Publications

The International Tamoxifen Pharmacogenomics Consortium was established to address the controversy regarding cytochrome P450 2D6 (CYP2D6) status and clinical outcomes in tamoxifen therapy. We performed a meta-analysis on data from 4,973 tamoxifen-treated patients (12 globally distributed sites). Using strict eligibility requirements (postmenopausal women with estrogen receptor-positive breast cancer, receiving 20 mg/day tamoxifen for 5 years, criterion 1); CYP2D6 poor metabolizer status was associated with poorer invasive disease-free survival (IDFS: hazard ratio = 1.25; 95% confidence interval = 1.06, 1.47; P = 0.009). However, CYP2D6 status was not statistically significant when tamoxifen duration, menopausal status, and annual follow-up were not specified (criterion 2, n = 2,443; P = 0.25) or when no exclusions were applied (criterion 3, n = 4,935; P = 0.38). Although CYP2D6 is a strong predictor of IDFS using strict inclusion criteria, because the results are not robust to inclusion criteria (these were not defined a priori), prospective studies are necessary to fully establish the value of CYP2D6 genotyping in tamoxifen therapy.

Current guidelines advocate primary percutaneous coronary intervention as the therapy of choice for ST-segment elevation myocardial infarction (STEMI) when available. Little is known about the outcomes of patients without a culprit lesion after referral for primary percutaneous coronary intervention for a presumed STEMI. Subjects were identified within a registry containing consecutive patients who underwent emergent angiography for a potential STEMI from October 2008 to July 2012. Vital status was obtained from the medical record and Social Security Death Index. Cox proportional hazards models were created to evaluate the relation between the angiographic findings and cardiovascular outcomes, including major adverse cardiovascular events (MACE) and mortality. Among 539 patients who underwent emergent angiography, 65 (12%) had no coronary artery disease (CAD), 110 (20%) had CAD without a culprit lesion, and 364 (68%) had a culprit lesion. Kaplan-Meier analysis of MACE demonstrated that patients with CAD who lack a culprit lesion had a similar rate of MACE to those with a culprit lesion (p = 0.64), and both groups had significantly increased risk compared with those with no CAD (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.01 to 3.41 and HR 2.0, 95% CI 1.15 to 3.54, respectively). Kaplan-Meier analysis of mortality illustrated a nonsignificant trend toward increased mortality in patients having a culprit lesion (HR 1.7, 95% CI 0.59 to 4.80) and those having CAD without a culprit lesion (HR 1.2, 95% CI 0.39 to 3.81) compared with those with no CAD. In conclusion, patients found to have CAD without a culprit lesion in emergent angiography after a presumptive STEMI diagnosis have similar long-term rates of MACE compared with those requiring emergent revascularization.

BACKGROUND

Patients with low-risk chest pain are frequently readmitted for evaluation of recurrent chest pain. It is unknown whether stress testing during the first admission for chest pain is a cost-effective means of reducing readmissions.

METHODS

Using a hospital administrative database, we conducted a retrospective cohort study of patients aged ≥18 years admitted under "observation status" to Baystate Medical Center between January 2007 and July 2009 for chest pain without acute coronary syndrome. We compared subsequent emergency department (ED) visits, readmissions, and costs within 1 year for patients who had a stress test at index admission to those who did not, adjusting for age, gender, race, insurance, and comorbidities.

RESULTS

The cohort included 3315 patients. Most (n = 2376, 71.7%) had a stress test during the index admission. Within 1 year, 256 (7.7%) patients returned to the ED at least once with chest pain. Of these, 112 (43.8%) were admitted during their first return visit. In the multivariable model, return visits for chest pain were negatively associated with previous stress testing (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.5 to 0.9). Once in the ED, however, the risk of admission did not vary by stress test during index admission (OR: 0.8, 95% CI: 0.4 to 1.4). Overall costs, including index admission and follow-up visits for chest pain, were higher for patients with stress testing at index admission.

CONCLUSION

Inpatient stress testing reduced subsequent resource utilization in terms of ED visits and resultant readmissions, but the savings were not enough to offset the cost of initial testing.