BackgroundFinal kissing balloon inflation (FKBI) is a percutaneous coronary intervention (PCI) technique that is considered mandatory to improve outcomes in two-stent strategies, but its use in single-stent bifurcation PCI remains controversial.MethodsIn this retrospective cohort study, we identified patients with coronary bifurcation lesions treated with one stent from January 2012 to March 2021 at a single academic medical center. Incidence rates per 1,000 patient-years (IR1000) were calculated for the outcomes of all-cause mortality, myocardial infarction (MI), stent thrombosis (ST), target lesion revascularization (TLR), coronary artery bypass graft (CABG), and cardiac readmission between patients who received FKBI and those who did not over a median follow up of 2.3 years. Studied outcomes were adjusted for all baseline clinical and procedural characteristics.ResultsThis study included 893 consecutive patients of which 256 received FKBI and 637 did not. The IR1000 for MI were 51.1 and 27.6 for patients who received FKBI and patients who did not, respectively (adjusted HR = 2.44, p = 0.001). The IR1000 for death were 31.2 and 52.3 for patients who received FKBI and patients who did not, respectively (adjusted HR = 0.68, p = 0.141). The incidence rates of ST, TLR, CABG, and cardiac readmissions were similar between patients who received FKBI and those who did not.ConclusionsThese results suggest that performing FKBI in a one-stent technique was associated with higher rates of myocardial infarction, particularly in the first 6 months, and no difference in death, ST, TLR, CABG, and cardiac readmission rates.

Many patients with severe mitral regurgitation cannot undergo conventional mitral valve surgery due to prohibitive surgical risk and are candidates for transcatheter repair with an edge-to-edge technique. Prior reports suggest efficacy with this approach for mitral regurgitation due to hypertrophic cardiomyopathy with left ventricular outflow obstruction. We present a case report of transcatheter mitral valve repair for posterior leaflet prolapse with concomitant left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve in the absence of hypertrophic cardiomyopathy.

Hypothesis: Distance to a PCI hospital will impact the treatment and outcome of patients presenting with ST elevation myocardial infarction (STEMI). Methods: We studied all STEMI patients treated w...

The HS3ST1 gene controls endothelial cell production of HSAT+ – a form of heparan sulfate containing a specific pentasaccharide motif that binds the anticoagulant protein antithrombin (AT). HSAT+ has long been thought to act as an endogenous anticoagulant; however, coagulation was normal in Hs3st1−/− mice that have greatly reduced HSAT+ (HajMohammadi et al., 2003). This finding indicates that HSAT+ is not essential for AT's anticoagulant activity. To determine if HSAT+ is involved in AT's poorly understood inflammomodulatory activities, Hs3st1−/− and Hs3st1+/+ mice were subjected to a model of acute septic shock. Compared with Hs3st1+/+ mice, Hs3st1−/− mice were more susceptible to LPS-induced death due to an increased sensitivity to TNF. For Hs3st1+/+ mice, AT treatment reduced LPS-lethality, reduced leukocyte firm adhesion to endothelial cells, and dilated isolated coronary arterioles. Conversely, for Hs3st1−/− mice, AT induced the opposite effects. Thus, in the context of acute inflammation, HSAT+ selectively mediates AT's anti-inflammatory activity; in the absence of HSAT+, AT's pro-inflammatory effects predominate. To explore if the anti-inflammatory action of HSAT+ also protects against a chronic vascular-inflammatory disease, atherosclerosis, we conducted a human candidate-gene association study on >2000 coronary catheterization patients. Bioinformatic analysis of the HS3ST1 gene identified an intronic SNP, rs16881446, in a putative transcriptional regulatory region. The rs16881446G/G genotype independently associated with the severity of coronary artery disease and atherosclerotic cardiovascular events. In primary endothelial cells, the rs16881446G allele associated with reduced HS3ST1 expression. Together with the mouse data, this leads us to conclude that the HS3ST1 gene is required for AT's anti-inflammatory activity that appears to protect against acute and chronic inflammatory disorders.

BACKGROUND:Patients with severe aortic stenosis (AS) at high risk for aortic valve replacement are a unique population with multiple treatment options, including medical therapy, surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR). Traditionally, in elderly populations, goals of treatment may favour quality of life over survival. Professional guidelines recommend that clinicians engage patients in shared decision making, a process that may lead to decisions more aligned with patient-defined goals of care. Goals of care for high-risk patients with AS are not well defined in the literature, and patient-reported barriers to shared decision making highlight the need for explicit encouragement from clinicians for patient involvement.OBJECTIVE:The purpose of this study was to elicit and report patient-defined goals from elderly patients facing treatment decisions for severe AS.METHODS:This analysis was conducted at Dartmouth-Hitchcock Medical Center, an academic medical institution. In a retrospective manner, we qualitatively analysed goal statements reported by high-risk, elderly patients with severe AS evaluated for TAVR between June 2012 and August 2014.RESULTS:Forty-six patients provided treatment goals during consideration of TAVR and defined preferred outcomes as maintaining independence, staying alive, reducing symptoms or, most commonly, increasing their ability to do a specific activity or hobby.CONCLUSIONS:In the high-risk patient population considering TAVR, patient-reported goals may be obtained with a simple question delivered during the clinical encounter. Encouraging patients to define their goals may lead to a greater degree of shared decision making, as advocated in current professional guidelines.

Introduction: Cardiovascular imaging and interventions account for 40% of total medical radiation exposure (excluding radiation therapy). Exposure to ionizing radiation may cause skin injuries or increased risk of cancer and genetic defects. Hypothesis: Changing fluoroscopy defaults to low dose and low frame rate, while maintaining the option to use higher settings when needed, would decrease average patient radiation dose during cardiac catheterization without compromising procedural success. Methods: In 5/2013 we changed fluoroscopy defaults in 1 of 4 cardiac catheterization laboratories to lower dose (600 nGy/sec from 660 nGy/sec to the detector), lower frame rate (7.5 frames/sec from 15 frames/sec) and lower maximum patient exposure (5 Rad/min from 10 Rad/min). We recorded the air kerma (AK) in mGy/case for 719 coronary angiograms (448 pre, 271 post intervention) and 730 coronary interventions (451 pre, 279 post intervention) performed in this laboratory from 6/12-12/13. We used statistical process control analysis to evaluate changes in average monthly AK and to assess for statistical significance. Results: Following fluoroscopy default changes, average AK/case decreased by 21.2% for coronary angiograms (1282.1 ± 857.7 pre vs 1010.9 ± 846.4 post) and by 17.7% for coronary interventions (2858.6 ± 1802.9 pre vs 2353.6 ± 1210 post). After 5/13 there was a significant reduction in average monthly AK with a value below the 3 sigma line in 10/13 for coronary angiograms, and 2 consecutive values below the 2 sigma line in 11/13 and 12/13 for coronary interventions. There were no temporal changes in the incidence of adverse outcomes for interventions. Conclusions: Utilizing low fluoroscopy dose and frame rate defaults can significantly decrease exposure to ionizing radiation for patients undergoing cardiac catheterizations without affecting procedural success.

Background— Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality after percutaneous coronary interventions and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine whether a 6-year regional multicenter quality improvement intervention could reduce CI-AKI after percutaneous coronary interventions. Methods and Results— We conducted a prospective multicenter quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21 067 nonemergent patients undergoing percutaneous coronary interventions at 10 hospitals between 2007 and 2012. Six intervention hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as benchmark sites and were used to develop the intervention, and 2 hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital level, we calculated adjusted risk ratios for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (risk ratio, 0.79; 95% confidence interval: 0.67–0.93; P =0.005) for all patients and by 28% in patients with baseline estimated glomerular filtration rate <60 mL/min per 1.73 m 2 (risk ratio, 0.72; 95% confidence interval: 0.56–0.91; P =0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration. Conclusions— Simple cost-effective quality improvement interventions can prevent ≤1 in 5 CI-AKI events in patients with undergoing nonemergent percutaneous coronary interventions.

The benefit of drug-eluding stents (DES) in reducing target vessel revascularization (TVR) is greatest in patients at high risk of restenosis with bare metal stents (BMS). Lowering the risk of TVR with DES must be weighed against the potential increased risks of stent thrombosis and of bleeding from

The genes encoding the cytochrome P450 2C9 enzyme (CYP2C9) and vitamin K-epoxide reductase complex unit 1 (VKORC1) are major determinants of anticoagulant response to warfarin. Together with patient demographics and clinical information, they account for approximately one-half of the warfarin dose variance in individuals of European descent. Recent prospective and randomized controlled trial data support pharmacogenetic guidance with their use in warfarin dose initiation and titration. Benefits from pharmacogenetics-guided warfarin dosing have been reported to extend beyond the period of initial dosing, with supportive data indicating benefits to at least 3 months. The genetic effects of VKORC1 and CYP2C9 in African and Asian populations are concordant with those in individuals of European ancestry; however, frequency distribution of allelic variants can vary considerably between major populations. Future randomized controlled trials in multiethnic settings using population-specific dosing algorithms will allow us to further ascertain the generalizability and cost-effectiveness of pharmacogenetics-guided warfarin therapy. Additional genome-wide association studies may help us to improve and refine dosing algorithms and potentially identify novel biological pathways.

Objectives: This study evaluates the variation in practice patterns associated with contrast-induced acute kidney injury (CI-AKI) and identifies clinical practices that have been associated with a reduction in CI-AKI.Background: CI-AKI is recognised as a complication of invasive cardiovascular procedures and is associated with cardiovascular events, prolonged hospitalisation, end-stage renal disease, and all-cause mortality. Reducing the risk of CI-AKI is a patient safety objective set by the National Quality Forum.Methods: This study prospectively collected quantitative and qualitative data from 10 centres, which participate in the Northern New England Cardiovascular Disease Study Group PCI Registry. Quantitative data were collected from the PCI Registry. Qualitative data were obtained through clinical team meetings to map care processes related to CI-AKI and focus groups to understand attitudes towards CI-AKI prophylaxis. Fixed and random effects modelling were conducted to test the differences across centres.Results: Significant variation in rates of CI-AKI were found across 10 medical centres. Both fixed effects and mixed effects logistic regression demonstrated significant variability across centres, even after adjustment for baseline covariates (p< 0.001 for both modelling approaches). Patterns were found in reported processes and clinical leadership that were attributable to centres with lower rates of CI-AKI. These included reducing nil by mouth (NPO) time to 4 h prior to case, and standardising volume administration protocols in combination with administering three to four high doses of N-acetylcysteine (1200 mg) for each patient.Conclusions: These data suggest that clinical leadership and institution-focused efforts to standardise preventive practices can help reduce the incidence of CI-AKI.

After 7 days of oral midodrine therapy for symptomatic idiopathic hypotension, a 74-year-old woman presented with angina at a local hospital. Her vital signs were normal, and physical examination revealed nothing unusual. Results of chest radiography, a complete blood count, and a chemistry profile, including cardiac troponin T and creatine kinase, were normal. An electrocardiogram revealed ST-segment elevation of less than 1 mm in leads II, III, and aVF. The patient was given aspirin, intravenous nitroglycerin, and heparin. Urgent coronary angiography revealed minor luminal irregularities with no evidence of plaque rupture or thrombus. Left ventriculography revealed an estimated ejection fraction of 0.40, akinesis of the mid and distal left ventricle, and normal systolic function of the basal segments (Fig. 1). Troponin T measurement was subsequently positive. The diagnosis of takotsubo cardiomyopathy was made. The patient reported no recent emotional stress or illnesses. Midodrine was suspected as the trigger of the cardiomyopathy because of its a1 agonist properties, and this therapy was discontinued. A transthoracic echocardiogram 2 weeks after the patient's hospital discharge showed complete recovery of left ventricular systolic function. Fig. 1 Left ventriculogram in end-systole shows akinesis of the mid and distal left ventricle and normal systolic function of the basal segments. Real-time motion image is available at www.texasheart.org/journal.

Background The aim of this study was to summarize our single-center real-world experience with percutaneous coronary intervention (PCI) stenting of unprotected left main coronary artery (ULMCA). PCI-stenting of the ULMCA, while controversial, is emerging as an alternative to coronary artery bypass graft (CABG) surgery in select patients and clinical situations. Methods Between January 2005 and December 2008, PCI-stenting was performed on 125 patients with ULMCA lesions at our institution. Clinical and procedural data were recorded at the time of procedure, and patients were followed prospectively (mean 1.7 years; range 1 day-4.1 years) for outcomes, including death, myocardial infarction (MI), and target vessel revascularization (TVR). Results The majority of cases were urgent or emergent (82.5%), 50.4% of patients were non-surgical candidates, and 63.2% had 3 vessel disease. Many emergent patients presented in shock (62.1%), were not surgical candidates (89.7%), and had high mortality (20.7% in-hospital, 44.8% long-term). Mortality in the elective group was 6.3%. Cumulative death and TVR rates were 28.8% and 13.6%, respectively. Independent predictors of mortality were ejection fraction (EF) ≤ 35% (HR 2.4, CI 1.1 - 5.4) and left main bifurcation (HR 2.7, CI 1.2 - 5.7). Conclusions PCI-stenting is a viable option in patients with LMCA disease and extends options to patients who are poor candidates for CABG. Elective PCI in low-risk CABG patients results in good long-term survival. Cumulative TVR is 13.6%. EF ≤ 35% and left main bifurcation are independently associated with increased mortality.

HomeCirculationVol. 126, No. 5Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBCardiac Disease Evaluation and Management Among Kidney and Liver Transplantation CandidatesA Scientific Statement From the American Heart Association and the American College of Cardiology Foundation Krista L. Lentine, MD, MS, Co-Chair, Salvatore P. Costa, MD, Co-Chair, Matthew R. Weir, MD, FAHA, John F. Robb, MD, FAHA, Lee A. Fleisher, MD, FAHA, Bertram L. Kasiske, MD, Robert L. Carithers, MD, Michael Ragosta, MD, Kline Bolton, MD, Andrew D. Auerbach, MD and Kim A. Eagle, MD, FAHA, Chair Krista L. LentineKrista L. Lentine Search for more papers by this author , Salvatore P. CostaSalvatore P. Costa Search for more papers by this author , Matthew R. WeirMatthew R. Weir Search for more papers by this author , John F. RobbJohn F. Robb Search for more papers by this author , Lee A. FleisherLee A. Fleisher Search for more papers by this author , Bertram L. KasiskeBertram L. Kasiske Search for more papers by this author , Robert L. CarithersRobert L. Carithers Search for more papers by this author , Michael RagostaMichael Ragosta Search for more papers by this author , Kline BoltonKline Bolton Search for more papers by this author , Andrew D. AuerbachAndrew D. Auerbach Search for more papers by this author and Kim A. EagleKim A. Eagle Search for more papers by this author and on behalf of the American Heart Association Council on the Kidney in Cardiovascular Disease and Council on Peripheral Vascular Disease Originally published2 Jul 2012https://doi.org/10.1161/CIR.0b013e31823eb07aCirculation. 2012;126:617–663Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 IntroductionThe challenges inherent in conducting accurate, clinically effective, and cost-effective cardiac evaluations among transplantation candidates relate to the large size of the target population, the prevalence of disease, the limited number of donated organs, and the often extended waiting periods between initial evaluation and transplantation surgery. According to Organ Procurement and Transplant Network (OPTN) records, nearly 85 000 candidates were on the waiting list for kidney transplantation in 2010, and ≈17 700 kidney transplantations (including 828 kidney-pancreas transplantations) were performed.1 Also in 2010, 16 000 people were awaiting liver transplantation and 6000 received liver allografts.1 Marked shifts in the age composition of transplant waitlists toward older adults are also raising the average medical complexity and comorbidity burden among listed candidates. In 2011, 62% of kidney transplantation candidates were ≥50 years of age compared with 28.7% of kidney transplantation candidates in 1991.1 A similar shift in age distribution has occurred among liver transplantation candidates; now, 77% are ≥50 years of age.1 Cardiovascular disease is a leading cause of morbidity and mortality among patients with end-stage failure of noncardiac organs before and after transplantation. Estimates of the cumulative incidence of myocardial infarction (MI) based on Medicare billing claims have ranged from 8.7% to 16.7% by 3 years after kidney transplant listing and from 4.7% to 11.1% after kidney transplantation.2,3 Observational data suggest particularly high frequencies of cardiovascular events in the first months after kidney transplantation.2,4,5 Cardiovascular diseases in aggregate make up the most common cause of death in patients with functioning allografts at all times after kidney transplantation, accounting for 30% of mortality overall, with highest rates in the peritransplantation period.6Guidelines and position papers by national organizations can serve as useful tools for informing cardiac evaluation practices before noncardiac surgery. However, the discrepancies among existing guidelines and the unique clinical characteristics of patients with end-stage organ failure raise questions about the applicability of available recommendations to transplantation candidates. In 2007, the American College of Cardiology (ACC) and American Heart Association (AHA) issued their most recent version of the “Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery.”7 The algorithm suggests consideration of further cardiac evaluation in symptomatic patients but does not encourage further testing for patients who have no cardiac symptoms with a functional capacity of ≥4 metabolic equivalent tasks (METS; ie, ability to climb a flight of stairs), regardless of diabetic status, history of coronary artery disease (CAD), or other traditional cardiac risk factors. Consideration of noninvasive testing was given a Class IIb recommendation in asymptomatic patients with at least 1 to 2 clinical risk markers and poor functional capacity who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B), with the evidence grade reflecting lack of large randomized trials to support this strategy (Table 1). Similarly, the “2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging”8 by the American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, deemed that radionuclide imaging is appropriate for perioperative evaluation before intermediate-risk noncardiac surgery in asymptomatic patients only when at least 1 risk marker in present and the patient has poor (<4 METS) or unknown functional capacity.8 The ACC/AHA and ACCF guidelines were not written specifically for patients with end-stage organ failure, and the predictive value of the “absence of cardiac symptoms” may differ in transplantation candidates compared with the general population. These guidelines also take the perspective that noncardiac surgery will be performed shortly after the evaluation and that any management decisions will affect short-term (perioperative) outcomes. In contrast, cardiac evaluation and interventions in transplantation candidates should be considered from both the short- and long-term perspective.Table 1. Evidence GradingEvidence Class: Magnitude of procedure/treatment effect IConditions for which there is evidence for and/or general agreement that the procedure/therapy is useful and effective IIConditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure/therapy IIaWeight of evidence/opinion is in favor of usefulness/efficacy IIbUsefulness/efficacy is less well established by evidence/opinion IIIConditions for which there is evidence and/or general agreement that the procedure/therapy is not useful/effective and in some cases may be harmfulEvidence Level: Estimate of certainty (precision) of procedure/treatment effect* AConsistent direction and magnitude of effect from multiple randomized controlled clinical trials BConsistent retrospective cohort, exploratory cohort, ecological, outcomes research, or case-control studies, or extrapolations from Level A studies CCase-series studies or extrapolations from Level B studies*A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Although randomized trials are not available, there may be a very clear consensus that a particular test or therapy is effective.The fundamental basis of the latest ACC/AHA recommendations is grounded in understanding of the role of coronary revascularization before noncardiac surgery. The authors state, “Patients with asymptomatic ischemia…do not appear to be candidates for prophylactic preoperative coronary revascularization unless cardiac catheterization reveals high-risk surgical anatomy.”7 This statement is supported by 2 recent randomized trials that did not demonstrate benefit of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for revascularization of asymptomatic CAD before major vascular surgery.9–11In 2005, the National Kidney Foundation published the “Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients” within the Kidney Disease Outcomes Quality Initiative (NKF/KDOQI).12 The section on CAD suggests more aggressive screening of patients with end-stage renal disease (ESRD) as part of the evaluation to determine candidacy for renal transplantation than would be suggested by ACC/AHA guidelines, although the statements were rated Level of Evidence C, this is, based on either weak evidence or the opinions of the working group. For example, this algorithm recommends that any patient on the kidney transplant waitlist with a history of diabetes mellitus or known CAD undergo noninvasive stress testing at baseline and then subsequently every 12 months until transplantation. There is a similar recommendation for transplantation candidates deemed at high risk per Framingham criteria (≥2 traditional risk factors, left ventricular ejection fraction [LVEF] ≤40%, or peripheral vascular disease).12Other consensus-based recommendations for cardiac risk assessment before kidney transplantation have been offered. These include a 2007 report from an international collaboration of the NKF and the Transplantation Society called the Lisbon Conference,13 the 2001 American Society of Transplantation (AST) guidelines,14 and the 2000 European Renal Association-European Dialysis Transplant Association (ERA-EDTA) “European Best Practice Guidelines.”15 These 2 clinical practice guidelines are now >10 years old, were based on expert consensus panels, and were not the product of systematic review of the evidence. Although all these documents suggest that symptomatic patients should undergo further testing, they offer differing recommendations for asymptomatic patients. A comparison of these 5 clinical documents and their recommendations on testing asymptomatic patients for CAD before renal transplantation is summarized in Table 2.Table 2. Published Recommendations for Testing for CAD in Asymptomatic Kidney Transplantation CandidatesReferenceRecommendations2012 AHA Scientific StatementNoninvasive stress testing may be considered in kidney transplantation candidates with no active cardiac conditions on the basis of the presence of multiple CAD risk factors regardless of functional status (Class IIb, Level of Evidence C)Relevant risk factors among transplantation candidates include diabetes mellitus, prior cardiovascular disease, >1 y on dialysis, LV hypertrophy, age >60 y, smoking, hypertension, and dyslipidemia; the specific number of risk factors that should be used to prompt testing remains to be determined, but the committee considers ≥3 to be reasonable2007 ACC/AHA Perioperative Guidelines for Noncardiac Surgery7No testing recommended if functional status ≥4 METSIf functional status <4 METS or unknown, then consideration of noninvasive stress testing is recommended based on the following clinical risk factorsIschemic heart diseaseCompensated or prior heart failureDiabetes mellitusRenal insufficiencyCerebrovascular diseaseRecommendations for testing are stronger if ≥3 clinical risk factors are present but may be considered in those with 1–2 risk factors2007 Lisbon Conference13Acknowledges that there are no data establishing that screening of asymptomatic patients in itself prevents cardiac events; noninvasive and/or invasive testing should be considered in highest-risk patients with the following conditionsDiabetes mellitusPrior cardiovascular diseaseMultiple cardiac risk factors such as >1 y on dialysis, LV hypertrophy, age >60 y, smoking, hypertension, and dyslipidemiaDoes not specify the number of risk factors to justify testing2005 NKF/KDOQI Guidelines12Noninvasive stress testing recommended forAll patients with diabetes; repeat every 12 moAll patients with prior CADIf not revascularized, repeat every 12 moIf prior PCI, repeat every 12 moIf prior CABG, repeat after first 3 y and then every 12 moRepeat every 24 mo in “high-risk” nondiabetic patients defined as≥2 traditional risk factorsKnown history of CADLVEF ≤40%Peripheral vascular disease2001 AST Guidelines16Noninvasive stress testing recommended for patients at “high risk,” defined as renal disease from diabetes, prior history of ischemic heart disease, or ≥2 risk factorsCoronary angiography for possible revascularization before transplantation recommended for patients with a positive stress testRevascularization before transplantation recommended for patients with critical coronary lesions2000 European Best Practice Guidelines15Thallium scanning recommended for patients with history of myocardial infarction or “high-risk” clinical featuresCoronary angiography recommended if thallium scanning is positiveRevascularization advised if lesions are suitableACC indicates American College of Cardiology; AHA, American Heart Association; AST, American Society of Transplantation; CABG, coronary artery bypass grafting; CAD, coronary artery disease; KDOQI, Kidney Disease Outcomes Quality Initiative; LV, left ventricular; LVEF, left ventricular ejection fraction; METS, metabolic equivalent tasks; and PCI, percutaneous coronary intervention.Several studies document heterogeneity in cardiac evaluation practices before kidney transplantation at the national level (Table 3). In a 1993 survey of directors of OPTN-participating centers, noninvasive stress testing was reported as the most common first approach to cardiac evaluation of asymptomatic patients, prompted by diabetes mellitus at 86% of responding centers, age (mean threshold, 52 years) at 67%, and multiple risk factors at 68%.18 Some centers used routine coronary angiography for patients with diabetes mellitus (15%), older age (7%; mean threshold, 57 years), or multiple risk factors (8%). A subsequent survey of OPTN centers about policies for patients on the deceased donor waiting list found that 8% of programs reported cardiac testing for all candidates, whereas 18% did not routinely order cardiac testing for any asymptomatic patient group; 59% screened patients with diabetes mellitus, 52% screened patients with a history of CAD, and 52% screened patients deemed to be high risk for cardiac events after transplantation given their age or obesity.19 Methods of screening were also variable: 40% pharmacological-nuclear, 33% exercise nuclear, 31% dobutamine stress echocardiography (DSE), and 15% cardiac catheterization. Cardiac surveillance policies among listed candidates also differ across centers. In a survey of 68 centers in 2005, 51% of program representatives indicated reliance on the initial cardiac evaluation and cardiac history, 7% used ACC/AHA criteria for noncardiac surgery in the general population to guide cardiac revaluation, and 32% applied a combination of ACC/AHA criteria, the initial cardiac evaluation, and cardiac history.20Table 3. Summary of Survey and Registry Data Demonstrating Variation in Cardiac Evaluation Practices Across US Transplantation CentersAuthors, YearSummaryRamos et al,18 19941993 survey of directors of UNOS-participating centers regarding practices for initial candidate evaluations; 81% response rate (147 of 182)Noninvasive stress testing was reported as the most common first approach to cardiac evaluation of asymptomatic patients, prompted by diabetes mellitus at 86% of responding centers, age (mean threshold 52 y) at 67%, and multiple risk factors at 68%A notable minority of centers espoused first-line angiography for patients with diabetes mellitus (15%), older age (7%; mean threshold, 57 y), or multiple risk factors (8%)Danovitch et al,19 20022001 survey of UNOS-participating centers regarding management practices for patients on the deceased donor waiting list67% final response rate (192 of 287)8% of programs reported cardiac testing for all listed candidates, whereas 18% did not order routine cardiac testing for any asymptomatic patient groupZarifian et al,20 20062005 survey of US kidney transplantation centers regarding reevaluation practices for patients on the deceased donor waiting list26% final response rate (68 of 257)51% of respondents indicated reliance on the initial cardiac evaluation and cardiac history; 7% of program representatives stated that AHA criteria were used to guide cardiac revaluation; and 32% espoused a combination of AHA criteria, the initial cardiac evaluation, and cardiac historyLentine et al,21 2008Retrospective study of pretransplantation cardiac evaluation practices among 27 786 Medicare beneficiaries transplanted in 1991–2004Pretransplantation cardiac evaluation testing was identified by billing claims for noninvasive stress tests and angiographyClinical traits defining “high” expected IHD risk were defined by AST guidelines16 as diabetes mellitus, prior IHD, or ≥2 other CAD risk factors46.3% (65.4% of high-risk and 20.4% of lower-risk patients) underwent cardiac evaluation testing before transplantation; the adjusted odds of transplantation without cardiac evaluation testing increased sharply with younger age and shorter dialysis duration, and also correlated with black race, female sex, and certain geographic regionsOverall, 9.5% who received cardiac evaluation testing also received pretransplantation revascularization, but only 0.3% of lower-risk patients undergoing cardiac evaluation testing were revascularized before transplantationAHA indicates American Heart Association; CAD, coronary artery disease; IHD, ischemic heart disease; and UNOS, United Network for Organ Sharing.Survey responses are limited by nonresponse rates, and reported policies may differ from actual practices. A retrospective study of the US Renal Data System (USRDS) registry used billing claims as measures of cardiac evaluation services in Medicare beneficiaries transplanted in 1991 to 2004.21 Forty-six percent of the sample received noninvasive stress testing or angiography at some time before transplantation (65% of high risk, defined as diabetes mellitus, prior ischemic heart disease, or ≥2 other coronary risk factors, and 20% of lower risk). There was substantial heterogeneity in cardiac evaluation frequency according to patient-level factors even within risk groups. After adjustment for patient traits and consistent within risk profile–stratified samples, transplantation without cardiac evaluation was more likely for black people, women, and patients in certain geographic regions. Race-related practice variables were notable because in the lower-risk group transplanted without cardiac evaluation, black patients faced higher risks of post-transplantation MI than nonblack patients. Black race has previously been identified as an independent predictor of failure to complete the pretransplantation evaluation22 and of reduced access to coronary angiography and revascularization in populations without kidney disease.23 Thus, some of the observed practice variation may reflect access barriers rather than appropriate determinations of low clinical risk. An important limitation of studies based on billing data, however, is that claims may not distinguish screening tests from tests performed because of cardiac symptoms.A recent single-center study examined the approach to the asymptomatic kidney transplantation candidate, which defines the majority of potential candidates at the time of referral.24 In this study, medical charts were reviewed to quantify the hypothetical frequency of recommended testing per practice recommendations and the observed results of cardiac testing (primarily DSE or myocardial perfusion scintigraphy [MPS]) among 204 consecutive patients who were determined to be free of an active cardiac condition by a cardiologist at the time of transplantation evaluation. Active cardiac conditions were defined according to the ACC/AHA definition including significant valvular disease, decompensated heart failure, significant arrhythmias, and unstable coronary syndromes. If followed precisely, the ACC/AHA guidelines recommended testing in only 20% of patients, whereas the KDOQI guidelines would have resulted in 100% of patients being tested. Among the 178 patients who underwent stress tests, the prevalence of ischemia was similar among those for whom testing was and was not recommended per the ACC/AHA guidelines, 10.3% versus 9.4%, respectively. The relatively low use of coronary revascularization after pretransplantation cardiac evaluation also raises concern for the clinical and cost-effectiveness of pretransplantation cardiac evaluation as applied. Several registry-based and single-center observational studies have found that only 2.9% to 9.5% of patients who receive pretransplantation cardiac stress testing or angiography proceeded to angioplasty or surgical bypass.21,25–28Given the variation between practice and prior guidelines in patients being evaluated for solid-organ transplantation, it is important to determine whether evidence can resolve the basis of this difference. The role for stress testing in the absence of symptoms has been called into question among patients undergoing noncardiac surgery because randomized studies of coronary revascularization before vascular surgery have failed to show a consistent benefit.9–11 Outside the perioperative setting, PCI has failed to demonstrate benefit for the risk of major adverse cardiovascular events (MACEs) in a randomized trial among stable patients with CAD,29 including a subgroup with chronic kidney disease (CKD) at trial enrollment.30 Evidence suggests that the only asymptomatic patients in whom coronary revascularization may be helpful are the minority found to have occult high-risk coronary anatomy such as significant left main disease or severe proximal 3-vessel disease, especially in the presence of reduced left ventricular systolic function.31,31a However, noninvasive cardiac testing of transplantation candidates might yield findings that call into question the appropriateness of transplantation or identify high-risk coronary lesions associated with long-term benefit from revascularization. This report evaluates the state of evidence regarding cardiac risk evaluation and management in kidney transplantation and liver transplantation candidates, considering data specific to these populations and the appropriateness of extrapolations when data from these populations are lacking. This article focuses on cardiac disease; issues related specifically to the evaluation of carotid or peripheral vascular disease are beyond the scope of this document.Methodology and EvidenceThe AHA Writing Committee on Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates conducted a comprehensive review of the literature relevant to perioperative cardiac evaluation of potential kidney or liver transplant recipients, including the prevalence of CAD in these populations; incidence of MACEs before and after transplantation; accuracy of clinical risk markers, symptoms, and noninvasive testing before and after transplant listing for detecting active cardiac conditions and CAD; and clinical outcomes of revascularization and the medical management of atherosclerosis. Each section was assigned to a lead author and coauthor. Literature searches were conducted in the following databases: PubMed, MEDLINE, and the Cochrane Library (including the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Register). Searches were limited to the English language, the years 1990 through March 2010, and human subjects. Related-article searches were conducted in MEDLINE to find additional relevant articles. Finally, committee members recommended applicable articles outside the scope of the formal searches. Interval drafts were discussed during conference calls and 2 face-to-face meetings. Recommendations included an evaluation of the strength of the evidence for or against a particular procedure or treatment in terms of the magnitude of effect (evidence class) and estimate of certainty (evidence level) (Table 1). Recommendations were subjected to formal, anonymous voting. The volume of text devoted to cardiac evaluation and management issues for kidney and liver transplantation candidates, respectively, reflects the relative sizes of the target populations; the number of patients awaiting and receiving kidney transplants is >4 times the number of patients awaiting and receiving liver allografts. Correspondingly, a substantially larger number of publications to date have addressed these issues for kidney compared with liver transplantation candidates.What Are the Goals of Preoperative Cardiac Risk Evaluation in Transplantation Candidates?The most compelling goal of preoperative cardiac risk evaluation is to reduce the morbidity and mortality of cardiovascular disease. Any test used to screen a population is associated with false-positive and -negative results that may diminish utility. False-positive results in particular may lead to patient and physician anxiety and the possibility of additional and often unnecessary testing or invasive procedures. Screening asymptomatic patients should be used only if the benefits of screening outweigh the harms. In asymptomatic patients, screening for CAD would be of value if the results of testing lead to management changes that reduce the occurrence of patient-level outcomes. Screening should also be cost-effective. For organ transplantation, cardiac evaluation could also be used to deny transplantation to high-risk patients, provided that it can be shown that patients with severe cardiovascular disease have sufficiently short life expectancy to make transplantation a poor use of scarce donated organs. However, studies have shown that survival is generally improved by transplantation compared with remaining on the transplant waiting list, even among high-risk patients.32–34 Thus, the burden of proof in using screening to determine transplantation candidacy from a patient-centered perspective is to demonstrate that denying transplantation on the basis of test results is in the best interest of the patient. Alternatively, society may decide that cardiovascular evaluation results can help in guiding allocation of organs to recipients who are most likely to benefit in the long term. However, nationally agreed-on allocation priorities of the OPTN use waiting time and a liver failure severity metric (Model for End-Stage Liver Disease score) as the dominant criteria for achieving fairness in kidney and liver allocation, respectively; allocation schemes that seek to maximize net societal benefit from donated allografts have not been adopted. Although prognostic information from noninvasive cardiac testing of asymptomatic patients may be useful for adjusting center performance metrics such as post-transplantation mortality for the “case mix” of each center's recipients, this approach would incur substantial expense compared with the use of information available from the history and physical examination.Some patients have been shown to undergo renal transplantation safely despite clinical markers of high cardiovascular risk. Jeloka et al35 retrospectively classified 429 renal transplant recipients as high cardiovascular risk (n=61) and low cardiovascular risk (n=368). The high-risk group included patients with a history of angina, MI, or significant CAD found on cardiac catheterization. Outcomes of interest were post-transplantation cardiac events (MI, angina, new arrhythmias, heart failure, and/or sudden cardiac death) and overall survival. The distribution of events among the high-risk and low-risk groups was 31.3% versus 6.5%, respectively (P=0.001). Five-year survival in the high-risk group was 82.8% compared with 93.1% in the low-risk group (P=0.004). Among the subgroup who underwent coronary revascularization before transplantation (n=28; 25% PCI, 75% CABG), 43% subsequently experienced a cardiac event. The authors contended that in selected high-risk patients, overall 5-year survival after renal transplantation was actually quite good, superior to the expected 5-year survival with continued dialysis.With regard to the pathophysiology of perioperative cardiac events, both demand-mediated ischemia and plaque rupture contribute to perioperative cardiac events. The stress response from surgery can lead to increases in heart rate and blood pressure, which can precipitate episodes of “demand ischemia” in myocardial areas distal to a coronary artery stenosis.36 Long periods of myocardial ischemia (either prolonged individual episodes or cumulative duration of shorter episodes) have been associated with myocardial necrosis and perioperative MI and death.37–39 A major mechanism of MI in the nonoperative setting is plaque rupture of a noncritical coronary stenosis with subsequent coronary thrombosis.40 The perioperative period is characterized by tachycardia, increased sheer stress, and a hypercoagulable state; thus, plaque rupture and thrombosis may also occur in this context.41 Ellis et al42 demonstrated that one third of all patients with perioperative MI sustained damage in areas distal to noncritical stenoses. Dawood et al43 demonstrated that fatal perioperative MI occurs predominantly in patients with multivessel CAD, especially left main and 3-vessel disease; however, the severity of preexisting underlying stenosis did not predict the resulting infarct territory. Because the nidus for the thrombosis is often a noncritical stenosis, preoperative cardiac evaluation before surgery may fail to identify patients at risk for plaque rupture, although control of heart rate may

Several high profile cases have called into question whether interventionalists are performing percutaneous coronary interventions (PCI) on lesions that are not flow limiting. We hypothesized that in northern New England there is agreement among interventionalists on what vessel segments have flow

Background: The incidence of myocardial infarctions has steadily declined over the past decade. PCI rates peaked in 2004-2005 and have then declined. Practice and patient related factors have contributed to the decline of PCI. Our purpose is to examine the impact of the economic recession on PCI trends from 2001-2010 for New Hampshire, Maine, and Vermont. Methods: The PCI were obtained through Dartmouth dynamic registry, which has a catchment area that encompasses New Hampshire, Vermont and Maine. Regional and National unemployment data were obtained through the Department of Labor and Statistic. National and State specific insurance rates were obtained through the US Census data for 2001-2010. State specific cardiovascular prevalence rates were obtained by through individual state specific CDC epidemiology department’s Behavioral Risk Factor Surveillance System (BRFS) questionnaire. Results: The overall prevalence of cardiovascular disease remained stable in the last 5 years (2005-2010) but remained higher than the national average. The national unemployment rate increased from 4.7% in 2001 to high of 9.6% in 2010 while New Hampshire, Vermont and Maine followed the overall national trends however, had on average 15%-30% less unemployment. National medical uninsured rate increased from 13.5% in 2001 to a high of 16.3% in 2010, while all three state’s medical uninsured rates stayed relatively stable between 8.8% and 10.8 and did not follow the national trend. DHMC catheterization lab showed steady increase in PCI volume 935 cases in 2001 to high of 1477 in 2005 but steadily declined to 1029 PCIs in 2010. During the same time STEMI cases have steadily increased from 10% to 28% of total volume. During the same time the PCIs due to NSTEMI/UA and stable angina percentage remained between 25%-30% of the total PCI volume but overall numbers declined. The New Hampshire unemployment rate was highly correlated with the STEMI rate (correlation coefficient 0.87, p-value 0.001). However, overall PCI volume trends did not correlate with state specific unemployment. Conclusions: STEMI cases have increased steadily, while PCI for other indications have declined since peaking in 2005. This trend does not seem to match the overall economic trends in the region.

The challenges inherent in conducting accurate, clinically effective, and cost-effective cardiac evaluations among transplantation candidates relate to the large size of the target population, the prevalence of disease, the limited number of donated organs, and the often extended waiting periods

Electronic health records (EHRs) that include computerized provider order entry (CPOE) have the potential to reduce medical errors and adverse drug events, improve health outcomes and reduce health care costs. The success of CPOE is dependent upon the development of standardized evidence-based order sets and care pathways that are developed and used by clinical providers. However, development is dependent upon the engagement and clinical expertise of health care providers who are busy caring for patients and may not have the time or resources to devote to order set development. This paper describes one academic institution's experience in adopting a new EHR that includes CPOE and the efforts to stimulate the development of order set content throughout all clinical sections and departments. Based on this experience, specific recommendations and guidance to facilitate the development of evidence-based order set and care pathway content are described in the article. Through the use of the described strategies and techniques, over a three-year period the institution developed, approved and implemented 495 order sets authored by 141 different providers and well exceeded the established goals of the committee and institution.