Revised guidelines for the management of non-ST-segment elevation acute coronary syndromes.

Unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) refer to a spectrum of acute severe cardiac disorders characterized by myocardial oxygen demand and supply mismatch, caused by atherosclerotic coronary artery disease. Patients presenting with acute coronary syndromes represent a major medical problem, accounting for 2.5 million hospitalizations and 500000 deaths annually in the United States alone.

Reducing costs and improving outcomes of percutaneous coronary interventions.

Objective: To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes.

Study Design: Single center registry analysis.

Patients And Methods: Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997.

Use patterns of low-molecular weight heparin and the impact on length of stay in patients hospitalized for atrial fibrillation.

Background: Low-molecular weight heparin, although unproven as a protective anticoagulant in atrial fibrillation, is not uncommonly used in this clinical setting. This investigation sought to assess the prevalence of its use for atrial fibrillation and its impact on length of hospital stay.

Methods: A retrospective analysis of patients admitted to the cardiology service at a university hospital with the primary diagnosis of atrial fibrillation was conducted for a 6-month interval in 3 consecutive years.

Closing the gap between science and practice: the need for professional leadership.

Major opportunity exists to better align clinical science and clinical practice. To do so will require efforts not only to develop clinical practice guidelines, but to facilitate their application in practice. The American College of Cardiology operates a program to develop and assess the effectiveness of tools that facilitate the application of guidelines in practice.

Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors.

Objectives: The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function.

Background: Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction.

Health-related quality of life in patients 7 months after a myocardial infarction: factors affecting the Short Form-12.

We assessed patients' health-related quality of life after myocardial infarction and identified related variables. Clinical data were obtained retrospectively from medical records of consecutive patients admitted to a Midwestern university-affiliated medical center with diagnosis of myocardial infarction from July 1999-July 2000. Telephone interviews 7 months after discharge were made to administer the Short Form-12 (SF-12) and obtain patient, disease, drug, and intervention data.

Influence of age on outcomes in patients undergoing mitral valve replacement.

Background: Although increasing age has been associated with greater risk of mortality for patients undergoing mitral valve replacement, it is less clear whether this elevated risk is related to age-related differences in comorbidity or other clinical characteristics.

Methods: A population of 31,688 patients from The Society of Thoracic Surgeons National Cardiac Database undergoing mitral valve replacement either alone or in combination with coronary artery bypass grafting or tricuspid surgical procedures from 1997 to 2000 was examined to assess age-related variation in clinical features, morbidity, and mortality. Multivariable logistic regression was used to determine the effect of age after adjusting for other known risk factors.

Development of a multicenter interventional cardiology database: the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) experience.

The technical challenges in the development of a quality-controlled registry of percutaneous coronary interventions (PCIs) are currently unknown. This article describes the authors' experience in the development of a regional, quality-controlled PCI registry. In 1996, 16 centers in Michigan were invited to participate in a multicenter PCI registry.

The Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) collaborative quality improvement initiative in percutaneous coronary interventions.

The past decade has been characterized by increased scrutiny of outcomes of surgical and percutaneous coronary interventions (PCIs). This increased scrutiny has led to the development of regional, state, and national databases for outcome assessment and for public reporting. This report describes the initial development of a regional, collaborative, cardiovascular consortium and the progress made so far by this collaborative group.

Syncope in acute aortic dissection: diagnostic, prognostic, and clinical implications.

Background: Syncope is a well-recognized symptom of acute aortic dissection, often indicating the development of dangerous complications such as cardiac tamponade.

Subjects And Methods: We identified consecutive patients with acute aortic dissection at 18 referral centers in six countries. Data on key clinical findings and outcomes were collected via extensive questionnaires.

Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose.

This study was undertaken to determine the incidence, risk factors, and in-hospital outcome of nephropathy requiring dialysis (NRD) after percutaneous coronary intervention (PCI), and to evaluate the role of a weight- and creatinine-adjusted maximum radiographic contrast dose (MRCD) on NRD. Data were obtained from a registry of 16,592 PCIs. The data were divided into development and test sets.

Asymptomatic coronary artery disease in a pregnant patient. A case report and review of literature.

Background: Acute myocardial infarction during pregnancy has been reported and has been shown to be associated with poor maternal and fetal outcomes. However, the vast majority of these patients do not have previously recognized ischemic heart disease. Pregnancy and delivery pose significant cardiac stress and risk to the mother and fetus.

Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-QI2).

Background: Peripheral vascular disease is a manifestation of systemic atherosclerosis and is associated with an increased risk of cardiovascular morbidity and mortality.

Methods And Results: We examined clinical outcomes in 66 consecutive patients undergoing peripheral vascular interventions at our institution between January 2001 and October 2001. At hospital discharge and at 6 months, lifestyle modifications and use of evidence-based therapy was suboptimal.

American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery.

Background: Methods used for evaluation of cardiac risk before noncardiac surgery vary widely. We evaluated the effect over time on practice and resource utilization of implementing the American College of Cardiology/American Heart Association Guidelines on Preoperative Risk Assessment.

Methods: We compared 102 historical control patients who underwent elective abdominal aortic surgery (from January 1993 to December 1994) with 94 consecutive patients after guideline implementation (from July 1995 to December 1996) and 104 patients in a late after guideline implementation (from July 1, 1997, to September 30, 1998).

Effects of end-of-month admission on length of stay and quality of care among inpatients with myocardial infarction.

Purpose: We studied whether transfer of care when house staff and faculty switch services affects length of stay or quality of care among hospitalized patients.

Subjects And Methods: We performed a retrospective analysis in 976 consecutive patients admitted with myocardial infarction from 1995 to 1998. Patients who were admitted within 3 days of change in staff were denoted end-of-month patients.

When zebras run with horses: the diagnostic dilemma of acute aortic dissection complicated by myocardial infarction.

In this issue of the Journal, Pinney and Wasserman describe the case of a patient who survives acute aortic dissection complicated by occlusion of the left main coronary ostium and anterior myocardial infarction (MI), due in part to the fortuitous presence of an anomalous left circumflex artery. The case illustrates the challenges of diagnosing aortic dissection, even in the current era of accurate and rapid aortic imaging, in individuals with concurrent acute MI. These comments are focused in this comment on two key aspects of the case: (1) How commonly do acute aortic dissections lead to myocardial ischemia and MI? and (2) When should clinicians consider ruling out acute aortic dissection in the setting of acute MI?

Coronary artery bypass grafting in octogenarians: clinical and economic outcomes at community-based healthcare facilities.

Background: Results of recent studies from high-volume academic centers suggest that coronary artery bypass grafting (CABG) is becoming safer to perform in octogenarians. Similar data from community-based facilities do not exist.

Objective: To assess the clinical and economic outcomes of nonemergency CABG in 338 octogenarians at 27 community-based facilities across the United States.

Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era.

Objectives: We sought to evaluate the clinical characteristics, management, and outcomes of elderly patients with acute type A aortic dissection.

Background: Few data exist on the clinical manifestations and outcomes of acute type A aortic dissection in an elderly patient cohort.

Methods: We categorized 550 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection into two age strata (<70 and >or=70 years) and compared their clinical features, management, and in-hospital events.

Chronobiological patterns of acute aortic dissection.

Background: Chronobiological rhythms have been shown to influence the occurrence of a variety of cardiovascular disorders. However, the effects of the time of the day, the day of the week, or monthly/seasonal changes on acute aortic dissection (AAD) have not been well studied.

Methods And Results: Accordingly, we evaluated 957 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2000 (mean age 62+/-14 years, type A 61%).