circulation2010-09-14

(Circulation. 2010;122:1056-1067.)
© 2010 American Heart Association, Inc.
Abstract 1 of 8
Coronary Heart Disease
Ticagrelor Versus Clopidogrel in Acute Coronary Syndromes in Relation to Renal Function
Results From the Platelet Inhibition and Patient Outcomes (PLATO) Trial
Stefan James, MD, PhD; Andrzej Budaj, MD, PhD; Philip Aylward, MD, PhD; Kristen K. Buck, MD; Christopher P. Cannon, MD; Jan H. Cornel, MD, PhD; Robert A. Harrington, MD; Jay Horrow, MD; Hugo Katus, MD, PhD; Matyas Keltai, MD, PhD; Basil S. Lewis, MD, PhD; Keyur Parikh, MD; Robert F. Storey, MD, PhD; Karolina Szummer, MD, PhD; Daniel Wojdyla, MSc; Lars Wallentin, MD, PhD
From the Uppsala Clinical Research Center, Uppsala, Sweden (S.J., L.W.); Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland (A.B.); Flinders Medical Centre, Bedford Park, Australia (P.A.); AstraZeneca Research and Development, Wilmington, Del (K.K.B., J.H.); TIMI Study Group, Brigham and Women’s Hospital, Boston, Mass (C.P.C.); Medisch Centrum Alkmaar, Alkmaar, the Netherlands (J.H.C.); Duke Clinical Research Institute, Durham, NC (R.A.H., D.W.); Universitätsklinikum Heidelberg, Germany (H.K.); Semmelweis University, Hungarian Institute of Cardiology, Budapest, Hungary (M.K.); Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.); The Heart Care Clinic, Ahmedabad, India (K.P.); University of Sheffield, Sheffield, UK (R.F.S.); and Karolinska University Hospital, Stockholm, Sweden (K.S.).
Correspondence to Stefan James, Uppsala Clinical Research Center, Uppsala University Hospital, 75185 Uppsala, Sweden. E-mail Stefan.james@ucr.uu.se
Received December 23, 2009; accepted June 30, 2010.
Background—Reduced renal function is associated with a poorer prognosis and increased bleeding risk in patients with acute coronary syndromes and may therefore alter the risk-benefit ratio with antiplatelet therapies. In the Platelet Inhibition and Patient Outcomes (PLATO) trial, ticagrelor compared with clopidogrel reduced the primary composite end point of cardiovascular death, myocardial infarction, and stroke at 12 months but with similar major bleeding rates.
Methods and Results—Central laboratory serum creatinine levels were available in 15 202 (81.9%) acute coronary syndrome patients at baseline, and creatinine clearance, estimated by the Cockcroft Gault equation, was calculated. In patients with chronic kidney disease (creatinine clearance <60 mL/min; n=3237), ticagrelor versus clopidogrel significantly reduced the primary end point to 17.3% from 22.0% (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.65 to 0.90) with an absolute risk reduction greater than that of patients with normal renal function (n=11 965): 7.9% versus 8.9% (HR, 0.90; 95% CI, 0.79 to 1.02). In patients with chronic kidney disease, ticagrelor reduced total mortality (10.0% versus 14.0%; HR, 0.72; 95% CI, 0.58 to 0.89). Major bleeding rates, fatal bleedings, and non–coronary bypass–related major bleedings were not significantly different between the 2 randomized groups (15.1% versus 14.3%; HR, 1.07; 95% CI, 0.88 to 1.30; 0.34% versus 0.77%; HR, 0.48; 95% CI, 0.15 to 1.54; and 8.5% versus 7.3%; HR, 1.28; 95% CI, 0.97 to 1.68). The interactions between creatinine clearance and randomized treatment on any of the outcome variables were nonsignificant.
Conclusions—In acute coronary syndrome patients with chronic kidney disease, ticagrelor compared with clopidogrel significantly reduces ischemic end points and mortality without a significant increase in major bleeding but with numerically more non–procedure-related bleeding.
Abstract 2 of 8
Imaging
Maladaptive Aortic Properties in Children After Palliation of Hypoplastic Left Heart Syndrome Assessed by Cardiovascular Magnetic Resonance Imaging
Inga Voges, MD; Michael Jerosch-Herold, PhD; Jürgen Hedderich, Dipl Inform; Charlotte Westphal, MD; Christopher Hart, MD; Michael Helle, Dipl Phys; Jens Scheewe, MD; Eileen Pardun; Hans-Heiner Kramer, MD; Carsten Rickers, MD
From the Department of Congenital Heart Disease and Pediatric Cardiology (I.V., C.W., C.H., M.H., E.P., H.H.-K., C.R.), Department of Cardiovascular Surgery (J.S.), and Department for Medical Informatics and Statistics (J.H.), University Hospital of Schleswig–Holstein, Kiel, Germany; and Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass (M.J.-H.).
Correspondence to Carsten Rickers, MD, Department of Pediatric Cardiology, University Hospital of Schleswig–Holstein, Campus Kiel, Arnold–Heller–Str 3, 24105 Kiel, Germany. E-mail rickers@pedcard.uni-kiel.de
Received December 9, 2009; accepted July 2, 2010.
Background—The status of the reconstructed aorta in hypoplastic left heart syndrome is considered an important determinant of long-term prognosis. Therefore, we assessed the anatomy, elastic properties, and viability of the aorta and right ventricular function in patients with hypoplastic left heart syndrome by cardiovascular magnetic resonance imaging.
Methods and Results—Cardiovascular magnetic resonance imaging was performed in 40 patients with hypoplastic left heart syndrome (age, 6.0±2.2 years) and 13 control subjects (age, 6.6±2.2 years). Aortic dimensions and distensibility were calculated at different locations of the aorta using gradient-echo cine imaging at 3.0 T. Additionally, pulse-wave velocity, right ventricular ejection fraction, and aortic late gadolinium enhancement for viability assessment were measured. Compared with control subjects, patients with hypoplastic left heart syndrome had increased axial diameters of the aortic root (36.0±5.5 versus 24.1±2.7 mm/m2; P<0.01), ascending aorta (32.0±5.0 versus 21.3±1.5 mm/m2; P<0.01), and transverse aortic arch (22.7±5.2 versus 18.7±2.5 mm/m2; P<0.01). Wall distensibility was reduced in the ascending aorta (4.1±2.4 versus 13.5±7.2 10–3 mm Hg–1; P<0.01) and transverse aortic arch (5.4±3.6 versus 10.3±3.5 10–3 mm Hg–1; P<0.01). Pulse-wave velocity trended higher in patients (P=0.06). Reduced distensibility in the ascending aorta correlated with the amount of late gadolinium enhancement in a volume that included the aortic root and the ascending aorta (r=–0.72, P<0.01), and both parameters correlated with decreased right ventricular ejection fraction.
Conclusions—Adverse aortic properties post palliation of hypoplastic left heart syndrome manifest themselves by aortic dilatation, decreased distensibility, and increased volume of nonviable aortic wall tissue. The negative association between aortic late gadolinium enhancement and right ventricular ejection fraction suggests unfavorable aortic-ventricular coupling. The potential impact of these findings on long-term right ventricular function should be evaluated in future studies.
Abstract 3 of 8
Interventional Cardiology
Incidence, Mechanisms, Predictors, and Clinical Impact of Acute and Late Stent Malapposition After Primary Intervention in Patients With Acute Myocardial Infarction
An Intravascular Ultrasound Substudy of the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) Trial
Ning Guo, MD, PhD; Akiko Maehara, MD; Gary S. Mintz, MD; Yong He, MD; Kai Xu, MD, PhD; Xiaofan Wu, MD, PhD; Alexandra J. Lansky, MD; Bernhard Witzenbichler, MD; Giulio Guagliumi, MD; Bruce Brodie, MD; Mirle A. Kellett, Jr, MD; Ovidiu Dressler, MD; Helen Parise, ScD; Roxana Mehran, MD; Gregg W. Stone, MD
From the Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (N.G., A.M., G.S.M., Y.H., K.X., X.W., A.J.L., O.D., H.P., R.M., G.W.S.); Charit University Medicine Campus Benjamin Franklin, Berlin, Germany (B.W.); Ospedali Riuniti di Bergamo, Bergamo, Italy (G.G.); LeBauer CV Research Foundation/Moses Cone Hospital, Greensboro, NC; and Maine Medical Center, Portland, Me (M.A.K.).
Correspondence to Akiko Maehara, MD, Cardiovascular Research Foundation, 111 E 59th St, New York, NY, 10022. E-mail amaehara@crf.org
Received August 31, 2009; accepted June 30, 2010.
Background—The incidence and mechanisms of acute and late stent malapposition after primary stent implantation in ST-segment elevation myocardial infarction remain unclear.
Methods and Results—The Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial was a dual-arm, factorial, randomized trial comparing paclitaxel-eluting stents (PES) and otherwise equivalent bare metal stents (BMS) in ST-segment elevation myocardial infarction patients. The intravascular ultrasound substudy enrolled 241 patients with 263 native coronary lesions (201 PES, 62 BMS) with baseline and 13-month follow-up imaging. Postintervention acute stent malapposition (ASM) occurred in 34.3% PES- and 40.3% BMS-treated lesions. Of these, 39.1% PES- and 40.0% BMS-treated lesions resolved at follow-up, especially within the stent body (66.7%); complete resolution was accompanied by a reduction in external elastic membrane area. An ASM area >1.2 mm2 best separated persistent from resolved ASM. At follow-up, a higher frequency of late stent malapposition was detected in PES-treated lesions (46.8%) mainly because of more late acquired stent malapposition (30.8%) compared with BMS-treated lesions. Late acquired stent malapposition area correlated to the decrease of peri-stent plaque in the subset of lesions without positive remodeling and only to change in external elastic membrane in the group with positive remodeling. Independent predictors of late acquired stent malapposition were plaque/thrombus protrusion (odds ratio, 5.60; 95% confidence interval [CI], 2.32 to 13.54) and PES use (odds ratio, 6.32; 95% CI, 2.15 to 18.62).
Conclusions—The incidence of ASM was similar in PES- and BMS-treated lesions, but late acquired stent malapposition was more common in PES-treated lesions. The reason for resolved ASM was negative remodeling, with larger ASM areas separating persistent from resolved ASM. Late acquired stent malapposition was due mainly to positive remodeling and plaque/thrombus resolution.
Abstract 4 of 8
Interventional Cardiology
Does Black Ethnicity Influence the Development of Stent Thrombosis in the Drug-Eluting Stent Era?
Sara D. Collins, MD; Rebecca Torguson, MPH; Michael A. Gaglia, Jr, MD, MSc; Gilles Lemesle, MD; Asmir I. Syed, MD; Itsik Ben-Dor, MD; Yanlin Li, MD; Gabriel Maluenda, MD; Kimberly Kaneshige, BS; Zhenyi Xue, MS; Kenneth M. Kent, MD, PhD; Augusto D. Pichard, MD; William O. Suddath, MD; Lowell F. Satler, MD; Ron Waksman, MD
From the Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC.
Correspondence to Ron Waksman, MD, Washington Hospital Center, 110 Irving St, NW, Ste 4B-1, Washington, DC 20010. E-mail ron.waksman@medstar.net
Received September 9, 2009; accepted June 21, 2010.
Background—It has been suggested that black race predicts stent thrombosis (ST) after drug-eluting stent implantation. Whether socioeconomic status or comorbid conditions confound the contribution of black race to the development of ST is unclear.
Methods and Results—We compared 1594 black patients who underwent drug-eluting stent implantation with 5642 nonblack patients. Overall, 108 definite STs were reported. Multivariable Cox regression analysis was performed with adjustment for comorbidities, including median household income as a marker of socioeconomic status, to assess the impact that black race may have on the development of ST. On univariable analysis, black patients were younger (63.43±12.42 versus 65.15±12.59 years; P<0.001) and more likely to have a history of hypertension (89.8% versus 81.7%; P<0.001), diabetes mellitus (45.5% versus 30.8%; P<0.001), chronic renal insufficiency (19.2% versus 10.7%; P<0.001), and congestive heart failure (18.7% versus 13.1%; P<0.001). Clopidogrel compliance at the time of the ST event was higher in the black than in the nonblack population (87.5% versus 77.8%; P=0.068). After multivariable analysis, including adjustment for median income and clopidogrel compliance, black race emerged as a strong predictor of definite late ST.
Conclusions—Black race is an independent predictor of definite drug-eluting stent ST. Because clopidogrel compliance was higher in black patients and socioeconomic status was not associated with ST, further investigation into the potential mechanisms of this influence of race on ST must be pursued.
Abstract 5 of 8
Interventional Cardiology
Late Outcomes After Carotid Artery Stenting Versus Carotid Endarterectomy
Insights From a Propensity-Matched Analysis of the Reduction of Atherothrombosis for Continued Health (REACH) Registry
Sripal Bangalore, MD, MHA; Deepak L. Bhatt, MD, MPH; Joachim Röther, MD; Mark J. Alberts, MD; Julie Thornton, MS; Kathy Wolski, MPH; Shinya Goto, MD; Alan T. Hirsch, MD; Sidney C. Smith, MD; Franz T. Aichner, MD; Raffi Topakian, MD; Christopher P. Cannon, MD; P. Gabriel Steg, MD, for the REACH Registry Investigators
From the The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY (S.B.); Brigham and Women’s Hospital, Boston, Mass (D.L.B.); Harvard Clinical Research Institute, Boston, Mass (S.B.); VA Boston Healthcare System, Boston, Mass (D.L.B.); Department of Neurology, Academic Teaching Hospital Hamburg Medical School, Asklepios Klinik Altona, Hamburg, Germany (J.R.); Northwestern University Feinberg School of Medicine, Chicago, Ill (M.J.A.); Cleveland Clinic, Cleveland, Ohio (J.T., K.W.); Tokai University School of Medicine, Isehara, Japan (S.G.); Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis (A.T.H.); Center for Cardiovascular Science and Medicine, University of North Carolina, Chapel Hill (S.C.S.); Academic Teaching Hospital Wagner-Jauregg, Linz, Austria (F.A., R.T.); TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass (C.P.C.); and INSERM U-698, Université Paris 7, AP-HP, Centre Hospitalier Bichat-Claude Bernard, Paris, France (P.G.S.).
Reprint requests to Deepak L. Bhatt, MD, MPH, Chief of Cardiology, VA Boston Healthcare System, Director, Integrated Interventional Cardiovascular Program, Brigham and Women’s Hospital and the VA Boston Healthcare System, Associate Professor of Medicine, Harvard Medical School, Senior Investigator, TIMI Study Group, 75 Francis St, PBB-146, Boston, MA 02115. E-mail dlbhat***@post.harvard.edu
Received December 19, 2009; accepted June 23, 2010.
Background—In patients with carotid artery disease, carotid endarterectomy (CEA) and carotid stenting (CAS) are treatment options. Controversy exists as to the relative efficacy of the 2 techniques in preventing late events.
Methods and Results—The Reduction of Atherothrombosis for Continued Health (REACH) Registry recruited >68 000 outpatients 45 years of age with established atherothrombotic disease or 3 risk factors for atherothrombosis. Patients with CAS or CEA were chosen and followed up prospectively for the occurrence of cardiovascular events. Propensity score matching was performed to assemble a cohort of patients in whom all baseline covariates would be well balanced. Primary outcome was defined as death or stroke at the 2-year follow-up. Secondary outcome was stroke or transient ischemic attack. Tertiary outcome was a composite of death, myocardial infarction, or stroke and the individual outcomes. Of the 68 236 patients with atherothrombosis, 3412 patients (5%) had a history of carotid artery revascularization (70% asymptomatic carotid stenosis), 1025 (30%) with CAS and 2387 (70%) with CEA. Propensity score analyses matched 836 CAS patients with 836 CEA patients. At the end of 2 years of follow-up, in the propensity score–matched cohort, CAS was associated with a risk similar to CEA for the primary (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.57 to 1.26), secondary (HR, 1.20; 95% CI, 0.73 to 1.96), and tertiary (HR, 0.72; 95% CI, 0.51 to 1.01) composite outcome, death (HR, 0.63; 95% CI, 0.40 to 1.00), and stroke (HR, 1.48; 95% CI, 0.79 to 2.80).
Conclusion—In a real-world cohort of patients with a history of carotid artery revascularization, CAS was comparable to CEA for late outcomes.
Abstract 6 of 8
Resuscitation Science
Time in Recurrent Ventricular Fibrillation and Survival After Out-of-Hospital Cardiac Arrest
Jocelyn Berdowski, MSc, MSE; Monique ten Haaf, MSc; Jan G.P. Tijssen, PhD; Fred W. Chapman, PhD; Rudolph W. Koster, MD, PhD
From the Academic Medical Center, University of Amsterdam, Department of Cardiology, Amsterdam, the Netherlands (J.B., M.t.H., J.G.P.T., R.W.K.), and Physio Control Inc, Redmond, Wash (F.W.C.).
Received April 1, 2010; accepted July 7, 2010.
Background—Current resuscitation guidelines (2005 guidelines [G2005]) accelerate ventricular fibrillation (VF) recurrence. We investigated whether patients resuscitated under G2005 spend more time in VF and have better survival rates than patients treated under the 2000 guidelines (G2000).
Methods and Results—We analyzed continuous ECG recordings of out-of-hospital cardiac arrests prospectively collected from January 2006 to January 2008. Patients treated according to G2000 (n=282) or G2005 (n=240) with VF as initial rhythm were included. We measured the total time a patient was in recurrent VF (the sum of all intervals from each onset of recurrent VF to each next successful shock) and the time a patient was in initial VF (time interval from rescuer arrival to first effective shock). The primary outcome measure was neurologically intact survival to discharge. The median time in recurrent VF was 2.7 minutes (quartile 1 to 3, 0.4 to 9.0 minutes) under G2000 versus 4.0 minutes (quartile 1 to 3, 0.2 to 11.6 minutes) under G2005 (P=0.03). Median time in initial VF was 2.7 minutes (quartile 1 to 3, 1.7 to 4.3 minutes) versus 3.9 minutes (quartile 1 to 3, 2.3 to 6.5 minutes), respectively (P<0.001). Increased time in recurrent VF was significantly associated with decreased neurologically intact survival in both G2000 use (odds ratio, 0.92; 95% confidence interval, 0.87 to 0.97; P=0.001) and G2005 use (odds ratio, 0.94; 95% confidence interval, 0.90 to 0.99; P=0.02). Neurologically intact survival decreased significantly with increasing time in initial VF under G2000 (odds ratio, 0.86; 95% confidence interval, 0.74 to 0.99; P=0.04). This observation was nonexistent in patients treated under G2005. Neurologically intact survival was 29% (82 of 282) under G2000 versus 27% (65 of 240) under G2005 (P=0.61).
Conclusions—With G2005, the time in recurrent VF remains associated with worse outcome. Studies of immediate defibrillation for recurrent VF are warranted.
Abstract 7 of 8
Valvular Heart Disease
Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema
David Attias, MD; Nicolas Mansencal, MD, PhD; Bertran Auvert, MD, PhD; Antoine Vieillard-Baron, MD, PhD; Aurélie Delos, MD; Pascal Lacombe, MD; Roland N'Guetta, MD; François Jardin, MD; Olivier Dubourg, MD
From the Department of Cardiology (D.A., N.M., A.D., R.N., O.D.), Intensive Care Unit (A.V.-B., F.J.), and Department of Radiology (P.L.), Université de Versailles–Saint Quentin, Ambroise Paré Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne, France; Centre de Référence pour les Maladies Cardiaques Héréditaires, Boulogne, France (N.M., O.D.); and Centre de Recherche en Epidémiologie et Santé des Populations, INSERM 1018, Villejuif, France, and Université de Versailles–Saint Quentin, Ambroise Paré Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne, France (B.A.).
Correspondence to David Attias, MD, AP-HP, Hôpital Universitaire Ambroise Paré, Service de Cardiologie et des Maladies Vasculaires, 9 Avenue Charles de Gaulle, 92100 Boulogne, France. E-mail david.attias@apr.aphp.fr
Received December 28, 2009; accepted July 12, 2010.
Background—Cardiogenic unilateral pulmonary edema (UPE) is a rare entity, frequently leading to initial misdiagnosis. We sought to assess the prevalence of UPE and to determine its impact on prognosis compared with bilateral pulmonary edema.
Methods and Results—We studied the characteristics and outcomes of patients admitted to our institution for cardiogenic pulmonary edema during an 8-year period. The study population included 869 consecutive patients. The prevalence of UPE was 2.1%: 16 right-sided UPE (89%) and 2 left-sided UPE (11%). In patients with UPE, blood pressure was significantly lower (P 0.01), whereas noninvasive or invasive ventilation and catecholamines were used more frequently (P=0.0004 and P<0.0001, respectively). The prevalence of severe mitral regurgitation in patients with bilateral pulmonary edema and UPE was 6% and 100%, respectively (P<0.0001). In patients with UPE, use of antibiotic therapy and delay in treatment were significantly higher (P<0.0001 and P=0.003, respectively). In-hospital mortality was 9%: 39% for UPE versus 8% for bilateral pulmonary edema (odds ratio, 6.9; 95% confidence interval, 2.6 to 18; P<0.001). In multivariate analysis, unilateral location of pulmonary edema was independently related to death whatever the model used (adjusted odds ratio, 6.5; 95% confidence interval, 1.3 to 32; P=0.021 for model A; and adjusted odds ratio, 6.8; 95% confidence interval, 1.1 to 41; P=0.037 for model B).
Conclusions—Unilateral pulmonary edema represented 2.1% of cardiogenic pulmonary edema in our study, usually appeared as an opacity involving the right lung, and was always associated with severe mitral regurgitation. Unilateral pulmonary edema is related to an independent increased risk of mortality and should be promptly recognized to avoid delays in treatment.
Abstract 8 of 8
Stroke
Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry
Get With The Guidelines-Stroke in Taiwan
Fang-I Hsieh, PhD*; Li-Ming Lien, MD*; Sien-Tsong Chen, MD; Chyi-Huey Bai, PhD; Mu-Chien Sun, MD, MSc; Hung-Pin Tseng, MD; Yu-Wei Chen, MD; Chih-Hung Chen, MD; Jiann-Shing Jeng, MD, PhD; Song-Yen Tsai, MD, MSc; Huey-Juan Lin, MD, MPH; Chung-Hsiang Liu, MD, MSc; Yuk-Keung Lo, MD; Han-Jung Chen, MD, PhD; Hou-Chang Chiu, MD; Ming-Liang Lai, MD; Ruey-Tay Lin, MD; Ming-Hui Sun, MD; Bak-Sau Yip, MD, PhD; Hung-Yi Chiou, PhD; Chung Y. Hsu, MD, PhD; the Taiwan Stroke Registry Investigators
From the School of Public Health and Dr. Chi-Chin Huang Stroke Research Center, Taipei Medical University, Taiwan (F.I.H., H.Y.C., C.H.B.); Neurology, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (L.M.L., H.C.C.); Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taiwan (L.M.L.); Neurology, Chang Gung University and Memorial Hospital, Linkou, Taiwan (S.T.C.); Central Laboratory, Shin Kong WHS Memorial Hospital, Taipei, Taiwan (C.H.B.); Neurology, Changhua Christian Hospital, Changhua, Taiwan (M.C.S.); Neurology, Lotung Poh Ai Hospital, Lotung, Taiwan (H.P.T.); Neurology, Landseed Hospital, Taoyuan, Taiwan (Y.W.C.); Neurology, National Taiwan University Hospital, Taipei (J.S.J., Y.W.C.); Neurology, National Cheng Kung University Hospital and National Cheng Kung University, Tainan, Taiwan (C.H.C., M.L.L.); Neurology, Changhua Christian Hospital Yunlin Branch, Yunlin, Taiwan (S.Y.T.); Neurology, Chi Mei Medical Center, Tainan, Taiwan (H.J.L.); Neurology, China Medical University Hospital, Taichung, Taiwan (C.H.L.); Neurology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan (Y.K.L.); Stroke Center, E Da Hospital, Kaohsiung, Taiwan (H.J.C.); Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan (R.T.L.); Neurology, Kuang Tien General Hospital, Taichung, Taiwan (M.H.S.); Neurology, DOH Hsinchu General Hospital, Hsinchu, Taiwan (B.S.Y.); Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan (C.Y.H.).
Correspondence to Hung-Yi Chiou, PhD, School of Public Health, Taipei Medical University, Taipei 11031, Taiwan (E-mail hychiou@tmu.edu.tw ); or Chung Y. Hsu, MD, PhD, Graduate Institute of Clinical Medical Science, China Medical University, Taichung, 40447, Taiwan (E-mail: hsuc@mail.cmu.edu.tw).
Received January 8, 2010; accepted July 15, 2010.
Background—Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. The Taiwan Stroke Registry, with 30 599 stroke admissions between 2006 and 2008, was used to assess the applicability of GWTG-Stroke in Taiwan, which spends 1/10 of what the United States does in medical costs per new or recurrent stroke.
Methods and Results—Taiwan Stroke Registry, sponsored by the Taiwan Department of Health, engages 39 academic and community hospitals and covers the entire country with 4 steps of quality control to ensure the reliability of entered data. Five GWTG-Stroke performance measures and 1 safety indicator are applicable to assess Taiwan Stroke Registry quality of stroke care. Demographic and outcome figures are comparable between GWTG-Stroke and Taiwan Stroke Registry. Two indicators (early and discharge antithrombotics) are close to GWTG-Stroke standards, while 3 other indicators (intravenous tissue plasminogen activator, anticoagulation for atrial fibrillation, lipid-lowering medication) and 1 safety indicator fall behind. Preliminary analysis shows that compliance with selected GWTG-Stroke guidelines is associated with better outcomes.
Conclusions—Results suggest that GWTG-Stroke performance measures, with modification for ethnic factors, can become global standards across national and economic boundaries for assessing and improving quality of stroke care and outcomes. GWTG-Stroke can be incorporated into ongoing stroke registries across nations.