Rachel Slack

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.

Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Noncardiac Surgery

Background—Noncardiac surgery performed after coronary stent implantation is associated with an increased risk of stent thrombosis, myocardial infarction, and death. The influence of stent type and period of risk still have to be defined. Methods and Results—We linked the Scottish Coronary Revascularisation Register with hospital admission data to undertake a Scotland-wide retrospective cohort study examining cardiac outcomes in all patients who received drug-eluting or bare-metal stents between April 2003 and March 2007 and subsequently underwent noncardiac surgery. Of 1953 patients, 570 (29%) were treated with at least 1 drug-eluting stent and 1383 (71%) with bare-metal stents only. There were no differences between drug-eluting and bare-metal stents in the primary end point of in-hospital mortality or ischemic cardiac events (14.6% versus 13.3%; P=0.3) or the secondary end points of in-hospital mortality (0.7% versus 0.6%; P=0.8) and acute myocardial infarction (1.2% versus 0.7%; P=0.3). Perioperative death and ischemic cardiac events occurred more frequently when surgery was performed within 42 days of stent implantation (42.4% versus 12.8% beyond 42 days; P<0.001), especially in patients revascularized after an acute coronary syndrome (65% versus 32%; P=0.037). There were no temporal differences in outcomes between the drug-eluting and bare-metal stent groups. Conclusions—Patients undergoing noncardiac surgery after recent coronary stent implantation are at increased risk of perioperative myocardial ischemia, myocardial infarction, and death, particularly after an acute coronary syndrome. For at least 2 years after percutaneous coronary intervention, cardiac outcomes after noncardiac surgery are similar for both drug-eluting and bare-metal stents.

Clinical outcomes following radial versus femoral artery access in primary or rescue percutaneous coronary intervention in Scotland: retrospective cohort study of 4534 patients

Objective To assess short-term and medium-term outcomes following radial and femoral artery access for primary or rescue percutaneous coronary intervention (PCI). Design Retrospective cohort study. Setting Scotland-wide. Patients All 4534 patients undergoing primary or rescue PCI in Scotland between April 2000 and March 2009 using the Scottish Coronary Revascularisation Register. Intervention Primary or rescue PCI. Main outcome measures Procedural success; peri-procedural complications; 30-day and 1-year mortality, myocardial infarction or stroke and long-term mortality. Results Use of the radial approach increased from no cases in 2000 to 924 (80.5%) in 2009 (p<0.001). Patients in whom the radial approach was used were more likely to be male (p=0.041) and to have multiple comorbidities (p<0.001), including hypertension (p<0.001) and left ventricular dysfunction (p<0.001). They were less likely to have renal impairment (p=0.017), multi-vessel coronary disease (p=0.001) and cardiogenic shock (p<0.001). In multivariable analyses, use of radial artery access was associated with greater procedural success (adjusted OR 1.89, 95% CI 1.26 – 2.82, p=0.002) and a lower risk of any complications (adjusted OR 0.67, 95% CI 0.51 – 0.87, p=0.001) or access site bleeding complications (adjusted OR 0.21, 0.08 – 0.56, p=0.002), as well as a lower risk of myocardial infarction (adjusted OR 0.66, 95% CI 0.51–0.87, p=0.003) or death within 30 days (adjusted OR 0.51, 95% CI 0.04 – 0.52, p<0.001). The differences in myocardial infarction and death remained significant up to 9 years of follow-up. Conclusion Use of the radial artery for primary or rescue PCI is associated with improved clinical outcomes.

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.

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.

Drug-Eluting Stents Versus Bare-Metal Stents for Off-Label Indications A Propensity Score–Matched Outcome Study

Background—The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results—We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; P=0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; P=0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93; P=0.02). Conclusions—At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents.Background— The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results— We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; P =0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; P =0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93; P =0.02). Conclusions— At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents. Received January 31, 2008; accepted May 15, 2008. # CLINICAL PERSPECTIVE {#article-title-2}

Improvements in carotid endarterectomy in Scotland: results of a national prospective survey

Abstract Background and aims: The effectiveness of carotid endarterectomy (CEA) depends upon selection of patients with a high absolute risk of stroke, avoidance of delays from initial presentation to surgery and provision of surgery with a low perioperative risk of stroke. We evaluated these aspects of practice in Scottish hospitals and, by encouraging adherence to national (SIGN) guidelines, attempted to improve the effectiveness of CEA. Methods: Prospective independent survey of patient selection, pre-operative delays and surgical performance for all CEAs performed in Scottish National Health Service hospitals over two 13 month periods from September 1997 and February 1999 respectively. Results: Thirteen hospitals performed 485 CEAs in the first period and 392 in the second, equating to an overall annual rate of 79 per million population. During both periods at least 95% of patients reported symptoms of carotid territory ischaemia, but the proportion with stenoses greater than > 70% rose from 89% to 97% (p < 0.0001). The delays between referral, surgical consultation and subsequent surgery fell significantly but remained unacceptably long. The proportion seen by the surgeon within two weeks of referral rose from 36% to 43% (p=0.05) and the proportion operated on within one month thereafter rose from 35% to 49% (p < 0.0001). The perioperative combined major stroke and death rate was 3% in both periods. Conclusion: We demonstrated significant changes in practice, in line with national guidelines, which would be expected to improve the effectiveness of our national programme of CEA. There is further scope for improving performance, particularly in relation to pre-operative delays.

Hospital and operator variations in drug-eluting stent use : a multi-level analysis of 5967 consecutive patients in Scotland

OBJECTIVE To determine whether drug-eluting stent (DES) use varies among Scottish hospitals, and the extent to which any variations are explained by differences between operators, patients and lesions. METHODS Multi-level analysis of consecutive patients treated with percutaneous coronary intervention (PCI) between April 2005 and March 2006 in Scotland, using the Scottish Coronary Revascularization Registry. RESULTS A total of 38 operators performed 5967 PCI procedures on 8489 lesions. Crude level of DES use was 47.6%, and the results varied among hospitals (range 30.6-61.8%, chi(2) = 341.6, P < 0.0001). There was significant between-operator variation in the null model. This was attenuated by the addition of hospital as a fixed effect. Nonetheless, the final model demonstrated significant between-operator variability [sigma(2) = 0.486 (0.249-0.971)] and between-hospital variation, after case-mix adjustment. CONCLUSIONS Within Scotland, marked variation existed among hospitals in the use of DES. Operator was the most important factor at patient level, and hospital of treatment, rather than case-mix, was the most important modifier of between-operator variation. Patient selection for DES is complex and may contribute to much of the variations demonstrated. Consensus criteria would provide more detail than is included in current guidance, may aid decision-making for individual patients, reduce opportunity costs and ensure equity of access.

Drug-Eluting Stents Versus Bare-Metal Stents for Off-Label IndicationsCLINICAL PERSPECTIVE

Background—The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results—We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; P=0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; P=0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93; P=0.02). Conclusions—At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents.Background— The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results— We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; P =0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; P =0.92). Target-vessel revascularization was reduced in patients treated with DES (13.9% versus 10.7%; hazard ratio 0.67; 95% confidence interval, 0.49 to 0.93; P =0.02). Conclusions— At 24 months, patients treated with DES for off-label indications had lower rates of death and target-vessel revascularization and similar rates of myocardial infarction, as compared with patients treated with bare-metal stents. Received January 31, 2008; accepted May 15, 2008. # CLINICAL PERSPECTIVE {#article-title-2}