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Objectives: This study aimed to assess direct costs of percutaneous coronary intervention (PCI) without hospital admission versus PCI with hospital admission longer than 24 hours in a private hospital-institutional perspective in the Dominican Republic in 2022., Methods: This study has a comparative approach based on a prospective cross-sectional partial-cost analysis. We evaluated the direct costs of 10 patients from PCI without hospital admission approach and 10 patients from a hospital admission longer than 24 hours as a control group. We used a "first-come-first-served" approach from December 2021 to March 2022. The analysis used the electronic invoice generated for each patient., Results: PCI without hospital admission approach represents $472.56 in patient savings, equivalent to a cost reduction of 12.5%. The subcosts analysis showed the pharmacy section as the main driver of the overall cost difference., Conclusions: PCI without hospital admission was economically cost-saving compared with the control approach in direct costs in the Dominican perspective. The economic benefit is substantial and compliments the ease of use. This analysis may lead to improvements in institutional management of resources and can potentially be adapted to other health systems in the region., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024 International Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Introduction: High-risk procedures in interventional cardiology include a wide spectrum of clinical and anatomical scenarios related to a higher periprocedural morbidity and mortality. The prophylactic use of short-term mechanical circulatory support (ST-MCS) may improve both the safety and efficacy of the intervention by leading to more stable procedural hemodynamics. However, the significant costs may limit its use in resource constrained settings. To overcome this limitation, we ideated a modified, low-cost, veno-arterial extracorporeal membrane oxygenator (V-A ECMO) setup., Methods: We conducted an observational prospective study including all patients undergoing a high-risk interventional cardiology procedure at our institution under prophylactic ST-MCS using a modified, low-cost version of V-A ECMO, where some components of the standard V-A ECMO circuit were replaced by supplies used for cardiac surgical cardiopulmonary bypass, achieving a cost reduction of 72%. We assessed in-hospital and mid-term outcomes, including procedural success, post-procedure complications and mortality., Results: Between March 2016 and December 2021, ten patients underwent high-risk IC procedures with prophylactic use of V-A ECMO. Isolated percutaneous intervention (PCI) was performed in six patients, isolated transcatheter aortic valve replacement (TAVR) in two, and a combined procedure (PCI + TAVR) in two. Mean ejection fraction was 34% (range 20-64%). Mean STS PROM was 16.2% (range 9.5-35.8%) and mean EuroScore was 23.7% (range 1.5-60%). The planned intervention was successfully performed in all cases. There were no reports of V-A ECMO malfunction. In nine patients the VA-ECMO was withdrawn immediately after the procedure but one patient required extended - 24 h - support with no significant issues. One patient experienced a periprocedural myocardial infarction and another developed a femoral pseudoaneurysm. In-hospital and 30-day survival were 100%, and 1-year survival was 80%., Conclusions: High-risk procedures in interventional cardiology can be successfully performed under prophylactic ST-MCS using a modified, low-cost V-A ECMO, suitable for limited-resource settings., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: This study aimed to assess whether the national centralised volume-based procurement policy and the Shanghai government's supportive measures (coronary stent policies) implemented in Shanghai, China, on 20 January 2021 affected the cost-effectiveness of percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) in the year after surgery., Design: A retrospective cohort study based on real-world data and propensity score (PS)-matched data was conducted to compare the cost-effectiveness of PCI before and after policy implementation., Patients and Setting: Patients with ACS who had undergone first-time PCI over 1 year previously in hospitals in Shanghai and were discharged between 1 March 2019 and 30 April 2022 were included in the study., Outcome Measures: In the present study, cost was defined as total direct medical expenses, and effectiveness was defined as the prevention of major adverse cardiac events (MACEs). Incremental cost-effectiveness ratios (ICERs) were used to measure the cost-effectiveness of PCI in patients with ACS 1 year after surgery., Results: The study included 31 760 patients. According to real-world and PS-matched data, the implementation of coronary stent policies in Shanghai reduced the total medical cost of patients with ACS 1 year after PCI by 24.39% (p<0.0001) and 22.26% (p<0.0001), respectively. The ICERs were ¥-1131.72 and ¥-842.00 thousand per MACE avoided, respectively. The ICERs were robust to parameter uncertainty, and there was a substantial chance for policy implementation to improve the cost-effectiveness of PCI among patients with ACS in the short term., Conclusions: The implementation of coronary stent policies has improved the cost-effectiveness of PCI for patients with ACS in the short term. The long-term impact of coronary stent policies on the cost-effectiveness of PCI in patients with ACS or other coronary heart diseases should be assessed in the future., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Numerous studies have identified the association of socioeconomic factors with outcomes of cardiac surgical procedures. Most have focused on easily measured demographic factors or on socioeconomic characteristics of patients' 5-digit zip codes. The impact of socioeconomic information that is derived from smaller geographic regions has rarely been studied., Methods: The association of the Area Deprivation Index (ADI) with short-term mortality and readmissions was tested for patients undergoing percutaneous coronary intervention (PCI) in New York while adjusting for numerous patient risk factors, including race, ethnicity, and payer. Changes in hospitals' risk-adjusted outcomes and outlier status with the addition of socioeconomic factors were examined., Results: After adjustment, patients in the 2 most deprived ADI quintiles were more likely to experience in-hospital and 30-day mortality after PCI (adjusted odds ratios [95% confidence intervals] 1.39 [1.18-1.65] and 1.24 [1.03-1.49], respectively), than patients in the first quintile (least deprived). Also, patients in the second and fifth ADI quintiles had higher 30-day readmissions rates than patients in the first quintile (1.12 [1.01-1.25] and 1.17 [1.04-1.32], respectively). Medicare patients had higher mortality and readmission rates, Hispanics had lower mortality, and Medicaid patients had higher readmission rates., Conclusions: Patients with the most deprived ADIs are more likely to experience short-term mortality and readmissions after PCI. Ethnicity and payer are significantly associated with adverse outcomes even after adjusting for ADI. This information should be considered when identifying patients who are at the highest risk for adverse events after PCI and when risk-adjusting hospital outcomes and assessing quality of care., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Clinical trials have shown that radial access percutaneous coronary intervention (PCI) is associated with improved patient outcomes compared to femoral artery access. However, few studies have evaluated the cost-effectiveness of radial access PCI. This analysis sought to evaluate the cost-effectiveness of transradial versus transfemoral access PCI for patients with acute coronary syndrome (ACS) using data from the Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) trial. A decision analytic Markov model was constructed from an Australian health care perspective with a 2 year time horizon. The model simulated recurrent cardiovascular disease and death post PCI among a hypothetical cohort of 1000 individuals with ACS. Population and efficacy data were based on the MATRIX trial. Cost and utility data were drawn from published sources. Over a 2-year time horizon, radial access was predicted to save 12 (discounted) quality adjusted life years (QALYs) compared with femoral access PCI. Cost savings (discounted) amounted to AUD $51,305. Hence from a health economic point of view, radial access PCI was dominant over femoral access PCI. Sensitivity analyses supported the robustness of these findings. Radial access PCI is likely to be associated with both better outcomes and lower costs compared to femoral access PCI over 2 years post procedure. In conclusion, these findings support radial access being the preferred approach in PCI for ACS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This meta-analysis was performed to compare the safety, efficacy, and pharmacoeconomic of bivalirudin versus heparin in high-risk patients for percutaneous coronary interventions (PCI). Earlier meta-analysis comparing bivalirudin and heparin during PCI demonstrated that bivalirudin caused less bleeding with more stent thrombosis. However, little data were available on the safety of bivalirudin versus heparin in high-risk patients for PCI. Thus, we performed a meta-analysis to evaluate the efficacy and safety in the "high-risk" patients. A systematic search of electronic databases was conducted up to July 30, 2020. The Cochrane Risk of Bias assessment tool was used to assess the quality of included studies. The primary outcomes were all-cause death and major adverse cardiac events (MACE); secondary outcomes were major and minor bleeding, followed by a cost-minimization analysis comparing bivalirudin and heparin using a local drug and medical costs reported in China. Subgroup analysis was based on the type of disease of the high-risk population. Finally, a total of 10 randomized controlled trials involved 42,699 patients were collected. The Cochrane Risk of Bias Tool was employed to appraise the research quality. No significant difference was noted between bivalirudin and heparin regarding all-cause death and MACE. However, subgroup analysis showed that bivalirudin caused less major bleeding in female (OR:0.65, 95% CI:0.53-0.79), diabetes (OR:0.55, 95%CI:0.42-0.73), and CKD (OR:0.59, 95%CI:0.63-1.65). The scatterers of the included literature were approximately symmetrical, and no research was outside the funnel plot. Additionally, cost-minimization analysis showed that heparin was likely to represent a cost-effective option compared with bivalirudin in China, with potential savings of 2129.53 Chinese Yuan (CNY) per patient for one PCI. Overall, the meta-analysis showed that although bivalirudin appeared to have a lower risk of major bleeding rate, the overall effectiveness and safety between the two groups showed no significant difference in high-risk patients for PCI. But the results of the cost-minimization analysis showed that heparin could be a potential cost-saving drug than bivalirudin in patients for PCI in China., (© 2021 The Authors. Pharmacology Research & Perspectives published by British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics and John Wiley & Sons Ltd.)

Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.

Although some studies have assessed the cost-effectiveness of percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI), there has been a lack of nationwide real-world studies estimating life expectancy (LE), loss-of-LE, life-years saved, and lifetime medical costs. We evaluated the cost-effectiveness of PCI versus non-PCI therapy by integrating a survival function and mean-cost function over a lifelong horizon to obtain the estimations for AMI patients without major comorbidities. We constructed a longitudinal AMI cohort based on the claim database of Taiwan's National Health Insurance during 1999-2015. Taiwan's National Mortality Registry Database was linked to derive a survival function to estimate LE, loss-of-LE, life-years saved, and lifetime medical costs in both therapies. This study enrolled a total of 38,441 AMI patients; AMI patients receiving PCI showed a fewer loss-of-LE (3.6 versus 5.2 years), and more lifetime medical costs (US$ 49,112 versus US$ 43,532). The incremental cost-effectiveness ratio (ICER) was US$ 3488 per life-year saved. After stratification by age, the AMI patients aged 50-59 years receiving PCI was shown to be cost-saving. From the perspective of Taiwan's National Health Insurance, PCI is cost-effective in AMI patients without major comorbidities. Notably, for patients aged 50-59 years, PCI is cost-saving.

Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline-concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee-for-service patients ≥65 years. Methods and Results Using data from the Colorado All-Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high-value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low-value test that provides minimal patient benefit: stress testing prior to low-risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee-for-service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high-value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73-0.98]; P =0.03) and heart failure (OR, 0.59 [0.51-0.70]; P <0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high-value testing for acute myocardial infarction (OR, 1.35 [1.15-1.59]; P <0.01) and less likely to receive low-value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55-0.72]; P <0.01) compared with Medicare fee-for-service patients. Conclusions Guideline-concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee-for-service Medicare. Insurance plan features may provide valuable targets to improve guideline-concordant testing.

Patients undergoing percutaneous coronary intervention (PCI) have an increased risk of both ischemic events and bleeding complications resulting from antithrombotic therapy. These events are particularly common in patients with a concomitant indication for oral anticoagulation, such as those with atrial fibrillation, and are associated with a substantial healthcare resource burden. Advances in procedural aspects of PCI have led to marked improvements in outcomes and a consequent reduction in the costs resulting from PCI-associated complications. Furthermore, recent randomized clinical trials have investigated the optimal antithrombotic strategy in the specific case of patients with atrial fibrillation undergoing PCI, leading to a shift toward the tailoring of antithrombotic therapy according to the patient's individual stroke and bleeding risks. Here we review these recent advances, with a particular focus on the improvements in antithrombotic strategies offered by the non-vitamin K antagonist oral anticoagulants., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: Blacks are more likely to live in poverty and be uninsured, and are less likely to undergo revascularization after am acute myocardial infarction compared to whites. The objective of this study was to determine whether Medicaid expansion was associated with a reduction in revascularization disparities in patients admitted with an acute myocardial infarction., Methods: Retrospective analysis study using data (2010-2018) from hospitals participating in the University Health Systems Consortium, now renamed the Vizient Clinical Database. Comparative interrupted time series analysis was used to compare changes in the use of revascularization therapies (PCI and CABG) in white versus non-Hispanic black patients hospitalized with either ST-segment elevation (STEMI) or non-ST-segment elevation acute myocardial infarctions (NSTEMI) after Medicaid expansion., Results: The analytic cohort included 68,610 STEMI and 127,378 NSTEMI patients. The percentage point decrease in the uninsured rate for STEMIs and NSTEMIs was greater for blacks in expansion states compared to whites in expansion states. For patients with STEMIs, differences in black versus white revascularization rates decreased by 2.09 percentage points per year (95% CI, 0.29-3.88, P = 0.023) in expansion versus non-expansion states after adjusting for patient and hospital characteristics. Black patients hospitalized with STEMI in non-expansion states experienced a 7.24 percentage point increase in revascularization rate in 2014 (95% CI, 2.83-11.7, P < 0.001) but did not experience significant annual percentage point increases in the rate of revascularization in subsequent years (1.52; 95% CI, -0.51-3.55, P = 0.14) compared to whites in non-expansion states. Medicaid expansion was not associated with changes in the revascularization rate for either blacks or whites hospitalized with NSTEMIs., Conclusion: Medicaid expansion was associated with greater reductions in the number of uninsured blacks compared to uninsured whites. Medicaid expansion was not associated, however, with a reduction in revascularization disparities between black and white patients admitted with acute myocardial infarctions., Competing Interests: Our affiliation with RAND and Vizient does not alter our adherence to PLOS ONE policies on sharing data and materials.

Aims: The Stent for Life initiative aims at the reduction of mortality in patients with ST-elevation myocardial infarction by enhancing timely access to primary percutaneous coronary intervention. To assess the associated health and socioeconomic impact, the Stent for Life economic project was launched and applied to four model regions: Romania, Portugal, the Basque Country in Spain, and the Kemerovo region in the Russian Federation., Methods and Results: The Stent for Life economic model is based on a decision tree that incorporates primary percutaneous coronary intervention rates and mortality. Healthcare costs and indirect costs caused by loss of productivity were estimated. A baseline scenario simulating the status quo was compared to the Stent for Life scenario which integrated changes initiated by the Stent for Life programme. In the four model regions, primary percutaneous coronary intervention numbers rose substantially between 29-303%, while ST-elevation myocardial infarction mortality was reduced between 3-10%. Healthcare costs increased by 8% to 70%. Indirect cost savings ranged from 2-7%. Net societal costs were reduced in all model regions by 2-4%., Conclusion: The joint effort of the Stent for Life initiative and their local partners successfully saves lives. Moreover, the increase in healthcare costs was outweighed by indirect cost savings, leading to a net cost reduction in all four model regions. These findings demonstrate that systematic investments to improve the access of ST-elevation myocardial infarction patients to guideline-coherent therapy is beneficial, not only for the individual, but also for the society at large.

Purpose: Two randomized controlled trials (RCTs), Mitra-Fr and Coapt, evaluating the benefit of percutaneous repair (PR) for heart failure (HF) patients with severe mitral regurgitation, have led to conflicting results. We aimed to evaluate the impact of these trial results on the cost-effectiveness of PR using effectiveness inputs from the two RCTs., Methods: We developed a time varying Markov type model with three mutually exclusive health states: alive without HF hospitalisation, alive with HF hospitalisation, and dead. Clinically plausible extrapolations beyond observed data were obtained by developing parametric modelling for overall survival and HF hospitalisations using published data from each trial. We adopted the perspective of the French Health System and used a 30-year time horizon. Results were expressed as € / quality-adjusted life year (QALY) gained using utility inputs from literature., Findings: Results are presented using treatment efficacy measures from Mitra-F and Coapt trials respectively. With the Mitra-Fr data, after annual discounting, the base case model generated an incremental 0.00387 QALY at a cost of €25,010, yielding an incremental cost effectiveness ratio (ICER) of €6,467,032 / QALY. The model was sensitive to changes made to model inputs. There was no potential of PR being cost-effective. With the Coapt data, the model generated 1.19 QALY gain at a cost of €26,130 yielding an ICER of €21,918 / QALY and at a threshold of >€50,000/QALY PR had a probability of 1 of being cost-effective., Implications: Cost effectiveness results were conflicting; reconciling differences between trials is a priority and could promote optimal cost effectiveness analyses and resource allocation., Competing Interests: The authors have read the journal's policy and declare the following competing interests: X.A. is a member of the steering committee of the Mitra-FR study. J.F.O. is the principal investigator of the Mitra-FR study and reports personal fees from Abbott Vascular, Delacroix-Chevalier, Landanger, and Medtronic, outside the submitted work. There are no patents associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Objectives: To assess national trends of acute kidney injury (AKI) incidence, incremental costs, risk factors, and readmissions among patients undergoing coronary angiography (CAG) and/or percutaneous coronary intervention (PCI) during 2012-2017., Background: AKI remains a serious complication for patients undergoing CAG/PCI. Evidence is lacking in contemporary AKI trends and its impact on hospital resource utilization., Methods: Patients who underwent CAG/PCI procedures in 749 hospitals were identified from Premier Healthcare Database. AKI was defined by ICD-9/10 diagnosis codes (584.9/N17.9, 583.89/N14.1, 583.9/N05.9, E947.8/T50.8X5) during 7 days post index procedure. Multivariable regression models were used to adjust for confounders., Results: Among 2,763,681 patients, AKI incidence increased from 6.0 to 8.4% or 14% per year in overall patients; from 18.0 to 28.4% in those with chronic kidney disease (CKD) and from 2.4 to 4.2% in those without CKD (all p < .001). Significant risk factors for AKI included older age, being uninsured, inpatient procedures, CKD, anemia, and diabetes (all p < .001). AKI was associated with higher 30-day in-hospital mortality (OR adjusted = 2.55; 95% CI: 2.40, 2.70) and readmission risk (OR adjusted = 1.52; 95% CI: 1.50, 1.55). The AKI-related incremental cost during index visit and 30-day readmissions were estimated to be $8,416 and $580 per inpatient procedure and $927 and $6,145 per outpatient procedure. Overall excess healthcare burden associated with AKI was $1.67 billion., Conclusions: AKI incidence increased significantly in this large, multifacility sample of patients undergoing CAG/PCI procedures and was associated with substantial increase in hospital costs, readmissions, and mortality. Efforts to reduce AKI risk in US healthcare system are warranted., (© 2020 Wiley Periodicals, Inc.)

Objectives: We sought to assess the national trends in the utilization and outcomes of percutaneous coronary interventions (PCI) in patients with cirrhosis., Background: Contemporary data on PCI in patients with liver cirrhosis are limited., Methods: The National-Inpatient-Sample was used to identify patients who underwent PCI between 2003 and 2016. We examined the annual PCI rate, and compared the in-hospital morbidity, mortality, resource utilization, and cost following PCI in patients with and without cirrhosis., Results: A total of 8,860,178 PCI hospitalizations were identified, of those, 20,339 (0.2%) were performed in patients with cirrhosis. Annual PCI rates decreased overtime in patients without liver cirrhosis but increased in those with cirrhosis (P trend < .001). Patients with cirrhosis had a characteristic clinical, demographic, and socioeconomic profile compared with those without cirrhosis. The use of bare-metal stents decreased from 69.1 to 11.4% in the noncirrhosis group, and from 81.9 to 21.3% in the cirrhosis group. Compared with propensity-matched patients without cirrhosis, PCI in cirrhotic patients was associated with higher in-hospital mortality across all indications (STEMI 19.1 vs. 11.5%, p = .002; NSTEMI 8.7 vs. 5.6%, p = .002; and UA/SIHD 7.7 vs. 4.3%, p < .001). Cirrhotic patients also had significantly higher rates of acute kidney injury, but similar rates of vascular complications and stroke. Additionally, cirrhotic patients had longer hospitalizations, were less likely to be discharged home, and accrued higher cost across all PCI indications., Conclusions: Patients with cirrhosis who are deemed "suitable PCI candidates" in current practice remain at high-risk for worse short-term morbidity and mortality, and higher cost of care., (© 2019 Wiley Periodicals, Inc.)

Background: The Center for Medicare and Medicaid Innovation launched the Bundled Payments for Care Initiative (BPCI) in 2013. Its effect on payments and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown., Methods and Results: We used Medicare inpatient files to identify index admissions for PCI and CABG from 2013 through 2016 at BPCI hospitals and matched control hospitals and difference in differences models to compare the 2 groups. Our primary outcome was the change in standardized Medicare-allowed payments per 90-day episode. Secondary outcomes included changes in patient selection, discharge to postacute care, length of stay, emergency department use, readmissions, and mortality. Forty-two hospitals joined BPCI for PCI and 46 for CABG. There were no differential changes in patient selection between BPCI and control hospitals. Baseline Medicare payments per episode for PCI were $20 164 at BPCI hospitals and $19 955 at control hospitals. For PCI, payments increased at both BPCI and control hospitals during the intervention period, such that there was no significant difference in differences (BPCI hospitals +$673, P =0.048; control hospitals +$551, P =0.022; difference in differences $122, P =0.768). For CABG, payments at both BPCI and control hospitals decreased during the intervention period (BPCI baseline, $36 925, change -$2918, P <0.001; control baseline, $36 877, change -$2618, P <0.001; difference in differences, $300; P =0.730). For both PCI and CABG, BPCI participation was not associated with changes in mortality, readmissions, or length of stay. Among BPCI hospitals, emergency department use differentially increased for patients undergoing PCI and decreased for patients undergoing CABG., Conclusions: Participation in episode-based payment for PCI and CABG was not associated with changes in patient selection, payments, length of stay, or clinical outcomes.

Introduction: Non-primary percutaneous coronary intervention (non-PPCI) recently received certificate of need approval in the state of Michigan at sites without cardiac surgery on-site (cSoS). This requires quality oversight through participation in the BMC2 registry. While previous studies have indicated the safety of this practice, real-world comprehensive outcomes, case volume changes, economic impacts, and readmission rates at diverse healthcare centers with and without cSoS remain poorly understood., Methods: Consecutive patients undergoing non-PPCI at 47 hospitals (33 cSoS and 14 non-cSoS) in Michigan from April 2016 to March 2018 were included. Using propensity-matching, patients were analyzed to assess outcomes and trends in non-PPCI performance at sites with and without cSOS., Results: Of 61,864 PCI's performed, 50,817 were non-PPCI, with 46,096 (90.7%) performed at sites with cSoS and 4,721 (9.3%) at sites without cSoS. From this cohort, 4,643 propensity-matched patients were analyzed. Rates of major adverse cardiac events (2.6% vs. 2.8%; p = 0.443), in-hospital mortality (0.6% vs. 0.5%; p = 0.465), and several secondary clinical and quality outcomes showed no clinically significant differences. Among a small subset with available post-discharge data, there were no differences in 90-day readmission rates, standardized episode costs, or post-discharge mortality. Overall PCI volume remained stable, with a near three-fold rise in non-PPCI at sites without cSoS., Conclusions: Non-PPCI at centers without cardiac SoS was associated with similar comprehensive outcomes, quality of care, 90-day episode costs, and post-discharge mortality compared with surgical sites. Mandatory quality oversight serves to maintain appropriate equivalent outcomes and may be considered for other programs, including the performance of non-PPCI at ambulatory surgical centers in the near future., Competing Interests: Dr. Hitinder S. Gurm receives research funding from BCBSM and the National Institutes of Health and is a consultant for Osprey Medical. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The other authors do not have any direct onflicts or competing interest that could affect the study or its data presentation.

Background: Despite international growth in the use of same day percutaneous coronary intervention (PCI), its widespread use remains limited. This study sought to determine the prevalence, clinical outcomes and cost implications of same day discharge (SDD) amongst Australian patients undergoing elective PCI., Methods: This is a retrospective, observational cohort study of patients who underwent elective PCI in Victoria between January 2014 and December 2017. Data from this study was obtained from the Victorian Cardiac Outcomes Registry (VCOR). The primary outcome measured was the incidence of 30-day major adverse cardiac events (MACE) and secondary outcomes included in hospital complications and 30-day readmissions, between SDD patients and those observed as inpatients overnight (ON). Propensity score matching for key clinical factors were used to compare both groups., Results: We studied 18,101 patients, with a mean age of 68±11years and 13,935 (77%) were male. The rate of SDD was 586 (3.2%) and 17,515 (96.8%) patients stayed in hospital overnight. Radial access was performed in 393 (67.1%) and 7,967 (45.5%) among SDD and ON patients respectively (p<0.001). At 30 days, unplanned cardiac re-hospitalisation occurred in 9.6% (n=56) amongst SDD and 11.6%, (n=2,033) amongst ON patients (p=0.173). Propensity matching highlighted SDD to be non-inferior to overnight, with no significant difference in 30-day MACE (0.5%, 95% CI: 0.34, 1.35) but SDD was associated with reduced average length of stay by 2.06 days (95% CI: 1.94, 2.19). We observed substantial hospital variation for SDD from 0% to 16.6% of elective PCI procedures., Conclusions: Same day discharge after elective PCI is performed infrequently in Victoria. Despite this, SDD appears to be safe and feasible. Given significant benefits in cost and bed utilisation, a more consistent use of SDD could markedly improve the value of PCI care in Australia., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Several studies have investigated early readmissions after percutaneous coronary interventions (PCIs). However, studies investigating 30-day readmission following PCI for chronic total occlusion (CTO) are lacking., Methods: The National-Readmission-Database (NRD) was queried to identify patients undergoing elective CTO PCI between January 1, 2016 and December 31, 2016. We assessed the incidence, predictors, and cost of 30-day readmissions., Results: A total of 30,579 CTO PCIs were identified in the NRD. After excluding patients who had acute myocardial infarction (n = 14,852), the final cohort included 15,907 patients. In this group of patients, 254 patients (1.5%) expired during their index admission and, 1600 patients (10%) had an unplanned readmission within 30 days. Cardiac causes constituted 54.2% of all causes of readmission. During the readmission, 15.8% of patients had coronary angiography, 8.4% underwent PCI, and 0.9% underwent bypass grafting. Independent predictors of 30-day readmission included baseline characteristics [age (OR 0.99, 95%CI 0.98-0.99), female (OR 1.14, 95%CI 1.01-1.28), lung disease (OR 1.36, 95%CI 1.20-1.55), heart failure (OR 1.42, 95%CI 1.24-1.62), anemia (OR 1.30, 95%CI 1.12-1.50), vascular disease (OR 1.18, 95%CI 1.03-1.35), history of stroke (OR 1.50, 95%CI 1.28-1.76) and the presence of a defibrillator (OR 1.68, 95%CI 1.39-2.03)], and procedural complications [acute kidney injury (OR 1.55, 95%CI 1.33-1.80) and gastrointestinal bleeding (OR 1.67, 95%CI 1.03-2.71)]., Conclusions: One-tenth of patients undergoing CTO PCI are readmitted within 30-days, mostly for cardiac causes. The majority undergo angiography but <10% receive revascularization. Certain patient and procedural characteristics independently predicted 30-day readmission., (Copyright © 2019 Elsevier Inc. All rights reserved.)

There is growing awareness that frailty may be an important marker of adverse outcomes in PCI but there is no literature from national cohorts. This study examines a national cohort of patients who underwent percutaneous coronary intervention (PCI) regarding the prevalence of frailty, changes over time, and associated outcomes. The National Inpatients Sample was used to identify adults who underwent PCI procedures between 2004 and 2014. Frailty risk was measured using a validated Hospital Frailty Risk Score (HFRS) using the cutoffs <5, 5-15 and >15 for low, intermediate and high HFRS. From 7,306,007 admissions, a total of 94.58% of admissions were for patients who had a low HFRS(<5), 5.39% had an intermediate HFRS(5-15) and 0.03% had a high HFRS(>15). The prevalence of intermediate or high frailty risk patients has increased over time from 1.9% in 2004 to 11.7% in 2014. The incidence of in-hospital death increased from 1.0% with low HFRS to 13.9% with high HFRS. Mean length of stay also increased from 2.9 days to 17.1 days from low to high HFRS. High frailty risk was independently associated with an OR 9.91 95%CI 7.17-13.71 for in-hospital death, OR 4.99 95%CI 3.82-6.51 for bleeding and OR 3.96 95%CI 3.00-5.23 for vascular injury as compared to patients with low risk of HFRS. While rare in frequency overall, frailty is increasing in prevalence in recent years and intermediate and high HFRS associated with increased odds of mortality compared to low risk of frailty., Competing Interests: Declaration of competing interest The authors report no relationships that could be construed as a conflict of interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The aim was to analyze the cost-effectiveness ratio (CER) of stress electrocardiogram (ES) and stress myocardial perfusion imaging (SPECT-MPI) according to coronary revascularization (CR) therapy, cardiac events (CE) and total mortality (TM)., Material and Methods: A total of 8,496 consecutive patients who underwent SPECT-MPI were followed-up (mean 5.3±3.5years). Cost-effectiveness for coronary bypass (CABG) or percutaneous CR (PCR) (45.6%/54.4%) according to combined electrocardiographic ischemia and scintigraphic ischemia were evaluated. Effectiveness was evaluated as TM, CE, life-year saved observed (LYSO) and CE-LYSO; costs analyses were conducted from the perspective of the health care payer. A sensitivity analysis was performed considering current CABG/PCR ratios (12%/88%)., Results: When electrocardiogram and SPECT approaches are combined, the cost-effectiveness values for CABG ranged between 112,589€ (electrocardiographic and scintigraphic ischemia) and 2,814,715€ (without ischemia)/event avoided, 38,664 and 2,221,559€/LYSO; for PCR ranged between 18,824€ (electrocardiographic and scintigraphic ischemia) and 46,377€ (without ischemia)/event avoided, 6,464 and 36,604€/LYSO. To CE: the cost-effectiveness values of the CABG and CPR in presence of electrocardiographic and scintigraphic ischemia were 269,904€/CE-avoided and 24,428€/CE-avoided, respectively; and the €/LYSO of the CABG and PCR were 152,488 and 13,801, respectively. The RCE was maintained for the current proportion of revascularized patients (12%/88%)., Conclusions: Combined ES and SPECT-MPI results, allows differentiation between patient groups, where the PCR and CABG are more cost-effective in different economic frameworks. The major CER in relation to CR, CE and TM occurs in patients with electrocardiographic and scintigraphic ischemia. PCR is more cost-effective than CABG., (Copyright © 2020 Sociedad Española de Medicina Nuclear e Imagen Molecular. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The recent BIOFLOW V trial (ClinicalTrials.gov: NCT02389946) showed that revascularization with an ultrathin strut, bioresorbable polymer sirolimus-eluting stent (BP SES) was associated with lower rates of clinically driven target lesion revascularization (TLR) and target vessel-related myocardial infarction (TVMI) at 24-month follow-up than that with a thin strut, durable polymer everolimus-eluting stent (DP EES). We simulated the impact on cost and mortality., Methods and Results: We projected the impact of the lower adverse event rates from a U.S. health system perspective over a 48-month horizon with a Markov model using event data from the BIOFLOW V trial and estimates for costs and excess mortality due to adverse events from published sources. All cost estimates were CPI-adjusted to 2018 US$ and future cost discounted by 3%. We estimated that use of BP SES compared to DP EES was associated with cumulative net reductions in medical cost of $2429 per patient over 48 months. Peri-procedural TVMI contributed $124 (5%), TLR in patients without TVMI $810 (33%) and spontaneous TVMI $1496 (62%) of cost. Use of BP SES compared to DP EES was associated with 2603 fewer deaths in one million patients over four years, corresponding to a relative risk reduction of 6%., Conclusions: Lower adverse event rates associated with revascularization using BP SES translate into reductions in direct medical cost and mortality. Most of the cost reduction is attributed to reduction in spontaneous TVMI. Given the high volume of coronary procedures, such results are an important consideration for patients, clinicians and payers., Competing Interests: Declaration of competing interest Supported through a contract from BIOTRONIK to Benecit Research. The sponsor provided comments on an earlier draft of the paper, but the authors had full control over study design and execution, interpretation of the data, preparation, review and approval of the manuscript and decision to submit. Soeren Mattke serves on the board of directors of Senscio Systems, Inc. and the scientific advisory board of aicure technologies, Boston Millennia Partners and ZanoZano. He has received consulting fees from AARP, Biotronik, Bristol-Myers Squibb, and Defined Health. Mark Hanson has received consulting fees from Biotronik. Marc Bentele is an employee of Biotronik. David Kandzari reports institutional research/grant support from Biotronik, Boston Scientific, Medinol, Medtronic, and Orbus Neich; and personal consulting honoraria from Biotronik, Cardiovascular Systems, Inc. and Medtronic., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To investigate the differences in risk factors and in-hospital outcomes for women undergoing percutaneous coronary intervention (PCI) and peripheral vascular intervention (PVI)., Background: The clinical impact of coronary artery disease (CAD) and peripheral artery disease (PAD) is well characterized and is associated with high morbidity and mortality. There is lack of data comparing risk factors and in-hospital outcomes for PCI and PVI, particularly in women., Methods: Only female hospitalizations (age ≥ 18 years) who underwent PCI or PVI from 2005 to 2014 were identified using appropriate International Classification of Diseases-Ninth Revision, Clinical Modification codes from the National Inpatient Sample database. Charlson's Comorbidity Index (CCI) was selected as the primary endpoint of the study. Coprimary endpoint was the cost of hospitalizations associated with PCI or PVI., Results: Of the 2,461,328 female hospitalizations that were included, 85.6% (N = 2,105,236) underwent PCI and 14.4% (N = 356,092) received PVI. Compared to PCI, PVI hospitalizations were 3.2 years older (p < .001) and consisted of significantly more hospitalizations above 80 years of age (26.5% vs. 18.6%; p < .001). Hospitalizations with CCI ≥3 were significantly higher in the PVI cohort (29.1% vs. 24%; p < .001). CCI in women increased during the study period for both groups. PVI hospitalizations had a significantly longer length of stay (3 days vs. 2 days; p < .001) and cost of hospitalization ($23,610 vs. $20,571; p < .001), compared to PCI. Finally, the mean cost of hospitalizations increased during the study period for PCI and PVI., Conclusion: Women hospitalized for PVI had a greater risk-profile and resource utilization as demonstrated by the longer length of stay and higher cost compared to PCI., (© 2019 Wiley Periodicals, Inc.)

Aims: The Compare-Acute trial showed superiority of fractional flow reserve (FFR)-guided acute complete revascularisation compared to culprit-only treatment in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) at one year. The aim of this study was to investigate the outcome at three years, together with cost analysis of this strategy., Methods and Results: After primary percutaneous coronary intervention (PCI), 885 patients with STEMI and MVD were randomised (1:2 ratio) to FFR-guided complete revascularisation (295 patients) or infarct-related artery (IRA)-only treatment (590 patients). After 36 months, the primary endpoint (composite of death, myocardial infarction, revascularisation, stroke) occurred significantly less frequently in the FFR-guided complete revascularisation group: 46/295 patients (15.6%) versus 178/590 patients (30.2%) (HR 0.46, 95% CI: 0.33-0.64; p<0.001). This benefit was driven mainly by the reduction of revascularisations in the follow-up (12.5% vs 25.2%; HR 0.45, 95% CI: 0.31-0.64; p<0.001). Cost analysis shows benefit of the FFR-guided complete revascularisation strategy, which can reduce the cost per patient by up to 21% at one year (8,150€ vs 10,319€) and by 22% at three years (8,653€ vs 11,100€)., Conclusions: In patients with STEMI and MVD, FFR-guided complete revascularisation is more beneficial in terms of outcome and healthcare costs compared to IRA-only revascularisation at 36 months.

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

Background Readmission after ST-segment-elevation myocardial infarction (STEMI) poses an enormous economic burden to the US healthcare system. There are limited data on the association between length of hospital stay (LOS), readmission rate, and overall costs in patients who underwent primary percutaneous coronary intervention for STEMI. Methods and Results All STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. From the patients who underwent primary percutaneous coronary intervention, we examined the 30-day outcomes including readmission, mortality, reinfarction, repeat revascularization, and hospital charges/costs according to LOS (1-2, 3, 4, 5, and >5 days) stratified by infarct locations. The 30-day readmission rate after percutaneous coronary intervention for STEMI was 12.0% in the anterior wall (AW) STEMI group and 9.9% in the non-AW STEMI group. Patients with a very short LOS (1-2 days) were readmitted less frequently than those with a longer LOS regardless of infarct locations. However, patients with a very short LOS had significantly increased 30-day readmission mortality versus an LOS of 3 days (hazard ratio, 1.91; CI, 1.16-3.16 [ P =0.01]) only in the AW STEMI group. Total costs (index admission+readmission) were the lowest in the very short LOS cohort in both the AW STEMI group ( P <0.001) and the non-AW STEMI group ( P <0.001). Conclusions For patients who underwent primary percutaneous coronary intervention for STEMI, a very short LOS was associated with significantly lower 30-day readmission and lower cumulative cost. However, a very short LOS was associated with higher 30-day mortality compared with at least a 3-day stay in the AW STEMI cohort.

Purpose of Review: Shorter hospital stay after percutaneous coronary intervention (PCI) can provide economic advantage. Same-day discharge (SDD) after transradial PCI is thought to reduce the cost of care while maintaining the quality and safety. This review summarizes the current knowledge of the benefits and safety of this concept., Recent Findings: Increase in rate of transradial PCI over the last two decades has resulted in recent growth in rate of acceptance of SDD after a successful procedure. SDD is shown to result in savings of $3500 to $5200 per procedure with comparable adverse event rate of traditional discharge processes. SDD after PCI is shown to be safe and results in cost advantage maintaining the safety profile. The acceptance rate of SDD is still not optimum, and further market penetration of SDD practice would be achieved only if the institutional and operator preference barriers are addressed.

Importance: More than 1 million US veterans are dually enrolled in a Medicare Advantage (MA) plan and in the Veterans Affairs (VA) health care system. The federal government prepays private MA plans to cover veterans; if a dually enrolled veteran receives an MA-covered service at the VA, the government is making 2 payments for the same service. It is not clear what proportion of veterans dually enrolled in VA and MA are undergoing coronary revascularization at VA vs non-VA hospitals., Objective: To describe where veterans who are enrolled in both VA and MA undergo coronary revascularization and the associated costs., Design, Settings, and Participants: This is a cohort study consisting of US veterans dually enrolled in VA and MA from January 1, 2010, to December 31, 2013, who had at least 1 VA encounter and underwent coronary revascularization during the study period. Data were analyzed from April 2019 to September 2019., Main Outcomes and Measures: Number of coronary artery bypass graft (CABG) operations and percutaneous coronary interventions (PCIs) performed through the VA and through MA during years 2010 to 2013, and the associated VA costs of coronary revascularization. In addition, multivariable logistic regression was performed to assess patient factors associated with receiving care through the VA., Results: A total of 18 874 VA users with concurrent MA enrollment who underwent coronary revascularization during 2010 to 2013 were identified (mean [SD] age, 75.3 [8.8] years; 18 739 men [99.0%]). Enrollees were predominantly white (17 457 patients [92.0%]). Among patients, 4115 (22.0%) underwent either CABG or PCI through the VA only, 14 281 (75.0%) did so through MA only, and 478 (2.5%) underwent coronary revascularization procedures through both payers. From 2010 to 2013, these veterans underwent 4764 coronary revascularization procedures (721 CABGs and 3043 PCIs) that cost the VA $214.7 million ($115.8 million for CABGs and $99.0 million for PCIs). In multivariable analysis, nonwhite patients were more likely than white patients to undergo coronary revascularization through the VA (odds ratio, 1.73; 95% CI, 1.52-1.96; P < .001), and for each year of age, veterans were less likely to undergo coronary revascularization through the VA (odds ratio, 0.95; 95% CI, 0.94-0.95; P < .001). There was no statistically significant association between undergoing coronary vascularization through the VA and distance in miles to the nearest VA hospital (odds ratio, 1.00; 95% CI, 0.99-1.00; P = .30)., Conclusions and Relevance: A substantial share of VA users concurrently enrolled in an MA plan underwent coronary revascularization procedures through the VA, incurring significant duplicative federal health care spending. Given the financial pressures facing both Medicare and the VA, government officials should consider policy solutions to mitigate redundant spending.

Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer. Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with '0', 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000-$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71-91%, '0' indications, 49-67%, 1 indication, 56-82%, 2 indications, 70-90%, and ≥3 indications, 97-99%. Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with '0' indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.

BACKGROUND Surgical treatment methods for patients with complex coronary artery disease (CAD) who have undergone vascular reconstruction mainly include coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). The purpose of the study aimed to compare a 1-year follow-up for the patient clinical outcomes and costs between PCI and CABG treatment. MATERIAL AND METHODS There were 840 patients enrolled in this study from July 2015 to September 2016. Among the study participants, 420 patients underwent PCI treatment and 420 patients underwent off-pump CABG. Patients costs were assessed from the perspective of the China healthcare and medical insurance system. EuroQOL 5-dimension 3 levels (EQ-5D-3L) questionnaire was used to evaluate the general health status, and the Seattle Angina Questionnaire (SAQ) was used to assess the disease-specific health status. RESULTS After a 1-year follow-up, the all-cause mortality (P=0.0337), the incidence of major adverse cardiac and cerebrovascular events (P<0.001), and additional revascularization (P<0.001) in PCI group were significantly higher than those in CABG group. Both groups have significant sustained benefits in the SAQ subscale. The CABG group had a higher score on the frequency of angina than the PCI group. In addition, the quality-adjusted life year value of PCI and CABG resulted was 0.8. The average total cost for PCI was $14 643 versus CABG cost of $13 842 (P=0.0492). CONCLUSIONS In the short-term, among the CAD patients with stable triple-vessel or left-main, costs and clinical outcomes are substantially higher for CABG than PCI. Long-term, economic, and health benefits analysis, is warranted.

Background: Impella was approved for mechanical circulatory support (MCS) in 2008, but large-scale, real-world data on its use are lacking. Our objective was to describe trends and variations in Impella use, clinical outcomes, and costs across US hospitals in patients undergoing percutaneous coronary intervention (PCI) treated with MCS (Impella or intra-aortic balloon pump)., Methods: From the Premier Healthcare Database, we analyzed 48 306 patients undergoing PCI with MCS at 432 hospitals between January 2004 and December 2016. Association analyses were performed at 3 levels: time period, hospital, and patient. Hierarchical models with propensity adjustment were used for association analyses. We examined trends and variations in the proportion of Impella use, and associated clinical outcomes (in-hospital mortality, bleeding requiring transfusion, acute kidney injury, stroke, length of stay, and hospital costs)., Results: Among patients undergoing PCI treated with MCS, 4782 (9.9%) received Impella; its use increased over time, reaching 31.9% of MCS in 2016. There was wide variation in Impella use across hospitals (>5-fold variation). Specifically, among patients receiving Impella, there was a wide variation in outcomes of bleeding (>2.5-fold variation), and death, acute kidney injury, and stroke (all ≈1.5-fold variation). Adverse outcomes and costs were higher in the Impella era (years 2008-2016) versus the pre-Impella era (years 2004-2007). Hospitals with higher Impella use had higher rates of adverse outcomes and costs. After adjustment for the propensity score, and accounting for clustering of patients by hospitals, Impella use was associated with death: odds ratio, 1.24 (95% CI, 1.13-1.36); bleeding: odds ratio, 1.10 (95% CI, 1.00-1.21); and stroke: odds ratio, 1.34 (95% CI, 1.18-1.53), although a similar, nonsignificant result was observed for acute kidney injury: odds ratio, 1.08 (95% CI, 1.00-1.17)., Conclusions: Impella use is rapidly increasing among patients undergoing PCI treated with MCS, with marked variability in its use and associated outcomes. Although unmeasured confounding cannot be ruled out, when analyzed by time periods, or at the hospital level or the patient level, Impella use was associated with higher rates of adverse events and costs. More data are needed to define the appropriate role of MCS in patients undergoing PCI.

Objectives: The aim of this study was to compare optical coherence tomographic (OCT) guidance and fractional flow reserve (FFR) guidance in patients with angiographically intermediate coronary lesions (AICLs) in a single-center, prospective, 1:1 randomized trial., Background: FFR and OCT imaging may help both in the assessment of AICLs and in percutaneous coronary intervention optimization., Methods: Patients with AICLs were randomized to FFR or OCT imaging. In the FFR arm, PCI was performed if FFR was ≤0.80. In the OCT imaging arm, PCI was performed if area stenosis was ≥75% or 50% to 75% with minimal luminal area <2.5 mm 2 or plaque rupture. Angina (evaluated using the Seattle Angina Questionnaire), major adverse cardiac events, and cost were assessed at the end of follow-up. The pre-defined primary endpoint was the composite of major adverse cardiac events or significant angina (defined as Seattle Angina Questionnaire frequency scale score <90) at 13 months., Results: A total of 350 patients (with 446 AICLs) were enrolled (176 randomized to FFR and 174 to OCT imaging). The primary endpoint of major adverse cardiac events or significant angina at 13 months occurred in 14.8% of patients in the FFR arm and in 8.0% in the OCT imaging arm (p = 0.048). This result was driven by a statistically nonsignificant lower occurrence of all primary endpoint components. Up to 13 months, the rate of medically managed patients was significantly higher (p < 0.001) and total cost significantly lower (p < 0.001) with FFR in comparison with OCT imaging., Conclusions: In patients with AICLs, OCT guidance is associated with lower occurrence of the composite of major adverse cardiac events or significant angina. FFR guidance is associated with a higher rate of medical management and lower costs. FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty [FORZA]; NCT01824030)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The clinical utility of routine electrocardiographic monitoring following percutaneous coronary interventions (PCI) is not well studied., Methods: We prospectively evaluated the incidence, cost, and the clinical implications of actionable arrhythmia alarms on telemetry monitoring following PCI. One thousand three hundred fifty-eight PCI procedures (989 [72.8%] for acute coronary syndrome and 369 [27.2%] for stable angina) on patients admitted to nonintensive care unit were identified and divided into 2 groups; group 1, patients with actionable alarms (AA) and group 2, patients with non-AA. AA included (1) ≥3 s electrical pause or asystole; (2) high-grade Mobitz type II atrioventricular block or complete heart block; (3) ventricular fibrillation; (4) ventricular tachycardia (>15 beats); (5) atrial fibrillation with rapid ventricular response; (6) supraventricular tachycardia (>15 beats). Primary outcomes were 30-day all-cause mortality. Cost-savings analysis was performed., Results: Incidence of AA was 2.2% (37/1672). Time from end of procedure to AA was 5.5 (0.5, 24.5) hours. Patients with AA were older, presented with acute congestive heart failure or non-ST-segment-elevation myocardial infarction, and had multivessel or left main disease. The 30-day all-cause mortality was significantly higher in patients with AA (6.5% versus 0.3% in non-AA [ P <0.001]). Applying the standardized costing approach and tailored monitoring per the American Heart Association guidelines lead to potential cost savings of $622 480.95 for the entire population., Conclusions: AA following PCI were infrequent but were associated with increase in 30-day mortality. Following American Heart Association guidelines for monitoring after PCI can lead to substantial cost saving.

This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To evaluate the cost-effectiveness of multigene testing (CYP2C19, SLCO1B1, CYP2C9, VKORC1) compared with single-gene testing (CYP2C19) and standard of care (no genotyping) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) from Medicare's perspective., Methods: A hybrid decision tree/Markov model was developed to simulate patients post-PCI for ACS requiring antiplatelet therapy (CYP2C19 to guide antiplatelet selection), statin therapy (SLCO1B1 to guide statin selection), and anticoagulant therapy in those that develop atrial fibrillation (CYP2C9/VKORC1 to guide warfarin dose) over 12 months, 24 months, and lifetime. The primary outcome was cost (2016 US dollar) per quality-adjusted life years (QALYs) gained. Costs and QALYs were discounted at 3% per year. Probabilistic sensitivity analysis (PSA) varied input parameters (event probabilities, prescription costs, event costs, health-state utilities) to estimate changes in the cost per QALY gained., Results: Base-case-discounted results indicated that the cost per QALY gained was $59 876, $33 512, and $3780 at 12 months, 24 months, and lifetime, respectively, for multigene testing compared with standard of care. Single-gene testing was dominated by multigene testing at all time horizons. PSA-discounted results indicated that, at the $50 000/QALY gained willingness-to-pay threshold, multigene testing had the highest probability of cost-effectiveness in the majority of simulations at 24 months (61%) and over the lifetime (81%)., Conclusions: On the basis of projected simulations, multigene testing for Medicare patients post-PCI for ACS has a higher probability of being cost-effective over 24 months and the lifetime compared with single-gene testing and standard of care and could help optimize medication prescribing to improve patient outcomes., (Copyright © 2019 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System., Methods: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30 days., Results: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (P < .001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, P = .24; mortality: 0% vs. 0.07%, P = .99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250)., Conclusions: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The treatment of acute coronary syndrome (ACS) using percutaneous coronary intervention (PCI) is a frequent intervention with a high economic impact., Objective: This study investigates the resource use and cost of PCI in Mexico where heart disease is a leading cause of death, and a large segment of the population does not have formal healthcare coverage., Methods: This retrospective observational study obtained resource utilization data from patient files and itemized costs from the pharmacy registry at the National Institute of Cardiology. Patients were aged >18 years, diagnosed with ACS, and treated with PCI and secondary prophylaxis with aspirin plus clopidogrel or prasugrel. Patients had a follow-up of >12 months at the institute. Statistical analysis was descriptive., Results: The sample included 156 patients (mean age: 58.66 years; male: 77.9%). Patients were diagnosed with ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction, and unstable angina 64.9%, 27.2%, and 7.9%, respectively. The mean (standard deviation [SD]) total medical cost was estimated to be $145 677 ($98 326) Mexican pesos 2018. The highest category of spending was surgical materials (mean [SD]: $47 834 [$32 569], comprising 32.8% of total costs); medications and access to the operating room represented 14.2% and 11.8%, respectively. Mean (SD) hospital stay was 9.07 (6.2) days; for the 11.5% of patients admitted to the intensive care unit, the mean (SD) stay was 4.61 (2.06) days. The mean cost of standard hospitalization was $12 572, or 8.6% of spending; intensive care unit hospitalization comprised 17.7% of total costs (mean: $25 802). The cost of the intervention is subsidized up to 95% for patients with a low social economic status, with the exception of surgical materials such as stents. This results in the highest burden component of the intervention being placed on the patient and not the institute., Conclusion: The mean cost per patient shows that PCI is an expensive procedure in Mexico. A lack of subsidies for surgical equipment places a high economic burden on the patient and represents a barrier of access for a vulnerable population that likely increases mortality and morbidity rates in those patients unable to pay for treatment and a potential high burden of debt for those who do pay., (Copyright © 2019 ISPOR--The professional society for health economics and outcomes research. Published by Elsevier Inc. All rights reserved.)

Objective: The fractional flow reserve (FFR) versus angiography for multivessel evaluation (FAME) study has demonstrated that FFR substantially reduces major adverse cardiac events and resource utilization in coronary artery disease (CAD) patients. We aimed to assess the cost utility of FFR in percutaneous coronary interventions (PCI) from the perspective of the Brazilian Public Health System (SUS)., Design: Patient-level cost-utility analysis along the FAME study., Participants: Multivessel coronary artery disease patients., Intervention: PCI, either guided by FFR or by angiography alone., Setting: The procedure costs were based on the mean amount of unitary resource utilization multiplied by the costs from SUS reimbursement list. The utilities were derived using Brazilian weights for time trade-off European Quality of Life-5 Dimensions. The World Health Organization recommendation based on gross domestic product per capita (international dollars [I$] 35 876/quality-adjusted life year [QALY]) was used as willingness-to-pay threshold., Main Outcome Measure: We determined the incremental cost-utility ratio (ICUR) in I$ per QALY gained during the 1-year time horizon., Results: One-year costs were I$ 8931 for the angiography-guided PCI and I$ 8968 for the FFR-guided PCI, resulting in an incremental cost of I$ 37. Effectiveness during 1 year was 0.798 QALYs for angiography-guided PCI and 0.811 for FFR-guided PCI, resulting in an incremental effectiveness of 0.013 QALYs. The base-case ICUR of FFR versus angiography-guided PCI was 2780 I$/QALY. Cost-saving results are achieved with a FFR price reduction of at least 2.2%., Conclusions: Developing countries should give attention to strategies proven to be cost-effective in other health systems. In our analysis, FFR-guided PCI is very cost-effective in the Brazilian SUS and with a minimal price reduction of the device, FFR could be cost saving., (© The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: We aimed to estimate the annual pharmaceutical costs for patients with stable coronary artery disease, using Australian administrative data, comparing patients who had undergone interventional treatment with those had not. We also aimed to compare the duration of dual antiplatelet therapy (DAPT) prescription in the real-world, with recommended guidelines., Design: An observational study using administrative data., Participants: We used data from the QSkin study, a population-based prospective study assessing skin cancer risk. Participants were invited from the Queensland population, not based on perceived skin cancer risk, and had consented to future use of their data for approved research projects., Main Outcome Measures: We calculated 12-month costs of pharmaceutical therapy for coronary artery disease for patients in each of three clinically relevant groups: medical therapy only, following coronary stent implantation and following coronary artery bypass graft surgery. We measured the duration of DAPT following stent implantation and total duration of DAPT, where it was prescribed, in the medical therapy only group., Results: Estimated mean annual pharmaceutical costs were highest in the stent group at AUD$1920, compared with AUD$1481 in the medical therapy group, and AUD$881 in the coronary artery bypass group. There were similar rates of prescriptions of symptom relief drugs following stent insertion, compared with the medical therapy only group. The median duration of DAPT in the stent group was 16, and 31 months in the medical therapy group., Conclusions: Our results suggest that despite the common expectation that the burden of medical therapy is reduced following coronary stent insertion for stable coronary artery disease, this does not occur in practice. Many patients also appear to continue DAPT longer than guidelines recommend, which may put them at unnecessarily elevated risk of bleeding events., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Coronary artery disease (CAD) has significant social and economic implications. It is necessary to create tools to identify the most cost-effectiveness treatments, which can assist clinicians in their therapeutic decisions so that the maximum possible benefit is reached with the lowest possible cost. Effectiveness must be measured by final treatment goals in which the most effective interventions are those with the lowest costs. This study is aimed to systematically review and compare the studies conducted on the cost-effectiveness of the three coronary artery disease treatment strategies (medical treatment, percutaneous coronary intervention, and coronary artery bypass graft). In this systematic review, the databases NHS Economic Evaluation Database, Embase, MEDLINE, Science Direct, and Scopus were searched for studies on the cost-effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) compared to medical therapy (MT) in patients with coronary artery disease between 1 January 2004 to 30 September 2018. The quality appraisal of the included studies was examined using the Consolidated Health Economics Evaluation Reporting Standards (CHEERS) statement. Out of 186 unique retrievals, 8 studies were included. The results showed that the all studies clearly stated the time horizon of the study and included direct medical costs in their analysis. In addition, in most of the studies, quality-adjusted life years (QALY) were the main outcome used for measuring the effectiveness. The studies reported various ranges of the incremental cost-effectiveness ratio (ICER); accordingly, the highest ratio was observed in the USA ($212,800) for PCI v MT and the lowest ratio was observed in Brazil ($4403) for CABG v MT. Although the results of the studies were different in terms of a number of aspects, such as the viewpoint of the study, the study horizons, and the costs of expenditure items, they reached similar results. Based on the result of the present study, it seems that each three treatment strategies for CAD yielded improvements in QALY.

Objective: The authors conducted a retrospective analysis to develop a predictive model consisting of factors associated with extended hospital stay among Medicare beneficiaries undergoing percutaneous coronary intervention (PCI)., Design: Retrospective cohort study., Setting: Multi-institutional., Participants: Data were obtained from the National (Nationwide) Inpatient Sample registry from 2013 to 2014 over a 2-year period., Interventions: None., Measurements and Main Results: The primary outcome was extended hospital stay, which was defined as an inpatient stay greater than 75th percentile for the cohort (≥5 d), among Medicare beneficiaries (fee-for-service and managed care) undergoing PCI. A multivariable logistic regression analysis was built on a training set to develop the predictive model. The authors evaluated model performance with area under the receiver operating characteristic curve (AUC) and performed k-folds cross-validation to calculate the average AUC. The final analysis included 91,880 patients. Inpatient hospital length of stay ranged from 0 to 247 days, with 3 and 5 days as the median and 3rd quartile hospital stay, respectively. The final multivariable analysis suggested that sociodemographic variables, hospital-related factors, and comorbidities were associated with a greater odds of extended hospital stay (all p < 0.05). The use of PCI with drug-eluting stent was associated with a 31% decrease in extended hospital stay (odds ratio 0.69, 95% confidence interval 0.66-0.72; p < 0.001). Model discrimination was deemed excellent with an AUC (95% confidence interval) of 0.814 (0.811-0.817) and 0.809 (0.799-0.819) for the training and testing sets, respectively., Conclusion: The authors' predictive model identified risk factors that have a higher probability of extended hospital stay. This model can be used to improve periprocedural optimization and improved discharge planning, which may help to decrease costs associated with PCIs. Management of Medicare beneficiaries after PCI calls for a multidisciplinary approach among healthcare teams and hospital administrators., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Rationale & Objective: Prior studies suggesting that medical therapy is inferior to percutaneous (percutaneous coronary intervention [PCI]) or surgical (coronary artery bypass grafting [CABG]) coronary revascularization in chronic kidney disease (CKD) have not adequately considered medication optimization or baseline cardiovascular risk and have infrequently evaluated progression to kidney failure. We compared, separately, the risks for kidney failure and death after treatment with PCI, CABG, or optimized medical therapy for coronary disease among patients with CKD stratified by cardiovascular disease risk., Study Design: Retrospective cohort study., Setting & Participants: 34,385 individuals with CKD identified from a national 20% Medicare sample who underwent angiography or diagnostic stress testing without (low risk) or with (medium risk) prior cardiovascular disease or who presented with acute coronary syndrome (high risk)., Exposures: PCI, CABG, or optimized medical therapy (defined by the addition of cardiovascular medications in the absence of coronary revascularization)., Outcomes: Death, kidney failure, composite outcome of death or kidney failure., Analytical Approach: Adjusted relative rates of death, kidney failure, and the composite of death or kidney failure estimated from Cox proportional hazards models., Results: Among low-risk patients, 960 underwent PCI, 391 underwent CABG, and 6,426 received medical therapy alone; among medium-risk patients, 1,812 underwent PCI, 512 underwent CABG, and 9,984 received medical therapy alone; and among high-risk patients, 4,608 underwent PCI, 1,330 underwent CABG, and 8,362 received medical therapy alone. Among low- and medium-risk patients, neither CABG (HRs of 1.22 [95% CI, 0.96-1.53] and 1.08 [95% CI, 0.91-1.29] for low- and medium-risk patients, respectively) nor PCI (HRs of 1.14 [95% CI, 0.98-1.33] and 1.02 [95% CI, 0.93-1.12], respectively) were associated with reduced mortality compared with medical therapy, but in low-risk patients, CABG was associated with a higher rate of the composite, death or kidney failure (HR, 1.25; 95% CI, 1.02-1.53). In high-risk patients, CABG and PCI were associated with lower mortality (HRs of 0.57 [95% CI, 0.51-0.63] and 0.70 [95% CI, 0.66-0.74], respectively). Also, in high-risk patients, CABG was associated with a higher rate of kidney failure (HR, 1.40; 95% CI, 1.16-1.69)., Limitations: Possible residual confounding; lack of data for coronary angiography or left ventricular ejection fraction; possible differences in decreased kidney function severity between therapy groups., Conclusions: Outcomes associated with cardiovascular therapies among patients with CKD differed by baseline cardiovascular risk. Coronary revascularization was not associated with improved survival in low-risk patients, but was associated with improved survival in high-risk patients despite a greater observed rate of kidney failure. These findings may inform clinical decision making in the care of patients with both CKD and cardiovascular disease., (Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Clopidogrel is an antiplatelet drug given to patients before and after having a percutaneous coronary intervention (PCI). Genomic variants in the CYP2C19 gene are associated with variable enzyme activities affecting drug metabolism and hence, patients with reduced or increased enzymatic function have increased risk of bleeding. We conducted a cost-effectiveness analysis to compare a pharmacogenomics versus a non-pharmacogenomics-guided clopidogrel treatment for coronary artery syndrome patients undergoing PCI in the Spanish healthcare setting. A total of 549 patients diagnosed with coronary artery disease followed by PCI were recruited. Dual antiplatelet therapy was administrated to all patients from 1 to 12 months after PCI. Patients were classified into two groups: the Retrospective group was treated with clopidogrel based on the clinical routine practice and the Prospective group were initially genotyped for the presence of CYP2C19 variant alleles before treatment with those carrying more than one CYP2C19 variant alleles given prasugrel treatment. We collected data on established clinical and health outcome measures, including, per treatment arm: the percentage of patients that suffered from (a) myocardial infraction, (b) major bleeding and minor bleeding, (c) stroke, (d) the number of hospitalization days, and (e) the number of days patients spent in Intensive Care Unit. Our primary outcome measure for the cost-effectiveness analysis was Quality Adjusted Life Years (QALYs). To estimate the treatment cost for each patient, individual data on its resource used were combined with unit price data, obtained from Spanish national sources. The analysis predicts a survival of 0.9446 QALYs in the pharmacogenomics arm and 0.9379 QALYs in the non-pharmacogenomics arm within a 1-year horizon. The cumulative costs per patient were €2971 and €3205 for the Prospective and Retrospective groups, respectively. The main cost driver of total cost in both arms was hospitalization costs. The incremental cost-effectiveness ratio (ICER) was negative indicating that the PGx was a dominant option. Our data show that pharmacogenomics-guided clopidogrel treatment strategy may represent a cost-effective choice compared with non-pharmacogenomics-guided strategy for patients undergoing PCI.

Objectives: The study estimated the health economic impact of a latest generation coronary stent with ultrathin struts and bioresorbable polymer coating., Background: The recent BIOFLOW V trial, an international FDA approval trial (ClinicalTrials.gov: NCT02389946), has shown that an ultrathin, bioresorbable polymer sirolimus-eluting stent had a significantly lower rate of target lesion failure and target vessel-related myocardial infarction than a thin, durable polymer everolimus-eluting stent at 12 months, driven by a lower rate of peri-procedural myocardial infarction (ppMI)., Methods: We used a Markov model to project mortality and cost outcomes of that lower ppMI rate from a U.S. health system perspective over a 12-month horizon. Model parameters were derived from BIOFLOW V trial data, a systematic literature review and expert interviews., Results: Use of the bioresorbable polymer sirolimus-eluting stent compared to durable polymer everolimus-eluting stent is associated with net reductions in medical cost of $124 (Interquartile Range (IQR) $97-154) per patient in 2018 US$, of which $115 (IQR $76-124) accrues to the initial admission and $10 (IQR $7-72) to cost of follow-up. The lower rate of ppMI translates into a gain of 0.000017 (IQR 0.000011-0.000022) quality-adjusted life-years (QALY) per patient., Conclusions: Lower ppMI rates of bioresorbable polymer sirolimus-eluting stent translate into reductions in direct medical cost, while improving patient outcomes. Most of the cost reduction is attributed to the initial admission with moderate savings up to 12 months post-discharge., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to assess temporal trends in the incidence of ischemic stroke among patients undergoing percutaneous coronary intervention (PCI), predictors of post-PCI ischemic stroke, and the impact of post-PCI ischemic stroke on in-hospital morbidity, mortality, length of stay, and cost., Background: Data on the incidence and outcomes of ischemic stroke in patients undergoing PCI in the contemporary era are limited., Methods: The National Inpatient Sample was used to identify patients who underwent PCI between January 1, 2003, and December 31, 2016. The incidence of post-PCI ischemic stroke was calculated, and its predictors were assessed. In-hospital outcomes of patients with and those without post-PCI stroke were also compared., Results: The adjusted incidence of post-PCI ischemic stroke increased during the study period from 0.6% to 0.96% following PCI for ST-segment elevation myocardial infarction, from 0.5% to 0.6% following PCI for non-ST-segment elevation myocardial infarction, and from 0.3% to 0.72% following PCI for unstable angina or stable ischemic disease (p trend  <0.001). Carotid disease, cardiogenic shock, atrial fibrillation, and older age were the strongest predictors of post-PCI ischemic stroke. Post-PCI stroke rates were lower at high-volume versus low- to intermediate-volume centers. Thrombolytics, cerebral angiography, and mechanical thrombectomy use increased over time but remained infrequent. After propensity score matching, in-hospital mortality was higher among patients with post-PCI stroke (23.5% vs. 11.0%, 9.5% vs. 2.8%, and 11.5% vs. 2.4% in the ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina or stable ischemic heart disease cohorts, respectively; p < 0.001). Post-PCI stroke was associated with a >2-fold increase in length of stay, a >3-fold increase in nonhome discharges, and a >60% increase in cost., Conclusions: The incidence of post-PCI ischemic stroke increased significantly over the past decade, partially because of the increasing complexity of patients undergoing PCI over time. Further studies are needed to systematically assess contributors to this worrisome trend and to identify effective strategies for its mitigation., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Clinical outcomes with respect to the evolution of comorbidity burden in national cohorts of patients undergoing PCI have not been reported., Objectives: We sought to explore the association between comorbidity burden and periprocedural outcomes in patients treated with PCI in the National Inpatient Sample., Methods: 6,601,526 PCI procedures were identified between 2004 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, length of stay and cost. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1-5, ECS IV = 6-13, and ECS V ≥ 14)., Results: Patients with a score over 13 had a fivefold increase in the odds of mortality (OR: 5.13, 95% CI: 4.76-5.54), major bleeding (OR: 11.46, 95% CI: 10.66-12.33) and doubled the hospitalization costs ($31,452 vs $17.566)., Conclusions: Our study of over six million PCI procedures demonstrates that patients with the greatest comorbid burden (as defined by an ECS of >13) have a fivefold increase risk of in-hospital mortality, a fourfold increase in in-hospital periprocedural complications and an 11-fold increase in major bleeding events once differences in baseline patient characteristics are adjusted for. In addition, ECS significantly impacts the length of stay and doubles the healthcare costs. Comorbid burden is an important predictor of poor outcomes after PCI and should be considered as part of the decision-making processes in patients undergoing PCI., (© 2019 Wiley Periodicals, Inc.)

Background: Survival after percutaneous coronary intervention (PCI) in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) has increased over the years. Short-term readmission rates in this high-risk population remain unknown., Methods: We queried the United States (U.S.) Nationwide Readmission Database (NRD) from January 2010 to November 2014 using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9 CM) codes to identify all patients ≥18 years readmitted within 30 days after surviving an index hospitalization for PCI in AMI-CS. Incidence, etiologies, and predictors of 30-day readmission were analyzed., Results: Among 46,435 patients who survived to discharge after PCI in AMI-CS, 9,020 (19.4%) were readmitted within 30 days. Median time to 30-day readmission was 11 days. Cardiac conditions were the most common causes of readmission (57.8%). Heart failure was the leading readmission diagnosis (24.8%). Private insurance including HMO and self-pay were predictive of lower 30-day readmission. Among other covariates, female sex, comorbidities such as heart failure, atrial fibrillation, in-hospital complications such as major bleeding, sepsis, respiratory complications, AKI requiring dialysis, utilization of mechanical circulatory support (IABP and ECMO) were independently predictive of 30-day readmission. Trend analysis showed decline in 30-day readmission rates from 21.9% in 2010 to 17.9% in 2014 (p trend  < 0.001)., Conclusion: In this large real-world database, one in five patients receiving PCI in AMI-CS was readmitted within 30 days after discharge. Cardiac conditions were the most common causes of readmission. Insurance type had significant influence on 30-day readmission., (© 2019 Wiley Periodicals, Inc.)

Objective: To identify the key drivers of cost-effectiveness for cardiovascular magnetic resonance (CMR) when patients activate the primary percutaneous coronary intervention (PPCI) pathway., Design: Economic decision models for two patient subgroups populated from secondary sources, each with a 1 year time horizon from the perspective of the National Health Service (NHS) and personal social services in the UK., Setting: Usual care (with or without CMR) in the NHS., Participants: Patients who activated the PPCI pathway, and for Model 1: underwent an emergency coronary angiogram and PPCI, and were found to have multivessel coronary artery disease. For Model 2: underwent an emergency coronary angiogram and were found to have unobstructed coronary arteries., Interventions: Model 1 (multivessel disease) compared two different ischaemia testing methods, CMR or fractional flow reserve (FFR), versus stress echocardiography. Model 2 (unobstructed arteries) compared CMR with standard echocardiography versus standard echocardiography alone., Main Outcome Measures: Key drivers of cost-effectiveness for CMR, incremental costs and quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios., Results: In both models, the incremental costs and QALYs between CMR (or FFR, Model 1) versus no CMR (stress echocardiography, Model 1 and standard echocardiography, Model 2) were small (CMR: -£64 (95% CI -£232 to £187)/FFR: £360 (95% CI -£116 to £844) and CMR/FFR: 0.0012 QALYs (95% CI -0.0076 to 0.0093)) and (£98 (95% CI -£199 to £488) and 0.0005 QALYs (95% CI -0.0050 to 0.0077)), respectively. The diagnostic accuracy of the tests was the key driver of cost-effectiveness for both patient groups., Conclusions: If CMR were introduced for all subgroups of patients who activate the PPCI pathway, it is likely that diagnostic accuracy would be a key determinant of its cost-effectiveness. Further research is needed to definitively answer whether revascularisation guided by CMR or FFR leads to different clinical outcomes in acute coronary syndrome patients with multivessel disease., Competing Interests: Competing interests: Chiara Bucciarelli-Ducci has received personal fees from Circle Cardiovascular Imaging. Barnaby C Reeves reports former membership of the Health Technology Assessment Commissioning Board (up to 31 March 2016) and Health Technology Assessment Efficient Study Designs Board (October 2014 to December 2014). He also reports current membership of the Health Technology Assessment IP Methods Group and Systematic Reviews Programme Advisory Group (Systematic Reviews NIHR Cochrane Incentive Awards and Systematic Review Advisory Group). Beyond this, all authors have no competing interests, except support from the NIHR grant as detailed in the funding statement., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)