Marc E. Shelton

Correlates of late and very late thrombosis of drug eluting stents

BACKGROUNDnLate and very late thrombosis of coronary drug-eluting stents (DES) has received much attention but essentially remains unpredictable. We sought to identify correlates of stent thrombosis (ST) developing >30 days after DES implantation.nnnMETHODSnWe analyzed data from our single-center registry on 5,342 consecutive patients, who underwent a first DES implant between May 2003 and December 2006. The Academic Research Consortium definitions were applied to classify definite, probable, and possible ST. Cox regression analysis was performed to identify predictors of ST.nnnRESULTSnFollow-up information was obtained at 6 months and at 1, 2, and 3 years after DES implantation in 97.2%, 95.2%, 92.4%, and 89.8% of patients, respectively. We identified 34 patients who developed definite and 5 with probable ST >30 days after the index stent procedure. The 3-year cumulative incidence of definite and definite + probable ST >30 days was 1.33% and 1.50%, respectively. By Cox multiple variable regression, predictors of definite + probable ST were age (hazard ratio [HR] 0.95, 95% CI 0.92-0.98, P < .001), current smoking (HR 2.55, 95% CI 1.29-5.07, P = .007), prior percutaneous coronary intervention (HR 2.68, 95% CI 1.42-5.05, P = .002), off-label DES indication (HR 3.10, 95% CI 1.10-8.75, P = .032), bifurcation stenting (HR 2.37, 95% CI 1.40-3.99, P = .001), and stenting an occluded vessel (HR 3.02, 95% CI 1.59-5.74, P < .001).nnnCONCLUSIONSnWe identified several baseline characteristics, which, when combined, may identify patients at risk for late-occurring ST, particularly after off-label DES placement.

Concordance of physician ratings with the appropriate use criteria for coronary revascularization.

OBJECTIVESnThe objective of this study was to compare the consistency in appropriate use criteria (AUC) ratings among a broad range of practicing cardiologists and the AUC Technical Panel.nnnBACKGROUNDnAUC for coronary revascularization have been developed by selected experts.nnnMETHODSnBefore AUC publication, 85 cardiologists from 10 U.S. institutions assessed the appropriateness of coronary revascularization for 68 indications that had been evaluated by the AUC Technical Panel. Each indication was classified as appropriate, uncertain, or inappropriate, based on the physician groups median rating. Rates of concordance between the physician group and the AUC Technical Panel (i.e., same appropriateness category assignment) and rates of nonagreement within the physician group (≥ 25% of panelists ratings outside the groups appropriateness category assessment) were determined.nnnRESULTSnOverall concordance between the 2 groups was 84%. Among indications classified as appropriate by the AUC Technical Panel, concordance between the 2 groups was excellent (94% [34 of 36]); however, nonagreement within the physician group was 44% (16 of 36). Among indications classified as uncertain, there was 73% (16 of 22) concordance between the 2 groups. Among inappropriate indications, concordance was moderate (70% [7 of 10]), but nonagreement occurred frequently (70% [7 of 10]). Moreover, there was substantial variation in appropriateness ratings between individual physicians and the AUC Technical Panel (weighted kappa range: 0.05 to 0.76).nnnCONCLUSIONSnAlthough there was good concordance in assessments of appropriateness for coronary revascularization between physicians and the AUC Technical Panel, nonagreement within the physician group was common and there was marked variation in ratings between individual physicians and the AUC Technical Panel.

Impact of abciximab and coronary stenting on outcomes and costs of percutaneous coronary interventions in a community hospital.

ObjectiveTo assess costs and outcomes of coronary stenting and balloon angioplasty with and without adjunctive treatment with abciximab for 3758 consecutive elective percutaneous coronary interventions at a single community center over the 2.5‐year period between 1 January 1995 and 30 June 1997. ResultsAbciximab was more common among patients who had recently suffered myocardial infarction, patients with unstable angina, and patients with more complex coronary lesions. Use of abciximab in conjunction with balloon angioplasty or stenting and stenting alone was associated with significant reductions in incidence of major adverse cardiovascular events in hospital. Multivariate analysis indicated that use of abciximab and stenting were associated with significant independent effects on risk of an event. Hospital costs were increased for patients administered abciximab, treated with stenting, or both. Total costs and costs inclusive of those incurred in catheterization laboratory and pharmacy increased significantly with increasing complexity of lesions. Multivariate regression analysis (baseline cost US

Long-Term Outcomes After Management of Restenosis or Thrombosis of Drug-Eluting Stents

5621) identified death (US

Short- and long-term clinical outcomes of coronary drug-eluting stent recipients presenting with chronic renal disease.

16u2005098), emergency revascularization (US

President's page: drug-eluting stents in contemporary practice--a call for a real-world, open-entry, device-tracking registry.

13u2005678), usage of multiple stents (US

Improving the process of informed consent for percutaneous coronary intervention: Patient Outcomes from the Patient Risk Information Services Manager ( e PRISM) study

1423 for each stent), and use of abciximab (US

Drug-Eluting Stents Long-Term Outcomes After Management of Restenosis or Thrombosis of

1269) as independent predictors of a greater cost. One‐year follow‐up revealed significant differences among treatment strategies in terms of risk of need for subsequent revascularization procedures. Lack of stenting but not use of abciximab was identified as a significant predictor of need for repeat revascularization procedures. ConclusionsOur findings are in general agreement with cost analyses of use of abciximab for populations in clinical trials and suggest that improvements of early clinical outcome with abciximab treatment and stenting justify the incremental cost of treatment in a community hospital setting.