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In 1964n first angioplasty was called Dotter's Folly

In 1964n first angioplasty was called Dotter's Folly | Heart and Vascular Health | Scoop.it

The first angioplasty procedure was performed 50 years ago. But it was some time before the work of "Crazy Charlie" Dotter caught on.

The patient was an 82-year-old woman whose painful left foot was horribly disfigured by ulcers and gangrene brought on by lack of circulation. Her doctors at what is now Oregon Health & Science University wanted to amputate, but when she objected, she was referred to Charles Dotter, a radiologist at the hospital who was experimenting with new ways to open up narrowed or blocked arteries. At the time, 50 years ago, clearing clogged arteries involved surgery, a long time in the hospital and a high risk of complications. Dotter’s idea was to try unblocking them with catheters—slender, hollow tubes normally used in radiology to prepare for X-rays by injecting contrast dye into blood vessels. 

X-rays showed that the woman’s leg had a narrowing in the femoral artery, which supplies blood to the lower extremities. That made her a perfect first candidate for Dotter’s scalpel-free artery repair. On January 16, 1964, he inserted a guide wire into the patient’s femoral artery and threaded it to the narrowed area. He then passed a catheter along the guide wire, followed by another, wider catheter. The procedure caused the artery to expand, and blood flow quickly returned to the woman’s foot. Several of her badly damaged toes eventually fell off, but the woman was able to walk out of the hospital on her own, living free of foot pain until she died two and a half years later. 

Seth Bilazarian, MD's insight:

Dotter’s innovation, 50 years ago was the beginning of the fields of interventional cardiology and radiology.

Dotter’s ideas, like his personality, were bold enough that many physicians in the United States dismissed him as “Crazy Charlie” and long ignored the procedure he eventually called percutaneous transluminal angioplasty (PTA). Dotter’s approach to clearing arteries had a better reception in Europe. In 1977, German-born physician Andreas Gruentzig introduced the balloon-tipped catheter, which uses tiny inflatable pouches to dilate narrowed coronary arteries. Today, angioplasty is performed on more than a million patients each year.  

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The passion for procedures to fix ailing arteries and hearts may be misguided

The passion for procedures to fix ailing arteries and hearts may be misguided | Heart and Vascular Health | Scoop.it
How gaps in medical knowledge affect matters of the heart
Seth Bilazarian, MD's insight:

David Jones, medical historian gives a review of the history of coronary bypass (CABG) and angioplasty (PCI). The essay does a good job putting into perspective the growth of these procedures. The medical approach has evolved from a belief that patients are "all fixed" when they receive a stent or have coronary bypass to our current understanding. We now recognize that these procedures need to be part of optimizing patients risk factors so the disease does not continue to worsen.
My concern about headlines like this is that patients will believe that stents are not appropriate under any circumstances and there is strong evidence that treatment for patients in the setting of a heart attack or threatened heart attack is valuable and often life saving.

Stents are not always valuable or appropriate, but a blanket impression that all stent procedures should be avoided puts patients at serious risk.

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CNN Lifestream Video

CNN Lifestream Video | Heart and Vascular Health | Scoop.it

Dr. Sanjay Gupta discusses coronary stents with Steve Nissen and Jeffrey Marshall president of SCAI

Seth Bilazarian, MD's insight:

Its reassuirng that Dr Gupta admits that the video is misleading when it implied that the patient profiled was mistreated and then went to Cleveland Clinic and was treated only with cholesterol medication.

Dr. Nissen takes a provocotave position not supported by the evidence (or my expereince) that most patients are being treated without preventitive efforts.  Its just not true. (It's irresponsible and misleading).  Of course we could do better.

Dr. Marshall makes a strong case that stents are critical and life saving in the setting of heart attaclks and threatend heart attacksd.  Scaring the public about stents does a huge disservice if patuients are discouraqged from recieving stents in the setting of a heart attack.

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Improving 'Door to Balloon Time' (D2B) for Angioplasty Patients

Improving 'Door to Balloon Time' (D2B) for Angioplasty Patients | Heart and Vascular Health | Scoop.it

My comment : The particular kind of heart attack called STEMI identified by EKG is the highest immediate risk of all heart attacks and hospitals have dramatically improved systems of care to quickly open these blocked arteries.  Every minute more heart muscle is lost with a higher likelihood of death or severe long term complications such as heart failure.  The success described in the article is a great accomplishment for patients. The one part we are not improving is the "pain to door" time.  The longer the patient waits with chest pain to activate the emrgency system the worse the outcome.  Call 911 to start the "Race to Open a Blocked Artery".

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The current standard is 90 minutes, but many hospitals aim for a faster standard of as soon as possible.\Researchers who studied Medicare data from more than 300,000 patients at 900 hospitals found so-called door-to-balloon times fell from a median of 96 minutes in 2005 to 64 minutes in 2010. The best-performing hospitals regularly achieved times under 60 minutes, which "may become the new standard," the study, published last year in the journal Circulation, concluded.

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Marked Variation in Angioplasty (#PCI) Prices in California

Marked Variation in Angioplasty (#PCI) Prices in California | Heart and Vascular Health | Scoop.it

Prices for the same surgical procedure can be four times higher, depending on where the hospital is located - even if it's in the same city. And often for reasons that are not easily apparent.

For example, hospitals in the San Mateo area charged a median price of $48,000 for a cesarean section in 2010; in San Diego, the same procedure was priced at $20,000. A hip replacement in Alameda County: $133,000; Orange County: $58,000.

Angioplasty
-- Alameda County: $97,000

-- Palm Springs: $87,000

-- Santa Barbara: $19,000

In California, total health care spending in 2009 stood at $230 billion. Hospital costs, at $76.6 billion, account for the biggest slice. In the past 10 years, health care costs in the Golden State have risen 80 percent, and they're still rising.

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Systems of Care for Heart Attack => ST-Segment–Elevation MI from AHA

Systems of Care for Heart Attack => ST-Segment–Elevation MI from AHA | Heart and Vascular Health | Scoop.it

Key take away for patients:

This paper was a survey of over 300 hospitals that take care of the sickest type of heart attack called the STEMI.  Best practices to improve care by reducing the time to open up the artery (called door to balloon time (D2B)) were identified. 

 

These practices are:

1.  accepting patients at a PCI hospital regardless of bed availability

2.  single phone call activation of cath lab

3.  emergency department physician activation
of lab without cardiology consultation

4.  national data registry participation

5.  Prehospital activation of the catheterization laboratory by paramedics & transferring physicians.

 

The most commonly reported barriers to system
implementation were hospital and cardiology group
competition and EMS transport and finances.

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Angioplasty Performed Without Pre-Procedural Aspirin

Angioplasty Performed Without Pre-Procedural Aspirin | Heart and Vascular Health | Scoop.it

Aspirin is an essential medicine before and after angioplasty or percutaneous coronary intervention (PCI). Previous studies suggest that pre-procedural aspirin is not administered to a clinically significant number of patients undergoing PCI. 

The study population comprised 65,175 patients, of whom 4,640 (7.1%) did not receive aspirin within 24 h before undergoing PCI. Aspirin nonreceivers were more likely to have had previous gastrointestinal bleeding or to present with cardiogenic shock or after cardiac arrest. Absence of aspirin before PCI was associated with a higher rate of death (3.9% vs. 2.8%; p < 0.001) and stroke (0.5% vs. 0.1%;  with no difference in need for transfusions. This association was consistent across multiple pre-specified subgroups.

Conclusions  Lack of aspirin before PCI was associated with significantly increased in-hospital mortality and stroke. Our study results support the need for quality efforts focused on optimizing aspirin use before PCI.

Seth Bilazarian, MD's insight:

The inexpensive, readily available medicine, aspirin before PCI reduces death and stroke significantly.  The 1.1% absolute risk reduction means that for every 91 people who are taking aspirin before angioplasty or PCI, one life will be saved.  This quality metric has become part of the pre-procedure assessment for patients it's so important

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Nonemergency PCI (angioplasty) at Hospitals with or without On-Site Cardiac Surgery

Nonemergency PCI (angioplasty) at Hospitals with or without On-Site Cardiac Surgery | Heart and Vascular Health | Scoop.it

A total of 3691 patients were randomly assigned to undergo PCI at a hospital without on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery (917 patients). The rates of major adverse cardiac events were 9.5% in hospitals without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at 30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98; 95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of death, myocardial infarction, repeat revascularization, and stroke (the components of the primary end point) did not differ significantly between the groups at either time point.

Seth Bilazarian, MD's insight:

Good news for community hospitals doing quality work and for patients relying on local care for heart disease and treatment with angioplasty (PCI). In Massachusetts, safety and efficacy of balloon angioplasty & stenting in community hospitals (without On-site cardiac surgery) to treat patients with coronary artery disease was not different than large academic hospitals (with surgery on site).  Study conducted by physicians at hospitals with on-site cardiac surgery.

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Why are Massachusetts hospitals doing fewer angioplasties on heart attack patients?

Why are Massachusetts hospitals doing fewer angioplasties on heart attack patients? | Heart and Vascular Health | Scoop.it

My comment: This is one of the unintended consequences of public reporting.  If a patient has a high risk of death in the setting of a heart attack, avoiding the procedure to prevent institutional or individual operator mortality statistics might be chosen.  Being risk averse in elective procedures is wise; A small potentail benefit in a critically ill patient however might warrant intervention.

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Seven years ago, Massachusetts mandated that hospitals report on a public database how often they perform minimally invasive heart procedures to open blocked arteries -- like angioplasty and stenting -- and their death rates from these procedures. That was meant to reduce unnecessary procedures and to lower death rates, but new research from the Harvard School of Public Health and two Boston hospitals indicates that the public reporting system might also be leading to fewer angioplasties in patients who need them the most: those in the throes of a heart attack.

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Handling inappropriate care appropriately in cardiology

Handling inappropriate care appropriately in cardiology | Heart and Vascular Health | Scoop.it

What do you do when your patient seeks inappropriate care—based on appropriate use and Choosing Wisely guidelines as well as your clinical judgment—from another cardiologist?  How do you then reconcile the situation with the patient?

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Long-Term Prognosis Following Cardiac Arrest: Role of Angioplasty & Cooling

Long-Term Prognosis Following Cardiac Arrest: Role of Angioplasty & Cooling | Heart and Vascular Health | Scoop.it

Take Home Message: Out of hospital cardiac arrest is still an enormous problem.  Looking at the patients successfully recussitated only 1 in 6 patients survived to discharge.  Best practices of angioplasty and cooling the patient initially resulted in better long term outcomes.

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This study looked at the influence of angioplasty (PCI)  & therapeutic hypothermia (TH) on long-term outcome. It's known that these strategies improve survival to hospital discharge but not much is known about long term outcomes. 

This study looked at adults who had nontraumatic cardiac arrest & discharged alive. Of the 5,958 persons who received EMS-attempted resuscitation

=> 16.8% discharged alive from hospital

=> PCI performed in 38.4%

=> TH performed in 25.6%

Five-year survival:

=> With PCI 78.7% vs. without PCI 54.4%

=> With TH  77.5%  vs. 60.4%  without TH

Conclusions: The effects of acute hospital interventions for post-resuscitation treatment extend beyond hospital survival & influences prognosis to 5 years.

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Choosing wisely for interventionalists: top 5

Choosing wisely for interventionalists:  top 5 | Heart and Vascular Health | Scoop.it

FFR, BMS, complete angiography, complete revascularization, radial approach: best patient care, save healthcare dollars.

 

Calling all interventionalists: What five practices would you highlight to promote best patient care and save healthcare dollars? Here are 5 ideas from my community practice perspectives:

1. Use FFR liberally for intermediate lesions but not for severe ones
2. Use bare-metal stents if there's any doubt about the patient's insurance status
3. Do complete angiography before intervention
4. Don't send patients home without complete revascularization
5. Take up the radial approach

 

What's on your list?

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