Blood loss from greater use of phlebotomy is independently associated with the development of HAA. These findings suggest that HAA may be preventable by implementing strategies to limit blood loss from laboratory testing.

Background-Improving patients' quality of life is a primary indication for percutaneous coronary intervention (PCI), yet little is known about patient characteristics associated with greater quality-of-life improvement from the procedure. This study was conducted to identify patient characteristics associated with quality-of-life benefit after PCI. Methods and Results-A consecutive series of 1518 patients undergoing PCI in nonacute myocardial infarction settings were prospectively enrolled into an observational study documenting their postprocedural health status. We examined univariate and multivariable associations between baseline patient characteristics and quality of life 1 year after the procedure using the disease-specific Seattle Angina Questionnaire (SAQ) to quantify the impact of patients' coronary disease on their quality of life. Baseline angina frequency and physical function were the strongest predictors of quality-of-life improvement 1 year after PCI. In comparing patients without angina to those experiencing monthly, weekly, and daily angina, the quality-of-life improvements (meanϮSEM) were 21.4Ϯ2.1, 30.7Ϯ2.2, and 34.6Ϯ2.6 points greater (PϽ0.001). Patients with mild, moderate, and severe physical limitation improved 13.8Ϯ1.9, 20.0Ϯ2.1, and 13.5Ϯ3.5 points more than those with minimal baseline physical limitation (PϽ0.001). These findings were maintained in multivariable models correcting for baseline differences in demographic, clinical, disease-severity, and health-status variables. Conclusions-Preprocedural angina frequency is the most important prognostic indicator of quality-of-life improvement after PCI. Although substantial quality-of-life benefits are attained in most patients with preprocedural angina, more careful consideration of the potential benefits and risks of the procedure are needed in asymptomatic patients.

No abstract

Background Anemia is common among patients hospitalized with acute myocardial infarction (AMI), and is associated with poor outcomes. Less is known about the incidence, correlates, and prognostic implications of acute, hospital-acquired anemia (HAA). Methods and Results We identified 2909 patients with AMI who had normal hemoglobin (Hgb) on admission in the multi-center TRIUMPH registry. We used hierarchical Poisson regression to identify independent correlates of HAA, and multivariable proportional hazards regression to identify the association of HAA with mortality and health status. At discharge, 1321 (45.4%) patients had HAA, of whom 348 (26.3%) developed moderate-severe anemia (Hgb 9.1–11). The incidence of HAA varied substantially across hospitals (range: 33.3% to 69.2%, median rate ratio for HAA development 1.13 (95% CI 1.07–1.23) controlling for patient characteristics). Although documented bleeding was more frequent with more severe HAA, fewer than half of patients with moderate-severe HAA had any documented bleeding. Independent correlates of HAA included age, female gender, white race, chronic kidney disease, ST segment elevation MI, acute renal failure, use of glycoprotein IIb/IIIa inhibitors, in-hospital complications (cardiogenic shock, bleeding and bleeding severity), and length of stay. After adjustment for GRACE score and bleeding, patients with moderate-severe HAA had higher mortality (HR 1.82 (95% CI 1.11–2.98) vs. no HAA), as well as poorer health status at 1-year. Conclusions HAA develops in nearly half of AMI hospitalizations, commonly in the absence of documented bleeding, and is associated with worse mortality and health status. Better understanding of how HAA can be prevented, and whether its prevention can improve patient outcomes is needed.

Background No previous reports have described the comprehensive care pathways involved in chronic total occlusion percutaneous coronary intervention (CTO PCI). Methods In a study of 1,000 consecutive patients undergoing CTO PCI using hybrid approach, a systematic algorithm of selecting CTO PCI strategies, the procedural characteristics, complication rates, and patient reported health status outcomes through 12 months were assessed. Results Technical success of the index CTO PCI was 86%, with 89% of patients having at least one successful CTO PCI within 12 months. A total of 13.8% underwent CTO PCI of another vessel or reattempt of index CTO PCI within 1 year. At 1 year, the unadjusted major adverse cardiac and cerebral event (MACCE) rate was lower in patients with successful index CTO PCI compared to patients with unsuccessful index CTO PCI (9.4% vs. 14.6%, p = .04). The adjusted hazard ratios of myocardial infarction and death at 12 months were numerically lower in patients with successful index CTO PCI, compared to patients with unsuccessful index CTO PCI. Patients with successful index CTO PCI reported significantly greater improvement in health status throughout 12‐months compared to patients with unsuccessful index CTO PCI. Conclusion CTO‐PCI in the real‐world often require treatment of second CTO, non‐CTO PCI or repeat procedures to treat initially unsuccessful lesions. Successful CTO PCI is associated with numerically lower MACCE at 1 year and persistent symptomatic improvement compared to unsuccessful CTO PCI. Understanding the relationship between the care pathways following CTO PCI and health status benefit requires further study.

IMPORTANCE Same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is associated with lower costs and preferred by patients. However, to our knowledge, contemporary patterns of SDD after elective PCI with respect to the incidence, hospital variation, trends, costs, and safety outcomes in the United States are unknown. OBJECTIVE To examine (1) the incidence and trends in SDD; (2) hospital variation in SDD;(3) the association between SDD and readmissions for bleeding, acute kidney injury (AKI), acute myocardial infarction (AMI), or mortality at 30, 90, and 365 days after PCI; and (4) hospital costs of SDD and its drivers. DESIGN, SETTING, AND PARTICIPANTS This observational cross-sectional cohort study included 672 470 patients enrolled in the nationally representative Premier Healthcare Database who underwent elective PCI from 493 hospitals between January 2006 and December 2015 with 1-year follow-up.EXPOSURES Same-day discharge, defined by identical dates of admission, PCI procedure, and discharge. MAIN OUTCOMES AND MEASURES Death, bleeding requiring a blood transfusion, AKI and AMI at 30, 90, or 365 days after PCI, and costs from hospitals' perspective, inflated to 2016. RESULTS Among 672 470 elective PCIs, 221 997 patients (33.0%) were women, 30 711 (4.6%) were Hispanic, 51 961 (7.7%) were African American, and 491 823 (73.1%) were white. The adjusted rate of SDD was 3.5% (95% CI, 3.0%-4.0%), which increased from 0.4% in 2006 to 6.3% in 2015. We observed substantial hospital variation for SDD from 0% to 83% (median incidence rate ratio, 3.82; 95% CI, 3.48-4.23), implying an average (median) 382% likelihood of SDD at one vs another hospital. Among SDD (vs non-SDD) patients, there was no higher risk of death, bleeding, AKI, or AMI at 30, 90, or 365 days. Same-day discharge was associated with a large cost savings of $5128 per procedure (95% CI, $5006-$5248), driven by reduced supply and room and boarding costs. A shift from existing SDD practices to match top-decile SDD hospitals could annually save $129 million in this sample and $577 million if adopted throughout the United States. However, residual confounding may be present, limiting the precision of the cost estimates.CONCLUSIONS AND RELEVANCE Over 2006 to 2015, SDD after elective PCI was infrequent, with substantial hospital variation. Given the safety and large savings of more than $5000 per PCI associated with SDD, greater and more consistent use of SDD could markedly increase the overall value of PCI care.

Objective The purpose of this study was to examine the incidence of nuisance bleeding after AMI and its impact on QOL. Background Prolonged dual antiplatelet therapy (DAPT) is recommended after acute myocardial infarction (AMI) to reduce ischemic events, but it is associated with increased rates of major and minor bleeding. The incidence of even lesser degrees of post-discharge “nuisance” bleeding with DAPT and its impact on quality of life (QOL) are unknown. Methods Data from the 24-center TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status) study of 3,560 patients, who were interviewed at 1, 6, and 12 months after AMI, were used to investigate the incidence of nuisance bleeding (defined as Bleeding Academic Research Consortium type 1). Baseline characteristics associated with “nuisance” bleeding and its association with QOL, as measured by the EuroQol 5 Dimension visual analog scale, and subsequent re-hospitalization were examined. Results Nuisance (Bleeding Academic Research Consortium type 1) bleeding occurred in 1,335 patients (37.5%) over the 12 months after AMI. After adjusting for baseline bleeding and mortality risk, ongoing DAPT was the strongest predictor of nuisance bleeding (rate ratio [RR]: 1.44, 95% confidence interval [CI]: 1.17 to 1.76 at 1 month; RR: 1.89, 95% CI: 1.35 to 2.65 at 6 months; and RR: 1.39, 95% CI: 1.08 to 1.79 at 12 months; p < 0.01 for all comparisons). Nuisance bleeding at 1 month was independently associated with a decrement in QOL at 1 month (−2.81 points on EuroQol 5 Dimension visual analog scale; 95% CI: 1.09 to 5.64) and non-significantly toward higher re-hospitalization (hazard ratio: 1.20; 95% CI: 0.95 to 1.52). Conclusions Nuisance bleeding is common in the year after AMI, associated with ongoing use of DAPT, and independently associated with worse QOL. Improved selection of patients for prolonged DAPT may help minimize the incidence and adverse consequences of nuisance bleeding.

No abstract