- Public reporting of mortality outcomes for coronary revascularization has resulted in significant risk aversion among PCI operators, potentially reducing patient care quality.
- After excluding refractory cardiogenic patients from publicly reported PCI data, New York operators were more likely to perform high-risk PCI for patients with acute coronary syndrome complicated by cardiogenic shock. This change resulted in a trend toward improved mortality.
Public reporting was originally designed to build public trust and improve care quality; however, there is some speculation that the reporting of treatment outcomes may lead to intervention avoidance, particularly for high-risk patients requiring percutaneous coronary intervention (PCI). This risk avoidance may negatively impact public health by reducing PCIs performed for at-risk patients.In 2006, the New York State Department of Public Health began excluding refractory cardiogenic shock (CS) patients from public reporting of PCI in an effort to combat risk avoidance.A study published in JAMA Cardiology examined the effects this policy change had for patients
with acute myocardial infarction (AMI) complicated by CS (n=45,977).1
Specifically, the change in rates of coronary revascularization and in-hospital mortality for New York AMI patients (n=11,298) complicated by CS following the exclusion of CS from public reporting were evaluated. Continue readingChanges in Public Reporting and Their Impact on Treatment and Outcomes of Acute Myocardial Infarction
- There are few studies that demonstrate the full impact of pulmonary arterial proportional pressure (PAPP) on advanced heart failure (HF) outcomes.
- It has been theorized that increases in PAPP would correlate with improved clinical outcomes in patients with advanced HF.
- Researchers evaluated the PAPP of a subset of patients in the ESCAPE trial who had received placement of a pulmonary artery catheter (PAC).
- A lower PAPP score was consistently associated with worse hemodynamics and increased clinical events at 6 months.
- PAPP may be an important risk stratification tool for HF patients, assisting in the prediction of mortality, LVAD transplant, and hospitalization.
The functional status of the right ventricle represents an important independent predictor for disease course in patients with advanced heart failure (HF). Pulmonary arterial proportional pulse pressure (PAPP), defined as [PA systolic pressure - PA diastolic pressure]/PA systolic pressure, on advanced HF outcomes has also been suggested as a risk predictor, yet this remains little explored. Continue readingDecreased PA Pulse Pressure After PA Catheter Optimization
- Myocardial function improvement following mechanical unloading with durable LVADs may occur in patients with chronic ischemic cardiomyopathy, but at a much lower rate than those with nonischemic cardiomyopathy (21% vs 5%).
- Little is known about the effect of LVADs on myocardial structure and function following treatment for ischemic cardiomyopathy (ICM).
- Peak LVEF can be achieved 6 months after LVAD support.
- Patient characteristics dictate the most favorable duration of mechanical unloading in patients with ICM.
- This study showed that chronic mechanical unloading can improve myocardial structure and function in both nonischemic cardiomyopathy (NICM) and ICM patients.
Left ventricular assist devices (LVADs) have become increasingly prevalent tools used in the treatment of heart failure (HF) patients. Reverse remodeling as well as myocardial function improvement may occur in HF patients receiving LVAD support. Continue readingThe Effect of LVAD Unloading on Cardiac Recovery in Patients with Ischemic and Nonischemic Cardiomyopathy
Patients undergoing complex coronary revascularization are at risk for periprocedural and postprocedural acute kidney injury (AKI), a complication which correlates with an increased risk of death, major bleeding, and myocardial infarction (MI).1
A reduction in cardiac output and renal hypoperfusion, which in turn leads to a decrease in glomerular filtration rate, may partly explain the increased risk for AKI during high-risk percutaneous coronary intervention (HRPCI).1
Currently, there are few published studies which examine the impact of micro-axial percutaneous left ventricular assist devices on AKI in patients undergoing HRPCI. Continue readingUse of Impella® Devices During High-Risk PCI is Associated with Reduced Occurrence of Acute Kidney Injury
- Dr. Alexander Truesdell of the INOVA Heart and Vascular Institute discusses how physicians can apply the same shock management principles found on the battlefront into everyday surgical practice.
- Early recognition of shock and early revascularization are two essential elements of successful treatment for shock on the battlefield as well as in conventional care centers.
For the past few decades, early revascularization has been considered the cornerstone of treatment for cardiogenic shock (CS). Despite widespread adoption and implementation of this management strategy, rates of mortality following interventional cardiology procedures for CS remain high.Dr. Alexander Truesdell of the INOVA Heart and Vascular Institute mentions in his editorial War on Shock
that the method for treating CS requires a more aggressive, combat-like approach, embracing strategies he learned while serving as an interventional cardiologist in Iraq and Afghanistan.1
“Only with strong leadership, teamwork, and a national commitment to a joint integrated countrywide network of cardiogenic shock care, research, and innovation,” said Truesdell, “can we hope to achieve our desired goal of zero preventable death from cardiogenic shock.” Continue readingManaging Shock at the “Battlefront” of Surgery
- Contrast-induced acute kidney injury caused by iodinated contrast medium is associated with high morbidity and mortality in at-risk patients.
- Previous studies note that automated contrast injectors, removal of contrast from the coronary sinus, and pressure-sensitive diversion devices may help reduce contrast exposure and lower the risk for AKI.
Contrast-induced nephropathy (CIN), one of the prime causes of contrast-induced acute kidney injury (CI-AKI),1
is now the third most frequent cause of hospital-acquired renal failure.2 Continue readingClinical Options for Minimizing Contrast Exposure and Reducing Contrast-Induced Kidney Injury Risk
- Obesity is paradoxically associated with favorable mortality outcomes in acute myocardial infarction (AMI).
- Association between obesity and in-hospital mortality among patients with cardiogenic shock (CS) complicating AMI (N=290,894) was retrospectively studied.
- Obese patients had lower in-hospital mortality compared with nonobese patients (28.2% vs 36.5%, respectively), but key baseline differences in the obese group may explain this association.
More than one-third of the adult population in the United States (35.7%) are considered clinically obese.1
The increasing prevalence of obesity has become difficult to ignore as research continues to support the association of obesity--defined as a body mass index of 30 or greater--with poor cardiovascular health.Despite obesity having a direct link to known cardiovascular risk factors, including diabetes, hypertension, and hypercholesterolemia, previous research has shown a paradoxical protective association between obesity and established cardiovascular disease.2
This “obesity paradox” states that patients with obesity may have better outcomes following a cardiovascular event when compared with nonobese patients. Continue readingThe Association Between Obesity and In-Hospital Mortality in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction
- Periprocedural myocardial infarction (PMI) is more prevalent in patients undergoing PCI for chronic total occlusions.
- Patients with PMI who require multiple lesion treatment, a retrograde approach to therapy, and more stents had a higher rate of mortality at follow-up.
Risks to the myocardium during percutaneous coronary intervention (PCI) have been minimized over the last few decades due to the advancement of interventional cardiology techniques and technology. Adverse events (AEs) following PCI are not uncommon, however, despite the ability of PCI to improve life quality among patients with coronary artery disease. Periprocedural myocardial injury (PMI) is one such AE that can occur during PCI and can be detected in up to 80% of patients. Continue readingMortality Related to Periprocedural Myocardial Injury in CTO-PCI
For patients with cardiogenic shock (CS), intra-aortic balloon pump (IABP) had been an important tool for maintaining patients and improving survival after percutaneous coronary intervention (PCI). Randomized controlled trials, however, have found very little evidence to support the notion that IABP is helpful for reducing mortality or improving hemodynamics for patients with CS.1,2 The Impella® … Continue reading “IMPRESS in Severe Shock Trial: Looking Closer at the Data”