Introduction: Anti-arrhythmic drugs can affect ICD function; however, patterns of the use of antiarrhythmic drugs among patients with ICDs have not been clearly established. Methods: We studied patients enrolled in the ICD Registry TM between 2006 and 2011 undergoing first-time ICD placement (n=500,995). We analyzed use of antiarrhythmics by class prescribed at discharge after implantation. Results: 15% of the cohort received an antiarrhythmic. Compared with those not receiving an antiarrhythmic drug, patients receiving an antiarrhythmic were on average older (71 yr vs. 68, p<.01) and more likely to have a history of atrial fibrillation/flutter (58% vs. 27%, p<.01), ventricular tachycardia (53% vs. 30%), or syncope (23% vs. 18%, p<.01). Patients receiving antiarrhythmic drugs were more likely to receive an ICD for secondary prevention (33% vs. 15%, P<.01). Amiodarone was the most commonly used (82%) followed by sotalol (10%) and class I agents (3%). Between 2006 and 2011, there was a modest increase in an...
Background: Semaglutide reduced 5-year rates of coronary revascularization by 23% in SELECT. The impact of broader adoption of glucagon-like peptide 1 (GLP-1) agonists on coronary stent use among elderly patients with cardiovascular (CV) disease is unclear. Methods: To project the impact of GLP-1 adoption on 5-year rates of coronary stent use, we analyzed claims data for the 5% random sample of fee-for-service Medicare and Medicare Advantage beneficiaries identified in 2016 (n=1,847,213). Patient risk for CV events was derived using the REGARDS study administrative CV risk algorithm. Five-year observed coronary stent use was based on treatment in 2017–21. The unadjusted association between derived CV event risk and observed stent use was modeled as a flexible linear spline. Projected impact of increased GLP-1 use on patients’ 5-year risk of stent use was calculated by applying SELECT estimates of coronary revascularization reduction (HR 0.77 95% CI 0.68–0.87) to patients’ REGARDS-derived CV event risk and estimating stent use at the GLP-1-driven reduced derived CV event risk level. We projected impact on 5-year stent use as GLP-1 use increased from 0% to 100% of beneficiaries under 4 CV risk-based adoption scenarios: highest CV risk first; lowest CV risk first; median CV risk patients first (base case); and random adoption. Results: Sixty percent adoption of GLP-1 (current statin use) by median CV risk patients first would reduce coronary stent use overall by 6.9% (95% CI 3.6%–9.8%). Impact varied by role of CV risk in GLP-1 adoption, with 60% use in highest CV risk patients first resulting in 21.5% (95% CI 14.3%–25.8%) reduction as opposed to 5.9% (95% CI 3.3%–8.3%) if driven by population with 60% lowest CV risk (Figure). Adoption by 25% highest CV risk would achieve 70% benefit of complete population use. Reductions varied more than two-fold across hospital referral regions (HRRs) in the base case, ranging from 4.5% (95% CI 2.4%–6.1%) to 9.2% (95% CI 4.7%–13.3%); the highest CV-risk-first approach impact ranged from 13.6% (95% CI 9.0%–16.8%) to 30.7% (95% CI 20.7%–35.6%). Conclusion: GLP-1 adoption by Medicare beneficiaries comparable to current statin use could reduce coronary stent use nationally by 6.9% if focused on median CV risk, but up to 21.5% if focused on highest CV risk patients first. Impact varies by HRR, with high GLP-1 use among highest CV risk patients reducing stent use as much as >30%.
Background— Current guidelines recommend >36 primary percutaneous coronary interventions (PCIs) per hospital per year. Whether these standards remain valid when routine coronary stenting and newer pharmacological agents are used is unclear. Methods and Results— We analyzed patients who underwent primary PCI from July 2006 through June 2009 included in the CathPCI Registry. Hospitals were separated into 3 groups: low (≤36 primary PCIs/y, current guideline recommendation), intermediate (>36–60 primary PCIs/y), and high volume (>60 primary PCIs/y). In-hospital mortality and door-to-balloon time were examined for each group. A total of 87 324 patient visits for 86 044 patients from 738 hospitals were included. There were 278 low- (38%), 236 (32%) intermediate-, and 224 (30%) high-volume hospitals. The majority of patients with primary PCI (54%) were treated at high-volume hospitals, with 15% at low-volume hospitals. Unadjusted mortality was significantly higher in low-volume hospitals compared with high-volume hospitals (5.6% versus 4.8%; P <0.001), which was maintained after multivariate adjustment (1.20; 95% confidence interval, 1.08–1.33; P =0.001). In contrast, mortality was not significantly different between intermediate-volume and high-volume hospitals (4.8% versus 4.8%; adjusted odds ratio, 1.02; 95% confidence interval, 0.94–1.11; P =0.61). Door-to-balloon times were significantly shorter in high-volume hospitals compared with low-volume hospitals (median, 72 minutes; interquartile range, [53–91] versus 77 [57–100] minutes; P <0.0001). Conclusions— Higher annual hospital volume of primary PCI continues to be associated with lower mortality, with higher mortality in hospitals performing ≤36 primary PCIs/y.
Background: Defibrillation testing is typically performed at the time of ICD implantation to establish effective arrhythmia termination. Despite technological advancements, including biphasic waveforms and higher output devices, an inadequate safety margin for defibrillation may still occur. The NCDR ICD Registry was examined to evaluate predictors of a high defibrillation requirement (DER) using modern day devices. Methods: Patients who underwent defibrillation testing in the NCDR ICD Registry were examined to determine characteristics associated with a high DER. This included 45,686 initial ICD implantation procedures from April 2010 to December 2010 performed at 1261 facilities. Patient characteristics were compared using chi-square tests for categorical variables and unbalanced t-tests for continuous variables. Multivariable logistic regression was used to assess independent predictors of a "high" DER, which was defined as >25 joules. Results: A high DER was noted in 4.1% of patients undergoing testing. Patients with a high DER were more often younger, male, on dialysis, and were more likely to have a higher NYHA functional class, lower LVEF, higher creatinine, and wider QRS. Patients on antiarrhythmic drugs and those with nonischemic heart disease were more likely to have a high DER. Independent predictors of a high DER included younger age, higher NYHA class, and increased QRS duration. A high DER was associated with longer post-procedure length of stay (1.6 ± 2.9 vs. 2.1 ± 3.8 days, p<0.001) as well as any complication or death prior to hospital discharge (2.6% vs. 4.0%, p<0.001). Conclusions: A high DER was observed in 4.1% of patients and was associated with more complications and mortality. Several clinical predictors of a high DER were identified, potentially enabling the identification of patients most likely to benefit from testing. Additional study is needed to determine if testing predicts long-term outcome of patients with modern day devices.
Background: The use of radial access for percutaneous coronary intervention (r-PCI) is associated with reduced risk of bleeding complications and higher patient satisfaction. However, the use of r-PCI differs greatly by country and is unknown in China. We examined trends in the adoption of r-PCI in China over the past decade and identified factors associated with its use. Methods: We used a two-stage random sampling strategy to create a nationally representative sample of 5,462 patients undergoing percutaneous coronary intervention (PCI) in China in 2001 (n=402; 24 sites), 2006 (n=1,390; 44 sites), and 2011 (n=3,670; 54 sites). We calculated the weighted proportion of patients receiving r-PCI in each time period and conducted multivariable analysis to identify the patient and hospital characteristics associated with not receiving r-PCI in 2011. Results: Among 5,462 patients who underwent PCI, the use of r-PCI increased markedly over time (2001: 3.4% [95% CI 0.0%-8.5%]; 2006: 36.5% [95% CI 34.2%-38.9%], 2011: 74.7% [95% CI 73.9-75.6]; P for trend <0.001). Increases in r-PCI use were widespread, including high-risk subgroups such as the elderly, women, and patients with acute coronary syndromes (Figure). In multivariable analysis of 3,670 patients undergoing PCI in 2011, cardiogenic shock and emergency PCI were strongly associated with failure to use r-PCI in 2011. Conclusion: Over a recent ten-year period, radial access became the predominant strategy for PCI in China, even among high-risk patients. This study demonstrates the responsiveness of the interventional cardiology community to emerging evidence. A deeper understanding of the factors facilitating r-PCI adoption in China may help increase its usage in countries in which r-PCI use remains low.
