NCDR Research Network™ News
The latest in NCDR Research

Patterns and Intensity of Medical Therapy in Patients Undergoing Percutaneous Coronary Intervention

A study published this week in the Journal of the American Medical Association (JAMA) provides insight into how clinical trials impact physician practice.

Seeking to describe current practice patterns surrounding the use of optimal medical therapy (OMT) before and after percutaneous coronary intervention (PCI) and to examine whether the use of OMT changed after the publication of the COURAGE trial in 2007, researchers used the CathPCI Registry^® to study records for patients with stable coronary artery disease (CAD) undergoing PCI between September 1, 2005, and June 30, 2009.

The COURAGE trial, a randomized trial comparing the effectiveness of OMT versus OMT plus PCI in stable CAD patients, was first presented at the American College of Cardiology’s Annual Scientific Session in 2007.

“By conducting this analysis using the country’s largest PCI registry, we could describe whether real-world practice adopted clinical trial evidence, and illuminate opportunities to improve patient care.

“While rates of OMT did increase after PCI, there was suboptimal use of OMT and minimal increases in the use of OMT after the publication of COURAGE. This study demonstrates to all physicians that important opportunities exist to improve the use of medical therapy before and after PCI,” said lead author William Borden, MD.

ACC President David Holmes, MD, FACC commented, “The findings show that the trial had minimal impact on physician practice, and demonstrate the need for continuous research in the medical field, specifically for the improvement of medical therapy before and after PCI. The study also shows us there is a need to improve how the results of comparative effectiveness research are distributed and become features of care, and how research is translated to practice.”

To read a CardioSource Journal Scan of the article, click here. For the abstract, click here.
 

Elevated B-Type Natriuretic Peptide Is Associated With Increased In-Hospital Mortality or Cardiac Arrest in Patients Undergoing ICD Implantation

Findings from a paper published in Circulation: Cardiovascular and Quality Outcomes, show that the rate of in-hospital mortality or cardiac arrest significantly increased among implantable cardioverter-defibrillator (ICD) implantation patients with elevated B-Type Natriuretic Peptide (BNP) levels.

Researchers examined data from the ICD Registry™, identifying more than 53,000 patients who received ICD implants and underwent preoperative BNP measurement from 2006 to 2008. The patients were categorized into four groups by BNP levels (<100, 100 to <300, 300 to <1000, and ≥1000 pg/ml). Complication rates were compared among groups, and odds ratios for in-hospital mortality or cardiac arrest were estimated by multiple hierarchical logistic regressions.

There were 2,952 complications reported, including 510 in-hospital deaths and 365 cardiac arrests. The rate of in-hospital mortality or cardiac arrest significantly increased with elevated BNP level (p < 0.001). This was particularly true in males, patients with renal dysfunction and patients undergoing CRT-D implantation.

The authors concluded that “Strategies aimed at reducing preprocedural BNP or creating systems to better manage procedural risk in these high-risk patients to decrease complications associated with ICD implantation merit further investigation."

To read a CardioSource Journal Scan of the article, click here.

In-Hospital Major Bleeding During ST-Elevation and Non–ST-Elevation Myocardial Infarction Care: Derivation and Validation of a Model from the
ACTION Registry^®-GWTG™

Seeking to develop a bleeding model that would allow for the standardization of bleeding events and risk adjustment across hospitals with varying case mix, researchers examined baseline characteristics and in-hospital major bleeding for 90,273 patients enrolled in 251 ACTION Registry-GWTG hospitals across the U.S.

Using multivariate analysis to outline the 12 presenting variables most closely associated with major bleeding, the authors developed a model to stratify risk of bleeding and enable risk-adjusted bleeding outcomes.

As published in The American Journal of Cardiology, findings indicated that the risk model discriminated well in the derivation (C-statistic=0.73) and validation (C-statistic=0.71) cohorts. Predicted risk for major bleeding derived from the model corresponded well with observed bleeding: very low risk (3.9%), low risk (7.3%), moderate risk (16.1%), high risk (29.0%), and very high risk (39.8%).

“Reporting of outcomes is an integral component for quality improvement initiatives among hospitals. This model enables adjustment for case-mix in outcomes, making it useful for clinical decision making as well as quality improvement. We believe our model will be of interest to multiple stakeholders and that advancing our understanding of adjustment for bleeding outcomes will facilitate AMI safety,” said Lead Author Robin Mathews, MD.

To read a CardioSource Journal Scan of the article, click here.

Effect of Prior Stroke on the Use of Evidence-Based Therapies and In-Hospital Outcomes in Patients with Myocardial Infarction

Examining use of evidence-based medications and procedures in patients with and without previous stroke, researchers analyzed data from 281 hospitals participating in the ACTION Registry^®-GWTG™ between January and December 2007. Patients with ST-segment elevation MI (STEMI; n=15,997) and non-STEMI (NSTEMI; n=25,514) were included.

The findings, published in The American Journal of Cardiology, show that previous stroke was reported in 5.1% of STEMI patients and 9.3% of NSTEMI patients. Of STEMI patients eligible for reperfusion therapy, those with prior stroke were less likely to receive the therapy compared to patients without previous stroke. Longer door-to-needle and door-to-balloon times were calculated in patients with previous stroke, and these patients were less likely to receive evidence-based therapies. Death, MACEs, and major bleeding were more common in patients with previous stroke. After adjusting for baseline risk, those with a previous stroke had an increased risk of death (only those with STEMI) and MACEs, but not bleeding.

Overall, STEMI patients with a previous stroke are at increased risk for death; and both STEMI and NSTEMI patients are at increased risk of MACE. Regardless, previous stroke patients are less likely to receive guideline-based MI therapies.

To read a Cardiosource Journal Scan of the article, click here.

Regional Variations in Physicians’ Attitudes and Recommendations Surrounding Implantable Cardioverter-Defibrillators

To examine whether physicians’ attitudes and recommendations surrounding implantable cardioverter-defibrillators (ICDs) are regionally associated with ICD use, researchers conducted a national electronic survey of 9,969 American College of Cardiology members. Responses were merged with ICD implantation rate data from the ICD Registry™ and multivariable regression was used to assess trends between regional use and responses.

Published in the Journal of Cardiac Failure, results (based on a 12% response rate) showed that independent of variations in physicians’ attitudes toward ICDs, physicians in regions of low ICD use are not less likely to recommend ICDs in situations clearly supported by guidelines while those in regions of high ICD use are more likely to recommend ICDs to patients who might have limited benefit.

To read the abstract, click here.

For more information about how analysis of NCDR data is being used to answer healthcare delivery and clinical questions, visit www.ncdr.com/research.

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