July 2010 Vol. 16 No.

7
From the publishers of The New England Journal of Medicine

CA RDI OLOGY
Stenting vs. Endarterectomy for Carotid Artery Stenosis: What Are the Trade-Offs?
Mid-term CREST findings indicate that surgery is more effective for stroke prevention, but stenting has some advantages.

The use of stenting as an alternative to surgical endarterectomy for treatment of carotid artery stenosis is controversial (JW Cardiol May 2010, p. 38, and Lancet 2010; 375:985). In this North American multicenter trial, 2502 adults with carotid stenosis (baseline age, 69) were randomized to undergo endarterectomy or stenting. Forty-seven percent of patients were asymptomatic, and embolic protection was employed in 96% of stenting procedures. The 4-year estimate of the primary combined endpoint of stroke, myocardial infarction (MI), and death did not differ significantly between the stenting and endarterectomy groups (7.2% and 6.8%, respectively). During a median follow-up of 2.5 years, the stroke rate was higher in the stenting group than in the endarterectomy group (4.1% vs. 2.3%; P=0.01), and the MI rate was higher in the endarterectomy

group than in the stenting group (2.3% vs. 1.1%; P=0.03). The treatment effect was unaffected by sex or symptomatic status. Efficacy was greater for stenting in younger patients and for endarterectomy in older patients, with a crossover at about age 70. Quality-of-life analyses at 1 year demonstrated a greater detrimental effect for stroke than for MI.
COMMENT

Brott TG et al. for the CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010 May 26; [e-pub ahead of print]. (http://dx.doi.org/10.1056/ NEJMoa0912321) Davis SM and Donnan GA. Carotid-artery stenting in stroke prevention. N Engl J Med 2010 May 26; [e-pub ahead of print]. (http://dx.doi.org/10.1056/ NEJMe1005220)

The outcomes for both therapies in this trial were excellent, probably reflecting the rigorous physician training and credentialing required for participation. These findings, like those of previous large trials, fail to demonstrate the superiority of stenting over endarterectomy, highlighting the fact that as the editorialists note stroke and MI should not be considered equivalent events. Nonetheless, I believe that stenting may be preferable in some patients, such as younger persons, those with ideal or nontortuous anatomy, and those with severe coronary artery disease. Individual circumstances and careful patient education should guide treatment choices.
Howard C. Herrmann, MD

Treating Disease, Not Risk Factors

One centers experience using total carotid arterial plaque burden to guide therapy for atherosclerotic disease

CONTENTS
SUMMARY & COMMENT

Trends in AMI: More Good News............................. 56 Reducing Racial and Ethnic Variations in Care of Patients with MI ..................................... 57 Discharge Follow-Up and Readmission for Heart Failure ........................................................ 58 The Role of CTCA in the Diagnosis of CAD............. 58 Endovascular AAA Repair: How Durable Is the Benet? .................................. 59 Valve Surgery for Asymptomatic Patients with Very Severe AS .................................... 59 Avoiding Bleeding During PCI ................................... 60
CLINICAL PRACTICE GUIDELINE WATCH

Quantitative measures of atherosclerosis, such as carotid intimamedia thickness, are considered to be strong surrogate markers of disease progression. However, patients with hyperlipidemia are typically treated to target LDL and HDL levels, without regard to quantitative measures of plaque. In 2001, investigators at a vascular prevention clinic in western Ontario, Canada, began using the results of ultrasound measurement of total carotid plaque area, rather than lipid levels, to guide treatment in adults with known atherosclerotic disease. They compared their plaque-progression results through 2007 with those of the 5-year period before 2001, during which target lipid levels were used to guide treatment. The investigators included serial plaque measurements from 4378 patients (47% women). Mean age at referral was 60 overall; during 19972001, mean age increased from 50 to 61 as the proportion of patients referred after a stroke grew. In 20012002, plaque was progressing in 55% of patients and regressing in 26%. By 2006, these proportions had essentially reversed: Plaque was regressing in 50% and progressing in 27%. In earlier years, patients with plaque progression had higher levels of LDL than those with regression. However,

Stenting vs. Endarterectomy for Carotid Artery Stenosis: What Are the Trade-Offs? ....................................... 53 Treating Disease, Not Risk Factors .......................... 53 Stroke Risk Grows with Waistlines in U.S. Women ........................................................... 54 Hamburgers, Hot Dogs, and Heart Health .............. 54 Fibrates and Cardiovascular Prevention ................ 55 Gains in Hypertension Management ....................... 55 Spin in Presentation of Randomized Trial Results ............................................................... 55 Interruptions and Medication Administration Errors............................................... 56 Staying Ahead of the Curve ....................................... 56

Diagnosis and Management of Thoracic Aortic Disease..................................... 57

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EDITOR-IN-CHIEF Harlan M. Krumholz, MD, SM, Harold H. Hines, Jr., Professor of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven EXECUTIVE EDITOR Kristin L. Odmark Massachusetts Medical Society DEPUTY EDITOR Howard C. Herrmann, MD, Professor of Medicine, Director, Interventional Cardiology and Cardiac Catheterization Laboratories, University of Pennsylvania Medical Center, Philadelphia ASSOCIATE EDITORS JoAnne M. Foody, MD, Director, Cardiovascular Wellness Center, Brigham and Womens Hospital, Boston Joel M. Gore, MD, Edward Budnitz Professor of Cardiovascular Medicine, University of Massachusetts, Worcester Mark S. Link, MD, Associate Professor of Medicine, New England Medical Center and Tufts University School of Medicine, Boston Frederick A. Masoudi, MD, MSPH, Division of Cardiology, Denver Health Medical Center and Associate Professor of Medicine, University of Colorado at Denver Beat J. Meyer, MD, Associate Professor of Cardiology, University of Bern; Chief, Division of Cardiology, Lindenhofspital, Bern, Switzerland CONTRIBUTING EDITORS William T. Abraham, MD, Professor of Medicine, Chief, Division of Cardiovascular Medicine, The Ohio State University Heart Center, Columbus Hugh Calkins, MD, Professor of Medicine and Director of Electrophysiology, The Johns Hopkins Hospital, Baltimore FOUNDING EDITOR Kim A. Eagle, MD, Albion Walter Hewlett Professor of Internal Medicine and Chief of Clinical Cardiology, Division of Cardiology, University of Michigan Medical Center, Ann Arbor MASSACHUSETTS MEDICAL SOCIETY Christopher R. Lynch, Vice President for Publishing; Alberta L. Fitzpatrick, Publisher Betty Barrer, Christine Sadlowski, Sharon S. Salinger, Staff Editors; Kara OHalloran, Copy Editor; Misty Horten, Layout; Matthew ORourke, Director, Editorial and Product Development; Robert Dall, Editorial Director; Art Wilschek, Christine Miller, Lew Wetzel, Advertising Sales; William Paige, Publishing Services; Bette Clancy, Customer Service Published 12 times a year. Subscription rates per year: $119 (U.S.), C$166.67 (Canada), US$165 (Intl); Residents/Students/Nurses/PAs: $69 (U.S.), C$96.19 (Canada), US$80 (Intl); Institutions: $219 (U.S.), C$256.19 (Canada), US$230 (Intl); individual print only: $89 (U.S.). Prices do not include GST, HST, or VAT. In Canada remit to: Massachusetts Medical Society C/O #B9162, P.O. Box 9100, Postal Station F, Toronto, Ontario, M4Y 3A5. All others remit to: Journal Watch Cardiology, P.O. Box 9085, Waltham, MA 02454-9085 or call 1-800-843-6356. E-mail inquiries or comments via the Contact Us page at JWatch.org. Information on our conflict-of-interest policy can be found at JWatch.org/misc/conflict.dtl

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by 2007, LDL levels in patients with progression were approximately half as high as in earlier years and were actually lower than LDL levels in patients with regression.
COMMENT

The rationale for this treatment paradigm is that, as the authors put it, treating arteries without measuring plaque would be like treating hypertension without measuring blood pressure. In this single-center study, treatment based on carotid total plaque area led to a substantial increase in plaque regression as compared with treatment based on lipid levels. However, these results must be tested in a large randomized trial with hard clinical outcomes before a major shift in clinical practice can be recommended. Joel M. Gore, MD
Spence JD and Hackam DG. Treating arteries instead of risk factors: A paradigm change in management of atherosclerosis. Stroke 2010 Jun; 41:1193.

19881994. In contrast, most key biomarker levels and traditional vascular risk factors remained stable or even improved in women, with the exception of glycemic markers and luteinizing hormone levels, which increased substantially between the two survey periods.
COMMENT

NHANES data reveal that midlife stroke rates have tripled among U.S. women during the past two decades. These results indicate that risk for stroke between the ages of 35 and 54 is higher in women than in men and compellingly suggest that obesity and metabolic syndrome (reflected by glycemic markers and luteinizing hormone levels) are driving much of the increase. Further longitudinal studies are required to illuminate trends in stroke incidence and to explore associated factors more closely. JoAnne M. Foody, MD
Towfighi A et al. Weight of the obesity epidemic: Rising stroke rates among middle-aged women in the United States. Stroke 2010 May 27; [e-pub ahead of print]. (http://dx.doi.org/10.1161/ STROKEAHA.109.577510)

Stroke Risk Grows with Waistlines in U.S. Women

Rising obesity is associated with rising midlife stroke rates in women, but not in men.

Recent research has demonstrated that the prevalence of stroke in women aged 45 to 54 is twice that in men of similar age (Neurology 2007; 69:1898). Investigators sought to determine whether this observed sex difference is a recent phenomenon, and if so, whether it could relate to worsening of vascular risk factors or increases in biomarker levels among women. They evaluated medical histories and biomarker data from participants in the National Health and Nutrition Examination Survey (NHANES) 19881994 compared with analogous data from NHANES 1999 2004. In all, 9706 women and men aged 35 to 54 answered the question about prior diagnosis of stroke. In women, stroke prevalence increased from 0.6% in 19881994 to 1.8% 1999 2004; no such increase was seen in men (0.9% and 1.0% in 19881994 and 1999 2004, respectively). The percentage of women with abdominal obesity (defined as waist circumference >88 cm [34.6 inches]) increased from 47% to 59% between the two survey periods; average waist circumference in women was nearly 4 cm (1.6 inches) greater in 19992004 than in

Hamburgers, Hot Dogs, and Heart Health

In a meta-analysis, processed meat conferred higher risks for CAD and diabetes than unprocessed red meat.

We make dietary choices and recommendations with less-than-complete evidence to guide us. A current controversy concerns the effects of meat, particularly red and processed meats, on cardiovascular risk. These investigators conducted a systematic review and meta-analysis of studies evaluating the associations between red and processed meat consumption and risks for coronary heart disease (CHD), stroke, and diabetes. The researchers did not identify any trials; their analysis included 17 prospective cohort studies and 3 case-control studies. Consumption of unprocessed red meat was not associated with CHD (4 studies; relative risk, 1.00 per 100-g serving/day; 95% confidence interval, 0.811.23) or diabetes (5 studies; RR, 1.16; 95% CI, 0.921.46). Consumption of processed meat was associated with a 42% increase in risk for CHD (5 studies; RR, 1.42 per 50-g serving/day; 95% CI, 1.071.89) and a 19% increase in risk for diabetes (7 studies; RR, 1.19; 95%

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COMMENT

CI, 1.111.27). Neither type of meat was associated with an elevated risk for stroke.
COMMENT

This meta-analysis encompasses relatively few studies, and confounding by imprecise or unmeasured factors is likely. Moreover, the CIs do not exclude substantial risks associated with unprocessed meat. Nevertheless, the main finding of an increase in risk with processed meats, with their high salt and preservative content, bolsters available evidence and should lead us to advise our patients to be cautious about consuming these products.
Harlan M. Krumholz, MD, SM
Micha R et al. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes mellitus: A systematic review and meta-analysis. Circulation 2010 Jun 1; 121:2271.

baseline triglyceride levels 177 mg/dL. The ACCORD Lipid Study was the only trial in which participants received concomitant statin treatment.
COMMENT

This analysis has been touted as a vindication of fibrates; however, it is much less conclusive than it appears at first glance. The effect size is relatively small, most patients in these trials were not on statins, and adding fibrates was unhelpful in the one trial that mandated background statin therapy. The authors highlight the benefit found in the high-triglyceride subgroup, but that analysis was unadjusted for number of comparisons. Overall, this analysis will not quiet the controversy over the value of fibrates in general or of fenofibrate in particular.
Harlan M. Krumholz, MD, SM
Jun M et al. Effects of fibrates on cardiovascular outcomes: A systematic review and meta-analysis. Lancet 2010 May 29; 375:1875.

These data suggest that as of 2008, BP is controlled in an estimated 50.1% of all adults with hypertension and that most of the improvement since 1988 has occurred after 2000. As an editorialist notes, this achievement merits celebration; however, hypertension control rates remain significantly lower in younger than in older adults and in Hispanic than in white patients. Much work remains to be done.
JoAnne M. Foody, MD
Egan BM et al. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010 May 26; 303:2043. Chobanian AV. Improved hypertension control: Cause for some celebration. JAMA 2010 May 26; 303:2082.

Fibrates and Cardiovascular Prevention

A meta-analysis shows a benefit, but the clinical value of fibrates is still in doubt.

Spin in Presentation of Randomized Trial Results

A study of data manipulation

Since the publication of the ACCORD Lipid Study, in which adding a fibrate (e.g., gemfibrozil, fenofibrate) to a statin did not improve cardiovascular outcomes in patients with diabetes (JW Cardiol Apr 2010, p. 29, and N Engl J Med 2010; 362:1563), fibrates have come under closer scrutiny. Now, investigators in Australia have conducted a meta-analysis of randomized trials evaluating the effects of fibrates versus placebo on cardiovascular outcomes. The investigators identified 18 trials including 45,058 patients. Fibrates were associated with the following: A barely significant 10% reduction in risk for cardiovascular events (5 trials; P=0.048; 95% confidence interval, 0.821.00) A 13% reduction in risk for coronary events (16 trials; P<0.0001; 95% CI, 0.810.93) A nonsignificant 7% reduction in risk for cardiac death (13 trials; P=0.116; 95% CI, 0.851.02) No reduction in all-cause death (16 trials; P=0.918; 95% CI, 0.931.08)

Gains in Hypertension Management

Public health efforts to improve blood pressure control reach an important milestone.

As many as 65 million U.S. adults have hypertension. These investigators used data from the National Health and Nutrition Examination Survey 19881994 and 19992008 cohorts to assess progress toward the U.S. governments Healthy People 2010 goal of achieving blood pressure (BP) control in 50% of individuals with hypertension. The analysis included 42,856 adults. The prevalence of hypertension increased significantly between 19881994 and 19992000 but remained stable between 19992000 and 20072008. Controlled hypertension (BP <140/90 mm Hg) rates increased from 27.3% in 19881994 to 50.1% in 20072008; during this time, mean BP in hypertensive patients fell from 143.0/80.4 mm Hg to 135.2/74.1 mm Hg. Rates of hypertension control improved significantly between 19881994 and 20072008 in all age, race, and sex categories, but the rate was lower in individuals aged 18 to 39 than in those aged 40 to 59 and in those aged 60 and older (P<0.001 for both comparisons), and was also lower in Hispanics than in whites (P=0.004).

Authors of journal articles often frame discussions to advance particular perspectives or agendas. To examine this issue, researchers searched PubMed and identified all randomized controlled trials (RCTs) published in December 2006 and selected the 72 RCTs with clearly identified primary outcomes that were not statistically significant (P0.05). The researchers analyzed each article for presence of spin, using their own classification scheme. Spin was identified in 18% of article titles; in 38% and 58% of abstract results and conclusion sections, respectively; and in 29%, 43%, and 50% of main-text results, discussion, and conclusion sections, respectively. The level of spin in conclusion sections was considered high in about 30% of articles. Common types of spin were excessive focus on subgroups or secondary outcomes, focus on improvements within

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Of 14 subgroup analyses for coronary events, none was significant at a level of P<0.01, although a benefit at P=0.03 was found in the subgroup of patients with

JWatch.org/online

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COMMENT

No. 7

intervention groups (instead of comparisons between intervention and control groups), emphasis on treatment benefits despite nonsignificant findings, and inappropriate interpretation of nonsignificant differences as treatment equivalence.
COMMENT

nificant; 2.7% were considered to be major errors (i.e., likely to lead to longer hospital stay or to permanent loss of function). Risk for a major error rose from 2.3% with no interruptions to 4.7% with four interruptions.
COMMENT

This study quantitates what we already knew qualitatively about spin in medical journals. Interested readers should consult this articles online-only appendix, which provides many specific examples from the 72 articles. Although I believe the researchers were a bit overzealous in considering some of these passages to be spin, this report nevertheless constitutes a welcome refresher course in how data can be manipulated both statistically and linguistically. Additional research on associations between spin and industry funding would be interesting. Allan S. Brett, MD,
Journal Watch General Medicine
Boutron I et al. Reporting and interpretation of randomized controlled trials with statistically nonsignificant results for primary outcomes. JAMA 2010 May 26; 303:2058.

In this study, nurses who were interrupted during medication administration were more likely to make errors. Although multitasking is a necessity for many occupations, it might have adverse effects on the delivery of healthcare, and the studys findings likely are applicable to many aspects of medicine.
Jamaluddin Moloo, MD, MPH, Journal Watch General Medicine
Westbrook JI et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010 Apr 26; 170:683.

These findings indicate that reductions in CHD mortality are attributable to improvements in both prevention and treatment. However, as obesity and diabetes rates continue to grow, we could see some retrenchment in these gains during the coming decades.
Harlan M. Krumholz, MD, SM
Wijeysundera HC et al. Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994-2005. JAMA 2010 May 12; 303:1841.

Trends in AMI: More Good News

Evidence is mounting that improvements in prevention and treatment are improving outcomes.

Staying Ahead of the Curve

Researchers relate trends in cardiovascular prevention and treatment to improvements in mortality from CHD.

Interruptions and Medication Administration Errors

Hospital nurses who were interrupted during medication administration made more errors.

Efforts to improve patient safety and reduce medical errors are receiving renewed attention. In this observational study, conducted at two Australian teaching hospitals, researchers assessed the association between interruptions during medication administration and medication administration errors. Ninety-eight nurses were observed directly as they prepared and administered medications; the nurses were aware of the study aim. Interruptions occurred during 53% of more than 4000 observed drug administrations for 720 patients. At least one procedural error (e.g., failure to check patients identification, record medication administration, use aseptic technique) occurred in 74%, and at least one clinical error (e.g., wrong drug, dose, route) occurred in 25% of administrations. Each interruption was associated with a 12% mean increase in procedural errors and a 13% mean increase in clinical errors. Most errors were rated as clinically insig-

Debate surrounds the relative contributions of preventive and treatment strategies to recent reductions in deaths from coronary heart disease (CHD). These investigators used epidemiologic data from Ontario, Canada, and the IMPACT CHD mortality model (slide presentation available on the Liverpool University website) to address this issue. Between 1994 and 2005, the ageadjusted CHD mortality rate in Ontario residents aged 2584 fell 35%, from 191 to 125 deaths per 100,000 residents. Changes in population risk factors accounted for 48% of the decrease, whereas medical and surgical treatments accounted for 43% (9% of the decrease was unaccounted for by variables included in the model). The 75-to-84-year-old age group had the greatest absolute reduction in CHD deaths. Among patients receiving treatment for various conditions, the greatest mortality reduction occurred in those with stable coronary artery disease. Improvements in the treatment of patients with acute myocardial infarction were responsible for 8% of the decrease. Increases in diabetes prevalence and body-mass index offset the mortality reductions (by 6% and 2%, respectively).

Recent studies of trends in acute myocardial infarction (AMI) have not included comprehensive information on MI type, diagnostic criteria, and medications. Now, investigators have examined data on 46,086 hospitalizations for AMI and 18,691,131 person-years of follow-up from the Kaiser Permanente Northern California integrated healthcare system between 1999 and 2008. They assessed changes in patient characteristics, medication use, biomarker levels, and outcomes using administrative codes to distinguish between ST-segment-elevation MI (STEMI) and nonST-segmentelevation MI (NSTEMI). During the study period, the hospitalization rate declined by 24%, and the proportion of STEMI events fell markedly. By the end of the study, patients were significantly older and more likely to be female, to have comorbidities, and to have previously undergone coronary revascularization than at the beginning of the study. Rates of prehospitalization use of statins, angiotensin-convertingenzyme inhibitors or angiotensin-receptor blockers, and beta-blockers all increased significantly, and median peak levels of creatine kinase-MB decreased. The adjusted odds ratio for 30-day mortality dropped significantly, by 24%. A 6.5% increase in the rate of revascularization within 30 days after MI was driven by a substantial increase in percutaneous coronary intervention (PCI).

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CLINICAL PRACTICE GUIDELINE WATCH Diagnosis and Management of Thoracic Aortic Disease
Experts from many disciplines provide welcome guidance about frequently asymptomatic conditions with potentially catastrophic outcomes.
Sponsoring Organizations: American College of Cardiology/

American Heart Association, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine, North American Society for Cardiovascular Imaging
Background and Purpose: These guidelines apply to diseases involving any or all segments of the thoracic aorta except the aortic valve, including the abdominal aorta when adjacent thoracic aortic disease is present. Because early recognition and prompt treatment of thoracic aortic disease requires exceptional diligence on the part of all healthcare professionals, the authors have amalgamated an enormous amount of information culled from more than 800 articles in 11 disciplines. Key Points:

dations depend on many different factors (e.g., anatomical location, size, presence or absence of connective tissue disease, growth rate). The guidelines provide detailed management algorithms as well as Class I and II recommendations on prophylactic surgery for various lesion types. 5. Medical treatment includes stringent control of hypertension, lipid profile optimization, smoking cessation, and other atherosclerosis risk-reduction measures. 6. Patients with thoracic aortic aneurysm can reasonably be treated with beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers to the lowest blood-pressure levels they can tolerate without adverse effects (Class IIa). 7. Most syndromes (e.g., Marfan) and familial forms of thoracic aortic disease are inherited in an autosomal dominant manner, but identification of the defective genes is still in the early stages. Therefore, the authors recommend using appropriate imaging studies to screen the probands first-degree relatives. Moreover, because the age of onset of aortic disease varies, repeat imaging of at-risk family members is warranted every 2 years.
COMMENT

1. Thoracic aortic disease is typically asymptomatic until a lifethreatening event occurs. 2. The only way to detect thoracic aortic disease and assess the risk for complications is by imaging of the thoracic aorta with computed tomography (CT) or magnetic resonance imaging (MRI) or, in some cases, echocardiography. The writing committee has formulated useful recommendations regarding a standard format for reporting imaging results. 3. Because it requires sedation, transesophageal echocardiography (TEE) is usually not recommended for surveillance of patients with thoracic aortic diseases. However, transthoracic echocardiography (TTE) allows accurate visualization of the aortic root and plays a primary role in monitoring aortic disease limited to the root, particularly in patients with Marfan syndrome. 4. For many thoracic aortic diseases, elective surgical treatment of stable, high-risk, often asymptomatic patients produces far better results than urgent treatment of acute disease, which can have catastrophic complications. However, specific recommen-

These wide-ranging guidelines help raise the awareness level of a disease that is mostly asymptomatic and associated with catastrophic complications. Detailed information on the use of aortic imaging techniques and on the management of acute and chronic thoracic aortic disease are especially valuable in the identification of patients who are at risk for rupture of aneurysms or dissections and who require prophylactic thoracic aortic repair. Identification of underlying genetic mutations may lead to more-specific management strategies (e.g., routine imaging for thoracic aortic disease only in family members who harbor mutations). Beat J. Meyer, MD
Hiratzka LF et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/ STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol 2010 Apr 6; 55:e27.

COMMENT

The authors use of administrative codes (which can be inaccurate) to classify the type of MI limits the strength of their conclusions. Nonetheless, these results are consistent with those of two studies in the Medicare population; one (JW Cardiol Oct 2009, p. 81, and JAMA 2009; 302:767) showing a marked recent decline in AMI

mortality, and the other (Circulation 2010; 121:1322) showing a marked reduction in hospitalizations for MI. The findings also reinforce those of recent studies showing increased PCI rates.
Harlan M. Krumholz, MD, SM
Yeh RW et al. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 2010 Jun 10; 362:2155.

Reducing Racial and Ethnic Variations in Care of Patients with MI

Disparities in hospital care shrink with overall adherence to evidence-based guidelines.

Studies have shown that members of racial and ethnic minorities are less likely than whites to receive evidence-based care for cardiovascular diseases and more likely

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to be treated at facilities with suboptimal results on composite performance measures. These investigators analyzed data from the U.S. Get With The Guidelines Coronary Artery Disease program to examine racial and ethnic differences in evidencebased care for myocardial infarction (MI) among participating hospitals and to assess whether such disparities decrease as performance measures show improvement over time. The analysis included 121,528 whites, 10,882 blacks, and 10,183 Hispanics treated at 443 hospitals between January 2002 and June 2007. Each performance measure for MI care showed significant improvement over the 5 years of the study in all racial and ethnic groups. Notably, during much of the first half of the study, blacks were significantly less likely than whites to receive defect-free care (i.e., all interventions for which they were eligible). At the end of the study period, more than 90% of all patients received defect-free care, with no substantial differences among racial and ethnic groups.
COMMENT

patients do not receive outpatient followup (N Engl J Med 2009; 360:1418). Patients with substantial comorbidities, such as heart failure or chronic lung disease, make up a large percentage of the readmitted population. Rapid outpatient evaluation after hospital discharge could prevent readmissions and might improve other outcomes. Using observational data from 225 hospitals, investigators evaluated the hospital stays of more than 30,000 older patients who were admitted with heart failure exacerbations. Twenty-one percent of patients were readmitted within 30 days. Hospitals varied widely in the percentage of heart failure patients who received rapid follow-up (defined as physician visit within 7 days). Hospitals that had the lowest rate of early follow-up also had the highest rate of 30-day readmission, but 30-day mortality was similar, regardless of overall postdischarge follow-up rates. For cardiology follow-up specifically, more than two thirds of patients received cardiology evaluations during hospitalization, but <10% visited cardiologists for follow-up within 7 days, and fewer than one third visited cardiologists within 1 month. Patients from hospitals with the highest rates of cardiology follow-up did have significantly lower mortality than did those from hospitals with the lowest rates.
COMMENT

The Role of CTCA in the Diagnosis of CAD

CTCA was more accurate than stress testing, but clinical probability of disease should also guide the choice of noninvasive test.

Several modalities are available for determining the presence and extent of suspected coronary artery disease (CAD). To assess the optimal use of computed tomographic coronary angiography (CTCA) relative to stress testing and invasive coronary angiography (ICA), investigators conducted a prospective study involving 517 patients referred to a single center in the Netherlands for evaluation of chest symptoms. The investigators used the Duke clinical score to classify patients pretest probability of having CAD as low (<20%), intermediate (20%80%), or high (>80%). All patients underwent both CTCA and stress testing. One hundred forty-one patients had both a negative stress test result and a normal CTCA result and were not referred for ICA. Compared with the assumption that none of these patients had CAD, assuming a 3% CAD prevalence did not significantly affect estimates. Compared with stress testing, CTCA had higher sensitivity, specificity, predictive values, and likelihood ratios for CAD in all pretest probability groups; indeed, CTCA sensitivity approached 100%. Results of an analysis comparing stress testing with CTCA as an initial test strategy are summarized in the table on the next page. The authors assumed that patients whose probability of having CAD is 5% did not need further testing, and that those with probabilities of 90% should proceed directly to ICA.
COMMENT

These findings demonstrate that systematic approaches to quality improvement in MI care are also likely to improve racial and ethnic disparities. However, as an editorialist notes, the study does not address whether this reduction in racial differences in hospital performance measures translates into reductions in disparities in MI outcomes. Further long-term studies are required to determine whether improvements in inpatient care lead to sustainable, long-term improvements in mortality and morbidity across all racial and ethnic groups.
JoAnne M. Foody, MD
Cohen MG et al. Racial and ethnic differences in the treatment of acute myocardial infarction: Findings from the Get With The GuidelinesCoronary Artery Disease Program. Circulation 2010 Jun 1; 121:2294. Cook NL. Disparities in cardiovascular care: Does a rising tide lift all boats? Circulation 2010 Jun 1; 121:2253.

Discharge Follow-Up and Readmission for Heart Failure

Rapid outpatient follow-up of discharged heart failure patients was associated with fewer hospital readmissions.

Transition from the inpatient to the outpatient setting is a vulnerable time for a patient, and careful coordination of care during this transition including rapid outpatient follow-up could help lower the rate of hospital readmissions. Heart failure patients might be particularly susceptible to rapid hospital readmission, because they often have substantial medication changes during hospital stays and might require rapid clinical assessment and laboratory follow-up. A subset of more complex patients will need rapid postdischarge follow-up with cardiologists. Implementation of care systems to assure rapid postdischarge follow-up could prevent unnecessary hospitalizations and costs in this high-risk patient population.
Daniel D. Dressler, MD, MSc, SFHM, Journal Watch Hospital Medicine
Hernandez AF et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 2010 May 5; 303:1716.

Nearly 20% of hospitalized Medicare patients are readmitted within 30 days of discharge, and more than 50% of readmitted

These findings suggest that although CTCA is more accurate than stress testing, as a first-line diagnostic test it is most useful in patients at intermediate risk for CAD, in whom CTCA discriminated between those who did and did not need ICA. However, the results do not show either test to be superior at directing patient care toward improved outcomes. Furthermore, that two tests evaluating coronary anatomy (CTCA and ICA) are in better agreement with each other than either is with a test measuring myocardial function (stress testing) is unsurprising. CTCA does expose patients to radiation,

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Clinical Utility of Stress Testing vs. CTCA as an Initial Diagnostic Test for CAD Initial Stress Test
Pretest probability of CAD Low (11%) Result + Intermediate (50%) + High (91%) + Posttest probability of CAD 32% 4% 78% 23% 95% 81%

Initial CTCA
Pretest probability of CAD Low (11%) Result + Intermediate (50%) + High (91%) + Posttest probability of CAD 52% 0% 93% 1% 97% 12%

techniques and prosthetic-valve technology prompted investigators in Korea to compare AVR with conventional care in this population. From 1996 to 2006, they enrolled 197 consecutive asymptomatic patients (mean age, 63; maximum age, 85) with very severe AS (mean peak aortic velocity 4.5 meters/ second or mean transaortic pressure gradient 50 mm Hg); 61% had AS of bicuspid or rheumatic etiology. In consultation with their physicians, 95 patients chose conventional care and 102 chose AVR. Patients with left ventricular systolic dysfunction, mitral valve disease, or coronary artery disease were excluded. The researchers used propensity score matching to adjust for baseline differences. No cases of operative mortality occurred. During a median follow-up of 4.1 years, no cardiac deaths occurred in the surgery group, and cardiac mortality was 19% in the conventional-care group. Significant predictors of cardiac mortality included male sex, aortic valve calcification, and aortic jet velocity 5 meters/second. The estimated actuarial survival rate at 6 years was significantly higher in the surgery group than in the conventional-care group (98% vs. 68%). During follow-up, symptoms developed in 59 conventional-care recipients (62%), 46 of whom then underwent surgery.
COMMENT

Probability of CAD: 5%, stop testing; 90%, proceed to invasive coronary angiography

which must be considered especially in patients with a low probability of having CAD. Joel M. Gore, MD
Weustink AC et al. Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med 2010 May 18; 152:630.

tality after endovascular repair was not directly attributable to these reinterventions.
COMMENT

Endovascular AAA Repair: How Durable Is the Benefit?

The short-term advantage of endovascular repair over open repair disappears in the long term.

As previously reported, endovascular repair of abdominal aortic aneurysms (AAAs) results in lower 30-day mortality than open surgical repair (JW Cardiol Jan 2005, p. 3, and N Engl J Med 2004; 351:1607). In this report, the DREAM investigators present their long-term, multicenter findings involving 351 patients (mean age, 70; 92% men) with AAAs 5 cm in diameter. Cumulative overall survival at 6 years was not significantly different between the open-repair and endovascular-repair groups (70% and 69%, respectively). The rate of reintervention after endovascular repair (including for endograft migration or endoleak) was higher than the rate of reintervention after surgery (30% vs. 18%; P=0.03). However, the increase in late mor-

These findings confirm the recently published long-term results of EVAR 1 (JW Cardiol May 2010, p. 37, and N Engl J Med 2010; 362:1863). The short-term benefit of endovascular repair of AAA is lost during long-term follow-up. Nonetheless, recent advances in endovascular devices, insertion techniques, and operator experience may affect future comparisons and are likely to influence both patient and physician preferences for one approach versus the other in individual situations.
Howard C. Herrmann, MD
De Bruin JL et al. for the DREAM Study Group. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010 May 20; 362:1881.

In this group of asymptomatic patients with very severe AS, those who underwent valve replacement had significantly lower cardiac and all-cause mortality than those who received conventional care. About half of the conventionally treated patients developed symptoms and required surgery within 6 years. Before practice guidelines are changed, these findings will need to be confirmed in a randomized trial, as well as in higher-risk patients and in patients with degenerative disease.
Howard C. Herrmann, MD
Kang D-H et al. Early surgery versus conventional treatment in asymptomatic very severe aortic stenosis. Circulation 2010 Apr 6; 121:1502.

Valve Surgery for Asymptomatic Patients with Very Severe AS

Survival was significantly better after surgery than with conventional care in a nonrandomized study.

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Current practice guidelines do not recommend aortic valve replacement (AVR) for asymptomatic patients with severe aortic stenosis (AS). However, advances in surgical

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JW ONLINE CME
JOURNAL WATCH SUBSCRIBERS HAVE 10 FREE CREDITS! This is one of four questions in a recent Journal Watch Online CME exam. from Valve Surgery for Asymptomatic Patients with Very Severe AS (p. 59) In a group of 102 patients who underwent aortic valve replacement for asymptomatic severe aortic stenosis (mean transaortic pressure gradient, 50 mm Hg), cardiac mortality at a median of 4 years was: A. 0%. B. 20%. C. 40%. D. 60%. Category: Cardiovascular Diseases Exam Title: Aortic Stenosis Posted Date: Jun 01 2010 View this exam and others at http://cme.jwatch.org User name and password are required. CME FACULTY Kelly Anne Spratt, DO, FACC, Section Editor, Cardiology

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60

CARDIOLOGY

Vol. 16

No. 7

Avoiding Bleeding During PCI

Registry data suggest that preventive strategies based on preprocedural risk assessment can reduce bleeding complications.

Periprocedural bleeding increases mortality and costs associated with percutaneous coronary intervention (PCI). Taking measures to prevent bleeding complications is garnering interest as a surrogate indicator of quality. Using the American College of Cardiology National Cardiovascular Data Registry, investigators assessed the effects of vascular closure devices, bivalirudin, or both in reducing bleeding during PCI in patients classified according to a risk model. The use of radial access to reduce bleeding was not evaluated in this study. The researchers reviewed records of PCI in >1.5 million patients at almost 1000 centers from January 2004 through September 2008. Bleeding (defined as requiring a blood transfusion or prolonged hospital stay or associated with a drop in hemoglobin level of >3 g/dL) occurred in 2% of patients overall.

The bleeding rate was 2.8% with manual compression, compared with 2.1% with closure devices, 1.6% with bivalirudin, and 0.9% with both (P<0.001). Differences in bleeding rates were more pronounced in patients at higher bleeding risk; in the highestrisk (>3% risk) group, bleeding rates were 6.1% with manual compression, compared with 4.6% with closure devices, 3.8% with bivalirudin, and 2.3% with both. Surprisingly, the combination of vascular closure device and bivalirudin was used least frequently in the highest-risk patients (14%, compared with 21% in the lowest-risk group).
COMMENT

increased use of preprocedural bleedingriskassessment algorithms.

Howard C. Herrmann, MD
Marso SP et al for the National Cardiovascular Data Registry. Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA 2010 Jun 2; 303:2156. Bhatt DL. Advancing the care of cardiac patients using registry data: Going where randomized clinical trials dare not. JAMA 2010 Jun 2; 303:2188.

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These results suggest that qualityimprovement measures aimed at lowering bleeding rates in high-risk patients undergoing PCI could reduce mortality and be cost-effective. Given the paradoxical finding that bleeding-avoidance strategies are used more often in low-risk than in highrisk patients, this report should prompt

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