Current Issue 15 February 2012 | Vol. 109, No. 4

Coronary Artery Disease

• Comparison of Role of Early (<6 Hours) to Later (>6 Hours) or No Cardiac Catheterization Following Resuscitation from Out-of-Hospital Cardiac Arrest

Despite reports of patients with resuscitated sudden cardiac arrest (rSCA) receiving acute cardiac catheterization, the efficacy of this strategy is largely unknown. We hypothesized that acute cardiac catheterization of patients with rSCA would improve survival to hospital discharge. A retrospective cohort of 240 patients with out-of-hospital rSCA due to ventricular tachycardia or fibrillation was identified from 11 institutions in Seattle, Washington, between 1999 and 2002. Patients were grouped into those receiving acute catheterization within 6 hours (≤ 6 hours group, n = 61) and into those with deferred catheterization at > 6 hours or no catheterization during the index hospitalization (>6 hours group, n = 179). We directed attention to survival to hospital discharge, neurologic status, extent of coronary artery disease presenting electrocardiographic (ECG) findings, and pre-arrest symptoms. Propensity score methods were used to adjust for the likelihood of receiving acute catheterization. Survival was greater in patients who underwent acute catheterization ≤ 6 hours group (72%) vs. >6 hours group (49%) (p=0.001). Percutaneous coronary intervention was performed in 38/61 (62%) of patients in ≤ 6 hours group, and 13/170 (7%) in > 6 hours group, p<0.0001. Neurologic status was similar for both groups. A significantly higher percentage of patients in the acute catheterization group had symptoms prior to cardiac arrest, and had ST-segment elevation on post-resuscitation ECG. Age, bystander cardiopulmonary resuscitation, daytime presentation, history of percutaneous coronary intervention or stroke, and acute ST elevation were all positively associated with receiving cardiac catheterization. In conclusion, in this series of patients who sustained out-of-hospital cardiac arrest, acute catheterization (within 6 hours of presentation) was associated with improved survival.

Preventive Cardiology

• Cardiovascular Disease and Risk in Primary Care Settings in the United States

Primary care site may play an important role in cardiovascular disease prevalence; however, the distribution of risk factors and outcomes across care sites is not known. We conducted a cross-sectional analysis of 21,778 adult participants from the National Health and Nutrition Examination Survey (99-08) using multivariable logistic regression to assess the relationship between site of usual care and disease prevalence. We examine patients' self-reported history of several chronic conditions (Hypertension, Diabetes, and Hypercholesterolemia), awareness of chronic conditions, and associated cardiovascular events (Angina, CHD, CVD, MI, and Stroke). After adjustment for demographic and healthcare utilization characteristics, there were no significant differences in the prevalence of diabetes or hypercholesterolemia between patients receiving usual care at private doctors' offices, hospital outpatient clinics, community-based clinics, and emergency rooms(ER). However, participants without a usual source of care and those receiving usual care at an ER have significantly lower awareness of their chronic conditions than participants at other sites. The odds of having a history of each of the adverse cardiovascular events ranged between 2.21 and 4.18 times higher for people receiving usual care at ER's relative to private doctors' offices. In conclusion, participants who report utilizing ER's as their usual site of care are disproportionately more likely to have a history of poor cardiovascular outcomes and are more likely to be unaware of having hypertension or hypercholesterolemia. As health care reform takes place and millions more begin seeking care, it is imperative to ensure access to longitudinal care sites designed for continuous disease management.

Valvular Heart Disease

• Comparison of Outcomes in Patients Having Isolated Transcatheter Aortic Valve Implantation versus Combined with Pre-Procedural Percutaneous Coronary Intervention

Coronary artery disease (CAD) negatively impacts the outcome of patients undergoing surgical aortic valve replacement and practice guidelines recommend revascularization at the time of surgery. In patients undergoing transcatheter aortic valve implantation (TAVI), the impact of pre-procedural percutanenous coronary intervention (PCI) on TAVI outcome has not been examined. We aimed in the current study to assess the feasibility and safety of performing PCI prior to TAVI, and to evaluate procedural, 30-day and 6-month clinical outcomes. We retrospectively analyzed 125 patients who underwent successful TAVI at a single institution, and divided them into an isolated TAVI and a PCI + TAVI group. During the study period, a strategy of pre-procedural PCI of all significant (>50%) lesions in major epicardial vessels was adopted. Study endpoints were adjudicated in accordance with the valve academic research consortium (VARC) consensus on event definition. All patients were treated with the Medtronic CoreValve prosthesis (n=55 with PCI + TAVI and n=70 with isolated TAVI). Thirty-day mortality was 2% vs. 6% for patients treated with PCI + TAVI vs. isolated TAVI, respectively (p=0.27). Neither peri-procedural nor spontaneous myocardial infarction occurred in either group. Rates of 30-day stroke, major bleeding, major vascular complications and the VARC-defined combined safety endpoint (11% vs. 13%, p=0.74) did not differ between both groups. Patients’ symptoms significantly improved in the first month after TAVI, and the extent of improvement did not differ between groups. Adverse events at 6 months were comparable. In conclusion, PCI prior to TAVI appears both feasible and safe. On the basis of these early results, revascularization should become an important consideration in patients with CAD undergoing TAVI.