Blankenship, James C.

AbstractCardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex‐based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non‐Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non‐Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.

Percutaneous coronary interventions (PCI) may be performed during the same session as diagnostic catheterization (ad hoc PCI) or at a later session (delayed PCI). Randomized trials comparing these strategies have not been performed; cohort studies have not identified consistent differences in safety or efficacy between the two strategies. Ad hoc PCI has increased in prevalence over the past decade and is the default strategy for treating acute coronary syndromes. However, questions about its appropriateness for some patients with stable symptoms have been raised by the results of recent large trials comparing PCI to medical therapy or bypass surgery. Ad hoc PCI for stable ischemic heart disease requires preprocedural planning, and reassessment after diagnostic angiography must be performed to ensure its appropriateness. Patients may prefer ad hoc PCI because it is convenient. Payers may prefer ad hoc PCI because it is cost‐efficient. The majority of data confirm equivalent outcomes in ad hoc versus delayed PCI. However, there are some situations in which delayed PCI may be safer or yield better outcomes. This document reviews patient subsets and clinical situations in which one strategy is preferable over the other. © 2012 Wiley Periodicals, Inc.

Background— Clopidogrel and ticlopidine are structurally very similar. In patients with an allergic or hematologic adverse reaction to either one of these drugs, the likelihood that an allergic or hematologic adverse effect will develop to the other is unknown. It is also unknown whether a reaction to the second thienopyridine is likely to be life threatening. Methods and Results— Medical records from 2 academic institutions were reviewed to identify patients who had an allergic or hematologic adverse reaction to either of the 2 currently commercially available thienopyridines and who were subsequently prescribed the other thienopyridine. Patient demographics, details of the adverse reactions, and subsequent clinical course were reviewed. A total of 76 patients were identified with an allergic or hematologic adverse reaction to clopidogrel or ticlopidine who had also received the other thienopyridine. Fourteen (27%; 95% CI, 16 to 41) patients who had an allergic or hematologic adverse reactions to clopidogrel had a similar reaction to ticlopidine; none developed a life-threatening reaction. The most common reaction was a rash (93%). Conclusions— In patients with an allergic or hematologic adverse reaction to one thienopyridine, there seems to be an increased frequency of such reactions to the other thienopyridine. However, no patient had a life-threatening reaction after exposure to the alternative thienopyridine.