Absence of Flow-Limiting Coronary Artery
Disease Among Patients Undergoing
Emergent Cardiac Catheterization For ST
Segment Elevation Myocardial Infarction in
the National Cardiovascular Data Registry
CathPCI Registry: Implications for Primary
Angioplasty Programs
Kalon KL Ho, H Vernon Anderson, Richard E Shaw,
Lloyd W Klein, James H Beachy, Christopher P Cannon,
Harlan M Krumholz, Susan Fitzgerald,
Anthony Hermann, Kristi Mitchell, John Rumsfeld,
Ralph G Brindis, on behalf of
the National Cardiovascular Data Registry
Author Disclosure Information
The following relationships exist related to this
presentation:
• KKL Ho: none
• HV Anderson: none
• RE Shaw: none
• LW Klein: none
• JH Beachy: none
• HM Krumholz: none
• A Hermann: none
• S Fitzgerald: none
• K Mitchell: none
• J Rumsfeld: none
• RG Brindis: none
• CP Cannon: significant research grants from Accumetrics,
AstraZeneca, Bristol-Myers Squibb, Glaxo Smith Kline,
Merck, Sanofi-Aventis, Schering Plough
Background
• Many hospitals have established primary
angioplasty programs with a goal of providing
consistently timely reperfusion for patients with
suspected acute ST segment elevation myocardial
infarction (STEMI).
• As the locus of control for activation of the cardiac
catheterization laboratory (CCL) moves from the
cardiologist to the emergency department (ED) and
even to pre-hospital activation by emergency
medical services, concerns have been raised about
“false positive” activations of the primary angioplasty
team.
Objective
• Estimate how often flow-limiting coronary
artery disease (CAD) was NOT found among
patients undergoing emergent cardiac
catheterization for presumed STEMI in the
National Cardiovascular Data Registry (NCDR)
CathPCI Registry, a large multi-center cardiac
catheterization and percutaneous coronary
intervention (PCI) quality improvement and
outcomes database.
Study Population
• From 01 January 2005 – 31 December 2006
–120,676 diagnostic coronary angiograms
–614 hospitals
• Procedural status coded as
–Emergent
• Ongoing ischemic dysfunction, or
• Cardiogenic shock
–Salvage
• CPR en route
Study Population
• Since the results of the angiogram (e.g., no
CAD) can be used to determine retrospectively
that STEMI was not the indication for the
procedure, we did NOT use the admission
symptom presentation to identify cases of
suspected STEMI.
Results
• Procedural status:
98.7% emergent
1.3% salvage
• Angiographic results:
91.9% CAD*
8.1% no CAD*
4.9% no stenoses
* CAD: 50% diameter stenosis in an epicardial
coronary artery >2 mm in diameter
Correlates of No CAD
• Age: no CAD median 54 yrs; CAD median 61 yrs
• Sex:
Men
6.6% no CAD
Women
11.4% no CAD
• Cardiogenic shock: Present
4.7% no CAD
Absent
7.6% no CAD
• Race:
Caucasian 7.3% no CAD
All others 11.7% no CAD
• Admission Source: Outpatient 11.9% no CAD
ED
7.8% no CAD
Transfer
6.1% no CAD
from acute care facility
Effect of Thrombolytic Therapy
• Angiographic results:
Thrombolytics given (7.8% of cases)
97.4% CAD*
2.6% no CAD*
1.4% no stenoses
No thrombolytics given
92.4% CAD*
7.6% no CAD*
4.6% no stenoses
* CAD: 50% diameter stenosis in an epicardial
coronary artery >2 mm in diameter
Outcomes
• Revascularization
Patients with CAD
Patients without CAD
• In-hospital Mortality
Patients with CAD
Patients with no CAD
82.9% ad hoc PCI
9.6% CABG
4.4% ad hoc PCI
0.7% CABG
6.0%
4.9%
Limitations
• Self-reported data without 100% auditing
• Information not uniformly available on suspected
STEMI as a specific indication for angiography
and other clinical details (e.g., the extent or
location of electrocardiographic abnormalities,
biomarker results, cocaine use, left ventricular
hypertrophy, and the final clinical diagnoses)
• The presence of CAD with 50% diameter
stenosis does not mean that the patient was
necessarily suffering a STEMI
Conclusions
• Among patients undergoing emergent or salvage
diagnostic cardiac catheterization nationwide in the
NCDR CathPCI Registry (>120,000 cases):
– Finding NO angiographically-apparent
flow-limiting CAD was uncommon (<10%).
• No clinical finding or test will perfectly discriminate
STEMI from “STEMI mimics”
– Current clinical practice appears to activate
primary PCI teams with reasonable specificity.
Acknowledgements
The authors wish to acknowledge the invaluable
contributions of
• The participants of the CathPCI Registry
• The analytical team at the Duke Clinical
Research Institute (Fang-Shu Ou, Barbara Lytle,
Matthew Roe)