Eagle, K.A.

Erdem, N.

Freedman, M.

Froehlich, J.B.

Karavite, D.J.

Russman, P.

Stanley, J.C.

Wakefield, T.W.

Wise, C.G.

Zelenock, G.B.

Elsevier - Publisher Connector 

Effect on costs of ACC/AHA guidelines for preoperative cardiac risk assessment before aortic surgery 

JACC Fcbman; Iqg8 4~tSA 
dosceded as lower at rest in athlete than sedentary SublOCls. The a,m et 
this study wlls to voflfy that e=trlal diastolic function IS mvolvnd in exorcise 
capaoty. 
M ~  38 Sut~e¢1,~, dlvK~[~ in thre~ gfoup~,, athlete (A), chronic heart 
ladum (CHF), sedentary control tC), made ~ m~p~lmal tnangulat exam=so wffh 
VO2 mea~uremem on cycle ergomemt, A Doppler e Ihoca~phy was 
I~Oft'/m¢l at msl and immediately alter n~lxle~U exemise In upnghl posmon, 
A and E w~ve were measured, della E/A represenlmg the differer~e between 
~JA at rest and EtA at exerose 
ReS~.~S At rest E/A ratio was hq~her in (A) (1 76 -* 042: p ~ 000t), 
and lower in CHF (084 ¢ 048; p ~ 005) ve f~ (Ci (11S ¢ 0.45) tn 
itealtt W s~is  (g !~ A and C) the mimosa el A wave dunng exercise was 
cowelated w~th V02 ma~ If = 0:59; P ~ 0 01), EtA de.eased d~nng e~erc~se 
and de~a EtA was also co,crated with V02 max it = -085; p .  0.00t) but 
not in CHF 
C~h-~prr; The l~maw msullS S~Sl  lhal A wave, i~llve atnal com, 
~nt  el dm--..~t~ lUn~mn, seems '.o represent a "athal reserve', available 
at o"ercise to maintain o~ m~rease ca~ ~ m healthy s~blecls, ~ not 
in CHF patients. 
Use of Algorithm and Computerized ~ ls  
in I~hemlc Heart Disease 
Wednesday, April 1, 1998, NoorP-2:00 p.m. 
Georgia World Congress Center, West Exhibit Hail Level 
Presentation Hour: 1:00 p.m.-2:00 p.m. 
~ Eft~'t on Costs of ACC/AHA Guidelines for 
- -  Preoperati~ Cardiac Risk Assessment Before 
Aort ic  Surgery  
J B Froehl~ch, P Russman, D.J. Kara.~te, N. Erdem+ M Freedman+ 
C G WLSe, GB. Zelenock, TW. Wakefi~H .IC Stanley, KA  Eagle 
Lh~tsz.~,, Ot Af~ct~gar~ Ann Arbor. A~ct~gar~ USA 
The ACC/AHA Joint Task Force Gurdehnes recommend a stepw~se alga- 
flthm approach to car~ac risk assessment prior to noncard~c surgery. We 
stu'~ed a strategy to in '~nt  ~ ACCIAHA Guidelines, by compa~ng g5 
~ e  etectzve abdOmh'~al ort~ surgery patients at the Unwers=ty of 
M~htgan 17/95 to 12,'96) with 102 h*storm...~ controls (1,~93 to 12/94), after a 
program consisting O1 lectures, a new preop dm~c, use o1 algont1"tm cams. 
and al~onlhrn-embed~l clin;,C notes We prev~Iy reported a s~gn,f~,ant 
red~'tton In resource ul]l~'a.bon, (stress test use. cath and PI"CA), wtthoul 
effect on outcomes el death or Mt Analys=s O1 total cost per case for sun, col 
a~n'ttsseon, cost at preoperal~ve valuabon (PREOP COST) and length O1 
stay (LOS) was gedon'nod, excfudm 9 12 subl"ects tar whom data was not 
avatlabte Total o~rect costs O1 preop evaluation anO surgical admission were 
~.oml,~ared using TSI data and cost, charge ratios 
Resu~s:We found a decrease m total costs for vascular surgmal admmsmn 
O1 .50%(P. 0.001). Preopcosts felt (S1.087 : 2371o$250 : 88. p - 0001) 
as o~d length el stay (;'0.8 to 15.3 days. p ~ 0.02). Using s~mple ducal]on31 
toots, we demonstrated a reductmn ,n total costs. PREOP COST and LOS 
=n patreuts undergoing electwe ao~c surgery The coml~nat~on at rmportant 
cost savt,-tgs ¢.~th ptesen,,ed outcomc~ argues for w~despread adoption of 
these go~dehnes 
-~- -~ PET Perl~sion Cuts the Cost Myocardial Imaging 
of Coronary Disease Management by Eliminating 
Unnecessary Invas|ve Diagnostic and Therapeutic 
Procedures  
M. Merhlge, T. Houston, V. Shelton. J. Kay, G Stem. J Olrveno E Fast, 
D. Saiki. J. Shanahan, C. Temo, B. Rueda. B D'Arcy. Buffalo Cwd~ology & 
Pulmonary Assoc~ateA PC: SUNY at Buffalo, Buffalo, NY. USA 
We hypothesized that myocardial p~ffusron imaging w~th Rb-82 PET results m 
cost savings in coronary disease (CAD) management, compared w~th SPECT 
imaging, because of improved test accuracy. We compared procedure costs 
and outcomes in 1,482 sequenbal patients (pts) referred for CAD evaluation 
w~th PET, with 102 pts imaged with SPECT who were matched for pretest 
likelihood of coronary disease with the first 102 PET pts. Cost was calculated: 
SPECT-S1,000. PET-S1.850, Angio-$4,800. PTCI-S10.000, CABG-S40.000. 
Average 6 month follow-up was obtained (3 rues-1 year). 
SPECT PET P Va~e 
n tQ2 141~2 
PteI~i plan 0 3(~ : 0 14 L138 ~ 0 16 
Ang'o Rate ::~ 4% t4 4% 13 ~1 
F~me Po~,t,ve 152~= 5 I% 0 0"-~' 
CABG Rate (~ ~-~ 35% 0 03? 
P?CI Fl~le 2 9% ~' 5% 0 40 
T(~tal Mortally 0020 0 0tf~ 0 3a 
Cam~- Mona~ 0 020 0 008 00f~ 
Acute MI 0029 0011 00~ 
Co~j~/cn' Management wrth P~ in pts with an mlenne~ale nsk at 
CAD results m: 50% reduc$on m angregtaphy & CABG; excellent shod term 
outcomes, ana 25% reo't~On =n CAD management costs 
• Precl!elk~n Of In,hospital  Sundva l  A l ter  Sudden 
(:1111111 Ol l ! lh :  I )e lv l t ton  led  Vi l l ldat lon Of a 
C l in ica l  Model  
PA. McCullough, K J Tobin. JK  Kahn. WW O'NedL R J Thompson 
Hen~/ Forcl Ho~pnat, DefraY, AWch~gan: Wi/ham Beaumont Hospnat, RGyat 
Oak. Mtch~an. USA 
Accurale and early predmlmn of uutcomes after w~e.-sed catt~ac arrest has 
not been achmved from previous works In the Ifferature Consequently, pa- 
tleflts wdh sudden cardiac death (SCD) are often left to "declare themselves" 
,n terms O1 iR-hosprtal sufvNa[ Recent slud~s indicate that the malonty ot 
SCD pal~ents have coronary occfusions makmg the early predlGllon el vrtal 
outcome cntlcal in de~s~ot~Pmaklng regarding revasculanzatlon and other 
aggmsswe measures Using ~nate  analyses, we denved a pre~on 
model lmm 127 wrtneseed, out-o1-hOSl~tat SCD cases and then tested the 
model prospe~lVely in 62 A SCD sCC~:O comprised Of the emergency room 
assessment O1 llme fo relum O1 spontaneous clreulatmn (ROSC), present- 
mg ~,,a-tol~c blood pressure (SBP), and mmal neurologm exam was denved 
from the mmal cohort ol 127 ~ sconng scheme was then applied to the 
va l~ gre'-'p =_.n~ recewer Operator charaotenstm cunm (ROC) snalysm 
was u~ to determine its ptespe¢tive utility. Care~vers were unaware of the 
SCD Sconng p.~£.Gure The two groups were simdar w~n respect to baseline 
charaotensl~s (age: 69 ~ 12vs. 65 ~_ 14. p=0 10. and overall surwvaL 42% 
vs. 53%, p = 0~51). The dlagnos~ accuracy at th~ most tavorat,!,.~ ore 
(ROSC - 25 ram. SBP ~90 mmHg, and areusable) in pred,ctmg sun~val to 
d~scbarge was 71% and 73% for the two groups The area under the ROC 
cur~s was found to be 0.81 and 091, p = 095, intimating vahdation of the 
SCO score as a highly useful arm consistent ~L=ctslon-support tool 
Ccnc~u~ons: A chmcal score can be o~tamed in the emergency de- 
partment hat prod=des ~mportant. real-re'no, prognostic mtormahon regarding 
which pal~ent~ are likely to survive This decision-support oot. therefore, may 
be used in family counseling and ~n weighing the opllons of eady angtography 
and revasculan~on, as wail as ~ther msource-mtens~e thcrapms. 
~ Evaluation ut Acute Chest Pain in the Diabetic 
Patient Without  Known Coronary  Artery  Disease 
F Lol~z-J=menez. L. Goldman. PA Johnson. EF  Cook, K Fle~schmann. 
E J  Orav. TH Lee. Bngham and Women's Hospital. Boston. MA. Untverslly 
at Cahforma t San Franosco, CA. USA 
To evaluate d dlabe~cs v, ntl~out known coronary artery d~sease (CAD) who 
present to the emergency department vath chest pain have: 1) a hTgher ate 
of myocardial infarcteon or malor cardiac complications, and 2) differences 
,n the qualdy O1 the chest pare among those who rule m myocardml mtam- 
tTon. compared wzth non diabel~c patients, we prospecfrvely evaluate 2.694 
subjects presenting V, nth acute chest pare w~thout known CAD 
Results: Diabetes was present m 301 1,11%) pal]ent~, Compared w~th 
non-diabetics, patients with diabetes were morn likely to be ~60 years old 
(51% vs. 20%). and to have a history el hypertension (70% vs. 35%) or 
h~gh blood cholesterol (35% vs. 19%). A discharge dtagnos#s of rnyocardml 
infarction was made m 25 diabetics (8%) and m 148 non-diabet~s (6%) (p 
= 0.16). A molar cardiac comphcatron occurred ,n two patients wdh d,abetes 
(0.7%) and m 20 patients ~thout diabetes (08%) (p = NS). Patients wdh 
and without diabetes who had atypical chest pare complmnts had svmdar 
rates of myocardial mfarotion (3% and 4%. respeotwely: p = 0.6). Despite the 
lack of difference in outcomes, diabetics were more likely to be hospitalized 
(67% vs. 47% p = 0.001) both before and after adjusting fur climcal and 
electrocardiographic data. 
Conclusions: For patients t',qth acute chest pain without a pnor history at 
CAD. diabetes was not assooated v, qth a h~gher ate of myocardial infarct=on 
or complicabens. However. diabetes was assocrateci wTth a h~gher ate of 
hospitalization in this population, suggasbng that physioans have a lower 
threshold for admissic, n to the hcsp,F,! of patients w'! h ~iabetes. 
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Effect on costs of ACC/AHA guidelines for preoperative cardiac risk assessment before aortic surgery

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