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Decreasing mortality with primary percutaneous coronary intervention in patients with acute myocardial infarction: The Mayo Clinic experience from 1991 through 1997

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MAYO CLINIC PROCEEDINGS 2000年第10期75卷 994-1001页

作者： Velianou, JL Wilson, SH Reeder, GS Caplice, NM Grill, DE Holmes, DR Bell, MR Mayo Clin Div Cardiovasc Dis & Internal Med Rochester MN 55905 USA Mayo Clin Biostat Sect Rochester MN 55905 USA

Objective: To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI). Patients and Methods: We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year. Results: The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997, Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P<.001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P<.001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P<.001). An increase in beta-blocker (58.3% to 75.3%;P<.001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%;P<.001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%;P<.001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%;P<.001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%;P=.05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P=.09), After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89;95% confidence interval, 0.79-1.00;P=.05) and during long-term follow-up (odds ratio, 0.93;95% confidence interval, 0.87-1.00;P=.04), Conclusions: Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.

关键词：肾上腺素能β受体拮抗剂/治疗应用血管成形术气囊冠状动脉/统计学和数值数据血管紧张素转换酶抑制药/治疗应用抗体单克隆/治疗应用钙通道阻滞药/治疗应用死亡原因置信区间混杂因素(流行病学) 随访研究医院联合开业羟甲基戊二酰基CoA还原酶类/治疗应用免疫球蛋白Fab片段/治疗应用明尼苏达/流行病学心肌梗死/药物疗法心肌梗死/死亡率心肌梗死/治疗比值比血小板聚集抑制剂/治疗应用血小板糖蛋白GPⅡb-Ⅲa复合物/拮抗剂和抑制剂回顾性研究支架/统计学和数值数据存活率噻氯匹定/治疗应用治疗结果老年人女(雌)性人类男(雄)性中年人

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The relationship between operator volume and outcomes after percutaneous coronary interventions in high volume hospitals in 1994-1996 - The northern New England experience

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第5期34卷 1471-1480页

作者： Malenka, DJ McGrath, PD Wennberg, DE Ryan, TJ Kellett, MA Shubrooks, SJ Bradley, WA Hettlemen, BD Robb, JF Hearne, MJ Silver, TM Watkins, MW O'Meara, JR VerLee, PN O'Rourke, DJ Dartmouth Coll Hitchcock Med Ctr Cardiol Sect Lebanon NH 03756 USA Dartmouth Coll Hitchcock Med Ctr Dartmouth Med Sch Ctr Evaluat & Clin Sci Hanover NH 03756 USA Maine Med Ctr Dept Med Div Hlth Serv Res Portland ME 04102 USA Maine Med Ctr Dept Med Div Cardiol Portland ME 04102 USA Catholic Med Ctr Manchester NH USA Beth Israel Deaconess Med Ctr Div Cardiol Boston MA USA Eastern Maine Med Ctr Div Cardiol Bangor ME USA Fletcher Allen Hlth Care Div Cardiol Burlington VT USA

OBJECTIVES The purpose of this study was to examine the relationship between annual operator volume and outcomes of percutaneous coronary interventions (PCIs) using contemporaneous data. BACKGROUND The 1997 American College of Cardiology (ACC)/American Heart Association task force based their recommendation that interventionists perform greater than or equal to 75 procedures per year to maintain competency in PCI on data collected largely in the early 1990s. The practice of interventional cardiology has since changed with the availability of new devices and drugs. METHODS Data were collected from 1994 through 1996 on 15,080 PCIs performed during 14,498 hospitalizations by 47 interventional cardiologists practicing at the five high volume (>600 procedures per hospital per year) hospitals in northern New England and one Massachusetts-based institution that support these procedures. Operators were categorized into terciles based on their annualized volume of procedures. Multivariate regression analysis was used to control for case-mix. In-hospital outcomes included death, emergency coronary artery bypass graft surgery (eCABG), non-emergency CABG (non-eCABG), myocardial infarction (MI), death and clinical success (greater than or equal to 1 attempted lesion dilated to <50% residual stenosis and no death, CABG or MI). RESULTS Average annual procedure rates varied across terciles from low = 68, middle = 115 and high = 209. After adjusting for case-mix, clinical success rates were comparable across terciles (low, middle and high terciles: 90.9%, 88.8% and 90.7%, p(trend) = 0.237), as were all the adverse outcomes including death (low-risk patients = 0.45%, 0.41%, 0.71%, p(trend) = 0.086;high-risk patients = 5.68%, 5.99%, 7.23%, p(trend) = 0.324), eCABG (1.74%, 2.05%, 1.75%, p(trend) = 0.733) and MI (2.57%, 1.90%, 1.86%, p(trend) = 0.065). CONCLUSIONS Using current data, there is no significant relationship between operator Volumes averaging greater than or equal to 68 per

关键词：血管成形术气囊冠状动脉/统计学和数值数据临床工作能力冠状动脉分流术/统计学和数值数据冠心病/治疗 Logistic模型新英格兰卫生保健质量支架/统计学和数值数据治疗结果人类

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A randomized trial of elective stenting after balloon recanalization of chronic total occlusions

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第3期34卷 722-729页

作者： Höher, M Wöhrle, J Grebe, OC Kochs, M Osterhues, HH Hombach, V Buchwald, AB Univ Ulm Dept Cardiol D-89081 Ulm Germany Univ Gottingen Dept Cardiol D-3400 Gottingen Germany

OBJECTIVES The aim of this study was to assess the role of Wiktor stent implantation after recanalization of chronic total coronary occlusions with regard to the clinical and angiographic outcome after six months. BACKGROUND Beside the common use of stents in clinical practice, the number of stent indications proven by randomized trials is still limited. METHODS Eighty-five patients with a thrombolysis in myocardial infarction grade 0 chronic coronary occlusion were examined. After standard balloon angioplasty, the patients were randomly assigned to stent implantation, or percutaneous transluminal coronary angioplasty (PTCA) alone (no further intervention). Quantitative coronary angiography was performed at baseline and after six months. RESULTS The minimal lumen diameter did not differ immediately after recanalization (stent group 1.61 +/- 0.30 mm vs. PTCA group 1.65 +/- 0.36 mm), and increased after stent implantation to 2.51 +/- 0.41 mm. After six months, the stent group still had a significantly greater lumen (1.57 +/- 0.59 vs. 1.06 +/- 0.90 mm;p < 0.01) and a significantly lower restenosis and reocclusion rate (32% and 3%) compared with the PTCA group (64% and 24%);restenosis analysis according to treatment was 72% (PTCA) versus 29% (stent, p < 0.01). Late loss was equal in both groups. At follow-up, the stent patients had a better angina class (p < 0.01), and fewer cardiac events (p < 0.03). A meta-analysis including this trial and three other controlled trials with the Palmaz-Schatz stent showed concordant results. CONCLUSIONS Stent implantation after reopening of a chronic total occlusion provides a better angiographic result, corresponding to a better clinical outcome with fewer recurrence of symptoms and reinterventions after six months. (J Am Coll Cardiol 1999;34:722-9) (C) 1999 by the American College of Cardiology.

关键词：血管成形术气囊冠状动脉/方法血管成形术气囊冠状动脉/统计学和数值数据慢性病冠状血管造影术/统计学和数值数据冠心病/诊断显像冠心病/治疗随访研究复发再治疗/方法再治疗/统计学和数值数据危险因素支架/统计学和数值数据时间因素治疗结果成年人老年人女(雌)性人类男(雄)性中年人

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Trends in clinical and economic outcomes of coronary angioplasty from 1992 to 1995: A population-based analysis

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AMERICAN HEART JOURNAL 1999年第6期137卷 1012-1018页

作者： Cohen, EA Young, W Slaughter, PM Oh, P Naylor, CD Univ Toronto Sunnybrook Hlth Sci Ctr Dept Med Div Cardiol Toronto ON M4N 3M5 Canada Inst Clin Evaluat Sci Toronto ON Canada

Background The impact of recent developments in coronary angioplasty on the brood spectrum of patients treated in routine practice is largely undefined. Analysis of population-based data can provide insight into trends in clinical outcomes and associated costs of coronary angioplasty procedures. Methods and Results With the use of a comprehensive hospital discharge database covering more than 11 million Canadians, we analyzed 12,748 first-time angioplasty procedures performed from 1992 to 1995 inclusive. Patient demographics and major adverse events were recorded. With the use of forward linkage, readmissions within 12 months were classified according to procedure performed and/or most responsible diagnosis, The proportion of patients readmitted, the number of readmissions per index procedure, and diagnosis-specific readmission costs were compared by calendar year. Over the 4-year study period, there was a 21% increase in the annual volume of index procedures. There were no statistically significant differences between 1992 and 1995 in sex distribution, mean age, comorbid conditions, length of stay, or need for coronary bypass surgery related to the index procedure. The all-cause readmission rate declined from 51.6% to 47.2% between 1992 and 1995 (P <.001), primarily because of a decline in the admission rate for repeat revascularization from 24.8% to 19.6% (P <.001). The 12-month readmission cost declined by $435 (1994 Canadian dollars) per patient. Conclusions The clinical outcomes of coronary angioplasty in a broad cohort of patients have improved in recent years. Although readmissions within year of an angioplasty procedure remain common, the number related to repeat revascularization has declined, with an associated decline in downstream costs.

关键词：队列研究费用效益分析医院费用/统计学和数值数据医院费用/发展趋势住院/经济学住院/统计学和数值数据住院/发展趋势安大略病人再入院/经济学病人再入院/统计学和数值数据病人再入院/发展趋势再治疗/经济学再治疗/统计学和数值数据再治疗/发展趋势支架/经济学支架/统计学和数值数据支架/发展趋势治疗结果人类中年人

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Acute and nine-month clinical outcomes after "suboptimal" coronary stenting - Results from the STent Anti-thrombotic Regimen Study (STARS) registry

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第3期34卷 698-706页

作者： Cutlip, DE Leon, MB Ho, KKL Gordon, PC Giambartolomei, A Diver, DJ Lasorda, DM Williams, DO Fitzpatrick, MM Desjardin, A Popma, JJ Kuntz, RE Baim, DS Beth Israel Deaconess Med Ctr Intervent Cardiol Sect Boston MA 02215 USA Univ Rochester Med Ctr Rochester NY 14642 USA Washington Hosp Ctr Washington DC 20010 USA Miriam Hosp Providence RI 02906 USA St Josephs Hosp Syracuse NY USA Georgetown Med Ctr Washington DC USA Allegheny Univ Hosp Allegheny Gen Hosp Pittsburgh PA USA Rhode Isl Hosp Providence RI USA Brigham & Womens Hosp Boston MA 02115 USA

OBJECTIVES This registry collected the 30-day and 9-month clinical outcomes of patients whose coronary stent implantation was suboptimal, and compared them with the cohort of patients with "optimal" stenting in the randomized portion of the STent Anti-thrombotic Regimen Study (STARS) trial. BACKGROUND Although "optimal" stenting combined with an aspirin and ticlopidine regimen carries a low (0.5%) incidence of subacute stent thrombosis, only limited data are available for patients in whom stents are deployed suboptimally. METHODS In the STARS, 312 (15.9%) of 1,965 patients enrolled were excluded from participation in the randomized trial based on a perceived "suboptimal" result of coronary stenting. Of these, 265 patients met prespecified criteria for suboptimal stenting, and were followed in a parallel registry, which was compared with the randomized STARS optimal stenting cohort. The primary end point was a 30-day composite of death, emergent target lesion revascularization, angiographic thrombosis of the target vessel without revascularization and nonfatal myocardial infarction (MI)unrelated to direct procedural complications. RESULTS Registry patients had a similar frequency of the primary end point compared with the overall randomized cohort (3.0% vs. 2.2%), with this end point correlating to use of multiple stents, smaller final lumen diameter and absence of ticlopidine from the poststent regimen. Overall 30-day mortality (1.1% vs. 0.06%, p = 0.009) and periprocedural non-Q wave MI (8.7% vs. 4.2%, p = 0.003) were more frequent in registry patients, and appeared to be related to acute procedural complications. Clinical restenosis was significantly higher for registry patients (26.8% vs. 16.0%, p = 0.001), relating to greater prevalence of independent predictors such as smaller final lumen diameter and multiple stent use. CONCLUSIONS In the STARS registry, the inability to perform optimal stenting correlated with smaller final lumen diameter and longer stent len

关键词：急性病血管成形术气囊冠状动脉/统计学和数值数据冠心病/治疗冠状动脉血栓形成/预防和控制 Logistic模型结果与过程评价(卫生保健)/统计学和数值数据复发登记/统计学和数值数据统计学非参数支架/统计学和数值数据时间因素美国老年人女(雌)性人类男(雄)性中年人

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Short-term outcomes after percutaneous coronary intervention: Effects of stenting and institutional volume shifts

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AMERICAN HEART JOURNAL 2002年第2期144卷 309-314页

作者： Watanabe, CT Maynard, C Ritchie, JL Univ Washington Dept Med Seattle WA 98195 USA Univ Washington Dept Hlth Sci Seattle WA 98195 USA Hlth Serv Res & Dev Seattle WA USA Dept Vet Affairs Dept Med Seattle WA USA

Background This study examines how the dissemination of stenting and procedural shifts to high-volume facilities have affected short-term outcomes after percutaneous coronary intervention (PCI). Methods Discharge information from the 1994 and 1997 US Nationwide Inpatient Sample was used. Data from 1994 involved 84,036 angioplasties, 27.3% of which were performed for acute myocardial infarction (AMI), at a time when stents were generally unavailable. Data from 1997 included 118,548 angioplasties, 30.2% of which were performed for AMI and 59% of which involved stenting. Outcomes included same-admission mortality and same-admission bypass grafting surgery (CABG). Results Compared with 1994, in 1997 stents were in widespread use, and there was a significant shift in PCI procedures to high-volume facilities. There was no significant difference in overall mortality rates between 1994 and 1997. However, same-admission CABG rates were lower in 1997 than in 1994 for the AMI group (2.9% vs,4.7%, P < .0001) and for the no-AMI group (1.8% vs 3.0%, P < .0001), which was attributable almost entirely to stenting. For 1997 only, patients receiving stents had a lower mortality rate than patients undergoing PCI without stenting (AMI 2.7% vs 4.7%, P < .0001, no AMI 0.7% vs 0.9%, P = .004). Conclusions Despite the dissemination of stenting and shifts to high-volume facilities, overall mortality rates after PCI have not significantly changed. However, patients undergoing stenting in 1997 had a significantly lower mortality rate than patients who did not undergo stenting, suggesting that stents may prevent inhospital deaths. Furthermore, same-admission CABG rates have decreased dramatically, an association seen with the introduction of stenting, but not with volume shifts.

关键词：血管成形术经腔经皮冠状动脉/死亡率冠状动脉分流术/统计学和数值数据医院死亡率/发展趋势住院病人/统计学和数值数据多元分析心肌梗死/流行病学心肌梗死/治疗比值比支架/统计学和数值数据存活率/发展趋势治疗结果美国/流行病学女(雌)性人类男(雄)性中年人

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Endovascular treatment of aortoiliac aneurysms: Made-to-measure stent-grafts increase feasibility

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ANNALS OF VASCULAR SURGERY 1999年第3期13卷 239-246页

作者： Koskas, F Cluzel, P Benhamou, AC Kieffer, E CHU Pitie Salpetriere Serv Chirurg Vasc F-75651 Paris 13 France

We describe here our preliminary experience with use of a range of made-to-measure stent-grafts made from commercially available components. From January 1996 to June 1998, 94 aortoiliac aneurysms (AIA) were treated with stent-grafts that were made to measure using Z autoexpandable stainless steel stents connected with polyester sutures and covered with commercially available polyester vascular prostheses. These stent-grafts were implanted through 18 to 24 (typically 20) Fr commercially available introducers via a surgical remote access. Made-to-measure tubular, bifurcated, tapered, and/or blind stents combined with extraanatomic bypass designs increased the rate of endovascular treatment (ET) of AIA in this series. This rate was further increased through the use of uncovered proximal or distal stents when dealing with short or tortuous necks near major collaterals and through use of hybrid, partly surgical designs, one with stented and the other with stentless ends, the latter allowing for a surgically made anastomosis. The results of our experience with these techniques show that use of made to-measure stent-grafts greatly increases the feasibility of the ET of AIA among unselected patients while offering enough efficiency and safety to deserve further investigation.

关键词：主动脉瘤腹/外科学人工血管/统计学和数值数据血管假体植入/统计学和数值数据可行性研究髂动脉瘤/外科学手术后并发症/流行病学假体设计支架/统计学和数值数据治疗结果人类

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Stented segment length as an independent predictor of restenosis

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第3期34卷 651-659页

作者： Kobayashi, Y De Gregorio, J Kobayashi, N Akiyama, T Reimers, B Finci, L Di Mario, C Colombo, A Ctr Cuore Columbus I-20145 Milan Italy

OBJECTIVES We sought to evaluate the relation between stented segment length and restenosis. BACKGROUND Multiple or long coronary stents are now being implanted in long lesions or in tandem lesions. A longer stented segment might result in a higher probability of restenosis. However, there is little information available on the relation between stented segment length and restenosis. METHODS Between April 1995 and December 1996, 725 patients with 1,090 lesions underwent stenting. Lesions were divided into three groups according to the length of the stented segment: 1) group I (n = 565): stented segment length less than or equal to 20 mm;2) group II (n = 278): stented segment length >20 but less than or equal to 35 mm;and 3) group III (n = 247): stented segment length >35 mm. RESULTS There was no significant difference in the incidence of subacute stent thrombosis among the three groups (0.4% in group I, 0.4% in group II, 1.2% in group III;p = NS). The minimal lumen diameter (MLD) after stenting was greater in group I than in group III (3.04 +/- 0.60 mm in group I, 3.01 +/- 0.54 mm in group II, 2.91 +/- 0.58 mm in group III;p < 0.05). At follow up, a smaller MLD was observed in group III as compared with group I and group II (2.04 +/- 0.93 mm in group I, 1.92 +/- 1.00 mm in group II, 1.47 +/- 0.97 mm in group III;p < 0.01). The restenosis rates were 23.9% in group I, 34.6% in group II and 47.2% in group III (p < 0.01). Using multivariate analysis, the longer stented segment, the angiographic reference vessel diameter and the percent diameter stenosis after stenting were independent predictors of restenosis. CONCLUSIONS The present study shows that a longer stented segment is an independent predictor of restenosis without an influence on the risk of subacute thrombosis. (J Am Coll Cardiol 1999;34:651-9) (C) 1999 by the American College of Cardiology.

关键词：血管成形术气囊冠状动脉/仪器和设备血管成形术气囊冠状动脉/方法血管成形术气囊冠状动脉/统计学和数值数据卡方分布冠状血管造影术/方法冠状血管造影术/统计学和数值数据冠心病/诊断显像冠心病/治疗冠状血管/诊断显像预后复发支架/统计学和数值数据超声检查介入性/方法超声检查介入性/统计学和数值数据老年人女(雌)性人类男(雄)性中年人

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