Stroke following percutaneous coronary intervention : type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007-12

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Determinants and outcomes of stroke following percutaneous coronary intervention by indication

Background and Purpose— Stroke after percutaneous coronary intervention (PCI) is a serious complication, but its determinants and outcomes after PCI in different clinical settings are poorly documented. Methods— The British Cardiovascular Intervention Society (BCIS) database was used to study 560 439 patients who underwent PCI in England and Wales between 2006 and 2013. We examined procedural-type specific determinants of ischemic and hemorrhagic stroke and the likelihood of subsequent 30-day mortality and in-hospital major adverse cardiovascular events (a composite of in-hospital mortality, myocardial infarction or reinfarction, and repeat revascularization). Results— A total of 705 stroke cases were recorded (80% ischemic). Stroke after an elective PCI or PCI for acute coronary syndrome indications was associated with a higher risk of adverse outcomes compared with those without stroke; 30-day mortality and major adverse cardiovascular events outcomes in fully adjusted model were odds ratios 37.90 (21.43–67.05) and 21.05 (13.25–33.44) for elective and 5.00 (3.96–6.31) and 6.25 (5.03–7.77) for acute coronary syndrome, respectively. Comparison of odds of these outcomes between these 2 settings showed no differences; corresponding odds ratios were 1.24 (0.64–2.43) and 0.63 (0.35–1.15), respectively. Conclusions— Hemorrhagic and ischemic stroke complications are uncommon, but serious complications can occur after PCI and are independently associated with worse mortality and major adverse cardiovascular events outcomes in both the elective and acute coronary syndrome setting irrespective of stroke type. Our study provides a better understanding of the risk factors and prognosis of stroke after PCI by procedure type, allowing physicians to provide more informed advice around stroke risk after PCI and counsel patients and their families around outcomes if such neurological complications occur

Cardiac rehabilitation for heart failure: Do older people want to attend and are they referred?

Purpose Uptake of cardiac rehabilitation services by older people is suboptimal. Offering suitable services may increase participation. This study investigated older heart failure patients' preferences between hospital, community and home-based service models and sociodemographic and clinical factors associated with these preferences. Rates of referral were examined. Methods Cross-sectional survey of patients aged 65 years and older consecutively admitted to elderly care, cardiology and general medicine wards in a large UK hospital with confirmed heart failure between March-December 2009. A 57-item interview schedule incorporating open and closed questions and standard measures was developed enabling both quantitative and qualitative analysis. Associations between patients' preferences and characteristics including disease severity (New York Heart Association [NYHA] classification) and comorbidity (Charlson comorbidity score) were analysed using Chi-squared tests and one-way ANOVA. Results One hundred and six interviews were completed (mean age 77.8 ± 7.3, 62% male, 47% lived alone). Most patients had moderate-severe heart failure (55% NYHA class III; 34% class II) and co-morbidities (mean Charlson score 3.3 ± 1.7). Most opted for cardiac rehabilitation (72%), preferring hospital to community classes. Those preferring hospital programmes were younger (mean 5.1 years, 95% CI -10.1 to -0.1, P = 0.043) than those preferring not to participate. Neither disease severity nor comorbidity was associated with preferences. Only 21% were referred to any cardiac rehabilitation service. Conclusion Most of these older heart failure patients wanted to attend cardiac rehabilitation, but few were referred. Age was related to preferring certain cardiac rehabilitation service models but not to an overall preference to attend. Referral processes need urgent improvement and offering choice of service models may increase participation. © 2014 Elsevier Masson SAS and European Union Geriatric Medicine Society

Sex differences in clinical profile and outcome after percutaneous coronary intervention for chronic total occlusion.

BACKGROUND: There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort. METHODS & RESULTS: We created a longitudinal cohort (2006-2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75-2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78-1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23-1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26-2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62-2.61, P < 0.001) were higher in women compared with men. CONCLUSION: Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients

Comparison of hospital variation in acute myocardial infarction care and outcome between Sweden and United Kingdom: population based cohort study using nationwide clinical registries

To assess the between hospital variation in use of guideline recommended treatments and clinical outcomes for acute myocardial infarction in Sweden and the United Kingdom

Factors influencing change in walking ability in patients with heart failure undergoing exercise-based cardiac rehabilitation

OBJECTIVES: Exercise-based cardiac rehabilitation (CR) is an effective intervention for patients with heart failure (HF), in which one of the main targets is to increase physical capacity. In the HF population this is traditionally assessed using distance covered during a walking test. This study aims to establish the extent to which change in walking ability, in HF patients attending CR, is determined by patient characteristics and service provision. METHODS: The study utilised routine clinical data from the National Audit of Cardiac Rehabilitation to perform a robust analysis. Change, in metres, between pre- and post-CR six-minute walk tests was calculated. Multivariate linear regression models were used to explore the relationship between patient characteristics, service-level variables, and change in metres walked. RESULTS: Complete and valid data from 633 patients was analysed, and a mean change of 51.30 m was calculated. Female gender (-34.13 m, p = 0.007), being retired (-36.41 m, p = 0.001) and being married/in a relationship (-32.54 m, p = 0.023) were all significant negative predictors of change. There was an additional negative relationship with body mass index (BMI) whereby for every unit increase in BMI, predicted change reduces by 2.48 m (p = 0.006). CONCLUSIONS: This study identified significant patient-level characteristics strongly associated with limited improvement in walking ability following CR. Improving physical capacity is a core component of CR, therefore services should aim to account for baseline characteristics identified in this study as part of tailoring the CR intervention around the individual. Pre- and post-CR physical capacity assessments, which constitute minimum standards for CR, are worryingly low and should be given high priority

组织际关系治理不同影响因素下策略选择的实证研究

组织际关系治理是以企业间的竞争合作为基点,以提高组织间关系的治理绩效、保护专用性投入、增强企业核心技术为目的,是企业获得竞争优势的重要来源。而寻找影响组织际关系治理的关键因素,是提高治理绩效的关键所在,是选择治理策略的重要依据。在相关文献基础上,从多视角出发系统总结了影响组织际关系治理的几年关键因素。实践中可行的治理策略有关系治理,正式治理,以及关系治理下的事前联合计划和事后联合解决问题,正式治理下的股权契约治理手段,提出了一种不同影响因素下的治理策略选择模型,通过因子分析验证问卷设计的信度和效度,通过结构方程和二元逻辑回归得出不同影响因素的治理策略选择

A grounded theory study: Exploring health care professionals decision making when managing end stage heart failure care

Aim: To explore how healthcare professionals in an acute medical setting make decisions when managing the care of patients diagnosed with end stage heart failure, and how these decisions impact directly on the patient's end of life experience. Design: A constructivist grounded theory approach was adopted. Method: A purposive sample was used to recruit participants that included 16 registered nurses, 15 doctors and 16 patients. Data were collected using semi-structured interviews and focus groups over a 12-month period of fieldwork concluding in 2017. The interviews were recorded and transcribed and the data were analysed using constant comparison and QSR NVivo. Findings: Four theoretical categories emerged from the data to explain how healthcare professionals and patients negotiated the process of decision making when considering end of life care. These were: signposting symptoms, organizing care, being informed and recognizing dying. The themes revolved around a core category ‘a vicious cycle of heart failure care’. Conclusion: Healthcare professionals need to engage in informed decision making with patients to break this ‘vicious cycle of care’ by identifying key stages in the terminal phase of heart failure and correctly signposting the patient to the most suitable healthcare care professional for intervention. Impact: This study provides a theoretical framework to explain a ‘vicious cycle of care’ for patients diagnosed with end stage heart failure. This theory grounded in data demonstrates the need for both acute and primary care to design an integrative end of life care pathway for heart failure patients which addresses the need for early shared decision making between the healthcare professional, family and the patient when it comes to end of life conversations