Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Access to catheterisation facilities in patients admitted with acute coronary syndromes
- Anthony A Bavry, Brian K Jefferson (19 February 2005)
-
Patient selection and periprocedural management.
- Richard G Fiddian-Green (25 February 2005)
-
Bariers to catheterisation
- Ann P Bowling, Clare Harries, Damien Forrest, Nigel Harvey (28 February 2005)
-
Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study
- Stephen J Leslie, James Spratt (1 March 2005)
-
Improper statistical explanation for surprising outcome in the GRACE-study of access to catheterisation facilities in patients admitted with ACS?
- Ulf Stenestrand (18 March 2005)
-
The Importance of Clinical Suspicion
- Richard Wray, Phil White and Hugh F McIntyre (7 October 2005)
|
|
|||
|
Anthony A Bavry, Fellow Cardiovascular Medicine Cleveland Clinic Foundation, Cleveland, OH 44195, Brian K Jefferson
Send response to journal:
|
Editor- Due to the presence of a large burden of evidence from recent prospective randomised clinical trials and several limitations of retrospective registry analysis the recent study by Van de Werf et al deserves further comment.1 We strongly feel that the conclusions from this study, which documents the incidence of adverse cardiac outcomes among acute coronary syndrome patients admitted to facilities with catheterisation facilities versus those without such facilities, should be tempered. The authors minimize the results of multiple randomised clinical trials that support an early invasive approach by stating that these studies rarely observed a reduction in mortality. Indeed, while the composite endpoint in these trials was largely influenced by a reduction in recurrent angina and the need for repeat revascularization, a systematic review of the data documented a long-term survival advantage from the use of early invasive therapy in unstable angina and non-ST- elevation myocardial infarction.2 Further, the authors attempted to control for confounding variables but their analysis was limited by the lack of the more clinically relevant data such as use of medications during the hospitalization including anti- platelet agents, beta-blockers, and anti-thrombotic agents. Additionally, many of the patients from this retrospective analysis were enrolled before the routine use of clopidogrel, glycoprotein IIb/IIIa inhibitors and drug- eluting stents which no doubt has contributed to the improved outcomes observed with an early invasive strategy. Given these limitations and the advantages demonstrated from early invasive therapy, we feel the present study overstates the benefits of directing acute coronary syndrome patients to the nearest hospital regardless of whether or not that facility has catheterization laboratories. Rather, given the evidence, we support the call to improve and expand the resources for routine direction of these patients to regional facilities with the specialized abilities to implement this management strategy. 1. Van de Werf F, Gore JM, Avezum A et al. Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ, doi: 10.1136/bmj.38335.390718.82. 2. Bavry AA, Kumbhani DJ, Quiroz R. Invasive therapy along with glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival in non-ST-segment elevation acute coronary syndromes: A meta- analysis and review of the literature. Am J Card 2004;93:830-5. Competing interests: None declared |
|||
|
|
|||
|
Richard G Fiddian-Green, None N/A
Send response to journal:
|
The failure to have demonstrated a significant benefit in outcome in this large study (1) might have been caused by a failure to have distinguished with consistent reliablity metabolically significant lesions from insignificant ones. In the gut we (2) and others (3,4) have found it impossible to make an accurate metabolic determination from the vascular anatomy alone especially when caused by an isolated celiac axis stenosis. Significant anatomically lesions might have been treated unnecessarily and insignificnt ones left untreated. The failure to have found any benefit might be more of an indictment of periprocedural cardiological management than of the procedures themselves. Compulsion in achieving the conventional hamodynamic goals of reversing hypotension and inceasing cardiac output and oxygen dispatch when considered inadequate together with prophylactic medications of uncertain metabolic benefit might have negated significant improvements in tissue energetics being achieved by endogenous means (5). It might even have contributed to the development of the complications of bleeding and strokes. Were there any significant differences in outcome at 7 and 30 days? Was using a pulmonary artery catheter for optimization an independent variable for outcome? 1. Frans Van de Werf, Joel M Gore, Álvaro Avezum, Dietrich C Gulba, Shaun G Goodman, Andrzej Budaj, David Brieger, Kami White, Keith A A Fox, Kim A Eagle, Brian M Kennelly for the GRACE Investigators Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study BMJ 2005; 330: 441 2. Chronic gastric ischemia. A cause of abdominal pain or bleeding identified from the presence of gastric mucosal acidosis. J Cardiovasc Surg (Torino). 1989 Sep-Oct;30(5):852-9. 3. Faries PL, Narula A, Veith FJ, Pomposelli FB Jr, Marsan BU, LoGerfo FW. The use of gastric tonometry in the assessment of celiac artery compression syndrome. Ann Vasc Surg. 2000 Jan;14(1):20-3. 4. van Wanroij JL, van Petersen AS, Huisman AB, Mensink PB, Gerrits DG, Kolkman JJ, Geelkerken RH. Endovascular treatment of chronic splanchnic syndrome. Eur J Vasc Endovasc Surg. 2004 Aug;28(2):193-200. 5 Fiddian-Green RG. Haemodynamic and/or tonometric monitoring in cardiac surgery. Br J Anaesth. 2000 Jan;84(1):128. Competing interests: Recipient of management in institutions with cccess to catheterisation facilities. |
|||
|
|
|||
|
Ann P Bowling, Professor of health services research University College London NW3 2PF, Clare Harries, Damien Forrest, Nigel Harvey
Send response to journal:
|
BMJ Rapid Response to; Frans Van de Werf, Joel M Gore, Álvaro Avezum, Dietrich C Gulba, Shaun G Goodman, Andrzej Budaj, David Brieger, Kami White, Keith A A Fox, Kim A Eagle, Brian M Kennelly for the GRACE Investigators Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study BMJ 2005; 330: 441 Van de Werf and colleagues (BMJ 2005; 330: 441) indicated, on the basis of their large multinational observational registry study, that the availability of a catheterisation laboratory is associated with more use of coronary intervention. They speculated that choice of management strategy is often governed by the facilities available at the hospital at which patients initially present. Results from our clinical judgement study in cardiology [1] support this. Seventy six cardiologists, care of the elderly physicians and general practitioners across England, who were interviewed after clinical decision making exercises (on a collective total of 6093 electronic patients), reported common barriers to their real life clinical decision making. The most common of these (mentioned by 53%) was poor access to equipment (from ECG, to exercise testing to catheterisation facilities). They also reported that this raised their thresholds for investigation and intervention. Limited, or lack of, availability of such equipment was said to lead to longer waiting times, and in turn to implicit rationing. The specialists who held both teaching and non-teaching hospital appointments were able to clearly distinguish between the type of care offered by site; as one said: '...lack of angio resources limits their use, as putting a patient on the (waiting) list clogs it for others. My patients are managed personally in different ways on different sites depending on resources - district general hospital patients with unstable angina don't get referred to (the) specialist centre due to bottle necks, in contrast to my own specialist site where they do get things done'. Regardless of the conclusions of Van de Werf et al's study, a rigorous investigation of equity of patient access to facilities and health outcomes is urgently required. 1. Harries C, Bowling, A., Forrest, D. and Harvey, N. How does a patient’s age affect physician decision making? Unpublished report. London: Department of Psychology, University College London, 2004. Ann Bowling Professor of health services research 1 Clare Harries Lecturer in Psychology 2 Damien Forrest Psychology Teaching Assistant and Doctoral Student 2 Nigel Harvey Professor of Psychology 2 1 Department of Primary Care and Population Sciences, University College London, London NW3 2PF 2 Department of Psychology, University College London, London WC1E 6BT Competing interests: None declared |
|||
|
|
|||
|
Stephen J Leslie, specialist registrar in cardiology Western General Hospital, Edinburgh, UK. EH4 2XU, James Spratt
Send response to journal:
|
Dear Sir Van der Wert and colleagues report data from the GRACE Registry and based on their findings support the current strategy of admitting patients with acute coronary syndromes as rapidly as possible to the nearest hospital irrespective of the availability of a catheterisation laboratory and argue against early routine transportation to a tertiary centre1. We feel that the data presented is limited and therefore their conclusions are flawed. As the authors acknowledge, early coronary intervention has a larger effect on improving symptoms, reducing recurrent admissions and coronary intervention2, than mortality. Thus, the use of ‘death’ as the main outcome measure in patients with acute coronary syndrome is misleading. Although the authors acknowledge and adjust the results, the baseline characteristics of the 2 population groups remain significantly different; those patients admitted to hospitals with interventional facilities were more likely to have had previous coronary interventions (both PCI & CABG) and more likely to be diabetic and therefore at higher baseline risk. In addition, an early invasive strategy allows the identification of patients with prognostically significant coronary artery disease who may gain benefit from surgical intervention. However, mortality benefits from coronary artery bypass surgery will not be apparent in the first 6 months following an acute event. Indeed, in the current paper CABG rates in the interventional centres were 7.1 vs 0.7%. How many of the patients denied an early intervention eventually underwent coronary angiography in the subsequent months, and in those who do not, how many with prognostically significant coronary artery disease were ultimately denied a surgical intervention through a lack of an angiogram? Furthermore, in a local review of clinical practice we found that patients eventually referred for coronary intervention from hospitals, with no on-site catheterisation laboratory, were treated conservatively for an average of 4 days before referral. Admission to a hospital with intervention cardiac facilities may therefore reduce hospital admission times with important resource and financial implications We believe that there are important issues beyond early mortality which should be considered when deciding which services to offer to patients with acute coronary syndromes. Yours sincerely 1 Van der Werf F, Gore JM, Avezum A, Gulba DC, Goodman G, Budaj A, et al. Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ 2005;330:441-4. 2 Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction the British Heart Foundation RITA-3 randomisation trial. Randomised intervention trial of unstable angina. Lancet 2002;360:743-51. Competing interests: None declared |
|||
|
|
|||
|
Ulf Stenestrand, Consultant invasive cardiologist Heart Center, University Hospital, SE-581 85 Linkoping, Sweden
Send response to journal:
|
Letter to the Editor of BMJ Regarding Access to catheterisation facilities in patients admitted with ACS; multinational registry study By Frans Van de Werf et al. BMJ 21 january 2005. The GRACE-registry article[1] had quite an impact in the daily press in Sweden and made headlines in several newspapers. A reason for this media attention might be that Sweden is moving from fibrinolysis towards primary PCI. This change of strategy is based on the previous meta-anlysis by Keeley et al[2] and also on the results from our neighbour country Denmark in the DANAMI-2 study.[3] Even though the GRACE-registry article does not say anything about primary PCI or fibrinolysis, Table 2 in the article leads several readers to interpret that there is no difference in outcome in STEMI patients irrespective of reperfusion therapy. However, if I have interpreted the article correctly the results only reflect whether the patients were treated at a hospital that had access to a catheterisation lab or not, and nothing about what therapy that actually was given. In Table 3 after adjustments by multiple logistic regression analysis a trend towards increased mortality is reported and major bleedings are significantly increased in the STEMI group treated at hospitals with access to a catheterisation lab. If the methods section is correctly written, there is a major problem with the multiple logistic regression analysis. Among the 15 variables included in the analyses were both percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG). This means that the authors have compensated for whether PCI or CABG was performed. In other words whatever effect is achieved by early revascularisation (good or bad) is compensated for, and what is really evaluated and compared are all other things that took place in hospitals with or without access to catheterisation lab. I wonder if this was the intention of the study? The way the study is presented I would be very hesitant to draw any clinical conclusions whether early revascularisation is beneficial or not in both STEMI and non-ST-segment elevation coronary syndrome patients. Personally I would have appreciated much more if the study population had been divided into what therapies the patients actually received, non- invasive or early revascularisation, rather than what type of hospital the patients were admitted to. An analysis based on given therapy has been reported previously on an unselected population with myocardial infarction, and showed significant reduction in 1-year mortality for those treated with early revascularisation.[4] The GRACE-registry has provided several excellent reports and registry studies are important complements to randomised trials as registries include all patients and reflect the routine care. However, it is most important that the statistics are performed with utterly correctness to give reliable conclusions. Sincerely, Ulf Stenestrand, MD, PhD, Consultant invasive cardiologist, Heart Center, University Hospital Linkoping, SE 581 85 Linkoping, Sweden Stenestrand@riks-hia.se References: 1. Van der Werf F, Gore J, Avezum A, et al. Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ. 2005;330:441-444. 2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13-20. 3. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349(8):733-742. 4. Stenestrand U, Wallentin L. Early revascularisation and 1-year survival in 14-day survivors of acute myocardial infarction: a prospective cohort study. Lancet. 2002;359(9320):1805-1811. Competing interests: None declared |
|||
|
|
|||
|
Richard Wray, Consultant Cardiologist Conquest Hospital, The Ridge, St Leonards on Sea, East Sussex, TN37 7RD, Phil White and Hugh F McIntyre
Send response to journal:
|
Dear Editor Serum troponin measurement has assumed such diagnostic importance from a medical, insurance and legal point of view that we thought it important to share a recent problem so others are aware of the difficulties that may arise.1 Clinical suspicion of an intermittent measurement fault led us to pursue this investigation. A number of patients admitted to hospital with a history suggestive of an Acute Coronary Syndrome were involved. Several cTnT results were reported as elevated on 5/5/05 but were normal when repeated 24h later. The original samples were re-assayed and shown to be normal. The error was sporadic as other cTnT samples gave the same result when repeated. Internal quality control (QC) results for cTnT on 5/5/05 were acceptable. During investigation of possible causes of the erroneous results it was noted that during the night of 4/5/05 the air-conditioning in the laboratory had failed and the room became extremely hot. The cTnT analyser does not have on-board reagent cooling and it was thought that the temperature increase lead to a gradual deterioration in the reagent during the following day. However similar events occurred during June. Once again the internal quality control results were acceptable. On these occasions there were no problems with room temperature. An engineer from the instrument supplier was called in on 2/6/05 and changed a valve on the sipper wash tower. Erratic results still occurred and an engineer re-visited on 7/6/05. This time he repaired a leaking wash tower, replaced the read-cell and a pressure sensor and realigned the sample probe. The latter (slight malalignment) may have been the problem. Since then there has been no recurrence of the erratic results. Lessons to be learned from this: Internal QC samples assayed 1 or 2 times per day are unlikely to detect faults leading to sporadic incorrect results. Running more frequent QC samples is costly as is running all samples in duplicate. Although the air-conditioning failure was a plausible explanation for the problem – it was a red herring. Authors:-
All at the Conquest Hospital, The Ridge, St Leonards-on-Sea, East Sussex, TN37 7RD 1 Frans Van de Werf, Joel M Gore, Álvaro Avezum, Dietrich C Gulba, Shaun G Goodman, Andrzej Budaj, David Brieger, Kami White, Keith A A Fox, Kim A Eagle, Brian M Kennelly for the GRACE Investigators Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study BMJ 2005; 330: 441 Competing interests: None declared |
|||