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Impact of socioeconomic status on guideline-recommended care for ST-elevation myocardial infarction
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Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129
Objectives: To investigate the efficacy and safety of transfemoral artery administration of autologous unfractionated bone marrow (AUBM) in patients with critical limb ischemia due to arteriosclerosis obliterans. Methods: The study comprised 16 patients having severe chronic limb ischemia with indication for major amputation. Primary end points were safety, total healing of the most important lesion while avoiding major amputation, and relief of rest pain. Secondary end points were changes in resting Ankle-Brachial Index (ABI) and angiographic evidence of collateral vessels formation. Bone marrow administration: Percutaneous retrograde common femoral artery and vein catheterization of the compromised limb was performed. Before transfemoral artery bolus administration of 120 mL of filtered AUBM, the iliac vein was occluded with balloon catheter 7 to 10/20 mm keeping the occlusion during 20 minutes. Results: Clinical characteristics: Sixteen patients (10 men) with a mean age of 62 (±10) years. Risk factors: Hypertension 100% (16/16), diabetes 100% (16/16); Fontaine stage grade IV 100% (16/16), rest pain 87% (14/16), ischemic ulcers 100% (16/16), indication of major amputation by vascular surgeons 100% (16/16), baseline resting ABI 0.39 (±0.19). Major amputation was needed in 56% (9/16) of the patients at 48 (±53) days. A total healing of the most important ischemic ulcers was achieved in 44% (7/16) of the patients. None of them underwent major amputation during the mean 24 (±8) months of follow-up. In this group of patients, significant improvement was observed in Fontaine stage, rest pain and resting ABI from a mean baseline of 0.48 (±0.21) to 0.67 (±0.30). Increase of collateral circulation was shown by angiography in 3/7 patients (42%). Skin biopsy 30 days after AUBM administration showed increased neoformation with CD31 + cells. No side effects nor complications were detected during the administration of AUBM and follow-up. Conclusions: We conclude that the combined transfemoral artery administration of AUBM with transitory vein occlusion could constitute a novel, clinically feasible and safe therapy for patients with severe peripheral arterial disease. doi:10.1016/j.carrev.2008.02.068
Does weekend hospitalization confer an adverse risk to patients with acute cardiac disease? SV Velamakanni, HA Cooper, JA Panza Washington Hospital Center, Washington, DC, USA Background: Weekend admission for acute coronary syndromes (ACS) and other critical illnesses has been reported to be associated with higher mortality. We hypothesized that treatment in a coronary care unit (CCU) with uniform staffing and availability of interventional cardiac procedures would eliminate this adverse “weekend effect.” Methods: We analyzed prospective data on consecutive first admissions to the CCU of a major teaching hospital. Use of interventional procedures and clinical outcomes was compared for weekend (Saturday-Sunday) and weekday (Monday-Friday) admissions. Multivariate logistic regression was used to determine the relationship between weekend admission and inhospital mortality. Results: From September 2002 to June 2007, there were 6255 admissions, including 3443 for ACS and 1847 for ST-elevation myocardial infarction. Weekend (n=1755) and weekday (n=4500) admissions were similar for all relevant baseline characteristics. Among weekend and weekday ACS admissions, coronary angiography (91.1% at 0.53±1.7 days vs 91.4% at 0.51±1.4 days) and percutaneous coronary intervention (70.1% at 0.70±2.1 days vs. 68.7% at 0.60±1.7 days) were performed with similar rates and timing. Weekend and weekday STEMI admissions also had similar rates of early angiography (92.6% at 0.33±1.6 days vs 93.6% at 0.30±1.2 days) and percutaneous coronary
intervention (79.3% at 0.42±1.8 days vs 80.6% at 0.41±1.7 days). On multivariate analysis, weekend admission was not associated with any increase in inhospital mortality among all admissions (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.78-1.13, P=.49), ACS admissions (OR 0.81, 95% CI 0.60-1.09, P=.17), and STEMI admissions (OR 1.12, 95% CI 0.72-1.74, P=.63). Conclusion: For patients admitted to the CCU of a major teaching hospital in which interventional cardiac procedures are performed uniformly throughout the week, differences in weekend vs weekday outcomes are eliminated. doi:10.1016/j.carrev.2008.02.069
Impact of socioeconomic status on guideline-recommended care for ST-elevation myocardial infarction SC Vasaiwala, M Vidovich University of Illinois at Chicago, Chicago, IL, USA Background: The ACC and AHA recommend goals of 30 minutes for doorto-needle time for initiation of fibrinolytic therapy and a door-to-balloon time of 90 minutes for percutaneous coronary intervention (PCI) for the treatment of patients diagnosed with ST-elevation myocardial infarction (STEMI). We sought to determine if the annual median household income (MHI) of the hospital neighborhood correlates with the rate at which these measures are met. Methods: We analyzed over 1500 hospitals in 26 US states from January 06 to December 07. Available data on the proportion of patients receiving guideline-recommended fibrinolytic and PCI therapies were obtained from Hospital Compare, a Department of Health and Human Services database. Data on MHI for each hospital ZIP code were obtained from the US Census Bureau. Median household income was grouped in tertiles; groups: 1-lowest, below $34 808; 2-middle, $34 809-$49 702; 3-highest, above $49 703. Kruskal-Wallis test was used due to a nonnormal distribution of MHI. Group differences were determined by the Mann-Whitney U test. Results: Groups
No. of hospitals
Mean (95% CI)
Proportion of patients receiving fibrinolytics within 30 min 1 150 0.67 (0.62-0.72) 2 147 0.68 (0.63-0.73) 3 130 0.70 (0.64-0.76) Overall 427 0.68 (0.65-0.71) Group 1 vs group 2: P=.96 Group 1 vs group 3: P=.56 Group 2 vs group 3: P=.46 Proportion of patients receiving PCI within 90 min 1 206 2 217 3 212 Overall 635 Group 1 vs group 2: P=.015 Group 1 vs group 3: P=.000 Group 2 vs group 3: P=.044
0.52 (0.49-0.55) 0.57 (0.54-0.60) 0.61 (0.58-0.64) 0.57 (0.55-0.58)
Conclusion: All hospitals, irrespective of neighborhood income perform poorly at meeting American College of Cardiology and American Heart Association standards. Compared to the highest-income neighborhoods, hospitals located in the lowest-income neighborhoods perform worse in meeting PCI standards for STEMI. Data for fibrinolytic therapy do not suggest such a trend. Additional process measures are needed to explain hospital-level variation in the care of patients with STEMI as it relates to PCI therapy. doi:10.1016/j.carrev.2008.02.070
Abstracts / Cardiovascular Revascularization Medicine 9 (2008) 101–129
Objectives: To investigate the efficacy and safety of transfemoral artery administration of autologous unfractionated bone marrow (AUBM) in patients with critical limb ischemia due to arteriosclerosis obliterans. Methods: The study comprised 16 patients having severe chronic limb ischemia with indication for major amputation. Primary end points were safety, total healing of the most important lesion while avoiding major amputation, and relief of rest pain. Secondary end points were changes in resting Ankle-Brachial Index (ABI) and angiographic evidence of collateral vessels formation. Bone marrow administration: Percutaneous retrograde common femoral artery and vein catheterization of the compromised limb was performed. Before transfemoral artery bolus administration of 120 mL of filtered AUBM, the iliac vein was occluded with balloon catheter 7 to 10/20 mm keeping the occlusion during 20 minutes. Results: Clinical characteristics: Sixteen patients (10 men) with a mean age of 62 (±10) years. Risk factors: Hypertension 100% (16/16), diabetes 100% (16/16); Fontaine stage grade IV 100% (16/16), rest pain 87% (14/16), ischemic ulcers 100% (16/16), indication of major amputation by vascular surgeons 100% (16/16), baseline resting ABI 0.39 (±0.19). Major amputation was needed in 56% (9/16) of the patients at 48 (±53) days. A total healing of the most important ischemic ulcers was achieved in 44% (7/16) of the patients. None of them underwent major amputation during the mean 24 (±8) months of follow-up. In this group of patients, significant improvement was observed in Fontaine stage, rest pain and resting ABI from a mean baseline of 0.48 (±0.21) to 0.67 (±0.30). Increase of collateral circulation was shown by angiography in 3/7 patients (42%). Skin biopsy 30 days after AUBM administration showed increased neoformation with CD31 + cells. No side effects nor complications were detected during the administration of AUBM and follow-up. Conclusions: We conclude that the combined transfemoral artery administration of AUBM with transitory vein occlusion could constitute a novel, clinically feasible and safe therapy for patients with severe peripheral arterial disease. doi:10.1016/j.carrev.2008.02.068
Does weekend hospitalization confer an adverse risk to patients with acute cardiac disease? SV Velamakanni, HA Cooper, JA Panza Washington Hospital Center, Washington, DC, USA Background: Weekend admission for acute coronary syndromes (ACS) and other critical illnesses has been reported to be associated with higher mortality. We hypothesized that treatment in a coronary care unit (CCU) with uniform staffing and availability of interventional cardiac procedures would eliminate this adverse “weekend effect.” Methods: We analyzed prospective data on consecutive first admissions to the CCU of a major teaching hospital. Use of interventional procedures and clinical outcomes was compared for weekend (Saturday-Sunday) and weekday (Monday-Friday) admissions. Multivariate logistic regression was used to determine the relationship between weekend admission and inhospital mortality. Results: From September 2002 to June 2007, there were 6255 admissions, including 3443 for ACS and 1847 for ST-elevation myocardial infarction. Weekend (n=1755) and weekday (n=4500) admissions were similar for all relevant baseline characteristics. Among weekend and weekday ACS admissions, coronary angiography (91.1% at 0.53±1.7 days vs 91.4% at 0.51±1.4 days) and percutaneous coronary intervention (70.1% at 0.70±2.1 days vs. 68.7% at 0.60±1.7 days) were performed with similar rates and timing. Weekend and weekday STEMI admissions also had similar rates of early angiography (92.6% at 0.33±1.6 days vs 93.6% at 0.30±1.2 days) and percutaneous coronary
intervention (79.3% at 0.42±1.8 days vs 80.6% at 0.41±1.7 days). On multivariate analysis, weekend admission was not associated with any increase in inhospital mortality among all admissions (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.78-1.13, P=.49), ACS admissions (OR 0.81, 95% CI 0.60-1.09, P=.17), and STEMI admissions (OR 1.12, 95% CI 0.72-1.74, P=.63). Conclusion: For patients admitted to the CCU of a major teaching hospital in which interventional cardiac procedures are performed uniformly throughout the week, differences in weekend vs weekday outcomes are eliminated. doi:10.1016/j.carrev.2008.02.069
Impact of socioeconomic status on guideline-recommended care for ST-elevation myocardial infarction SC Vasaiwala, M Vidovich University of Illinois at Chicago, Chicago, IL, USA Background: The ACC and AHA recommend goals of 30 minutes for doorto-needle time for initiation of fibrinolytic therapy and a door-to-balloon time of 90 minutes for percutaneous coronary intervention (PCI) for the treatment of patients diagnosed with ST-elevation myocardial infarction (STEMI). We sought to determine if the annual median household income (MHI) of the hospital neighborhood correlates with the rate at which these measures are met. Methods: We analyzed over 1500 hospitals in 26 US states from January 06 to December 07. Available data on the proportion of patients receiving guideline-recommended fibrinolytic and PCI therapies were obtained from Hospital Compare, a Department of Health and Human Services database. Data on MHI for each hospital ZIP code were obtained from the US Census Bureau. Median household income was grouped in tertiles; groups: 1-lowest, below $34 808; 2-middle, $34 809-$49 702; 3-highest, above $49 703. Kruskal-Wallis test was used due to a nonnormal distribution of MHI. Group differences were determined by the Mann-Whitney U test. Results: Groups
No. of hospitals
Mean (95% CI)
Proportion of patients receiving fibrinolytics within 30 min 1 150 0.67 (0.62-0.72) 2 147 0.68 (0.63-0.73) 3 130 0.70 (0.64-0.76) Overall 427 0.68 (0.65-0.71) Group 1 vs group 2: P=.96 Group 1 vs group 3: P=.56 Group 2 vs group 3: P=.46 Proportion of patients receiving PCI within 90 min 1 206 2 217 3 212 Overall 635 Group 1 vs group 2: P=.015 Group 1 vs group 3: P=.000 Group 2 vs group 3: P=.044
0.52 (0.49-0.55) 0.57 (0.54-0.60) 0.61 (0.58-0.64) 0.57 (0.55-0.58)
Conclusion: All hospitals, irrespective of neighborhood income perform poorly at meeting American College of Cardiology and American Heart Association standards. Compared to the highest-income neighborhoods, hospitals located in the lowest-income neighborhoods perform worse in meeting PCI standards for STEMI. Data for fibrinolytic therapy do not suggest such a trend. Additional process measures are needed to explain hospital-level variation in the care of patients with STEMI as it relates to PCI therapy. doi:10.1016/j.carrev.2008.02.070