Outcomes similar with different low-osmolar iodinated contrast agents.

Among patients undergoing coronary angiography or percutaneous coronary interventions with low-osmolar contrast media (LOCM), adverse outcomes are uncommon, with no advantage apparent between different agents.

That finding comes from a retrospective look at data on more than 100,000 patients, reported in theAmerican Journal of Cardiology online March 22 by Dr. James K. Min, with Cedars-Sinai Medical Center in Los Angeles, California, and colleagues.

“In contrast to previous studies that compared LOCM to iso-osmolar contrast media, our study directly compared alternate LOCM for differences in clinical outcomes,” the authors point out.

They note that previous reports have suggested that iohexol may be associated with increased rates of contrast-induced nephropathy (CIN) compared to an iso-osmolar contrast medium, whereas this has not been reported with other LOCM such as ioversol and iopamidol.

To determine if there is any difference between LOCMs, the team looked at outcomes in patients exposed to iohexol (n = 20,136), iopamidol (n = 21,539), or ioversol (n = 66,319) during invasive coronary procedures.

Propensity scoring generated 19,482 matched pairs of patients exposed to iohexol versus ioversol, and 10,204 pairs exposed to iohexol versus iopamidol.

The researchers found no significant difference between the iohexol-ioversol pairs in rates of new inpatient hemodialysis (relative risk 0.72; p = 0.05), inpatient mortality (RR 0.90; p = 0.42), or 30-day readmission for CIN (RR 0.81; p = 0.52).

Outcomes were also similar between the matched iohexol-iopamidol patients in terms of inpatient hemodialysis (RR 1.18; p = 0.45), inpatient mortality (RR 1.09; p = 0.60), or 30-day CIN readmission (RR 1.11; p = 0.82).

“Encouragingly, in this large dataset, even before matching, rates of in-hospital hemodialysis and mortality and 30-day readmission rates for CIN were low for all patients, irrespective of contrast medium used,” Dr. Min and colleagues comment.

“After matching,” they conclude, “we could not identify any significant differences in adverse events for patients who underwent ICA and/or PCI with different LOCM.”


Source: Am J Cardiol 


Can We Build a Better SYNTAX Score?


Adding clinical factors to the anatomical SYNTAX model improved prediction of 4-year mortality with surgery versus stenting for complex coronary artery disease.

The SYNTAX score provides an anatomically based measure of coronary artery disease to help physicians and patients choose an appropriate revascularization strategy. However, other patient characteristics are often important factors in clinical decisions.

To improve the SYNTAX scoring system, investigators used SYNTAX trial data to identify six clinical factors — age, creatinine clearance, left ventricular ejection fraction [LVEF], peripheral vascular disease, female sex, and chronic obstructive pulmonary disease [COPD]) — that independently predicted 4-year mortality or showed an interaction effect between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for long-term mortality (notably, diabetes did not meet either of these criteria and was excluded from the model). These variables were combined with two anatomic measures: SYNTAX score and presence of left main disease.

Compared with the original SYNTAX model, the SYNTAX score II predicted similar 4-year mortality with CABG and PCI at lower scores with some clinical factors (female sex, lower LVEF) and at higher scores with others (older age, COPD, left main disease). The new model discriminated well between CABG and PCI, both in the SYNTAX population and in a validation cohort of 2900 participants in an international registry.

Comment: The inclusion of clinical variables improves the SYNTAX score by allowing clinicians to identify lower-risk patients in high categories of anatomic risk, and vice versa. Although externally validated, the new score requires further validation in randomized studies. In the meantime, clinicians should consider taking this common-sense approach to making revascularization decisions.

Source: Journal Watch Cardiology

If Possible, STEMI Patients Should Go Straight to a Cath Lab.

Within a system designed to reduce time to reperfusion, mortality was lower in patients transported directly to a PCI-capable center than in those transferred from a non–PCI-capable center.

In the city of Ottawa, emergency medical system providers trained in electrocardiogram interpretation can triage patients with ST-segment-elevation myocardial infarction (STEMI) directly to a center with percutaneous coronary intervention (PCI) capability. In a registry study, investigators compared outcomes in 822 patients transported directly to a PCI-capable hospital with those in 567 patients transported initially to a non–PCI-capable hospital, then transferred for primary PCI.

The median door-to-balloon time was significantly shorter in patients transported directly for PCI (66 minutes) than in those transferred for PCI (117 minutes). At 180 days, all-cause mortality was lower in directly transported patients than in those first taken to a non–PCI-capable hospital (5.0% vs. 11.5%; P<0.001). After multivariable adjustment, direct transfer was associated with about a 50% reduction in mortality risk (odds ratio, 0.52; P=0.01).

Comment: This study strengthens evidence that standardized geographic protocols designed to reduce time to reperfusion for ST-segment-elevation myocardial infarction reduce mortality. The importance of prehospital STEMI diagnosis and systems for rapid transport and treatment are now reflected in guideline recommendations (JW Cardiol Jan 6 2010), and implementation of these practices should be a public-health priority.

Source: Journal Watch Cardiology