CARDIO SURGERY
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ENDARTERECTOMY
Regional performance of carotid endarterectomy. Appropriateness, outcomes, and risk factors for complications.
Wong JH, Findlay JM, Suarez-Almazor ME.
Stroke 1997 May;28(5):891-8.This study evaluated retrospectively the appropriateness of carotid endarterectomy (CEA), a surgical procedure to remove plaque from the arteries supplying the brain, in a sample of 291 consecutive patients who received the operation. Indications for CEA were deemed appropriate in 33% of cases, uncertain in 49% and inappropriate in 18%.
Approximately 5% of patients died or had a stroke within 30 days from the operation, and another 9% experienced at least one cardiac complication such as congestive heart failure, myocardial infarction, angina or dysrhythmia. These data indicate that many more surgeries are performed than what is necessary, and as a consequence some patients are needlessly exposed to the risk of severe complications and death.
The appropriateness of carotid endarterectomy.
Winslow CM, Solomon DH, Chassin MR, Kosecoff J, Merrick NJ, Brook RH.
N Engl J Med 1988 Mar 24;318(12):721-7.This study evaluated the appropriateness of carotid endarterectomy (CEA) in a random sample of 1302 patients from 3 different geographic areas. Indications for CEA were considered appropriate, equivocal and inappropriate in 35%, 32% and 32% of cases, respectively. Approximately 10% of patients either died or had a stroke within 30 days of the operation. The authors conclude that the high risk of severe complications make the indication for CEA questionable even in some patients with appropriate indications, in whom the risks associated with the procedure outweigh the benefits.
A systematic review of the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis.
Rothwell PM, Slattery J, Warlow CP.
Stroke 1996 Feb;27(2):260-5.This study reviewed all the literature published since 1980 on mortality and risk of stroke and/or death associated with carotid endarterectomy (CEA), and found that, overall, CEA is associated with a 1.62% mortality and a 5.6% risk of stroke and/or death. The estimated risk was higher in studies in which patients were assessed by a neurologist after the operation (7.7%) and lower in studies with a single author affiliated with a surgical department (2.3%). Overall, the risk of stroke and/or death remained unchanged through the period 1980-1995.
Group judgments of appropriateness: the effect of panel composition.
Leape LL, Park RE, Kahan JP, Brook RH.
Qual Assur Health Care 1992 Jun;4(2):151-9.This study evaluated whether the composition of a panel of experts influences the final opinion on the appropriateness of a specific treatment. For this purpose, two different panels of experts were asked to judge how appropriate was the decision of performing carotid endarterectomy on a sample population of 1302 patients who had undergone the procedure. One panel consisted of surgeons only; the other was formed by 4 surgeons, 2 neurologists, and 1 specialist each from family practice, internal medicine, and radiology. Their views on the appropriateness of surgery were significantly different: while 70% of operations were judged to be appropriate by the all-surgeons panel, only 38% received this rating from the more heterogeneous panel. Similarly, only 19% of surgeries were judged inappropriate by the all-surgical panel, compared to 31% of those evaluated by the more balanced panel. These data indicate that judgments on the appropriateness of a treatment modality can vary greatly, according to the composition of the panel that is evaluating it. This may have important consequences on the development of treatment guidelines.
Complications after carotid endarterectomy are related to surgical errors in less than one-fifth of cases.
Troeng T, et al.
Eur J Vasc Endovasc Surg 1999 Jul;18(1):59-64This study evaluated 65 patients with a stroke and/or death within 30 days of undergoing carotid endarterectomy (CEA), and found that 17% of these events occurred as a consequence of a surgical or postoperative error. Indications for CEA were deemed inappropriate in 9% of cases, and questionable in 21.5% of cases.
Causes and Severity of Ischemic Stroke in Patients With Internal Carotid Artery Stenosis.
Barnett, HJM. et al.
JAMA. 2000;283:1429-1436.The results of this study show that the cause of stroke in patients with narrowed internal carotid artery is often unrelated to the artery lesion. The study was conducted on 2885 U.S. patients with symptomatic obstruction of the carotid artery who were followed-up for 5 years do determine the cause of subsequent strokes. The researchers found that approximately 35% and 50% of strokes that occurred in patients with moderate (less than 70% narrowing) and severe (60-99% narrowing) carotid stenosis, respectively, were unrelated to the stenosis. This finding is important, because it implies that a large number of patients will not benefit from endarterectomy (surgical excision of a part of the carotid lining), a procedure commonly performed to relieve blockage of the artery and improve blood flow.
The Causes and Risk of Stroke in Patients with Asymptomatic Internal-Carotid-Artery Stenosis.
Inzitari D. Eliasziw M. Gates, P. Sharpe BL. Chan RKT. Meldrum HE. Barnett HJM.
N Engl J Med 2000;342:1693-1700, 1743-1745.The results of this study indicate that the majority of patients with asymptomatic carotid-artery stenosis will not benefit from endarterectomy, because these patients have a relatively low risk of developing a stroke, and in almost half of the cases the stroke is due to causes unrelated to the stenosis, such as lacunes or cardioembolism.
PULMONARY ARTERY CATHETERIZATION
Effectiveness of pulmonary artery catheters in aortic surgery: a randomized trial.
Valentine RJ, Duke ML, Inman MH, Grayburn PA, Hagino RT, Kakish HB, Clagett GP.
J Vasc Surg 1998 Feb;27(2):203-11; discussion 211-2.The results of this study show that patients who receive pulmonary artery catheterization for monitoring before surgery have a significantly higher risk of developing an adverse event during surgery, compared to those who do not receive it. In the study, 120 patients scheduled for aortic surgery were randomized to undergo either pulmonary artery catheterization (PAC) for perioperative monitoring and hemodynamic tune up in the intensive care unit on the night before the operation, or standard monitoring in the ward without PAC. Adverse intraoperative events occurred in 18% of patients with PAC and in 5% of patients without it, indicating an over 3-fold higher risk of complications associated with pulmonary catheterization.
Evaluation of the use of the pulmonary artery catheter in patients with acute myocardial infarct
The PAEEC study. Project of the Epidemiologic Analysis of Critical Illness.
Latour-P´erez J ; Calvo-Embuena R.
Med Clin (Barc), 110(19):721-6 1998 May 30.The results of this study, conducted on a cohort of 1721 patients admitted to the hospital with myocardial infarction, show that, after adjusting for possible confounders, those who received pulmonary artery catheterization were three times as likely to die than those without the catheter.
The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators.
Connors AF Jr, et al.
JAMA 1996 Sep 18;276(11):889-97.The results of this study, conducted on 5,735 patients admitted to the intensive care unit (ICU) of 5 U.S. teaching hospital, indicate that patients who receive right heart catheterization (pulmonary artery catheterization) during the first 24 hours of ICU stay have, compared to those who do not receive it, a 24% higher 30-day mortality rate. These results are adjusted for treatment selection bias. RHC use versus non-use is also associated with increased hospital costs ($49,000 vs. $35,700) and longer hospital stay (14.8 vs. 13.0 days).
Complications of right heart catheterization. A prospective autopsy study.
Connors AF Jr, et al.
Chest 1985 Oct;88(4):567-72.The results of this study indicate that patients who die with a right heart catheter in the pulmonary artery have a high prevalence of thrombosis and hemorrhage on autopsy findings. The risk of this complication increases with the duration of pulmonary catheterization.
A randomized control trial of right-heart catheterization in critically ill patients.
Ontario Intensive Care Study Group.
Guyatt G.
J Intensive Care Med 1991 Mar-Apr;6(2):91-5.The results of this randomized, controlled trial show that patients who undergo right heart catheterization have higher mortality rates (63% vs. 53%) and longer hospital stay (10.3 vs. 8.1) than those who received no catheterization.
REVASCULARIZATION PROCEDURES
The appropriateness of performing coronary artery bypass surgery.
Winslow CM, Kosecoff JB, Chassin M, Kanouse DE, Brook RH.
JAMA 1988 Jul 22-29;260(4):505-9.This study evaluated the appropriateness of bypass surgery in three hospitals with high prevalence of this procedure. Bypass surgery was performed for appropriate reasons in 56% of cases, for inappropriate reasons in 14% of cases, and for uncertain reasons in 30% of cases. The percentage of appropriate surgeries varied from 37% to 78% depending on the hospital. The authors conclude that elimination of unnecessary surgeries could result in health care savings and improved patients' outcome.
Effect of variability in the interpretation of coronary angiograms on the appropriateness of use of coronary revascularization procedures.
Leape LL, Park RE, Bashore TM, Harrison JK, Davidson CJ, Brook RH.
Am Heart J 2000 Jan;139(1 Pt 1):106-13.In this study a panel of experts reviewed the readings of 308 coronary angiograms to determine if errors in previous interpretations led to unnecessary surgical procedures or to avoidance of essential treatment. The angiograms came from patients who have been studied previously for appropriateness of angiography, coronary artery bypass grafting (CABG), and percutaneous transluminal coronary angioplasty (PTCA). The panel of experts found lack of significant disease in all the vessels while previous readings found it in 16% of the vessels. The experts also found significant less severity of stenosis and of disease extension. As a consequence, 17% to 33% of CABG and 10% of PTCA that have been previously judged as appropriate were now considered uncertain or inappropriate. These results demonstrate a high rate of inaccurate readings of coronary angiograms leading to potentially inappropriate cardiac surgeries and to inaccurate conclusions of studies whose results are based on those readings.
New concepts and paradigms in cardiovascular medicine: the noninvasive management of coronary artery disease.
Gould KL.
Am J Med 1998 Jun 22;104(6A):2S-17S.This article emphasizes that invasive revascularization procedures such as CABG and PTCA have been shown to cause more harm than good in patients with good left ventricular function, and are beneficial only in a limited number of individuals such as those with three-vessel disease and reduced ventricular function and those with "stunned" myocardium. New knowledge acquired from clinical trial indicates that management of coronary artery disease should be directed at risk factors modification through diet, cholesterol lowering drugs, anti-hypertensive treatment and smoking cessation, and invasive procedures, contrary to common practice, should be reserved only for cases unresponsive to treatment.
The appropriateness of use of percutaneous transluminal coronary angioplasty in New York State.
Hilborne LH, et al.
JAMA 1993 Feb 10;269(6):761-5.This study evaluated rate of appropriate use of percutaneous transluminal coronary angioplasty (PTCA) in a cohort of 1306 randomly chosen patients from 15 New York State hospitals. PTCA was performed for appropriate reasons only in 58% of cases, and for uncertain and inappropriate reasons in 38% and 4% of cases, respectively. Overall, depending on the hospital, 29% to 57% of PTCAs were rated inappropriate/uncertain.
Diagnosis and treatment of coronary disease: comparison of doctors' attitudes in the USA and the UK.
Brook RH, Kosecoff JB, Park RE, Chassin MR, Winslow CM, Hampton JR.
Lancet 1988 Apr 2;1(8588):750-3.The results of this study indicate that U.S. and U.K. physicians use significantly different criteria to judge the appropriateness of coronary angiography and coronary artery bypass graft (CABG) surgery. In particular, when U.K. doctors were asked to evaluate rates of inappropriate use of coronary angiography in two cohorts of patients, they rated the procedure as inappropriate in 42% and 60% of cases, compared to U.S. doctors' ratings of inappropriateness of 17% and 27%. Similarly, 35% of CABG operations were deemed inappropriate by U.K. ratings, compared to 13% of those judged by U.S. doctors. These data suggest that diagnosis and treatment of coronary artery disease may rest more on personal opinions than on established guidelines.
Effect of the increasing use of coronary angioplasty on outcome at one year in patients with unstable angina.
De Servi S, et al.
Br Heart J 1995 Dec;74(6):680-4.The results of this study indicate that from 1988 to 1992, rates of coronary angioplasty in individuals with unstable angina almost doubled, from 29% to 56%, whereas rates of bypass surgery decreased from 36% to 23%. The increased use of invasive revascularization procedures did not result in improved 1-year survival or in decreased myocardial infarction rates. In addition, the increased use of coronary angioplasty was associated with an almost two-fold increase in number of patients requiring a secondary revascularization procedure (10% in 1988 vs.19% in 1992).
Results of a second-opinion program for coronary artery bypass graft surgery.
Graboys TB, Headley A, Lown B, Lampert S, Blatt CM.
JAMA 1987 Sep 25;258(12):1611-4.The results of this study show that rates of coronary artery bypass graft (CABG) surgeries decrease by 50% when patients receive a second medical opinion. In the study, 60 of 88 patients who had been recommended CABG deferred surgery after receiving a second opinion and continued medical treatment. They were all alive after a follow-up period of over 2 years. These results indicate that medical treatment is a safe option in the management of patients with coronary artery disease.
Results of a second-opinion trial among patients recommended for coronary angiography.
Graboys TB, Biegelsen B, Lampert S, Blatt CM, Lown B.
JAMA 1992 Nov 11;268(18):2537-40.In this study 168 patients who were urged to undergo coronary angiography were referred for a second opinion to reevaluate the need for the procedure. Coronary angiography was judged unnecessary in 80% of patients. In 16% of patients further studies were needed before any recommendation could be made, and only in 4% of patients it was recommended. The authors conclude that even if these results cannot be extrapolated to all patients with coronary artery disease, it is reasonable to assume that at least 50% of all coronary angiography performed in the U.S. are unnecessary.
Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs.
Peterson ED, Wright SM, Daley J, Thibault GE.
JAMA. 1994 Apr 20;271(15):1175-80.The results of this study, conducted on all 33,641 patients admitted to Veterans Affairs Medical Centers during a 2-year period, show that although black patients with myocardial infarction received 33% less cardiac catheterizations, 42% less coronary angioplasties, and 54% less bypass surgeries than white patients, not only their chances of being alive one and two years after the infarction were equivalent to those of white patients, but also their 30-day survival rates were significantly greater than those of whites. These data indicate that a lower utilization of revascularization procedures and cardiac catheterizations in black versus white patients do not translate in worse outcome during a 2-year follow-up period.
Impact of availability of hospital-based invasive cardiac services on racial differences in the use of these services.
Gregory PM, Rhoads GG, Wilson AC, O'Dowd KJ, Kostis JB.
Am Heart J 1999 Sep;138(3 Pt 1):507-17.The results of this study show that in spite of the fact that black patients with myocardial infarction are significantly less likely to undergo cardiac catheterization, coronary angioplasty and coronary bypass surgery than white patients, their 1-year survival rates after the infarction are equivalent to those of white patients.
Long-term implications of racial differences in the use of revascularization procedures (the Myocardial Infarction Triage and Intervention registry).
Maynard C, Every NR, Martin JS, Weaver WD.
Am Heart J 1997 Jun;133(6):656-62.The results of this study indicate that despite the fact that coronary angioplasty and coronary bypass surgery after myocardial infarction are performed more frequently in white compared to black patients (26% vs. 18% and 12% vs. 7%, respectively), 2-year survival rates in the two groups are equivalent.
Coronary revascularization in diabetic patients: a comparison of the randomized and observational components of the Aypass Angioplasty
Revascularization Investigation (BARI).
Detre KM, et al.
Circulation 1999 Feb 9;99(5):633-40.The results of this study indicate that diabetic patients with myocardial infarction randomized to receive coronary angioplasty (PTCA) after myocardial infarction have a 3-fold increase in 5-year cardiac mortality rates and an almost 2-fold increase in overall mortality, compared to those randomized to receive coronary bypass surgery (23.4% vs. 8.2% and 34.5% vs.19.5%, respectively).
Use of cardiac procedures and outcomes in elderly patients with myocardial infarction in the United States and Canada.
Tu JV et al.
N Engl J Med, 336(21):1500-5 1997 May 22.The results of this study, conducted on approximately 234,000 elderly U.S. and Canadian individuals who had a new myocardial infarction in 1991, show that the rate of invasive revascularization procedures is almost 8-fold higher in Americans versus Canadian patients, with 11.7% and 10.6% of American patients undergoing angioplasty and bypass surgery, respectively, compared to 1.5% and 1.4% of Canadians. Although 30-days mortality rates were slightly lower in American versus Canadian patients (21.4% vs. 22.3%), 1-year death rates were practically equivalent in the two populations (34.3% vs. 34.4%), indicating that a significantly higher rate of utilization of invasive cardiac procedures and health care resources in the U.S. does not translate in improved long-term outcome in elderly individuals with acute myocardial infarction.
Predicting the occurrence of adverse events after coronary artery bypass surgery.
Geraci JM, Rosen AK, Ash AS, McNiff KJ, Moskowitz MA.
Ann Intern Med 1993 Jan 1;118(1):18-24.The results of this study, conducted on a cohort of 2213 patients aged 65 or older who underwent bypass surgery, show that 6.6% of them died in the 30 days following hospital admission and one third of them experienced at least one postoperative event ranging in severity from wound infection to death. These results indicate a high rate of adverse events in elderly patients undergoing coronary artery bypass surgery.
Factors related to rehospitalization within thirty days of discharge after coronary artery bypass grafting.
Beggs VL, Birkemeyer NJ, Nugent WC, Dacey LJ, O'Connor GT.
Best Pract Benchmarking Healthc 1996 Jul-Aug;1(4):180-6.The results of this study indicate that 13.8% of patients who undergo coronary artery bypass grafting (CABG) are re-admitted to the hospital within 30 days after discharge. After adjusting for patient-related severity of illness, it was shown that antiarrhythmics, diuretics, and hospital stay longer than 7 days were associated with a 3.3-, 2.2- and 2.1-fold increased risk of early rehospitalization, respectively. The risk of early rehospitalization decreased by 56% in patients discharged on beta-blockers.
Hospital readmission after cardiac surgery. Does "fast track" cardiac surgery result in cost saving or cost shifting?
Lahey SJ; Campos CT; Jennings B; Pawlow P; Stokes T; Levitsky S.
Circulation, 98(19 Suppl):II35-40 1998 Nov 10.The results of this study show that 20.9% of patients who undergo cardiac surgery are readmitted to the hospital within 30 days from surgery. Approximately 50% of re-admissions are to outside hospitals.
Medicare beneficiaries: adverse outcomes after hospitalization for eight procedures.
Riley G, Lubitz J, Gornick M, Mentnech R, Eggers P, McBean M.
Med Care 1993 Oct;31(10):921-49.This study evaluated the frequency of adverse events in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery. Adverse events were defined as complications, failure of the procedure to reach its therapeutic goal, and adverse events associated with the natural course of the disease treated with surgery. Approximately 36% of patients who underwent PTCA and 20% of those who underwent CABG were rehospitalized for an adverse event within one year from surgery.
Adverse cerebral outcomes after coronary bypass surgery.
Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators.
Roach GW et al.
N Engl J Med, 335(25):1857-63 1996 Dec 19.The results of this study indicate that 6.1% of patients who undergo coronary bypass surgery experience a neurological complication. Cerebral complications include death from cerebral injury, non-fatal stroke, stupor or coma (type 1 outcome), deterioration of intellectual function and seizures (type 2 outcome). Patients with type 1 and type 2 outcome, compared to patients without cerebral complications, have higher mortality rates (21% and 10%, vs. 2%) and longer hospital stays (25 and 21 days vs. 10 days). In addition, 69% and 39% of patients with type 1 and type 2 outcome, respectively, are discharged to intermediate or long-term facilities after bypass surgery, compared to 10% of those without neurological complications. These data indicate a high rate of neurological complications with adverse outcome associated with coronary bypass surgery procedures.
Reoperations, redo surgery and other interventions constitute more than one-third of vascular surgery.
A study from Swedvasc (the Swedish Vascular Registry).
The Swedish Society for Vascular Surgery.
Eur J Vasc Endovasc Surg 1997 Oct;14(4):244-51.This study evaluated the frequency of reoperations in patients undergoing vascular surgery for acute ischemia, aortic aneurysms, intermittent claudication and carotid artery stenosis. In the 4 years after the primary operation, 31% of patients had to be re-operated. Twenty-four percent of reinterventions occurred within 30 days from the initial surgery, 30% in the remaining year, and 14%, 10.5% and 8.5% in the second, third and fourth year, respectively. The authors conclude that is important to take into account the high risk of reintervention and the limited life expectancy of patients, when considering treatment options for the management of vascular disease.
Restenosis--an open file.
Gottsauner-Wolf M, Moliterno DJ, Lincoff AM, Topol EJ.
Clin Cardiol 1996 May;19(5):347-56.This article highlights that 33%-50% of patients who undergo percutaneous coronary angioplasty experience a reocclusion of the treated site within 6 months from the procedure.
Angiographic patterns of in-stent restenosis and implications on subsequent revascularization.
Kini A, Marmur JD, Dangas G, Choudhary S, Sharma SK.
Catheter Cardiovasc Interv 2000 Jan;49(1):23-9.This article emphasizes that 6% to 40% of patients who undergo percutaneous revascularization develop occlusion of the implanted stent.
In-stent restenosis: the Washington Hospital Center experience.
Mintz GS et al.
Am J Cardiol. 1998 Apr 9;81(7A):7E-13E.This article emphasizes that the incidence of stent re-occlusion after percutaneous revascularization is high, and this complication occurs significantly more frequently in the general patient population than in clinical trials, were patients are carefully selected. In 1997 alone, up to 100,000 patients worldwide were treated for in-stent reocclusion.
Frequency, predictors, and appropriateness of blood transfusion after percutaneous coronary interventions.
Moscucci M, Ricciardi M, Eagle KA, Kline E, Bates ER, Werns SW, et al.
Am J Cardiol 1998 Mar 15;81(6):702-7.The results of this study indicate that approximately 10% of patients who undergo percutaneous coronary revascularization receive a blood transfusion, which is unnecessary in almost two-thirds of cases. Since transfusions carry a risk of transmission of blood-related infections and of transfusion reactions and additionally increase the costs of care by approximately $500 per patient, effort should be put to increase doctors' compliance with current published guidelines in order to reduce the number of inappropriate transfusions.
Preoperative predictors of cost in Medicare-age patients undergoing coronary artery bypass grafting.
Longo KM, et al.
Ann Thorac Surg 1998 Sep;66(3):740-5.This article indicates that the average cost of a CABG procedure is $15,198.
Regression analysis of recent changes in cardiovascular morbidity and mortality in The Netherlands.
Bonneux L, Looman CW, Barendregt JJ, Van der Maas PJ.
BMJ 1997 Mar 15;314(7083):789-92.The results of this study indicate that while mortality rates from coronary heart disease have continued to decrease from 1979 through 1993, death rates from other cardiovascular diseases such as congestive heart failure and stroke have been increasing.
Angioplasty may be no better than medical treatment for non-acute heart disease
In the West the use of percutaneous transluminal coronary angioplasty (PCTA) has increased over recent years. In a systematic review, Bucher et al (p 73) identified six randomised controlled trials in over 1900 patients that compared PCTA with medical treatment. In non-acute coronary heart disease PCTA reduced angina but resulted in a higher risk of need for coronary bypass grafting during later stages of the disease. For other end points, such as myocardial infarction, death, coronary bypass grafting, and repeated angioplasty, risk ratios all showed trends in favour of medical treatment. Although angioplasty is increasingly used in non-acute coronary heart disease, evidence on its effects on myocardial infarction, death, or subsequent revascularisation is limited because trials have not included sufficient patients for informative estimates.
