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1.  Multivariate prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England 
Heart  2005;92(5):658-663.
Objective
To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry.
Setting
All NHS centres undertaking adult PCIs in north west England.
Methods
Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer‐Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling.
Main outcome measures
MACE, which were in‐hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents.
Results
Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable.
Conclusions
A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators.
doi:10.1136/hrt.2005.066415
PMCID: PMC1860907  PMID: 16159983
major adverse cardiac events; percutaneous coronary interventions; risk prediction
2.  Coronary steal induced by angiogenesis following bypass surgery 
Heart  2005;91(7):863.
doi:10.1136/hrt.2004.043471
PMCID: PMC1768979  PMID: 15958345
Images in cardiology
3.  One year comparison of costs of coronary surgery versus percutaneous coronary intervention in the stent or surgery trial 
Heart  2004;90(7):782-788.
Objectives: To compare initial and one year costs of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in the stent or surgery trial.
Design: Prospective, unblinded, randomised trial.
Setting: Multicentre study.
Patients: 988 patients with multivessel disease.
Interventions: CABG and stent assisted PCI.
Main outcome measures: Initial hospitalisation and one year follow up costs.
Results: At one year mortality was 2.5% in the PCI arm and 0.8% in the CABG arm (p  =  0.05). There was no difference in the composite of death or Q wave myocardial infarction (6.9% for PCI v 8.1% for CABG, p  =  0.49). There were more repeat revascularisations with PCI (17.2% v 4.2% for CABG). There was no significant difference in utility between arms at six months or at one year. Quality adjusted life years were similar 0.6938 for PCI v 0.6954 for PCI, Δ  =  0.00154, 95% confidence interval (CI) −0.0242 to 0.0273). Initial length of stay was longer with CABG (12.2 v 5.4 days with PCI, p < 0.0001) and initial hospitalisation costs were higher (£7321 v £3884 for PCI, Δ  =  £3437, 95% CI £3040 to £3848). At one year the cost difference narrowed but costs remained higher for CABG (£8905 v £6296 for PCI, Δ  =  £2609, 95% CI £1769 to £3314).
Conclusions: Over one year, CABG was more expensive and offered greater survival than PCI but little added benefit in terms of quality adjusted life years. The additional cost of CABG can be justified only if it offers continuing benefit at no further increase in cost relative to PCI over several years.
doi:10.1136/hrt.2003.015057
PMCID: PMC1768324  PMID: 15201249
coronary angioplasty; coronary bypass surgery; health care cost
4.  Observational research in the evidence based environment: eclipsed by the randomised controlled trial? 
Heart  2002;87(2):101-102.
PMCID: PMC1767005  PMID: 11796537
quality of life; randomised controlled trial; research methodology
5.  Post-stent management with a pneumatic groin compression device and self injected low molecular weight heparin. 
Heart  1996;75(6):588-590.
BACKGROUND: The benefits of intracoronary stent implantation are offset by an increased risk of complications at the arterial puncture site and a prolonged hospital stay. Much of this morbidity can be attributed to the generally perceived need to achieve systemic anticoagulation after stent implantation. AIM: To test a simplified protocol for post-stent management using the Femostop pneumatic groin compression device and low molecular weight (fractionated) heparin (LMWH) administered by subcutaneous injection. PATIENTS: A case series of 100 consecutive patients, with stable angina pectoris, undergoing coronary stenting for a suboptimal result after conventional balloon angioplasty. METHODS: All patients were managed with a new post-stent protocol using the Femostop pneumatic groin compression device and LMWH. The incidence of complications and the length of hospital stay were recorded. RESULTS: The clinical course was uncomplicated in 92 patients and their discharge from hospital was achieved on the first post-procedural day for 44 patients and on the second for the remaining 48. The rate of vascular or bleeding complications was 6%. CONCLUSIONS: LMWH administered by subcutaneous injection may provide a practical and effective alternative to the use of intravenous heparin when systemic anticoagulation is used after stent implantation.
PMCID: PMC484382  PMID: 8697162
6.  Coronary stenting in the management of myocardial ischaemia caused by muscle bridging. 
British Heart Journal  1995;74(1):90-92.
A man of 64 was admitted for the investigation of post infarction angina. He was found to have angiographically normal coronary arteries, except for the presence of a muscle bridge in the left anterior descending coronary artery, believed to be subtending the ischaemic area. He had sustained a completed myocardial infarction in this territory 8 months before with identical findings at coronary angiography. A coronary stent was implanted in the intramyocardial segment and the patient made a good recovery with no adverse events at follow up 6 months later.
PMCID: PMC483955  PMID: 7662465
7.  Prospective assessment of the value of a chest radiograph in the performance of diagnostic cardiac catheterisation in adults. 
British Heart Journal  1994;72(6):540-541.
OBJECTIVE--To assess the value of a chest radiograph in the performance of diagnostic cardiac catheterisation in adults. PATIENTS AND METHODS--340 consecutive diagnostic cardiac catheter procedures in adults at one institution. It is normal practice for primary operators to report the results of catheterisation using a graphical user interface database system. Data entry screens were modified to present a study questionnaire to assess the use made of the chest radiograph in the performance of the catheter procedure. SETTING--Tertiary referral cardiac centre. RESULTS--The chest radiograph was judged of value in only 12/340 procedures (4%). The radiograph influenced catheter selection in six procedures, the volume of injected radiographic contrast medium in five, and showed an abnormality important to the planning or conduct of the procedure in six procedures. A dual benefit was reported in five procedures. Utility of the radiograph was related to the pre-catheter diagnosis. It proved of value in only 2/283 (0.7%) procedures with a working diagnosis of ischaemic heart disease, influencing only catheter selection. Its utility was greater in congenital heart disease, contributing in 3/4 (75%) procedures, dilated cardiomyopathy in 2/6 (33%) procedures, and valvar heart disease in 4/35 (11.5%) procedures. CONCLUSIONS--In the performance of diagnostic cardiac catheterisation in adults access to a recent chest radiograph contributes little to the conduct of investigations performed for suspected ischaemic heart disease, but may be of greater value in congenital disease, valve abnormalities, and dilated cardiomyopathy.
PMCID: PMC1025639  PMID: 7857736
9.  Doctor on a mountaineering expedition. 
BMJ : British Medical Journal  1995;310(6989):1248-1252.
Doctors are welcome members on mountaineering expeditions to remote areas, but practical advice on how to prepare and what kit to take can be difficult to find. This article is a ragbag of useful advice on diverse topics. It explains the necessary preparation, provides tips for a healthy expedition, and summarises the common disorders encountered at high altitude. The comprehensive drug and equipment lists and first aid kit for climbers were used for the 1992 Everest in winter expedition. They are there to be sacrificed to personal preference and the experience and size of individual expeditions.
Images
PMCID: PMC2549621  PMID: 7767198

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