Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes.

Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals.

Twenty Years of an Institutional Chest Pain Pathway: What's Come and What's Yet to Come.

Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level.

Impact of Nonobstructive Left Main Coronary Artery Atherosclerosis on Long-Term Mortality.

Background: Although the presence of severe stenosis in the left main coronary artery (LMCA) is a well-established predictor of mortality, whether this extends to nonobstructive atherosclerosis in the LMCA is unknown.

Objectives: The aim of this study was to evaluate the association between LMCA disease by intravascular ultrasound (IVUS) and long-term mortality.

Methods: Between 2005 and 2013, 3,239 patients with LMCA IVUS imaging without LMCA revascularization (either before angiography or scheduled based on index angiography or IVUS) were included.

Reasons for lesion uncrossability as assessed by intravascular ultrasound.

Objectives: The purpose of the current study was to use intravascular ultrasound (IVUS) to clarify anatomical and morphological lesion characteristics of uncrossable lesions.

Background: Uncrossable lesions are not always severely calcified. The prevalence of uncrossable lesions that are nonseverely calcified as well as other mechanisms for uncrossability has not been well clarified.

Intravascular Ultrasound-Derived Calcium Score to Predict Stent Expansion in Severely Calcified Lesions.

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Intravascular ultrasound analysis of intraplaque versus subintimal tracking in percutaneous intervention for coronary chronic total occlusions: One year outcomes.

Objectives: We sought to determine the 1-year outcomes of patients receiving successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures comparing subintimal versus intraplaque wire tracking patterns.

Background: CTO PCI utilizes both intraluminal and subintimal wire tracking to achieve successful percutaneous revascularization. Intravascular ultrasound (IVUS) can be used to precisely determine the path of wire tracking.

Evidence of an early projectile point technology in North America at the Gault Site, Texas, USA.

American archeology has long been polarized over the issue of a human presence in the Western Hemisphere earlier than Clovis. As evidence of early sites across North and South America continues to emerge, stone tool assemblages appear more geographically and temporally diverse than traditionally assumed. Within this new framework, the prevailing models of Clovis origins and the peopling of the Americas are being reevaluated.

Simple technologies and diverse food strategies of the Late Pleistocene and Early Holocene at Huaca Prieta, Coastal Peru.

Simple pebble tools, ephemeral cultural features, and the remains of maritime and terrestrial foods are present in undisturbed Late Pleistocene and Early Holocene deposits underneath a large human-made mound at Huaca Prieta and nearby sites on the Pacific coast of northern Peru. Radiocarbon ages indicate an intermittent human presence dated between ~15,000 and 8000 calendar years ago before the mound was built. The absence of fishhooks, harpoons, and bifacial stone tools suggests that technologies of gathering, trapping, clubbing, and exchange were used primarily to procure food resources along the shoreline and in estuarine wetlands and distant mountains.

Intravascular Ultrasound Analysis of Intraplaque Versus Subintimal Tracking in Percutaneous Intervention for Coronary Chronic Total Occlusions and Association With Procedural Outcomes.

Objectives: Using intravascular ultrasound (IVUS), the authors compared outcomes by observed wire position (intraplaque vs. subintimal) achieved during successful chronic total occlusion (CTO) lesion treatment.

Background: Recent successes in CTO percutaneous coronary intervention (PCI) have used both intraluminal and subintimal wire tracking to improve procedural success.

Percutaneous Coronary Intervention With Bioresorbable Scaffolds in a Young Child.

Importance: Although much less frequent than in adults, coronary artery disease requiring revascularization may develop in children because of homozygous familial hypercholesterolemia or other underlying conditions. Percutaneous coronary intervention (PCI) with a bioresorbable scaffold (BRS) may have advantages over metallic coronary stents in this population.

Objective: To present a case of the successful treatment of unstable, multivessel coronary artery disease in a child with PCI with BRS implantation.

Imaging- and physiology-guided percutaneous coronary intervention without contrast administration in advanced renal failure: a feasibility, safety, and outcome study.

Aims: The feasibility, safety, and clinical utility of percutaneous coronary intervention (PCI) without radio-contrast medium in patients with advanced chronic kidney disease (CKD) are unknown. In this series, we investigated a specific strategy for 'zero contrast' PCI with the aims of preserving renal function and preventing the need for renal replacement therapy (RRT) in patients with advanced CKD.

Methods And Results: A total of 31 patients with advanced CKD [creatinine = 4.

Percutaneous coronary artery revascularization procedures in pediatric heart transplant recipients: A large single center experience.

Objectives: To describe our experience, at a large pediatric heart transplant center, with percutaneous coronary interventions (PCI) for cardiac allograft vasculopathy (CAV).

Background: CAV is a leading cause of late graft failure, mortality, and re-transplantation in pediatric heart transplant (HTx) recipients. Studies of PCI in adult patients have shown some short-term improvements, but no significant change in long-term outcomes.

New Archaeological Evidence for an Early Human Presence at Monte Verde, Chile.

Questions surrounding the chronology, place, and character of the initial human colonization of the Americas are a long-standing focus of debate. Interdisciplinary debate continues over the timing of entry, the rapidity and direction of dispersion, the variety of human responses to diverse habitats, the criteria for evaluating the validity of early sites, and the differences and similarities between colonization in North and South America. Despite recent advances in our understanding of these issues, archaeology still faces challenges in defining interdisciplinary research problems, assessing the reliability of the data, and applying new interpretative models.

Mechanisms and Patterns of Intravascular Ultrasound In-Stent Restenosis Among Bare Metal Stents and First- and Second-Generation Drug-Eluting Stents.

The most common causes of in-stent restenosis (ISR) are intimal hyperplasia and stent under expansion. The purpose of this study was to use intravascular ultrasound (IVUS) to compare the ISR mechanisms of bare metal stents (BMS), first-generation drug-eluting stents (DES), and second-generation DES. There were 298 ISR lesions including 52 BMS, 73 sirolimus-eluting stents, 52 paclitaxel-eluting stents, 16 zotarolimus-eluting stents, and 105 everolimus-eluting stent.

Magnetic positioning system in coronary angiography and percutaneous intervention: a feasibility and safety study.

Objectives: This study sought to evaluate the safety and feasibility of a magnetic medical positioning system (MPS) to determine the three-dimensional (3D) position and orientation of intracoronary wires and catheters and to guide angiography and percutaneous coronary intervention (PCI).

Background: Coronary angiography relies on fluoroscopy for catheter navigation and often fails to accurately portray vessel tortuosity, overlap, and length because of complex anatomy and foreshortening of curved coronary segments.

Methods: Forty adult participants underwent coronary angiography and/or PCI with MPS guidance.

Practices and complications of vascular closure devices and manual compression in patients undergoing elective transfemoral coronary procedures.

Femoral arterial puncture is the most common access method for coronary angiography and percutaneous coronary interventions (PCIs). Access complications, although infrequent, affect morbidity, mortality, costs, and length of hospital stay. Vascular closure devices (VCDs) are used for rapid hemostasis and early ambulation, but there is no consensus on whether VCDs are superior to manual compression (MC).