Background-Although numerous studies have reported that cardiac rehabilitation (CR) is associated with reduced mortality after myocardial infarction, less is known about its association with mortality after percutaneous coronary intervention. Methods and Results-We performed a retrospective analysis of data from a prospectively collected registry of 2395 consecutive patients who underwent percutaneous coronary intervention in Olmsted County, Minnesota, from 1994 to 2008. The association of CR with all-cause mortality, cardiac mortality, myocardial infarction, or revascularization was assessed with 3 statistical techniques: propensity score-matched analysis (nϭ1438), propensity score stratification (nϭ2351), and regression adjustment with propensity score in a 3-month landmark analysis (nϭ2009). During a median follow-up of 6.3 years, 503 deaths (199 cardiac), 394 myocardial infarctions, and 755 revascularization procedures occurred in the study subjects. Participation in CR, noted in 40% (964 of 2395) of the cohort, was associated with a significant decrease in all-cause mortality by all 3 statistical techniques (hazard ratio, 0.53 to 0.55; PϽ0.001). A trend toward decreased cardiac mortality was also observed in CR participants; however, no effect was observed for subsequent myocardial infarction or revascularization. The association between CR participation and reduced mortality rates was similar for men and women, for older and younger patients, and for patients undergoing elective or nonelective percutaneous coronary intervention. Conclusion-We found that CR participation after percutaneous coronary intervention was associated with a significant reduction in mortality rates. These findings add support to published clinical practice guidelines, performance measures, and insurance coverage policies that recommend CR for patients after percutaneous coronary intervention. (Circulation. 2011;123:2344-2352.)Key Words: angioplasty Ⅲ cardiac rehabilitation Ⅲ exercise Ⅲ mortality Ⅲ prevention Ⅲ stents C ardiac rehabilitation (CR) is associated with a 20% to 30% reduction in mortality in persons with coronary artery disease, particularly after myocardial infarction (MI). [1][2][3] This benefit is thought to be mediated by several factors, including the physiological benefits of exercise training, 4,5 psychological benefits of group support and counseling, 6 improved adherence to preventive therapies, 7 and improved control of cardiovascular risk factors. 4,8 Unfortunately, even with this strong evidence, only Ϸ25% of eligible patients in the United States participate in CR. 9 Clinical Perspective on p 2352More than 1 million percutaneous coronary intervention (PCI) procedures are performed in the United States annually. 10 However, very little direct evidence has been published regarding CR participation rates and the impact of CR on mortality after PCI. Even with the paucity of data, several national guidelines have recommended CR after PCI, 11 and in 2006, the Centers for Medicare and Medicaid Services included PCI ...

Background— Diabetes portends an adverse prognosis in patients undergoing percutaneous coronary intervention (PCI). Whether improvements in current clinical practice (stents, IIb/IIIa antagonists) have resulted in substantial improvement of these outcomes remains an issue. The aim of this study was to determine the influence of diabetes on 9-month outcomes of patients undergoing PCI in the current era. Methods and Results— The 11 482 patients enrolled in the Prevention of REStenosis with Tranilast and its Outcomes (PRESTO) Trial were stratified according to the presence (n=2694) or absence (n=8798) of diabetes. Diabetic patients were older; were more likely to be female; had a higher proportion of congestive failure, hypertension, prior CABG, and unstable angina; and had higher body mass index and lower ejection fraction than nondiabetic patients ( P <0.01 for all comparisons). The degree of multivessel disease was similar between the two groups. American College of Cardiology/American Heart Association type C lesions were more common in diabetic patients (17% versus 15%, P <0.01). Angiographic and procedural success rates and in-hospital events were similar between the two groups. The primary end point of death, myocardial infarction, or target vessel revascularization (TVR) was analyzed as time-to-first event within 9 months of the index PCI. After adjusting for certain baseline characteristics, diabetes was independently associated with death at 9 months (relative risk [RR], 1.87; 95% CI, 1.31 to 2.68, P <0.01) and with an increased likelihood of TVR (RR, 1.27; 95% CI, 1.14 to 1.42, P <0.01), as well as the composite end point of death/myocardial infarction/TVR (RR, 1.26; 95% CI, 1.13 to 1.40, P <0.01). Conclusions— Despite advances in interventional techniques, diabetes remains a significant independent predictor of adverse events in the intermediate term after PCI.

Coronary embolism is the underlying cause of 3% of acute coronary syndromes but is often not considered in the differential of acute coronary syndromes. It should be suspected in the case of high thrombus burden despite a relatively normal underlying vessel or recurrent coronary thrombus. Coronary embolism may be direct (from the aortic valve or left atrial appendage), paroxysmal (from the venous circulation through a patent foramen ovale), or iatrogenic (following cardiac intervention). Investigations include transesophageal echocardiography to assess the left atrial appendage and atrial septum and continuous electrocardiographic monitoring to assess for paroxysmal atrial fibrillation. The authors review the historic and contemporary published data about this important cause of acute coronary syndromes. The authors propose an investigation and management strategy for work-up and anticoagulation strategy for patients with suspected coronary embolism.

(1) To assess the efficacy of a 20 minute massage therapy session on pain, anxiety, and tension in patients before an invasive cardiovascular procedure. (2) To assess overall patient satisfaction with the massage therapy. (3) To evaluate the feasibility of integrating massage therapy into preprocedural practices. Experimental pretest-posttest design using random assignment. Medical cardiology progressive care units at a Midwestern Academic Medical Center. Patients (N=130) undergoing invasive cardiovascular procedures. The intervention group received 20 minutes of hands on massage at least 30 minutes before an invasive cardiovascular procedure. Control group patients received standard preprocedural care. Visual analogue scales were used to collect verbal numeric responses measuring pain, anxiety, and tension pre- and postprocedure. The differences between pre- and postprocedure scores were compared between the massage and standard therapy groups using the Mann-Whitney Wilcoxon's test. Scores for pain, anxiety, and tension scores were identified along with an increase in satisfaction for patients who received a 20-minute massage before procedure compared with those receiving standard care. This pilot study showed that massage can be incorporated into medical cardiovascular units' preprocedural practice and adds validity to prior massage studies.

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