Author + information
- Received June 12, 2017
- Revision received October 30, 2017
- Accepted December 5, 2017
- Published online February 19, 2018.
- Carolina Malta Hansen, MD, PhDa,∗ (, )
- Tracy Y. Wang, MD, MHS, MSca,
- Anita Y. Chen, MSa,
- Karen Chiswell, PhDa,
- Deepak L. Bhatt, MD, MPHb,
- Jonathan R. Enriquez, MDc,
- Timothy Henry, MDd and
- Matthew T. Roe, MD, MHSa
- aDuke Clinical Research Institute, Durham, North Carolina
- bBrigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
- cUniversity of Missouri-Kansas City, Kansas City, Missouri
- dCedars-Sinai Heart Institute, Los Angeles, California
- ↵∗Address for correspondence:
Dr. Carolina Malta Hansen, Duke Clinical Research Institute, 2400 Pratt Street, Durham, North Carolina 27705.
Objectives The study sought to characterize patient- and hospital-level variation in early angiography use among non–ST-segment elevation myocardial infarction (NSTEMI) patients.
Background Contemporary implementation of guideline recommendations for early angiography use in NSTEMI patients in the United States have not been described.
Methods The study analyzed NSTEMI patients included in ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry (2012 to 2014) who underwent in-hospital angiography. Timing of angiography was categorized as early (≤24 h) vs. delayed (>24 h). The study evaluated factors associated with early angiography, hospital-level variation in early angiography use, and the relationship with quality-of-care measures.
Results A total of 79,760 of 138,688 (57.5%) patients underwent early angiography. Factors most strongly associated with delayed angiography included weekend or holiday presentation, lower initial troponin ratio values, higher initial creatinine values, heart failure on presentation, and older age. Median hospital-level use of early angiography was 58.5% with wide variation across hospitals (21.7% to 100.0%). Patient characteristics did not differ substantially across hospitals grouped by tertiles of early angiography use (low, middle, and high). Hospitals in the highest tertile tended to more commonly use guideline-recommended medications and had higher defect-free care quality scores.
Conclusions In contemporary U.S. practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients; hospital-level use of early angiography varied widely despite few differences in case mix. Hospitals that most commonly utilized early angiography also had higher quality-of-care metrics, highlighting the need for improved NSTEMI guideline adherence.
This project was funded by the American College of Cardiology’s National Cardiovascular Data Registry. The views expressed in this manuscript represent those of the author(s), and do not necessarily represent the official views of the National Cardiovascular Data Registry or its associated professional societies identified at CVQuality.ACC.org/NCDR. The ACTION registry is an initiative of the American College of Cardiology and the American Heart Association, with partnering support from Society of Cardiovascular Patient Care, and the American College of Emergency Physicians. Dr. Malta Hansen has received research grants from TrygFonden, Helsefonden, and the Laerdal Foundation. Dr. Wang has received research funding from AstraZeneca, Gilead, Eli Lilly, The Medicines Company, Pfizer, Boston Scientific, Bristol-Myers Squibb, Daiichi Sankyo, Regeneron, and Canyon Pharmaceuticals; participated in educational activities or lectures (generating money for Duke) for AstraZeneca (modest); and served as a consultant for Medco (modest) and American College of Cardiology (significant). Dr. Bhatt has served on the advisory board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; has served on the Board of Directors of the Boston VA Research Institute and Society of Cardiovascular Patient Care; has served as the chair of American Heart Association Quality Oversight Committee; has served on the data monitoring committees of the Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; has received honoraria from the American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), J Am Coll Cardiol (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), and WebMD (CME steering committees); has served as the Deputy Editor for Clinical Cardiology; has served as the chair of the NCDR-ACTION Registry Steering Committee and VA CART Research and Publications Committee; has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Eli Lilly, Medtronic, Pfizer, Roche, Sanofi, and The Medicines Company; has received royalties from Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald Heart Disease); has served as a site co-investigator for Biotronik, Boston Scientific, and St. Jude Medical (now Abbott); has served as a trustee of American College of Cardiology; and has performed unfunded research for FlowCo, PLx Pharma, and Takeda. Dr. Roe has received research funding from Eli Lilly, Sanofi, Daiichi Sankyo, Janssen Pharmaceuticals, Ferring Pharmaceuticals, Myokardia, AstraZeneca, the American College of Cardiology, the American Heart Association, the Familial Hypercholesterolemia Foundation; and has served as a consultant for or received honoraria from PriMed, AstraZeneca, Boehringer Ingelheim, Merck, Actelion, Amgen, Myokardia, Eli Lilly, Novartis, Daiichi Sankyo, Quest Diagnostics, and Elsevier. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 12, 2017.
- Revision received October 30, 2017.
- Accepted December 5, 2017.
- 2018 American College of Cardiology Foundation