Risk‐Treatment Paradox in the Selection of Transradial Access for Percutaneous Coronary Intervention

Background: Access site complications contribute to morbidity and mortality during percutaneous coronary intervention (PCI). Transradial arterial access significantly lowers the risk of access site complications compared to transfemoral arteriotomy. We sought to develop a prediction model for access site complications in patients undergoing PCI with femoral arteriotomy, and assess whether transradial access was selectively used in patients at high risk for complications. Methods and Results: We analyzed 17 509 patients who underwent PCI without circulatory support from 2008 to 2011 at 5 institutions. Transradial arterial access was used in 17.8% of patients. In those who underwent transfemoral access, 177 (1.2%) patients had access site complications. Using preprocedural clinical and demographic data, a prediction model for femoral arteriotomy complications was generated. The variables retained in the model included: elevated age (P<0.001), female gender (P<0.001), elevated troponin (P<0.001), decreased renal function or dialysis (P=0.002), emergent PCI (P=0.01), prior PCI (P=0.005), diabetes (P=0.008), and peripheral artery disease (P=0.003). The model showed moderate discrimination (optimism‐adjusted c‐statistic=0.72) and was internally validated via bootstrap resampling. Patients with higher predicted risk of complications via transfemoral access were less likely to receive transradial access (P<0.001). Similar results were seen in patients presenting with and without ST‐segment myocardial infarction and when adjusting for individual physician operator. Conclusions: We generated and validated a model for transfemoral access site complications during PCI. Paradoxically, patients most likely to develop access site complications from transfemoral access, and therefore benefit from transradial access, were the least likely to receive transradial access

The type IC SN 1990B in NGC 4568

We present a study of the Type Ic supernova (SN) 1990B that includes most of the observations obtained from around the world. The combined data set comprises 84 BV(RI)c photometric points spanning approximately 360 days after maximum light and 14 spectra from 5 up to ~150 days after maximum light. In contrast to other Type Ic SNe, SN 1990B did not display a weak but distinct He I λ5876 line indicating that its He content was smaller or that the He layers were rather effectively shielded from the radioactive matter in the ejecta. The behavior of the Na I D line, however, suggests that He I λ5876 was blended with it. SN 1990B appeared on a sharply varying background that complicates the usual techniques of digital photometry. In order to do unbiased photometry, we modeled and subtracted the background of each image with the SN using images of NGC 4568 taken ~2500 days after the explosion, when SN 1990B had faded beyond detection. We compare the performance of standard point-spread function fitting photometry of the SN in the images with and without the background of the parent galaxy and find the results to differ systematically at late times. The photometry done on the images with the background light of NGC 4568 subtracted shows the light curves of SN 1990B to be of the slow Type Ic variety, with a slope steeper than that of the Type Ib SN 1983N or the Type II transition (Type IIb) SN 1993J but slower than that of the Type Ic SN 1994I. We estimate the reddening by foreground matter in the Galaxy and NGC 4568 and compute BV(RI)c light curves spanning ~110 days after maximum light

Myocardial Infarction as a Presentation of Clinical In-Stent Restenosis

Abstract Background In-stent restenosis is considered to be a gradual and progressive condition and there is scant data on myocardial infarction (MI) as a clinical presentation. Methods and Results Of 2,462 consecutive patients who underwent percutaneous coronary intervention between June 2001 and December 2002, clinical in-stent restenosis occurred in 212 (8.6%), who were classified into 3 groups: ST elevation MI (STEMI), non-ST elevation MI (NSTEMI) and non-MI. Of the 212 patients presenting with clinical in-stent restenosis, 22 (10.4%) had MI (creatine kinase (CK) ≥2 × baseline with elevated CKMB). The remaining 190 (89.6%) patients had stable angina or evidence of ischemia by stress test without elevation of cardiac enzymes. Median interval between previous intervention and presentation for clinical in-stent restenosis was shorter for patients with MI than for non-MI patients (STEMI, 90 days; NSTEMI, 79 days; non-MI, 125 days; p=0.07). Diffuse in-stent restenosis was more frequent in MI patients than in non-MI patients (72.7% vs 56.3%; p<0.005). Renal failure was more prevalent in patients with MI than in those without MI (31.8% vs 6.3%, p=0.001). Compared with the non-MI group, patients with MI were more likely to have acute coronary syndromes at the time of index procedure (81.8% vs 56.8%, p=0.02). Conclusion Clinical in-stent restenosis can frequently present as MI and such patients are more likely to have an aggressive angiographic pattern of restenosis. Renal failure and acute coronary syndromes at the initial procedure are associated with MI. (Circ J 2006; 70: 1026 - 1029

Improvement in Mortality Risk Prediction After Percutaneous Coronary Intervention Through the Addition of a “Compassionate Use” Variable to the National Cardiovascular Data Registry CathPCI Dataset A Study From the Massachusetts Angioplasty Registry

ObjectivesThis study investigated the impact of adding novel elements to models predicting in-hospital mortality after percutaneous coronary interventions (PCIs).BackgroundMassachusetts mandated public reporting of hospital-specific PCI mortality in 2003. In 2006, a physician advisory group recommended adding to the prediction models 3 attributes not collected by the National Cardiovascular Data Registry instrument. These “compassionate use” (CU) features included coma on presentation, active hemodynamic support during PCI, and cardiopulmonary resuscitation at PCI initiation.MethodsFrom October 2005 through September 2007, PCI was performed during 29,784 admissions in Massachusetts nonfederal hospitals. Of these, 5,588 involved patients with ST-segment elevation myocardial infarction or cardiogenic shock. Cases with CU criteria identified were adjudicated by trained physician reviewers. Regression models with and without the CU composite variable (presence of any of the 3 features) were compared using areas under the receiver-operator characteristic curves.ResultsUnadjusted mortality in this high-risk subset was 5.7%. Among these admissions, 96 (1.7%) had at least 1 CU feature, with 69.8% mortality. The adjusted odds ratio for in-hospital death for CU PCIs (vs. no CU criteria) was 27.3 (95% confidence interval: 14.5 to 47.6). Discrimination of the model improved after including CU, with areas under the receiver-operating characteristic curves increasing from 0.87 to 0.90 (p < 0.01), while goodness of fit was preserved.ConclusionsA small proportion of patients at extreme risk of post-PCI mortality can be identified using pre-procedural factors not routinely collected, but that heighten predictive accuracy. Such improvements in model performance may result in greater confidence in reporting of risk-adjusted PCI outcomes