Objectives The aim of the study was to develop and validate a tool for predicting risk of contrast-induced nephropathy (CIN) in patients undergoing contemporary percutaneous coronary intervention (PCI).Background CIN is a common complication of PCI and is associated with adverse short-and long-term outcomes. Previously described risk scores for predicting CIN either have modest discrimination or include procedural variables and thus cannot be applied for pre-procedural risk stratification.Methods Random forest models were developed using 46 pre-procedural clinical and laboratory variables to estimate the risk of CIN in patients undergoing PCI. The 15 most influential variables were selected for inclusion in a reduced model. Model performance estimating risk of CIN and new requirement for dialysis (NRD) was evaluated in an independent validation data set using area under the receiver-operating characteristic curve (AUC), with net reclassification improvement used to compare full and reduced model CIN prediction after grouping in low-, intermediate-, and high-risk categories.Results Our study cohort comprised 68,573 PCI procedures performed at 46 hospitals between January 2010 and June 2012 in Michigan, of which 48,001 (70%) were randomly selected for training the models and 20,572 (30%) for validation. The models demonstrated excellent calibration and discrimination for both endpoints (CIN AUC for full model 0.85 and for reduced model 0.84, p for difference <0.01; NRD AUC for both models 0.88, p for difference 0.82; net reclassification improvement for CIN 2.92%, p = 0.06).Conclusions The risk of CIN and NRD among patients undergoing PCI can be reliably calculated using a novel easy-to-use computational tool (https://bmc2.org/calculators/cin). This risk prediction algorithm may prove useful for both bedside clinical decision making and risk adjustment for assessment of quality. (C) 2013 by the American College of Cardiology Foundation

This study sought to examine the prevalence and clinical implications of morbid obesity among patients undergoing percutaneous coronary intervention (PCI). Background Theprevalenceofobesity,andmorbidobesityinparticular,continuestoriserapidlyintheUnitedStates.Obesepatients are at increased risk for cardiac disease and are more likely to need invasive cardiac procedures. There is a paucity of contemporary data on the prevalence and clinical implications of morbid obesity among patients undergoing PCI. Methods We examined the prevalence of morbid obesity (body mass index [BMI] (cid:2) 40 kg/m 2 ) among 227,044 patients undergoing PCI and enrolled in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium registry from 1998 to 2009. Results The proportion of morbidly obese patients undergoing PCI increased from 4.38% in 1998 to 8.36% in 2009. Compared with overweight patients (BMI 25 to 30 kg/m 2 ), these patients had signi fi cantly increased vascular complications (adjusted odds ratio [OR]: 1.31; 95% CI: 1.17 to 1.47; p < 0.0001), contrast-induced nephropathy (adjusted OR: 1.89; 95% CI: 1.70 to 2.11; p < 0.0001), nephropathy requiring dialysis (adjusted OR: 4.08; 95% CI: 2.98 to 5.59; p < 0.0001), and mortality (adjusted OR: 1.63; 95% CI: 1.33 to 2.00; p < 0.0001). Morbid in prevalence among patients PCI and with a higher risk of

Background. Evidence of the safety and effectiveness of bariatric surgery is based mainly on administrative data or on reports from high volume academic centers. It is unknown whether these results are representative of outcomes in general. Methods. We used data from the Michigan Bariatric Surgery Collaborative, an externally-audited, statewide, prospective clinical registry to evaluate short-term (30 day) morbidity and long-term outcomes, including weight loss, quality of life, and resolution of comorbid diseases at 1 year for patients undergoing bariatric procedures in the state of Michigan from 2006 to 2008. Results. During the study period, 4,961 (35%) patients had laparoscopic adjustable gastric band (lap-band) and 7,702 (54%) had laparoscopic gastric bypass (lap-gastric bypass) procedures. Serious complications occurred in 0.7% of lap-band and 3.4% of lap-gastric bypass patients, including death in 2 (0.04%) lap-band and 10 (0.1%) lap-gastric bypass patients. At one-year follow-up, excess body weight loss was 40% for lap-band and 67% for lap-gastric bypass patients. Lap-gastric bypass was more effective with regard to comorbidity resolution (e.g. diabetes resolved in 47% versus 77%, hypertension in 25% versus 55%, and hyperlipidemia in 30% versus 66% for lap-band and lap-gastric bypass patients, respectively). Quality of life scores were improved by 15 points for lap-band and 23 points for lap-gastric bypass patients. Sixty four percent of lap-band and ninety percent of lap-gastric bypass patients reported that they were very satisfied with their results. Conclusions. In this study, population-based peri-operative safety outcomes were comparable to those reported from large academic centers. While complication rates are lower for patients undergoing lap-band procedures, lap-gastric bypass is more effective for weight loss and related long-term outcomes.

Studies have shown poor prognostic implications of anemia in patients with myocardial infarction (MI) and in patients undergoing percutaneous coronary intervention (PCI). The impact of blood transfusion in these populations remains controversial. The objective of this study was to examine the effect of transfusion on in-hospital mortality in anemic patients undergoing PCI for MI. Data from 67,051 PCIs (June 1, 1997 to January 31, 2004) were prospectively collected in a multicenter registry (Blue Cross Blue Shield of Michigan Cardiovascular Consortium). Of these, 4,623 patients who were classified as anemic according to the World Health Organization criteria underwent PCI within 7 days of presentation with acute MI. A propensity score for being transfused was estimated for each patient, and propensity matching and a prediction model for in-hospital death were developed. The average age was 67.8 years, 57.7% of patients were men, and 22.3% of patients received a transfusion during hospitalization. Transfused patients, compared to nontransfused patients, were more likely to be older, female, have lower preprocedure hemoglobin levels, more comorbidities, and a higher unadjusted in-hospital mortality rate (14.52% vs. 3.01%, p < 0.0001). After adjustment for comorbidities and propensity for transfusion, blood transfusion was associated with a higher risk of in-hospital mortality (adjusted odds ratio = 2.02, 95% confidence interval 1.47-2.79, p < 0.0001). In anemic patients undergoing PCI for MI, transfusion was associated with an increased crude and adjusted rate of in-hospital mortality. A randomized controlled trial is needed to determine the value of transfusion and the ideal transfusion criteria.

Assessing efforts to apply clinical guidelines in community practice, with the goal of improving the quality and outcomes of care, presents many challenges

OBJECTIVES The purpose of this research was to determine the potential effect of public reporting on case selection for percutancous coronary intervention (PCI).BACKGROUND Previous studies have suggested that public reporting of coronary artery bypass graft surgery (CABG) mortality might result in case selection bias and in denial of care to or out migration of high-risk patients. The potential effect of public reporting on case selection for PCI is unknown.METHODS We compared demographics, indications, and outcomes of 11,374 patients included in a multicenter (eight hospitals) PCI database in Michigan where no public reporting is present, with 69,048 patients in a statewide (34 hospitals) PCI database in New York, where public reporting is present. The primary end point was in-hospital mortality.RESULTS Patients in Michigan more frequently underwent PCI for acute myocardial infarction (14.4% vs. 8.7%, p < 0.0001) and cardiogenic shock (2.56% vs. 0.38%, p < 0.0001) than those in New York. The Michigan cohort also had a higher prevalence of congestive heart failure and extracardiac vascular disease. The unadjusted in-hospital mortality rate was significantly lower in New York than in Michigan (0.83% vs. 1.54%, p < 0.0001; odds ratio [OR] 0.54, 95% confidence interval [CI] 0.45 to 0.63). However, after adjustment for comorbidities, there was no significant diffierence in mortality between the two groups (adjusted OR 1.05, 95% Cl 0.84 to 1.31, p = 0.70, c-statistic 0.88).CONCLUSIONS There are significant differences in case mix between patients undergoing PCI in Michigan and New York that result in marked differences in unadjusted mortality rates. A propensity in New York toward not intervening on higher-risk patients because of fear of public reporting of high mortality rates is a possible explanation for these differences.(c) 2005 by the American College of Cardiology Foundation

With growing recognition that surgical outcomes vary widely across providers,1-4 employers and payers are becoming more actively involved in strategies for improving the quality of surgical care.5 Employers have obvious interests in minimizing productivity losses from employees undergoing surgical procedures. With ever-rising health care costs, purchasers and payers are also increasingly aware of the financial implications of surgical complications. According to one recent analysis, major complications add over $11,000 to the baseline cost of a surgical procedure.

Background Prior history of heart failure (HF) has been shown to be a predictor of poor, outcomes after percutaneous coronary intervention (PCI). Clinical predictors of the development of inhospital HF and its prognostic significance after PCI have yet to be defined. In this study, we sought to identify the incidence, risk factors, and prognosis of inhospital HF after PCI.Methods Using a contemporary registry of consecutive PCIs, the incidence of HF after PCI was identified. Multivariate logistic regression analysis was used to determine predictors of the development of HF after PCI as well as the impact of HF on inhospital mortality.Results The incidence of HF after PCI in the overall patient population was 1.4%. Independent predictors of HF were female sex, age >= 60 years, exceeding a maximum weight- and creatinine-adjusted contrast dose, diabetes, prior HF, prior gastrointestinal bleeding, prior chronic obstructive pulmonary disease, history of atrial fibrillation, American College of Cardiology type B2 or C vessel, emergency PCI, ejection fraction <50%, myocardial infarction with or without cardiogenic shock, and repeat angiography. After adjustment for comorbidities, the development of HF was independently associated with an increased risk of inhospital death (adjusted OR 2.48, 95% CI 1.77-3.48).Conclusions The development of HF is a relatively uncommon occurrence after PCI and is associated with a poor prognosis. The identification of risk factors for HF could foster the development of interventions aimed toward its prevention in high-risk patients.

Purpose: We sought to examine whether statin therapy before percutaneous coronary intervention results in reduction in contrast-induced nephropathy (CIN). Intravascular administration of contrast media can have nephrotoxic effects, particularly in patients with baseline renal insufficiency. Along with lowering serum cholesterol, statins have pleiotropic effects in the vasculature. The effect of statin use on CIN is unknown.Subjects and Methods: We Studied 29 409 patients who had both baseline preprocedure and peak postprocedure serum creatinine measured at the time of their percutaneous coronary intervention (PCI). Baseline demographics and creatinine profile before and after the procedure were compared between patients who received preprocedure statins and those who did not. CIN was defined as an increase in serum creatinine of <= 0.5 mg/dL.Results: Baseline serum creatinine was similar between the two groups. When compared with patients who did not receive preprocedure statins, patients on preprocedure statins had a lower incidence of CIN (4.37 vs 5.93, P<0.0001) and nephropathy requiring dialysis (0.32 vs 0.49, P=0.03). After adjustments for comorbidities, preprocedure statin use was associated with a significant reduction in CIN (odds ration [OR] 0.87, 95% confidence interval [CI] 0.77-0.99, P=0.03).Conclusions: Preprocedure statin use is associated with significant reduction in CIN after contemporary PCI. This reinforces the need to initiate statin therapy before percutaneous coronary interventions. (C) 2005 Elsevier Inc. All rights reserved.

OBJECTIVES:The aim of our study was to evaluate the volume-outcome relationship in a large, quality-controlled, contemporary percutaneous coronary interventions (PCI) database. BACKGROUND:Whether the relationship between physician volume of PCI and outcomes still exists in the era of coronary stents is unclear. METHODS:Data on 18,504 consecutive PCIs performed by 165 operators in calendar year 2002 were prospectively collected in a regional consortium. Operators' volume was divided into quintiles (1 to 33, 34 to 89, 90 to 139, 140 to 206, and 207 to 582 procedures/year). The primary end point was a composite of major adverse cardiovascular events (MACE) including death, coronary artery bypass grafting, stroke or transient ischemic attack, myocardial infarction, and repeat PCI at the same site during the index hospital stay. RESULTS:The unadjusted MACE rate was significantly higher in quintiles one and two of operator volume when compared with quintile five (7.38% and 6.13% vs. 4.15%, p = 0.002 and p = 0.0001, respectively). A similar trend was observed for in-hospital death. After adjustment for comorbidities, patients treated by low volume operators had a 63% increased odds of MACE (adjusted odds ratio [OR] 1.63, 95% confidence interval [CI] 1.29 to 2.06, p < 0.0001 for quintile [Q]1; adjusted OR 1.63, 95% CI 1.34 to 1.90, p < 0.0001 for Q2 vs. Q5), but not of in-hospital death. Overall, high volume operators had better outcomes than low volume operators in low-risk and high-risk patients. CONCLUSIONS:Although the relationship between operator volume and in-hospital mortality is no longer significant, the relationship between volume and any adverse outcome is still present. Technological advancements have not yet completely offset the influence of procedural volume on proficiency of PCIs.