The American journal of cardiology
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The American College of Cardiology and American Heart Association guidelines recommend that management of adult congenital heart disease (ACHD) be coordinated by specialty ACHD centers and that ACHD surgery for patients with moderate or complex congenital heart disease (CHD) be performed by surgeons with expertise and training in CHD. Given this, the aim of this study was to determine the proportion of ACHD surgery performed at specialty ACHD centers and to identify factors associated with ACHD surgery being performed outside of specialty centers. This retrospective population analysis used California's Office of Statewide Health Planning and Development's discharge database to analyze ACHD cardiac surgery (in patients 21 to 65 years of age) in California from 2000 to 2011. ⋯ In multivariate analysis among those discharges for ACHD surgery in patients with moderate or complex CHD, performance of surgery outside a specialty center was more likely to be associated with patients who were older, Hispanic, insured by health maintenance organizations, and living farther from a specialty center. In conclusion, although the proportion of ACHD surgery for moderate or complex CHD being performed at specialty ACHD centers has been increasing, 1 in 4 patients undergo surgery at nonspecialty centers. Increased awareness of ACHD care guidelines and of the patient characteristics associated with differential access to ACHD centers may help improve the delivery of appropriate care for all adults with CHD.
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The goal of this study was to assess outcomes of patients who underwent implantation of left ventricular assist devices (LVADs) at nontransplantation mechanical circulatory support centers. As the availability of LVADs for advanced heart failure has expanded to nontransplantation mechanical circulatory support centers, concerns have been expressed about maintaining good outcomes. Demographics and outcomes were evaluated in 276 patients with advanced heart failure who underwent implantation of LVADs as bridge to transplantation or destination therapy at 27 open-heart centers. ⋯ Quality-of-life measures and 6-minute walk distances showed sustained improvements throughout support. In conclusion, outcomes with LVAD support at open-heart centers are acceptable and comparable with results from the INTERMACS registry. With appropriate teams, training, center commitment, and certification, LVAD therapy is being disseminated in a responsible way to open-heart centers.
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Inappropriate shock is a frequently seen clinical problem despite advanced technologies used in modern implantable cardioverter-defibrillator (ICD) devices. Our aim was to investigate whether simply raising the ICD detection zones can decrease inappropriate therapies while still providing appropriate therapy. We randomized 223 patients with primary prevention to either the conventional programming group with 3 zones as VT1 (167 to 182 beats/min) with discriminators, VT2 (182 to 200 beats/min) with discriminators, and ventricular fibrillation (>200 beats/min) (n=100) or the high-zone programming group with 3 zones as VT1 (171 to 200 beats/min) with discriminators, VT2 (200 to 230 beats/min) with discriminators, and ventricular fibrillation (>230 beats/min; n=101). ⋯ During 12-month follow-up, the first episode of appropriate therapy was higher (22% vs 10%, hazard ratio [HR] 2.18, 95% confidence interval [CI], 1.09 to 4.36, p=0.028) and the first episode of inappropriate therapy was lower (5% vs 28%, HR 0.18 [95% CI 0.07 to 0.44], p<0.001) in the high-zone group compared with the conventional group. Although all-cause mortality did not differ (2% for the high-zone group vs 3% for the conventional group, HR 0.65 [95% CI 0.11 to 3.99], p>0.05), hospitalization for heart failure was significantly higher in the conventional group (13% vs 4%, HR 0.28 [95% CI 0.09 to 0.88], p=0.021). In conclusion, in a real-world population, high-zone settings of the single-, dual-, and triple-chamber ICDs were associated with reduction in inappropriate therapy while still providing appropriate therapy.
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Aspirin is the key treatment in the secondary prevention of atherothrombosis. Interindividual variability of response has been linked to a higher risk for ischemic events. The aim of this study was to identify clinical and biologic factors predicting high on-aspirin platelet reactivity (HPR) in a high-risk, "real-world" population of vascular patients. ⋯ Similar results were found in patients treated with aspirin alone or dual-antiplatelet therapy. A fibrinogen level>4.0 g/L was associated with a 3.9-fold increased risk for HPR in patients aged <75 years. In conclusion, fibrinogen level was the major predictor of HPR on aspirin in this large population of high-risk vascular patients.
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The impact of preoperative stable angina pectoris on postoperative cardiovascular outcomes in patients with previous myocardial infarction (MI) who underwent major noncardiac surgery is not well studied. We studied patients with previous MI who underwent elective major noncardiac surgeries within the American College of Surgeons-National Surgical Quality Improvement Program (2005 to 2011). Primary outcome was occurrence of an adverse cardiac event (MI and/or cardiac arrest). ⋯ In secondary outcomes, reintervention rates (22.5% vs 11%, p <0.001) and length of stay (median 6-days vs 5-days; p <0.001) were also higher in patients with preoperative angina. In multivariable analyses, preoperative angina was a significant predictor for postoperative MI (odds ratio 2.49 [1.20 to 5.58]) and reintervention (odds ratio 2.40 [1.44 to 3.82]). In conclusion, our study indicates that preoperative angina is an independent predictor for adverse outcomes in patients with previous MI who underwent major noncardiac surgery, and cautions against overreliance on predictive tools, for example, the Revised Cardiac Risk Index, in these patients, which does not treat stable angina and previous MI as independent risk factors during risk prognostication.