Search

Objectives The aim of this study was to examine the effect of CYP2C19 genotype on clinical outcomes in patients with coronary artery disease (CAD) who predominantly underwent percutaneous coronary intervention (PCI), comparing those treated with ticagrelor or prasugrel versus clopidogrel. Background The effect of CYP2C19 genotype on treatment outcomes with ticagrelor or prasugrel compared with clopidogrel is unclear. Methods Databases through February 19, 2020, were searched for studies reporting the effect of CYP2C19 genotype on ischemic outcomes during ticagrelor or prasugrel versus clopidogrel treatment. Study eligibility required outcomes reported for CYP2C19 genotype status and clopidogrel and alternative P2Y12 inhibitors in patients with CAD with at least 50% undergoing PCI. The primary analysis consisted of randomized controlled trials (RCTs). A secondary analysis was conducted by adding non-RCTs to the primary analysis. The primary outcome was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia. Meta-analysis was conducted to compare the 2 drug regimens and test interaction with CYP2C19 genotype. Results Of 1,335 studies identified, 7 RCTs were included (15,949 patients, mean age 62 years; 77% had PCI, 98% had acute coronary syndromes). Statistical heterogeneity was minimal, and risk for bias was low. Ticagrelor and prasugrel compared with clopidogrel resulted in a significant reduction in ischemic events (relative risk: 0.70; 95% confidence interval: 0.59 to 0.83) in CYP2C19 loss-of-function carriers but not in noncarriers (relative risk: 1.0; 95% confidence interval: 0.80 to 1.25). The test of interaction on the basis of CYP2C19 genotype status was statistically significant (p = 0.013), suggesting that CYP2C19 genotype modified the effect. An additional 4 observational studies were found, and adding them to the analysis provided the same conclusions (p value of the test of interaction Conclusions The effect of ticagrelor or prasugrel compared with clopidogrel in reducing ischemic events in patients with CAD who predominantly undergo PCI is based primarily on the presence of CYP2C19 loss-of-function carrier status. These results support genetic testing prior to prescribing P2Y12 inhibitor therapy.

Objectives This study sought to determine whether machine learning can be used to better identify patients at risk for death or congestive heart failure (CHF) rehospitalization after percutaneous coronary intervention (PCI). Background Contemporary risk models for event prediction after PCI have limited predictive ability. Machine learning has the potential to identify complex nonlinear patterns within datasets, improving the predictive power of models. Methods We evaluated 11,709 distinct patients who underwent 14,349 PCIs between January 2004 and December 2013 in the Mayo Clinic PCI registry. Fifty-two demographic and clinical parameters known at the time of admission were used to predict in-hospital mortality and 358 additional variables available at discharge were examined to identify patients at risk for CHF readmission. For each event, we trained a random forest regression model (i.e., machine learning) to estimate the time-to-event. Eight-fold cross-validation was used to estimate model performance. We used the predicted time-to-event as a score, generated a receiver-operating characteristic curve, and calculated the area under the curve (AUC). Model performance was then compared with a logistic regression model using pairwise comparisons of AUCs and calculation of net reclassification indices. Results The predictive algorithm identified a high-risk cohort representing 2% of all patients who had an in-hospital mortality of 45.5% (95% confidence interval: 43.5% to 47.5%) compared with a risk of 2.1% for the general population (AUC: 0.925; 95% confidence interval: 0.92 to 0.93). Advancing age, CHF, and shock on presentation were the leading predictors for the outcome. A high-risk group representing 1% of all patients was identified with 30-day CHF rehospitalization of 8.1% (95% confidence interval: 6.3% to 10.2%). Random forest regression outperformed logistic regression for predicting 30-day CHF readmission (AUC: 0.90 vs. 0.85; p = 0.003; net reclassification improvement: 5.14%) and 180-day cardiovascular death (AUC: 0.88 vs. 0.81; p = 0.02; net reclassification improvement: 0.02%). Conclusions Random forest regression models (machine learning) were more predictive and discriminative than standard regression methods at identifying patients at risk for 180-day cardiovascular mortality and 30-day CHF rehospitalization, but not in-hospital mortality. Machine learning was effective at identifying subgroups at high risk for post-procedure mortality and readmission.

Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.

Objectives This study sought to assess temporal trends and outcomes of percutaneous coronary intervention (PCI) in nonagenarians. Background With increasing life expectancy, nonagenarians requiring PCI are increasing even though outcomes data are limited. Methods The National Inpatient Sample was used to identify all hospitalizations for PCI in patients aged ≥90 years from January 1, 2003, to December 31, 2014. The primary outcome was in-hospital mortality. Results Nonagenarians (n = 69,271) constituted 0.9% of all PCI hospitalizations, increasing from 0.6% in 2003 to 2004 to 1.4% in 2013 to 2014 (ptrend Conclusions The rate of in-hospital mortality, major bleeding, vascular complications, and stroke after PCI in nonagenarians changed significantly from 2003 to 2014. This study provides a benchmark for discussion of PCI-related risks among physicians, patients, and families.

Objectives The first aim of this study was to assess the magnitude of radiation dose to tissues of the head and neck of physicians performing x-ray-guided interventional procedures. The second aim was to assess protection of tissues of the head offered by select wearable radiation safety devices. Background Radiation dose to tissues of the head and neck is of significant interest to practicing interventional physicians. However, methods to estimate radiation dose are not generally available, and furthermore, some of the available research relating to protection of these tissues is misleading. Methods Using a single representative geometry, scatter radiation dose to a humanoid phantom was measured using radiochromic film and normalized by the radiation dose to the left collar of the radioprotective thorax apron. Radiation protection offered by leaded glasses and by a radioabsorbent surgical cap was measured. Results In the test geometry, average radiation doses to the unprotected brain, carotid arteries, and ocular lenses were 8.4%, 17%, and 50% of the dose measured at the left collar, respectively. Two representative types of leaded glasses reduced dose to the ocular lens on the side of the physician from which the scatter originates by 27% to 62% but offered no protection to the contralateral eye. The radioabsorbent surgical cap reduced brain dose by only 3.3%. Conclusions A method by which interventional physicians can estimate dose to head and neck tissues on the basis of their personal dosimeter readings is described. Radiation protection of the ocular lenses by leaded glasses may be incomplete, and protection of the brain by a radioabsorbent surgical cap was minimal.

A growing body of evidence now supports the use of transradial percutaneous intervention (TRI) as the preferred access site for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Historically, TRI has been avoided in the STEMI population due to concerns over longer procedure time, longer door-to-device time, higher crossover rates, and the experience level required with TRI compared with transfemoral access. However, in recent years, recognition of the impact of periprocedural bleeding on mortality in patients with acute coronary syndromes has garnered interest in the utility of TRI as an established method to reduce bleeding. Registry data, meta-analyses, and randomized control trials all similarly demonstrate that TRI is associated with reduced periprocedural bleeding and lower mortality compared with transfemoral access in the STEMI population. Additional benefits of TRI include enhanced patient comfort, reduced hospital length of stay, and reduced cost. Despite the evidence, trends in use of TRI in the United States have shown a slow adoption rate as a result of multiple barriers in clinical practice and doubts about the mechanism and causal relationship of mortality reduction with TRI. We summarize the current evidence and propose a call to action to foster training of TRI in cardiovascular fellowship programs and post-fellowship courses, and for more widespread implementation of TRI in STEMI patients.

Objectives The objectives of this work were to establish the primary clinical determinants of patient radiation dose associated with percutaneous coronary interventional (PCI) and to identify opportunities for dose reduction. Background Use of X-ray imaging and associated radiation dose is a necessary part of PCI. Potential adverse consequences of radiation dose include skin radiation injury and predicted increase in lifetime cancer risk. Methods Cumulative skin dose (CSD) (measured in gray [Gy] units) was selected as a measurement of patient radiation burden. Several patient-, disease-, and treatment-related variables, including 15 performing physicians, were analyzed in a multiple linear regression statistical model with cumulative skin dose CSD as the primary end point. The model results provide an estimate of the relative CSD increase (decrease) attributable to each variable. Results Percutaneous coronary interventions performed on 1,287 male and 540 female patients were included. Median patient age was 68.6 years, median body mass index was 29.7 kg/m2, and median weight was 88 kg. Median CSD was 1.64 Gy per procedure for male and 1.15 Gy for female patients. Increasing body mass index, patient sex, lesion complexity, lesion location, and performing physician were significantly associated with CSD. Physicians who performed more procedures were associated with lower CSD. Conclusions Several primary determinants of patient radiation dose during PCI were identified. Along with physician development of radiation-sparing methods and skills, pre-procedure dose planning is proposed to help minimize radiation dose for PCI.

Objectives The purpose of this study was to evaluate secular trends and factors associated with major femoral bleeding after percutaneous coronary intervention (PCI) in routine clinical practice during the past decade and to assess the impact of these complications on outcomes including mortality. Background Significant changes in patient demographic data, adjunctive pharmacotherapy, and access site management have occurred during the coronary stent era. Trends in major vascular complications after PCI during this time have not been well characterized. Methods Consecutive patients who underwent transfemoral PCI from 1994 to 2005 at the Mayo Clinic (n = 17,901) were studied. Patients were divided into 3 groups: Group 1 (1994 to 1995, n = 2,441); Group 2 (1996 to 1999, n = 6,207); and Group 3 (2000 to 2005, n = 9,253). Results The incidence of major femoral bleeding complications decreased (from 8.4% to 5.3% to 3.5%; p l 0.001). Reductions in sheath size, intensity and duration of anticoagulation with heparin, and procedure time were observed (p l 0.001), and multivariate analysis confirmed each as an independent predictor of complications (p l 0.001). Adverse outcomes of major femoral bleeding included prolonged hospital stay (mean 4.5 vs. 2.7 days; p l 0.0001) and increased requirement for blood transfusion (39% vs. 4.7%; p l 0.0001). Major femoral bleeding and blood transfusion were both associated with decreased long-term survival, driven by a significant increase in 30-day mortality (p l 0.001 for both). Conclusions We noted a marked decline in the incidence of major femoral bleeding after PCI over the past decade. Mortality associated with these bleeding complications and with blood transfusion remains a significant issue.

Objectives We implemented the Mayo Clinic ST-segment elevation myocardial infarction (STEMI) protocol and evaluated the timeliness of reperfusion therapy during off hours versus regular hours. Background Patients with STEMI who present during off hours have longer door-to-balloon times and door-to-needle times. Methods The Mayo STEMI protocol was implemented in May 2004 to optimize timeliness of reperfusion therapy for STEMI patients presenting to Saint Marys Hospital, a tertiary facility with on-site percutaneous coronary intervention (PCI), and for those presenting to 28 regional hospitals located up to 150 miles away from Saint Marys Hospital. We compared door-to-balloon times and door-to-needle times for 597 consecutive patients who presented during off hours (weekdays from 5 pm to 7 am and any time on weekends or holidays) versus regular hours (weekdays from 7 am to 5 pm). In 2003, prior to implementing the protocol, median door-to-balloon time at Saint Marys Hospital was 85 min during regular hours and 98 min during off hours. Results Among 258 patients who presented to Saint Marys Hospital, median door-to-balloon time was 65 min during regular hours versus 74 min during off hours (p = 0.085). Among 105 patients transferred from regional hospitals for primary PCI, median door-to-balloon time was 118 min during regular hours versus 114 min during off hours (p = 0.15). Among 131 patients treated with fibrinolytic therapy at regional hospitals, median door-to-needle time was 21 min during regular hours versus 26 min during off hours (p = 0.067). Conclusions The Mayo Clinic STEMI protocol demonstrates the rapid times that can be achieved through coordinated systems of care for STEMI patients presenting during off hours and regular hours.