In-hospital complications after invasive strategy for the management of Non STEMI: women fare as well as men

<p>Abstract</p> <p>Background</p> <p>To analyze the in-hospital complication rate in women suffering from non-ST elevation myocardial infarction treated with percutaneous coronary intervention (PCI) compared to men.</p> <p>Methods</p> <p>The files of 479 consecutive patients (133 women and 346 men) suffering from a Non STEMI (Non ST-segment elevation myocardial infarction) between the January 1^st2006 and March 21^st2009 were retrospectively analyzed with special attention to every single complication occurring during hospital stay. Data were analyzed using nonparametric tests and are reported as median unless otherwise specified. A p value < .05 was considered significant.</p> <p>Results</p> <p>As compared to men, women were significantly older (75.8 <it>vs</it>. 65.2 years; p < .005). All cardiovascular risk factors but tobacco and hypertension were similar between the groups: men were noticeably more often smoker (p < .0001) and women more hypertensive (p < .005). No difference was noticed for pre-hospital cardiovascular drug treatment. However women were slightly more severe at entry (more Killip class IV; p = .0023; higher GRACE score for in-hospital death - p = .008 and CRUSADE score for bleeding - p < .0001). All the patients underwent PCI of the infarct-related artery after 24 or 48 hrs post admission without sex-related difference either for timing of PCI or primary success rate. During hospitalization, 130 complications were recorded. Though the event rate was slightly higher in women (30% <it>vs</it>. 26% - p = NS), no single event was significantly gender related. The logistic regression identified age and CRP concentration as the only predictive variables in the whole group. After splitting for genders, these parameters were still predictive of events in men. In women however, CRP was the only one with a borderline p value.</p> <p>Conclusions</p> <p>Our study does not support any gender difference for in-hospital adverse events in patients treated invasively for an acute coronary syndrome without ST-segment elevation and elevated troponin.</p

Clinical Utilities of Peripheral Blood Gene Expression Profiling in the Management of Cardiac Transplant Patients

Cardiac allografts induce host immune responses that lead to endomyocardial tissue injury and progressive graft dysfunction. Inflammatory cell infiltration and myocyte damage characterize acute cellular rejection (ACR) that presents episodically in either a subclinical or symptom-associated manner. Sampling of the endomyocardium by transvenous biopsy enables pathologic grading using light microscopic criteria to distinguish severity based on the focality or diffuseness of inflammation and associated myocyte injury. Monitoring for ACR utilizes endomyocardial biopsy in conjunction with history and physical examination and assessment of allograft function by echocardiography. However, procedural and interpretive issues limit the diagnostic certainty provided by endomyocardial biopsy. The dynamic profiling of genes expressed by peripheral blood mononuclear cells (PBMCs) enables quantitative assessments of intracellular mRNA whose levels fluctuate during systemic alloimmune responses. Gene expression profiling of PBMCs using a multi-gene ACR classifier enables the AlloMap® molecular expression test to distinguish moderate to severe ACR (p = 0.0018) in heart transplant patients. The AlloMap test provides molecular insights into a patient's risk for ACR by distilling the aggregate expression levels of its informative genes into a single score on a scale of 0 to 40. The selection of a score as a threshold value for clinical decision-making is based on its associated negative predictive value (NPV), which ranges from 98 to 99% for values in three post-transplant periods: >2 to ≤6 months, > 6to ≤ 12 months, and >12 months. Scores below the threshold value rule out ACR, while those above suggest increased ACR risk. Incorporating the AlloMap test into immunomonitoring protocols provides an opportunity for clinicians to enhance patient care and to define its role in immunodiagnostic strategies to optimize the clinical outcomes of heart transplant recipients. This summary highlights the concepts presented in an invited presentation at a conference focused on Immunodiagnostics and Immunomonitoring: From Research to Clinic, in San Diego, CA on November 7, 2006

Abstract 303: The Association Between Change in Hospital-Level Use of Transradial PCI and Periprocedural Outcomes: Insights from the NCDR®

Background: Although radial artery access reduces access site bleeding, increasing use of transradial PCI (TRI) may compromise facility-level outcomes due to patient selection, procedural learning curve, and unintended consequences on femoral PCI management. We sought to determine the relationship between increasing facility-level use of TRI and change in rates of access site bleeding. Methods: Within the National Cardiovascular Data Registry CathPCI Registry®, we restricted our analyses to hospitals reporting at least 50 PCI procedures annually and with less than 10% TRI use in the first year of observation. We evaluated 1,438,516 patients undergoing PCI at 818 facilities participating in NCDR CathPCI between 2009 and 2012. We identified categories of hospital change in TRI use from latent class growth analysis with time modeled continuously across quarters. Controlling for bleeding risk calculated from prior CathPCI bleeding risk models, we estimated the association between hospital category of change in TRI use and access site bleeding rates using generalizing estimating equations accounting for clustering within hospitals and time. Results: Latent growth curve analysis identified four classes of hospital-level change in TRI use with widely divergent patterns (Figure 1a). Patients’ predicted bleeding risk was similar across hospital categories of change in TRI use (predicted bleeding from lowest to highest hospital category of TRI increase, 6.0% vs 5.8% vs 6.1% vs 5.7%). Risk-adjusted bleeding decreased over time for all hospitals, regardless of change in TRI use (Figure 1b). The decreasing rate of access site bleeding (determined from the relative risk [RR] of access site bleeding in the last quarter of study compared to the first quarter) was greater for hospitals with moderate or high increases in TRI use (RR 0.45; 95% confidence interval [CI] 0.36-0.56) compared with hospitals with very low or low increases in TRI use (RR 0.65; 95% CI 0.58-0.74; p for comparison=.002). Conclusions: In a national sample of hospitals performing PCI, access site bleeding decreased over time for all hospitals. The trajectory of decline in access site bleeding was greatest at hospitals with the largest increases in TRI use. </jats:p

Association Between Periprocedural Bleeding and Long-Term Outcomes Following Percutaneous Coronary Intervention in Older Patients

ObjectivesThe authors sought to describe the association between post-procedural bleeding and long-term recurrent bleeding, major adverse cardiac events (MACE), and mortality among older patients undergoing percutaneous coronary intervention (PCI).BackgroundBleeding complications after PCI are associated with an increased risk for acute morbidity and long-term mortality, but the association of these bleeding complications with other events is unknown.MethodsPatients entered into the National Cardiovascular Data Registry (NCDR) CathPCI Registry (n = 461,311; 946 sites) from January 2004 to December 2008 were linked with claims from the Centers for Medicare & Medicaid Services and grouped according to in-hospital post-PCI bleeding. The association between post-PCI bleeding and 1-, 12-, and 30-month readmission for bleeding, MACE, and all-cause mortality was examined with Cox regression that included patient and procedural characteristics using no bleeding as the reference.ResultsOverall, 3.1% (n = 14,107) of patients experienced post-PCI bleeding. Patients who bled were older, more often female, had more medical comorbidities, less often received bivalirudin, and more often underwent PCI via the femoral approach. After adjustment, bleeding after the index procedure was significantly associated with readmission for bleeding (adjusted hazard ratios [95% confidence interval]: 1 month, 1.54 [1.42 to 1.67]; 12 months, 1.52 [1.40 to 1.66]; 30 months, 1.29 [1.11 to 1.50]), MACE (1 month, 1.11 [1.07 to 1.15]; 12 months, 1.17 [1.13 to 1.21]; 30 months, 1.12 [1.06 to 1.19]) and all-cause mortality (1 month, 1.32 [1.26 to 1.38]; 12 months, 1.33 [1.27 to 1.40]); 30 months, 1.22 [1.15 to 1.30]).ConclusionsPost-PCI bleeding complications are associated with an increased risk for short- and long-term recurrent bleeding, MACE, and all-cause mortality. These data underscore the prognostic importance of periprocedural bleeding and the need for identifying strategies to reduce long-term bleeding risk among patients undergoing PCI