Title: Delays in Filling Clopidogrel Prescription After Hospital Discharge and Adverse Outcomes After Drug-Eluting Stent Implantation: Implications for Transitions of Care
Topic: General Cardiology
Date Posted: 4/26/2010
Author(s): Ho PM, Tsai TT, Maddox TM, et al.
Citation: Circ Cardiovasc Qual Outcomes 2010;Apr 20:[Epub ahead of print].
Clinical Trial: No
Study Question: How do delays in filling clopidogrel prescriptions impact on outcomes after drug-eluting stent (DES) placement?
Methods: Data from three large integrated health care systems, from January 1, 2004 to December 20, 2007, were reviewed as part of the present analysis. The study population comprised patients who were discharged after DES placement. Information regarding clopidogrel prescriptions was obtained from pharmacy dispensing data. The primary endpoint of interest was all-cause mortality or myocardial infarction (MI), ascertained through April 2008.
Results: A total of 7,402 patients were included in the cohort, of which 1,210 (16%) did not fill their clopidogrel prescription on the day of discharge. The median time delay was 3 days (interquartile range, 1-23 days). Compared to patients who filled their clopidogrel prescription on the day of discharge, patients with any delay had higher rates of the primary endpoint (death or MI) during follow-up (14.2% vs. 7.9%, p < 0.001). In multivariate analysis, patients who had delays in filling clopidogrel prescriptions had an increased risk for death or MI (hazard ratio, 1.53; 95% confidence interval, 1.25-1.87). Similar risks were observed when different time delay periods were examined from greater than 1-day delay to greater than 5-day delay. Adverse outcomes occurred most frequently in the first 30 days after discharge. Additional factors associated with delay included older age, prior MI, diabetes, renal failure, prior revascularization, cardiogenic shock, in-hospital bleeding, and clopidogrel use within 24 hours of admission.
Conclusions: The authors concluded that a substantial number of patients delay filling clopidogrel prescriptions after DES implantation and that this delay is associated with increased risk for adverse outcomes including death and MI.
Perspective: These data support the need for early follow-up after discharge from the hospital. Patients who are seen shortly after discharge are more likely to adhere to cardiac medications. It is concerning that many of the factors associated with delay in clopidogrel prescriptions are also associated with increased risk for in-stent thrombosis. It would be prudent to make sure that such patients have early follow-up with their health care providers or support staff. Elizabeth A. Jackson, M.D., F.A.C.C.
Title: Transcatheter Valve-in-Valve Implantation for Failed Bioprosthetic Heart Valves
Topic: Cardiovascular Surgery
Date Posted: 4/26/2010
Author(s): Webb JG, Wood DA, Ye J, et al.
Citation: Circulation 2010;121:1848-1857.
Clinical Trial: No
Study Question: What is the role of transcatheter heart valve implantation within a failed bioprosthesis?
Methods: The investigators performed valve-in-valve implantations in 24 high-risk patients. Surgical reasons for determination of high risk included ≥2 prior thoracotomies in seven, severe pulmonary hypertension in seven, complex congenital cardiac disease in six, severe double-valve disease in five, hepatic cirrhosis in two, severe coronary disease in two, malignancy in one, and carcinoid syndrome in one patient. In addition, a subjective impression of frailty was documented by surgeons in seven elderly patients. Failed valves were aortic (n = 10), mitral (n = 7), pulmonary (n = 6), or tricuspid (n = 1) bioprostheses.
Results: The study investigators reported that implantation was successful, with immediate restoration of satisfactory valve function in all but one patient. No patient had more than mild regurgitation after implantation. No patients died during the procedure. Thirty-day mortality was 4.2%. Mortality was related primarily to learning-curve issues early in this high-risk experience. At baseline, 88% of patients were in New York Heart Association functional class III or IV; at the last follow-up, 88% of patients were in class I or II. At a median follow-up of 135 days (interquartile range, 46-254 days) and a maximum follow-up of 1,045 days, 91.7% of patients remained alive, with satisfactory valve function.
Conclusions: The authors concluded that transcatheter valve-in-valve implantation is a reproducible option for the management of bioprosthetic valve failure. Aortic, pulmonary, mitral, and tricuspid tissue valves were amenable to this approach.
Perspective: This is an important report about the utility of transcatheter valve-in-valve implantation for a failed bioprosthetic valve. Although the sample size is small, the encouraging results suggest that this approach may ultimately become the procedure of choice in valve replacement given the low perioperative risk accompanying this procedure. Large multicenter studies are needed to determine whether indeed this technique can be widely utilized. Ragavendra R. Baliga, M.B.B.S.