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Low utilisation of functional tests prior to coronary angiography in patients with low to moderate pretest probability of coronary disease
A72
Selected abstracts Cardiology, May
from the XIVth 5-9,2002
World
Congress
of
multivariate predictor of physical functioning (P = 0.005), physical role functioning (P = 0.038), and DASS Anxiety (D = 0.04). Other significant multivariate predictors of 6-month QOL included preoperative QOL scores, perioperative myocardial infarction, and length of stay. Conclusion NP deficits detected 6 months after cardiac surgery have a negative impact on QOL. These results highlight the importance of assessments of NP deficits and QOL in cardiac surgery patients. Key words: Cardiac surgery, Quality of life Low Utilisation of Functional Tests Prior to Coronary Angiography in Patients with Low to Moderate Pretest Probability of Coronary Disease Dominic Y Leung, Chee T Liew, Adeline Wong, Ian Molyneux, Craig P Juergens, Sidney T Lo, Andrew I’ Hopkins Liverpool Hospital, Australia Background Functional tests (FT) are often performed in patients with suspected coronary disease (CAD). Impact on management and costeffectiveness of FT are most optimal in patients with moderate pretest probability. However, pattern of FT utilisation in practice, especially for those found to have normal coronaries subsequently, is unclear. Methods From 12/92 to 7/00,6409 patients underwent 8069 coronary angiograms at Liverpool Hospital. Only studies referred primarily for suspected CAD (n = 6862) were analysed. 769 patient studies (11.2%) showed normal coronaries. Histories of 718 patients (94%) were reviewed. Patient characteristics, utilisation of FT before angiography, main practice location and subspecialty of referrers were correlated. Results There were 387 women and 331 men with mean age of 55 f 12 years and pretest probability of 44 f 30%. Prior to angiography, FT were performed on only 459 patients (63.9%), of whom 239 had exercise ECG, 10 had stress Echo, 131 had stress nuclear scans, 79 had > 1 test. There were no significant differences in sex distribution, age (55 f 11 vs. 54 f 13 years) and pretest probability (45 f 29 vs. 44 f 31%) between patients with FT and those without. Patients who underwent angiography as inpatients were less likely to have undergone FT (41 vs 80%, P < 0.001). Referrers with the following characteristics were more likely to have performed FT: Cardiologist referrers (66 vs 53%, P = 0.007); referrers with direct access to catheterisation laboratory (68 vs 50%, P < 0.001) and referrers who perform angiography (68 vs 61%, P = 0.037). Of the 459 patients with FT, 137 (19.1%) had no inducible ischaemia at an adequate workload. Conclusion In our patients with low to moderate pretest probability of CAD who were found to have normal coronaries (1) FT utilisation was low; (2) a significant proportion proceeded despite lack of inducible ischaemia with adequate stress; (3) Referrer characteristics and patient location, rather than pretest probability of CAD, seemed to have greater impact on utilisation of FT. Key words: Angiography, Coronary artery disease, Coronary heart disease, Exercise tests Clinical Outcomes of a Coronary Interventional Program in a Hospital Without On-Site Cardiac Surgical Backup Greeorv Szto, Betty Williamson, Brian Wood, Judith Bladen, Wendy Dyble Frankston Hospital, Australia Background Following revision of the CSANZ guidelines governing PC1 in hospitals without on-site surgical backup, we prospectively set up a program at a metropolitan hospital situated 50 km from the city centre. Methods Two cardiac surgical units nearest to hospital (18 and 40 km) were formally contacted and written agreements for emergency support were reached. A modern complement of equipment was purchased and inserviced. Ambulance service was informed. A full protocol documented all aspects of the program, and covered all possible coronary emergencies, including coronary dissection, perforation, cardiogenic shock, intubation (ICU is situated next door to cath lab), and placement of perfusion catheters while awaiting for the perfusion team to arrive (40 min). Patient and lesion selection was left up to the discretion of the interventionist. Results In 10 months to September 2001,100 cases were performed on 112 lesions using 129 stents: Elective: 76, Emergency: 6 and adhoc PTCA: 18.
Heart,
Lung
and Circulation
2003; 12
Location LAD-44, LCX-15, RCA-4O,Other-13. Stent rate was 99%. GP IIb/IIIa use: 30%. Procedural success rate was 97% (2 cases: poor guide catheter backup, 1 case: could not cross occlusion). Inhospital mortality = 1 (AMI, heart block, shock, could not cross occlusion). No cases of acute closure or return to lab. Post-PC1 MACE: Restenosis (n = 2), Large Haematoma (n = 6), Cerebral embolus (n = 1), Death (n = 1). Conclusion Strict adherence to the CSANZ coronary angioplasty guidelines has enabled us to achieve a very high level of success at this early stage. This has bolstered our confidence and we anticipate increasing our workload and complexity as our experience matures. Key words: Angioplasty, Coronary artery disease, Patient care, Stent Coronary Collateralisation - Determinants of Adequate Distal Filling After Arterial Occlusion Jens G Kilian, Anthony Keech, Mark R Adams, David S Celermajer Royal Prince Alfred Hospital, Sydney, Australia
Vessel
Background The protective effect of collateral vessels in coronary artery disease (CAD) is well established. Little is known, however, about factors which influence collateral formation. Methods We studied coronary angiograms of 200 consecutive subjects with single vessel occlusion. Patients were excluded if stenoses were present in other vessels or if prior revascularisation had been undertaken. Collateral circulation to the occluded artery was graded as ‘poor’ (no or incomplete filling) or ‘rich’ (complete filling). Patient characteristics, including mode of presentation, medications and CAD risk factors were assessed. Results On univariate testing, correlates of rich collaterals included increasing age (OR 1.03, P = 0.016), ‘statin’ use (OR 2.50, P = 0.005), nitrate use (OR 1.96, P = 0.034), calcium channel blocker use (OR 4.07, P < O.OOl), presentation with stable angina (OR 2.34, P = 0.006), longer time since diagnosis of CAD (OR 1.12, P = 0.002) and hyperlipidaemia (OR 3.55, P < 0.001). Variables correlated with poor collaterals were presentation with acute infarction (OR 0.23, P < O.OOl), diabetes (OR 0.33, P = 0.003), impaired LV function (OR 0.64, P = 0.015) and occlusion of the left anterior descending (LAD) artery (OR 0.28, P < 0.001). On stepwise logistic regression using principle component analysis, good collateralisation was associated with hyperlipidaemia (P = 0.003) and calcium channel blocker use (P = 0.028). Independent predictors of poor collaterals were diabetes (P < O.OOl), LAD occlusion (P = 0.001) and presentation with acute MI (P = 0.017). Conclusion Diabetes mellitus, occlusion of the LAD and presentation with acute MI are associated with poor distal vessel collateralisation, whereas a longer history of stable CAD, hyperlipidaemia and use of calcium channel blockers were associated with rich collateralisation. Factors determining coronary collateral formation may in turn influence outcomes after coronary occlusion. Key words: Angiography, Collateral circulation, Coronary artery disease, Risk factors Nineteen Year (1980-98) Review of Coronary Angioplasty in Australia Joanne Davies’, Susana Series*, Con N Aroney3, Ian T Meredith4, Louis Bernstein5 ‘Australian Institute ofHealth and Welfare, Australia; *Australian institute of Health and Welfare, Canberra, ACT, Australia; 3Prince Charles Hospital, Brisbane, Qld, Australia; 4Monash Medical Centre, Melbourne, Vie, Australia; 5Royal Prince Alfred Hospital, Sydney, NSW, AustraIia Background The Coronary Angioplasty Register (CAR) was established by the National Heart Foundation of Australia (NHF) in 1980 to document percutaneous coronary interventions (ICI) in Australia (AU). The CAR is currently compiled annually by the Australian Institute of Health and Welfare (AIHW) and the NHF based on data collection forms completed by coronary interventionalists (CI). The reports provide information on patterns and trends in the use of PCI, indications, complications and results. Methods This review is based on the above reports provided in 1998 by 108 CI in 46 cardiac units. Results Between 1980 and 1998, 108 785 PC1 were reported in AU including 18 094 in 1998, i.e. an increase of 14% since 1997. The agestandardised national average rate in 1998 was 908 per million (M) population. This varied across the AU States from 675 per M in
Selected abstracts Cardiology, May
from the XIVth 5-9,2002
World
Congress
of
multivariate predictor of physical functioning (P = 0.005), physical role functioning (P = 0.038), and DASS Anxiety (D = 0.04). Other significant multivariate predictors of 6-month QOL included preoperative QOL scores, perioperative myocardial infarction, and length of stay. Conclusion NP deficits detected 6 months after cardiac surgery have a negative impact on QOL. These results highlight the importance of assessments of NP deficits and QOL in cardiac surgery patients. Key words: Cardiac surgery, Quality of life Low Utilisation of Functional Tests Prior to Coronary Angiography in Patients with Low to Moderate Pretest Probability of Coronary Disease Dominic Y Leung, Chee T Liew, Adeline Wong, Ian Molyneux, Craig P Juergens, Sidney T Lo, Andrew I’ Hopkins Liverpool Hospital, Australia Background Functional tests (FT) are often performed in patients with suspected coronary disease (CAD). Impact on management and costeffectiveness of FT are most optimal in patients with moderate pretest probability. However, pattern of FT utilisation in practice, especially for those found to have normal coronaries subsequently, is unclear. Methods From 12/92 to 7/00,6409 patients underwent 8069 coronary angiograms at Liverpool Hospital. Only studies referred primarily for suspected CAD (n = 6862) were analysed. 769 patient studies (11.2%) showed normal coronaries. Histories of 718 patients (94%) were reviewed. Patient characteristics, utilisation of FT before angiography, main practice location and subspecialty of referrers were correlated. Results There were 387 women and 331 men with mean age of 55 f 12 years and pretest probability of 44 f 30%. Prior to angiography, FT were performed on only 459 patients (63.9%), of whom 239 had exercise ECG, 10 had stress Echo, 131 had stress nuclear scans, 79 had > 1 test. There were no significant differences in sex distribution, age (55 f 11 vs. 54 f 13 years) and pretest probability (45 f 29 vs. 44 f 31%) between patients with FT and those without. Patients who underwent angiography as inpatients were less likely to have undergone FT (41 vs 80%, P < 0.001). Referrers with the following characteristics were more likely to have performed FT: Cardiologist referrers (66 vs 53%, P = 0.007); referrers with direct access to catheterisation laboratory (68 vs 50%, P < 0.001) and referrers who perform angiography (68 vs 61%, P = 0.037). Of the 459 patients with FT, 137 (19.1%) had no inducible ischaemia at an adequate workload. Conclusion In our patients with low to moderate pretest probability of CAD who were found to have normal coronaries (1) FT utilisation was low; (2) a significant proportion proceeded despite lack of inducible ischaemia with adequate stress; (3) Referrer characteristics and patient location, rather than pretest probability of CAD, seemed to have greater impact on utilisation of FT. Key words: Angiography, Coronary artery disease, Coronary heart disease, Exercise tests Clinical Outcomes of a Coronary Interventional Program in a Hospital Without On-Site Cardiac Surgical Backup Greeorv Szto, Betty Williamson, Brian Wood, Judith Bladen, Wendy Dyble Frankston Hospital, Australia Background Following revision of the CSANZ guidelines governing PC1 in hospitals without on-site surgical backup, we prospectively set up a program at a metropolitan hospital situated 50 km from the city centre. Methods Two cardiac surgical units nearest to hospital (18 and 40 km) were formally contacted and written agreements for emergency support were reached. A modern complement of equipment was purchased and inserviced. Ambulance service was informed. A full protocol documented all aspects of the program, and covered all possible coronary emergencies, including coronary dissection, perforation, cardiogenic shock, intubation (ICU is situated next door to cath lab), and placement of perfusion catheters while awaiting for the perfusion team to arrive (40 min). Patient and lesion selection was left up to the discretion of the interventionist. Results In 10 months to September 2001,100 cases were performed on 112 lesions using 129 stents: Elective: 76, Emergency: 6 and adhoc PTCA: 18.
Heart,
Lung
and Circulation
2003; 12
Location LAD-44, LCX-15, RCA-4O,Other-13. Stent rate was 99%. GP IIb/IIIa use: 30%. Procedural success rate was 97% (2 cases: poor guide catheter backup, 1 case: could not cross occlusion). Inhospital mortality = 1 (AMI, heart block, shock, could not cross occlusion). No cases of acute closure or return to lab. Post-PC1 MACE: Restenosis (n = 2), Large Haematoma (n = 6), Cerebral embolus (n = 1), Death (n = 1). Conclusion Strict adherence to the CSANZ coronary angioplasty guidelines has enabled us to achieve a very high level of success at this early stage. This has bolstered our confidence and we anticipate increasing our workload and complexity as our experience matures. Key words: Angioplasty, Coronary artery disease, Patient care, Stent Coronary Collateralisation - Determinants of Adequate Distal Filling After Arterial Occlusion Jens G Kilian, Anthony Keech, Mark R Adams, David S Celermajer Royal Prince Alfred Hospital, Sydney, Australia
Vessel
Background The protective effect of collateral vessels in coronary artery disease (CAD) is well established. Little is known, however, about factors which influence collateral formation. Methods We studied coronary angiograms of 200 consecutive subjects with single vessel occlusion. Patients were excluded if stenoses were present in other vessels or if prior revascularisation had been undertaken. Collateral circulation to the occluded artery was graded as ‘poor’ (no or incomplete filling) or ‘rich’ (complete filling). Patient characteristics, including mode of presentation, medications and CAD risk factors were assessed. Results On univariate testing, correlates of rich collaterals included increasing age (OR 1.03, P = 0.016), ‘statin’ use (OR 2.50, P = 0.005), nitrate use (OR 1.96, P = 0.034), calcium channel blocker use (OR 4.07, P < O.OOl), presentation with stable angina (OR 2.34, P = 0.006), longer time since diagnosis of CAD (OR 1.12, P = 0.002) and hyperlipidaemia (OR 3.55, P < 0.001). Variables correlated with poor collaterals were presentation with acute infarction (OR 0.23, P < O.OOl), diabetes (OR 0.33, P = 0.003), impaired LV function (OR 0.64, P = 0.015) and occlusion of the left anterior descending (LAD) artery (OR 0.28, P < 0.001). On stepwise logistic regression using principle component analysis, good collateralisation was associated with hyperlipidaemia (P = 0.003) and calcium channel blocker use (P = 0.028). Independent predictors of poor collaterals were diabetes (P < O.OOl), LAD occlusion (P = 0.001) and presentation with acute MI (P = 0.017). Conclusion Diabetes mellitus, occlusion of the LAD and presentation with acute MI are associated with poor distal vessel collateralisation, whereas a longer history of stable CAD, hyperlipidaemia and use of calcium channel blockers were associated with rich collateralisation. Factors determining coronary collateral formation may in turn influence outcomes after coronary occlusion. Key words: Angiography, Collateral circulation, Coronary artery disease, Risk factors Nineteen Year (1980-98) Review of Coronary Angioplasty in Australia Joanne Davies’, Susana Series*, Con N Aroney3, Ian T Meredith4, Louis Bernstein5 ‘Australian Institute ofHealth and Welfare, Australia; *Australian institute of Health and Welfare, Canberra, ACT, Australia; 3Prince Charles Hospital, Brisbane, Qld, Australia; 4Monash Medical Centre, Melbourne, Vie, Australia; 5Royal Prince Alfred Hospital, Sydney, NSW, AustraIia Background The Coronary Angioplasty Register (CAR) was established by the National Heart Foundation of Australia (NHF) in 1980 to document percutaneous coronary interventions (ICI) in Australia (AU). The CAR is currently compiled annually by the Australian Institute of Health and Welfare (AIHW) and the NHF based on data collection forms completed by coronary interventionalists (CI). The reports provide information on patterns and trends in the use of PCI, indications, complications and results. Methods This review is based on the above reports provided in 1998 by 108 CI in 46 cardiac units. Results Between 1980 and 1998, 108 785 PC1 were reported in AU including 18 094 in 1998, i.e. an increase of 14% since 1997. The agestandardised national average rate in 1998 was 908 per million (M) population. This varied across the AU States from 675 per M in