708-3 Impact of Exercise SPECT Thallium Imaging on Patient Management and Outcome

This study examined the impact of exercise thallium imaging on patient (pt) management Ithe need for coronary angiography and revascularization) and outcome (hard cardiac event: cardiac death or non fatal acute myocardial infarction) in 2700 pts being evaluated for diagnostic purposes. None of the pts had prior coronary angiography, PTCA or CABG or Q-wave myocardial infarction. The SPECT images were normal in 2027 pts (Group 1) and abnormal in 673 pts (Group 2). The exercise ECG was positive in 190 pts (9%), negative in 1461 pts (72%) and non-diagnostic in 376 pts (19%) in Group 1. The corresponding numbers were 218 pts (32%), 240 pts (36%) and 215 pts (32%) in Group 2. Within 6 months after thallium imaging, 53 pts in Group 1 (3%) and 242 pts in Group 2 (36%) underwent coronary angiography (P=0.0001). The pts who underwent cardiac catheterization in Group 1 had higher pre-test probability of coronary disease (48±39% vs 39±27%) and lower exercise workload (7.1±3.2 vs 9.4±4.4 METs) than the pts who did not. The pts in Group 2 who underwent coronary angiography had more perfusion defects (8.8±4.8 vs 6.3±4.4 abnormal segments, P=0.0001) than pts who did not. Coronary revascularization within 3 months of coronary angiography was performed in 1 of the 53 pts in Group 1 (2%) and in 87 of 242 pts (30%) in Group 2 (P=0.0001). Among the remaining pts who had angiography and were treated medically there were no events in Group 1 and 15 events in Group 2. The event-free survival was significantly worse in Group 2 than Group 1 (Mantel-Cox statistic=5, P=0.02). Thus, the results of exercise SPECT thallium imaging are important in pt management and outcome. Coronary angiography, coronary revascularization and events are rare in pts with normal images

Sex‐Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/1/jah32481-sup-0001-TableS1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/2/jah32481.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/3/jah32481_am.pd

Association of Same-Day Discharge After Elective Percutaneous Coronary Intervention in the United States With Costs and Outcomes

Importance Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. Objective To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD; (3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. Design, Setting, and Participants This observational cross-sectional cohort study included 672 470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up. Exposures Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. Main Outcomes and Measures Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals’ perspective, inflated to 2016. Results Among 672 470 elective PCIs, 221 997 patients (33.0%) were women, 30 711 (4.6%) were Hispanic, 51 961 (7.7%) were African American, and 491 823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95$5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save$129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates. Conclusions and Relevance Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than$5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care

The Accuracy of the Electrocardiogram during Exercise Stress Test Based on Heart Size

BACKGROUND: Multiple studies have shown that the exercise electrocardiogram (ECG) is less accurate for predicting ischemia, especially in women, and there is additional evidence to suggest that heart size may affect its diagnostic accuracy. HYPOTHESIS: The purpose of this investigation was to assess the diagnostic accuracy of the exercise ECG based on heart size. METHODS: We evaluated 1,011 consecutive patients who were referred for an exercise nuclear stress test. Patients were divided into two groups: small heart size defined as left ventricular end diastolic volume (LVEDV) <65 mL (Group A) and normal heart size defined as LVEDV ≥65 mL (Group B) and associations between ECG outcome (false positive vs. no false positive) and heart size (small vs. normal) were analyzed using the Chi square test for independence, with a Yates continuity correction. LVEDV calculations were performed via a computer-processing algorithm. SPECT myocardial perfusion imaging was used as the gold standard for the presence of coronary artery disease (CAD). RESULTS: Small heart size was found in 142 patients, 123 female and 19 male patients. There was a significant association between ECG outcome and heart size (χ(2) = 4.7, p = 0.03), where smaller hearts were associated with a significantly greater number of false positives. CONCLUSIONS: This study suggests a possible explanation for the poor diagnostic accuracy of exercise stress testing, especially in women, as the overwhelming majority of patients with small heart size were women

Effects of alirocumab on types of myocardial infarction: insights from the ODYSSEY OUTCOMES trial

Aims  The third Universal Definition of Myocardial Infarction (MI) Task Force classified MIs into five types: Type 1, spontaneous; Type 2, related to oxygen supply/demand imbalance; Type 3, fatal without ascertainment of cardiac biomarkers; Type 4, related to percutaneous coronary intervention; and Type 5, related to coronary artery bypass surgery. Low-density lipoprotein cholesterol (LDL-C) reduction with statins and proprotein convertase subtilisin–kexin Type 9 (PCSK9) inhibitors reduces risk of MI, but less is known about effects on types of MI. ODYSSEY OUTCOMES compared the PCSK9 inhibitor alirocumab with placebo in 18 924 patients with recent acute coronary syndrome (ACS) and elevated LDL-C (≥1.8 mmol/L) despite intensive statin therapy. In a pre-specified analysis, we assessed the effects of alirocumab on types of MI. Methods and results  Median follow-up was 2.8 years. Myocardial infarction types were prospectively adjudicated and classified. Of 1860 total MIs, 1223 (65.8%) were adjudicated as Type 1, 386 (20.8%) as Type 2, and 244 (13.1%) as Type 4. Few events were Type 3 (n = 2) or Type 5 (n = 5). Alirocumab reduced first MIs [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77–0.95; P = 0.003], with reductions in both Type 1 (HR 0.87, 95% CI 0.77–0.99; P = 0.032) and Type 2 (0.77, 0.61–0.97; P = 0.025), but not Type 4 MI. Conclusion  After ACS, alirocumab added to intensive statin therapy favourably impacted on Type 1 and 2 MIs. The data indicate for the first time that a lipid-lowering therapy can attenuate the risk of Type 2 MI. Low-density lipoprotein cholesterol reduction below levels achievable with statins is an effective preventive strategy for both MI types.For complete list of authors see http://dx.doi.org/10.1093/eurheartj/ehz299</p