Thomas Pappas

Impact of severity of renal dysfunction on determinants of in‐hospital mortality among patients undergoing percutaneous coronary intervention

Background: Chronic kidney disease (CKD) is a known prognostic indicator of poor outcomes following percutaneous coronary intervention (PCI) for coronary artery disease. However, it is unclear whether other predictors of mortality differ among patients with varying degrees of renal impairment. Thus, we aimed to identify determinants of in‐hospital mortality which are specific to patients with preserved renal function, moderate CKD, or end stage renal disease (ESRD) on dialysis, undergoing PCI. Methods: The study population included 25,018 patients who underwent PCI between January 1, 2004, and December 31, 2007, at four New York State hospitals. The primary endpoint of the study was in‐hospital mortality. Results: A total of 474 (1.9%) patients had ESRD on dialysis, 6,596 (26.4%) had moderate CKD (GFR<60 ml/min/1.73m2), and 17,948 (71.7%) had preserved renal function (GFR>60 ml/min/1.73m2). Patients with ESRD and moderate CKD were older, more often male, and had higher rates of prior coronary revascularization, peripheral vascular disease, congestive heart failure, prior stroke, and diabetes than those with preserved function. All‐cause in‐hospital mortality rates were significantly higher in patients with ESRD and moderate CKD compared to patients with GFR >60ml/min/1.73m2 (2.1% and 1.3%, respectively vs. 0.3%, p < 0.001). In multivariable analysis, ESRD (OR: 3.68, 95% CI 1.62–8.36) and moderate CKD (OR: 2.92, 95% CI 1.91–4.46) were independently associated with higher rates of in‐hospital mortality. Independent predictors of mortality were markedly distinct in each group and included female gender and myocardial infarction within the past 72 hr in the ESRD group, versus left ventricular ejection fraction, peripheral vascular disease, congestive heart failure, emergency PCI, and absence of prior PCI in the moderate CKD group and age, prior bypass graft surgery, congestive heart failure, emergency PCI, and absence of prior myocardial infarction in patients with preserved renal function Conclusions: Patients with moderate CKD or ESRD undergoing PCI have an approximately threefold increase in the risk of in‐hospital mortality compared with patients with preserved renal function, with radically different mortality predictors existing for varying levels of renal function.

Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention

OBJECTIVE The aim of this study was to determine if insurance status is associated with adverse outcomes in patients with coronary artery disease. METHODS A cohort of 13,456 patients who underwent percutaneous coronary intervention (PCI) between January 1, 2004, and December 31, 2007, at 4 New York State teaching hospitals was retrospectively studied. The primary outcome of interest was in-hospital mortality from any cause. RESULTS Of the 13,456 patients studied, 11,927 (88.6%) were insured by private carriers, 1,036 (7.7%) patients were covered by Medicaid, and 493 (3.7%) were uninsured. Uninsured and Medicaid patients tended to be younger and more often nonwhite and Hispanic. They had a higher prevalence of congestive heart failure and worse left ventricular function. Compared with privately insured patients, uninsured and Medicaid patients had increased all-cause mortality (1.2% and 0.9%, respectively, vs 0.3%; P < .001). For all patients, lack of insurance (OR 3.02, 95% CI 1.10-8.28) and Medicaid (OR 4.39, 95% CI 1.93-9.99) were independently associated with mortality. Lack of insurance (OR 5.02, 95% CI 1.58-15.93) and Medicaid (OR 4.55, 95% CI 1.19-17.45) were also independently associated with increased mortality in patients undergoing emergent PCI. CONCLUSION Lack of insurance and Medicaid insurance are both independently associated with an increased risk of in-hospital mortality after PCI for coronary artery disease.

Effect of Gender and Race on Outcomes in Dialysis-Dependent Patients Undergoing Percutaneous Coronary Intervention

We aimed to determine whether gender and race are independently associated with in-hospital major adverse cardiac and cerebrovascular events (MACCE) and hospital length of stay in chronic dialysis patients undergoing percutaneous coronary intervention (PCI). Cardiovascular disease is the leading cause of mortality in patients with end-stage renal disease requiring dialysis. Whether gender or race independently influences the outcomes in patients undergoing PCI is not fully understood. The study population included 474 chronic dialysis patients who underwent PCI at 4 New York State teaching hospitals from January 1, 2004 to December 31, 2007. The primary end point of the study was the composite of in-hospital MACCE, defined as all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. The secondary end points included in-hospital all-cause mortality and hospital length of stay. Of the 474 chronic dialysis patients, 172 (36.3%) were women. The women undergoing PCI were more likely to be black or Hispanic and had a greater left ventricular ejection fraction. The women had significantly greater rates of in-hospital MACCE (5.8% vs 1.7%, p=0.013) and mortality (4.7% vs 0.7%, p=0.006). No significant difference in the MACCE rates was found between the black and white patients (4.9% vs 2.2%, respectively, p=0.125), although black patients showed a trend toward greater in-hospital mortality (4.1% vs 1.2%, p=0.069). After adjustment for the baseline clinical and procedural characteristics, female gender was an independent predictor of MACCE (odds ratio 7.41, 95% confidence interval 1.81 to 30.27) and all-cause mortality (odds ratio 13.23, 95% confidence interval 1.55 to 113.25), but race was not. No significant difference in the hospital length of stay was observed by either gender or race. In conclusion, in this study, female gender was independently associated with a greater risk of MACCE and all-cause mortality in dialysis-dependent patients undergoing PCI. Although being a black woman was an independent predictor of mortality, race per se was not an independent predictor of in-hospital mortality.

Safety of same-day discharge after percutaneous coronary intervention with orbital atherectomy

BACKGROUND Severely calcified lesions present many challenges to percutaneous coronary intervention (PCI). Orbital atherectomy (OA) aids vessel preparation and treatment of severely calcified coronary lesions. Same-day discharge (SDD) after PCI has numerous advantages including cost savings and improved patient satisfaction. The aim of this study is to evaluate the safety of SDD among patients treated with OA in a real-world setting. METHODS This was a single-center retrospective analysis of patients undergoing OA. In-hospital and 30-day outcomes were assessed for major adverse cardiac events (MACE), device-related events and hospital readmissions. RESULTS There were 309 patients treated with OA of whom 94 had SDD (30.4%). Among SDD patients, there were no acute procedural complications and all patients were safely discharged on the day of the procedure. MACE at 30 days occurred in 1 patient (1.06%) due to major bleeding in the setting of a gastric arteriovenous malformation. There were 8 patients with unplanned 30-day readmissions (8.5%). CONCLUSION SDD after OA in patients with heavily calcified lesions appears to be safe, with low rates of adverse events and readmissions in select patients. In patients with SDD treated with OA, unplanned readmission occurred at a similar rate to the statewide average 30-day PCI readmission rate. Larger studies are needed to confirm the safety of this treatment paradigm and the potential cost savings.

THE EFFECTIVENESS OF EXCIMER LASER ANGIOPLASTY TO TREAT CORONARY IN-STENT RESTENOSIS WITH PERI-STENT CALCIUM AS ASSESSED BY OPTICAL COHERENCE TOMOGRAPHY

Background: We used optical coherence tomography to evaluate excimer laser coronary angioplasty (ELCA) to treat in-stent restenosis (ISR) due to peri-stent calcium (Ca) related stent underexpansion. Methods: We studied 53 ISR lesions with >90° peri-stent Ca and compared ECLA (n=21) vs no-ELCA (n=

PRIOR CORONARY ARTERY BYPASS GRAFT SURGERY IS ASSOCIATED WITH INCREASED MORTALITY IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Background: An estimated 500,000 new ST-elevation myocardial infarctions (STEMI) occur annually in the U.S. The impact of prior surgical (CABG) or percutaneous coronary (PCI) revascularization on the in-hospital outcomes of these patients has not been described. We sought to assess the effect of previous CABG or PCI on in-hospital outcomes in STEMI patients undergoing primary PCI and determine whether prior CABG is an independent predictor of adverse outcomes.