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Item Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation(Lippincott, Williams, and Wilkins, 2016-03) Musey, Paul Idun, Jr.; Studnek, Jonathan R.; Garvey, Lee; Department of Emergency Medicine, IU School of MedicineObjectives: To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system. Methods: We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression. Results: Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91–16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03–10.53), and non-white race (AOR, 3.53; 95% CI, 1.76–7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36–6.25). Conclusions: Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.Item The Paradoxical Impact of Insurance Status on Inter-facility Transfer Times and Outcomes in Patients with ST-Elevation Myocardial Infarction(Elsevier, 2019) Nanda, Amit; Urban, Alex; Duong, Vinh; Heckle, Mark; Ibebuogu, Uzoma N.; Reed, Guy; Jefferies, John; Khouzam, Rami N.; Medicine, School of MedicineItem Predicting In-Hospital Mortality in Patients Undergoing Percutaneous Coronary Intervention(Science Direct, 2021-07-20) Castro-Dominguez, Yulanka S.; Wang, Yongfei; Minges, Karl E.; McNamara, Robert L.; Spertus, John A.; Dehmer, Gregory J.; Messenger, John C.; Lavin, Kimberly; Anderson, Cornelia; Blankinship, Kristina; Mercado, Nestor; Clary, Julie M.; Osborne, Anwar D.; Curtis, Jeptha P.; Cavender, Matthew A.; Medicine, School of MedicineBackground Standardization of risk is critical in benchmarking and quality improvement efforts for percutaneous coronary interventions (PCI). In 2018, the CathPCI Registry was updated to include additional variables to better classify higher-risk patients. Objectives We sought to develop a model for predicting in-hospital mortality risk following PCI incorporating these additional variables. Methods Data from 706,263 PCIs performed between 7/2018-6/2019 at 1,608 sites were used to develop and validate a new full and pre-catheterization model to predict in-hospital mortality, and a simplified bedside risk score. The sample was randomly split into a development (70%, n=495,005) and validation cohort (30%, n=211,258). We created 1,000 bootstrapped samples of the development cohort and used stepwise selection logistic regression on each sample. The final model included variables that were selected in at least 70% of the bootstrapped samples and those identified a priori due to clinical relevance. Results In-hospital mortality following PCI varied based on clinical presentation. Procedural urgency, cardiovascular instability, and level of consciousness after cardiac arrest were most predictive of in-hospital mortality. The full model performed well, with excellent discrimination (c-index: 0.943) in the validation cohort and good calibration across different clinical and procedural risk cohorts. The median hospital risk-standardized mortality rate was 1.9% and ranged from 1.1% to 3.3% (interquartile range: 1.7%-2.1%). Conclusions The risk of mortality following PCI can be predicted in contemporary practice by incorporating variables that reflect clinical acuity. This model, which includes data previously not captured, is a valid instrument for risk stratification and for quality improvement efforts.Item Procedural and long-term ischemic outcomes of tight subtotal occlusions treated with orbital atherectomy: An ORBIT II subanalysis(Elsevier, 2018) Lee, Michael S.; Shlofmitz, Richard A.; Shlofmitz, Evan; Behrens, Ann N.; Revtyak, George; Martinsen, Brad J.; Chambers, Jeffrey W.; Medicine, School of MedicineBackground/purpose Orbital atherectomy is an effective treatment strategy to modify severely calcified coronary lesions prior to stent placement. Traversing a severely calcified subtotal occlusion with the crown may be more challenging compared with a less severely stenotic lesion. The purpose of this ORBIT II subanalysis was to evaluate outcomes post-orbital atherectomy (OA) treatment of lesions with ≥95% stenosis. Methods/materials ORBIT II, a single-arm, prospective, multicenter trial, enrolled 443 subjects with severely calcified coronary lesions. Patients with chronic total occlusions were excluded from the trial. Subjects with the OA device activated were stratified based on pre-procedure percent stenosis: ≥95% stenosis (N = 91) and <95% stenosis (N = 341). Procedural success and 3-year major adverse cardiac event (MACE) rates were compared. Results The severe angiographic complications rates were 6.6% and 6.7% in the ≥95% and <95% stenosis groups, respectively. There was no significant difference in procedural success (94.5% vs. 88.3%, p = 0.120). 3-year MACE rates were similar (27.1% vs. 22.5%, p = 0.548), as were the rates of cardiac death (5.7% vs. 7.1%, p = 0.665) and MI (7.9% vs. 12.1%, p = 0.244). The TVR rate was higher in the ≥95% stenosis group (19.1% vs. 7.5%, p = 0.004). Conclusions In ORBIT II, OA treatment of lesions with ≥95% stenosis resulted in a high rate of procedural success. Although the 3-year revascularization rate was higher in the ≥95% stenosis group, it is not unexpected given the challenge of treating such complex lesions. The results of this analysis suggest that OA may be a reasonable treatment strategy for tight, severely calcified subtotal occlusions. Summary The purpose of this ORBIT II subanalysis was to evaluate outcomes post-orbital atherectomy (OA) treatment of lesions with ≥95% stenosis. In ORBIT II, OA treatment of lesions with ≥95% stenosis resulted in a high rate of procedural success. Although the 3-year revascularization rate was higher in the ≥95% stenosis group, it is not unexpected given the challenge of treating such complex lesions. The results of this analysis suggest that OA may be a reasonable treatment strategy for tight, severely calcified subtotal occlusions.Item Simultaneous administration of high-dose atorvastatin and clopidogrel does not interfere with platelet inhibition during percutaneous coronary intervention(Dove Medical Press, 2016) Kreutz, Rolf P.; Breall, Jeffrey A.; Sinha, Anjan; von der Lohe, Elisabeth; Kovacs, Richard J.; Flockhart, David A.; Department of Medicine, IU School of MedicineBACKGROUND: Reloading with high-dose atorvastatin shortly before percutaneous coronary interventions (PCIs) has been proposed as a strategy to reduce periprocedural myonecrosis. There has been a concern that statins that are metabolized by cytochrome P450 3A4 may interfere with clopidogrel metabolism at high doses. The impact of simultaneous administration of high doses of atorvastatin and clopidogrel on the efficacy of platelet inhibition has not been established. METHODS: Subjects (n=60) were randomized to receive atorvastatin 80 mg together with clopidogrel 600 mg loading dose (n=28) versus clopidogrel 600 mg alone (n=32) at the time of PCI. Platelet aggregation was measured at baseline, 4 hours after clopidogrel loading dose, and 16-24 hours after clopidogrel loading dose by light transmittance aggregometry using adenosine diphosphate as agonist. RESULTS: Platelet aggregation was similar at baseline in both the atorvastatin and the control groups (adenosine diphosphate 10 µM: 57%±19% vs 61%±21%; P=0.52). There was no significant difference in platelet aggregation between the atorvastatin and the control groups at 4 hours (37%±18% vs 39%±21%; P=0.72) and 16-24 hours post-clopidogrel loading dose (35%±17% vs 37%±18%; P=0.75). No significant difference in incidence of periprocedural myonecrosis was observed between the atorvastatin and control groups (odds ratio: 1.02; 95% confidence interval 0.37-2.8). CONCLUSION: High-dose atorvastatin given simultaneously with clopidogrel loading dose at the time of PCI does not significantly alter platelet inhibition by clopidogrel. Statin reloading with high doses of atorvastatin at the time of PCI appears to be safe without adverse effects on platelet inhibition by clopidogrel (ClinicalTrials.gov: NCT00979940).