were also conducted. Results Of 414 administrations of thrombolytic treatment, 146 (35%) were given by general practitioners and 268 (65%) were deferred until after hospital admission. Median call-to-needle times were 45 (94% ⩽ 90) and 145 (7% ⩽ 90) minutes, respectively. Survival at one year was improved with prehospital compared with hospital thrombolysis (83%v 73%; p < 0.05). The proportion of patients receiving thrombolytic treatment from their general practitioners did not increase during the audit. Conclusions In practices ⩾ 30 minutes from hospital, the BHF audit standard was readily achieved if general practitioners gave thrombolytic treatment, but not otherwise. Knowledge of the benefits of early thrombolysis, and feedback of audit results, did not lead to increased prehospital thrombolytic use. Additional incentives are required if general practitioners are to give thrombolytic treatment.