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Author Interview: Dr Ameet Bakhai, MBBS, MD, FRCP, MESH, FESC
Consultant Cardiologist
Cardiology R&D Lead
Trust Commercial R&D Lead
Barnet Heart Failure Lead
Barnet General Hospital
Wellhouse Lane Barnet EN5 3DJ
Education Lead
North Central London Cardiac & Stroke Network
Camden PCT Stephenson House
75 Hampstead Road London NW1 2PL
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Publication:
Clinical Outcomes, Resource Use, and Costs at 1 Year in Patients with Acute Coronary Syndrome Undergoing PCI: Results from the Multinational APTOR Registry.
Bakhai A, Ferrieres J, Iñiguez A, Sartral M, Belger M, Schmitt C, Zeymer U.
Barnet & Chase Farm NHS Trust, Barnet, United Kingdom AMORE Health Ltd, London, United Kingdom Department of Cardiology, Toulouse Rangueil University Hospital, Toulouse, France Hospital Meixoeiro, Vigo, Spain Eli Lilly and Company, United Kingdom & France Institut für Herzinfarktforschung, Ludwigshafen, Germany.
J Interv Cardiol. 2011 Dec 8. doi: 10.1111/j.1540-8183.2011.00690.x.
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What are the main findings of the study?
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In the contemporary APTOR 1 study, recruiting 1525 people from 3 European countries who had a PCI in the context of an acute coronary syndrome, 1 in 7 patients went on to have a further cardiac event within the next 12 months after their procedure resulting in almost a doubling of expenditure over that time span, with the expected reduction in quality of life.
These real world data, suggest about 1 in 25 patients will have a hard endpoint of death, stroke or a further MI following discharge (4.3)%).
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Were any of the findings unexpected?
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The unexpected feature is that so many people continue to have recurrent events and one of the key findings was that only 68% of patients were on dual anti-platelets at 12 months despite guidelines recommending 1 year. Also while quality of life was reduced, the EQ-5D tool is limited in its ability to capture the full disutility for patients with recurrent events.
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What should clinicians and patients take away from this study?
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While revascularisation is effective at protecting patients with an ACS from further events, more work is needed to optimise both medication and lifestyle adherence post discharge with changes needed in the behaviour of both patients and their physicians to maximise the full recovery potential of these patients. Otherwise expensive resources continue to be consumed due to recurrent events.
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What recommendations do you have for cardiology health care providers as a result of your study?
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Predicting who is likely to have recurrent events still require large scale simple registries. Older patients are disadvantaged but within that cohort, identifying those who would improve with rehabilitation strategies is worth understanding. Factors such as marital status, independence and social interaction may have value in determining who is likely to deteriorate or become non-compliant post discharge and require closer attention. The most cost effective strategies may not simply be procedures and medications but may involve lifestyle programs.
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Abstract: |
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Featured Angina| Acute Coronary Syndrome and Heart Disease Interviews
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Dr. Eran Leshem - Rubinow MD, MHA
Prehospital Cardiac Markers in Defining Ambiguous Chest Pain
E. Leshem-Rubinow, Y. Abramowitz, N. Malov, M. Hadad, M. Tamari, M. Golovner,
A. Roth. Arch Intern Med. 2011 Dec 12;171(22):2056-7.
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What are the main findings of the study?
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1. Assessing cardiac markers at the point of care for diagnosing ambiguous acute chest pain avoided numerous unnecessary hospitalizations and assisted in the diagnosis of ambiguous chest pain.
2. Application of a cardiac marker examination in the pre-hospital assessment led to the justification of following a conservative approach when the kit results were negative for an acute cardiac event (98% negative predictive value).
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Were any of the findings unexpected?
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One-half of the 180 patients with a positive cardiac enzyme test result at the point of care who otherwise would not have been transferred to the hospital were eventually diagnosed as suffering from an acute myocardial infarction.
While misdiagnosis can be anticipated when symptoms are not consistent or clear-cut, the high percentage of true myocardial infarction that would have been missed by clinical and electrocardiographic evaluations alone was disturbing.
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What should clinicians and patients take away from this study?
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Pre-hospital point of care cardiac marker testing provides physicians and paramedics with an additional assessment tool, especially in the setting of vague symptoms, and is instrumental in reducing the rate of misdiagnosis and costs of unnecessary transport to hospital as well as hospitalization.
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What recommendations do you have for nephrology health care providers as a result of your study?
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We have shown that cardiac marker testing in the pre-hospital setting can guide the physician facing the dilemma of whether or not to send a patient to hospital or to treat expectantly but only after 6 hours had elapsed since the onset of chest pain.
Further research is recommended:
(1) to develop additional and more sensitive biochemical markers for use at the point of care, and
(2) to enhance electrocardiographic technology so that acute coronary syndrome can be telemedically identified within the first 1-2 hours of symptom presentation.
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Abstract
Background— Despite data showing the benefits of implantable cardioverter-defibrillator (ICD) insertion for primary prevention in populations at risk for sudden death, professional society guidelines recommending primary prevention, and recognition by payers of the clinical value of ICDs in these populations, ICDs for primary prevention remain underused. We sought to determine whether implementing a screening tool would increase appropriate identification of patients showing clinical evidence of ICD benefit and prompt referral to an electrophysiologist for ICD implantation.
Methods and Results— Screening tools were affixed to medical records for patients seen in 2 outpatient cardiology offices that queried ejection fraction and whether referral to an electrophysiologist was made (N=6632).
The number of appropriate referrals in the screening period were compared with analogous data collected before implementation of the screening tool (control period) through retrospective record review (n=3606). Significantly more eligible patients were offered referral during the screening period than during the control period at both sites, 80% (8/10 eligible) versus 33% (5/15) at site 1 (P<0.02) and 100% (44/44) versus 60% (21/35) at site 2 (P<0.001). Of all patients offered referral, 41% (32/78) accepted.
Conclusions— The use of a screening tool increases referral to electrophysiology for patients in whom placement of an ICD confers the benefit of sudden cardiac death primary prevention. Barriers to referral include both physician and patient factors. Verification of these findings on a larger scale as well as studies defining the foundation of these barriers may further improve use of ICDs in patients for whom their mortality benefit is well described.
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