Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure in Patients With Reduced Ejection Fraction and Coronary Artery Disease: A Meta-Analysis.

PubMed

Wolff, Georg; Dimitroulis, Dimitrios; Andreotti, Felicita; Kołodziejczak, Michalina; Jung, Christian; Scicchitano, Pietro; Devito, Fiorella; Zito, Annapaola; Occhipinti, Michele; Castiglioni, Battistina; Calveri, Giuseppe; Maisano, Francesco; Ciccone, Marco M; De Servi, Stefano; Navarese, Eliano P

2017-01-01

Heart failure with reduced ejection fraction caused by ischemic heart disease is associated with increased morbidity and mortality. It remains unclear whether revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) carries benefits or risks in this group of stable patients compared with medical treatment. We performed a meta-analysis of available studies comparing different methods of revascularization (PCI or CABG) against each other or medical treatment in patients with coronary artery disease and left ventricular ejection fraction ≤40%. The primary outcome was all-cause mortality; myocardial infarction, revascularization, and stroke were also analyzed. Twenty-one studies involving a total of 16 191 patients were included. Compared with medical treatment, there was a significant mortality reduction with CABG (hazard ratio, 0.66; 95% confidence interval, 0.61-0.72; P<0.001) and PCI (hazard ratio, 0.73; 95% confidence interval, 0.62-0.85; P<0.001). When compared with PCI, CABG still showed a survival benefit (hazard ratio, 0.82; 95% confidence interval, 0.75-0.90; P<0.001). The present meta-analysis indicates that revascularization strategies are superior to medical treatment in improving survival in patients with ischemic heart disease and reduced ejection fraction. Between the 2 revascularization strategies, CABG seems more favorable compared with PCI in this particular clinical setting. © 2017 American Heart Association, Inc.

Surgical versus percutaneous revascularization for multivessel disease in patients with acute coronary syndromes: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.

PubMed

Ben-Gal, Yanai; Moses, Jeffrey W; Mehran, Roxana; Lansky, Alexandra J; Weisz, Giora; Nikolsky, Eugenia; Argenziano, Michael; Williams, Matthew R; Colombo, Antonio; Aylward, Philip E; Stone, Gregg W

2010-10-01

The aim of this study was to evaluate outcomes of patients with moderate- and high-risk acute coronary syndromes (ACS) and multivessel coronary artery disease managed with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). There is uncertainty about the preferred revascularization strategy for high-risk patients with multivessel disease. Among 13,819 moderate- and high-risk ACS patients enrolled in the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 5,627 had multivessel disease (including left anterior descending artery involvement) and were managed by PCI (n = 4,412) or CABG (n = 1,215). Propensity score matching was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 1,056 patients (528 managed by PCI, and 528 managed by CABG). Propensity-matched patients undergoing CABG had higher 1-month rates of stroke (1.1% vs. 0.0%, p = 0.03) and myocardial infarction (13.3% vs. 8.8%, p = 0.03), received more blood transfusions (40.3% vs. 6.3%, p < 0.0001) and more frequently developed acute renal injury (31.7% vs. 14.2%, p < 0.0001), whereas PCI was associated with higher rates of unplanned revascularization at both 1 month and at 1 year (0.8% vs. 5.2%, p < 0.0001; and 3.8% vs. 16.5%, p < 0.0001, respectively). There were no significant differences between the CABG and PCI groups in 1-month or 1-year mortality (2.5% vs. 2.1%, p = 0.69; and 4.4% vs. 5.7%, p = 0.58, respectively). In this propensity-matched comparison from the ACUITY trial, moderate- and high-risk patients with ACS and multivessel disease treated with PCI rather than CABG had lower rates of peri-procedural stroke, myocardial infarction, major bleeding, and renal injury, with comparable 1-month and 1-year rates of mortality, but more frequently developed recurrent ischemia requiring repeat revascularization procedures during follow-up. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158). Copyright © 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

A comparison of outcomes with coronary artery calcium scanning in unselected populations: the Multi-Ethnic Study of Atherosclerosis (MESA) and Heinz Nixdorf RECALL study (HNR).

PubMed

Budoff, Matthew J; Möhlenkamp, Stefan; McClelland, Robyn; Delaney, Joseph A; Bauer, Marcus; Jöckel, Heinz Karl; Kälsch, Hagen; Kronmal, Richard; Nasir, Khurram; Lehmann, Nils; Moebus, Susanne; Mukamal, Ken; Erbel, Raimund

2013-01-01

The Multi-Ethnic Study of Atherosclerosis (MESA) and the Heinz Nixdorf RECALL (Risk factors, Evaluation of Coronary Calcium and Lifestyle Factors) study (HNR) differed in regard to informing physicians and patients of the results of their subclinical atherosclerosis. This study investigates whether the association of the presence of coronary calcium with incident nonfatal and fatal cardiovascular events is different among these 2 large, population-based observational studies. All white subjects aged 45 to 75 years, free of baseline cardiovascular disease were included (n = 2232 in MESA; n = 3119 HNR participants). We studied the association between coronary calcium and event rates at 5 years, including hard cardiac events (myocardial infarction, cardiac death, resuscitated cardiac arrest), and separately added revascularizations and strokes (fatal and nonfatal) to determine adjusted hazard ratios. Both cohorts showed low coronary heart disease (including revascularization) rates with zero coronary calcium (1.13% and 1.16% over 5 years in MESA and HNR, respectively) and increasing significantly in both groups with Agatston score 100 to 399 (6.71% and 4.52% in MESA and HNR, respectively) and Agatston score > 400 (12.5% and 13.54% in MESA and HNR, respectively) and showing strong independent predictive values for Agatston scores of 100 to 399 and >400, despite multivariable adjustment for risk factors. Risk factor-adjusted 5-year revascularization rates were nearly identical for HNR and MESA and were generally low for both studies (1.4% [45 of 3119] for HNR and 1.9% [43 of 2232] for MESA) over 5 years. Across 2 culturally diverse populations, Agatston score >400 is a strong predictor of events. High Agatston score did not statistically result in revascularization, and knowledge of the presence of coronary calcium did not increase revascularizations. Copyright © 2013 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Single-Staged Compared With Multi-Staged PCI in Multivessel NSTEMI Patients: The SMILE Trial.

PubMed

Sardella, Gennaro; Lucisano, Luigi; Garbo, Roberto; Pennacchi, Mauro; Cavallo, Erika; Stio, Rocco Edoardo; Calcagno, Simone; Ugo, Fabrizio; Boccuzzi, Giacomo; Fedele, Francesco; Mancone, Massimo

2016-01-26

A lack of clarity exists about the role of complete coronary revascularization in patients presenting with non-ST-segment elevation myocardial infarction. The aim of our study was to compare long-term outcomes in terms of major adverse cardiovascular and cerebrovascular events of 2 different complete coronary revascularization strategies in patients with non-ST-segment elevation myocardial infarction and multivessel coronary artery disease: 1-stage percutaneous coronary intervention (1S-PCI) during the index procedure versus multistage percutaneous coronary intervention (MS-PCI) complete coronary revascularization during the index hospitalization. In the SMILE (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction Patients: One Stage Versus Multistaged Percutaneous Coronary Intervention) trial, 584 patients were randomly assigned in a 1:1 manner to 1S-PCI or MS-PCI. The primary study endpoint was the incidence of major adverse cardiovascular and cerebrovascular events, which were defined as cardiac death, death, reinfarction, rehospitalization for unstable angina, repeat coronary revascularization (target vessel revascularization), and stroke at 1 year. The occurrence of the primary endpoint was significantly lower in the 1-stage group (1S-PCI: n = 36 [13.63%] vs. MS-PCI: n = 61 [23.19%]; hazard ratio [HR]: 0.549 [95% confidence interval (CI): 0.363 to 0.828]; p = 0.004). The 1-year rate of target vessel revascularization was significantly higher in the MS-PCI group (1S-PCI: n = 22 [8.33%] vs. MS-PCI: n = 40 [15.20%]; HR: 0.522 [95% CI: 0.310 to 0.878]; p = 0.01; p log-rank = 0.013). When the analyses were limited to cardiac death (1S-PCI: n = 9 [3.41%] vs. MS-PCI: n = 14 [5.32%]; HR: 0.624 [95% CI: 0.270 to 1.441]; p = 0.27) and myocardial infarction (1S-PCI: n = 7 [2.65%] vs. MS-PCI: n = 10 [3.80%]; HR: 0.678 [95% CI: 0.156 to 2.657]; p = 0.46), no significant differences were observed between groups. In multivessel non-ST-segment elevation myocardial infarction patients, complete 1-stage coronary revascularization is superior to multistage PCI in terms of major adverse cardiovascular and cerebrovascular events. (Impact of Different Treatment in Multivessel Non ST Elevation Myocardial Infarction [NSTEMI] One Stage Versus Multistaged Percutaneous Coronary Intervention [PCI] [SMILE]: NCT01478984). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Coronary artery bypass surgery compared with percutaneous coronary interventions in patients with insulin-treated type 2 diabetes mellitus: a systematic review and meta-analysis of 6 randomized controlled trials.

PubMed

Bundhun, Pravesh Kumar; Wu, Zi Jia; Chen, Meng-Hua

2016-01-06

Data regarding the long-term clinical outcomes in patients with insulin-treated type 2 diabetes mellitus (ITDM) revascularized by either coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) are still controversial. We sought to compare the long-term (≥1 year) adverse clinical outcomes in patients with ITDM who underwent revascularization by either CABG or PCI. Randomized Controlled Trials (RCTs) comparing the long-term clinical outcomes in patients with ITDM and non-ITDM revascularized by either CABG or PCI were searched from electronic databases. Data for patients with ITDM were carefully retrieved. Odd Ratio (OR) with 95 % confidence interval (CI) was used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3. Six RCTs involving 10 studies, with a total of 1297 patients with ITDM were analyzed (639 patients from the CABG group and 658 patients from the PCI group). CABG was associated with a significantly lower mortality rate compared to PCI with OR: 0.59, 95 % CI 0.42-0.85; P = 0.004. Major adverse cardiovascular and cerebrovascular events as well as repeated revascularization were also significantly lower in the CABG group with OR: 0.51, 95 % CI 0.27-0.99; P = 0.03 and OR 0.34, 95 % CI 0.24-0.49; P < 0.00001 respectively. However, compared to PCI, the rate of stroke was higher in the CABG group with OR: 1.41, 95 % CI 0.64-3.09; P = 0.40, but this result was not statistically significant. CABG was associated with significantly lower long-term adverse clinical outcomes compared to PCI in patients with ITDM. However, due to an insignificantly higher rate of stroke in the CABG group, further researches with a larger number of randomized patients are required to completely solve this issue.

Troponin and Cardiac Events in Stable Ischemic Heart Disease and Diabetes.

PubMed

Everett, Brendan M; Brooks, Maria Mori; Vlachos, Helen E A; Chaitman, Bernard R; Frye, Robert L; Bhatt, Deepak L

2015-08-13

Cardiac troponin concentrations are used to identify patients who would benefit from urgent revascularization for acute coronary syndromes. We hypothesized that they might be used in patients with stable ischemic heart disease to identify those at high risk for cardiovascular events who might also benefit from prompt coronary revascularization. We measured the cardiac troponin T concentration at baseline with a high-sensitivity assay in 2285 patients who had both type 2 diabetes and stable ischemic heart disease and were enrolled in the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes trial. We tested for an association between the troponin T concentration and a composite end point of death from cardiovascular causes, myocardial infarction, or stroke; we then evaluated whether random assignment to prompt revascularization reduced the rate of the composite end point in patients with an abnormal troponin T concentration (≥14 ng per liter) as compared with those with a normal troponin T concentration (<14 ng per liter). Of the 2285 patients, 2277 (99.6%) had detectable (≥3 ng per liter) troponin T concentrations and 897 (39.3%) had abnormal troponin T concentrations at baseline. The 5-year rate of the composite end point was 27.1% among the patients who had had abnormal troponin T concentrations at baseline, as compared with 12.9% among those who had had normal baseline troponin T concentrations. In models that were adjusted for cardiovascular risk factors, severity of diabetes, electrocardiographic abnormalities, and coronary anatomy, the hazard ratio for the composite end point among patients with abnormal troponin T concentrations was 1.85 (95% confidence interval [CI], 1.48 to 2.32; P<0.001). Among patients with abnormal troponin T concentrations, random assignment to prompt revascularization, as compared with medical therapy alone, did not result in a significant reduction in the rate of the composite end point (hazard ratio, 0.96; 95% CI, 0.74 to 1.25). The cardiac troponin T concentration was an independent predictor of death from cardiovascular causes, myocardial infarction, or stroke in patients who had both type 2 diabetes and stable ischemic heart disease. An abnormal troponin T value of 14 ng per liter or higher did not identify a subgroup of patients who benefited from random assignment to prompt coronary revascularization. (Funded by the National Institutes of Health and Roche Diagnostics; BARI 2D ClinicalTrials.gov number, NCT00006305.).

Cardiovascular Disease Outcomes Among the NASA Astronaut Corps

NASA Technical Reports Server (NTRS)

Charvat, Jacqueline M.; Lee, Stuart M. C.; Wear, Mary L.; Stenger, Michael B.; Van Baalen, Mary

2018-01-01

BACKGROUND: Acute effects of spaceflight on the cardiovascular system have been studied extensively, but the combined chronic effects of spaceflight and aging are not well understood. Preparation for and participation in spaceflight activities are associated with changes in the cardiovascular system such as decreased carotid artery distensibility and decreased ventricular mass which may lead to an increased risk of cardiovascular disease. Additionally, astronauts who travel into space multiple times or for longer durations may be at an increased risk across their lifespan. To that end, the purpose of this study was to determine the incidence of common cardiovascular disease (CVD) outcomes among the NASA astronaut corps during their active career and through retirement. METHODS: Cardiovascular disease outcomes were defined as reports of any of the following: myocardial infarction (MI), revascularization procedures (coronary artery bypass graft surgery [CABG] or percutaneous coronary intervention [PCI]), hypertension, stroke or transient ischemic attack [TIA], heart failure, or total CVD (as defined by the AHA - combined outcome of MI, Angina Pectoris, heart failure, stroke, and hypertension). Each outcome was identified individually from review of NASA's Electronic Medical Record (EMR), EKG reports, and death certificates using ICD-9 codes as well as string searches of physician notes of astronaut exams that occurred between 1959 and 2016. RESULTS: Of 338 NASA astronauts selected as of 2016, 9 reported an MI, 12 reported a revascularization procedure, (7 PCI and 5 CABG), 4 reported Angina (without MI), 5 reported heart failure, 9 reported stroke/TIA, and 96 reported hypertension. Total CVD was reported in 105 astronauts. No astronaut who had an MI or revascularization procedure flew a spaceflight mission following the event. All MI, revascularization, and stroke events occurred in male astronauts. When reviewing astronaut ECG reports, abnormal ECG reports were found in only 8% of records (n=430) and mainly among retired astronauts (82%), with marked sinus bradycardia being the reason for the abnormal classification.

New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease: The EXCEL Trial.

PubMed

Kosmidou, Ioanna; Chen, Shmuel; Kappetein, A Pieter; Serruys, Patrick W; Gersh, Bernard J; Puskas, John D; Kandzari, David E; Taggart, David P; Morice, Marie-Claude; Buszman, Paweł E; Bochenek, Andrzej; Schampaert, Erick; Pagé, Pierre; Sabik, Joseph F; McAndrew, Thomas; Redfors, Björn; Ben-Yehuda, Ori; Stone, Gregg W

2018-02-20

There is limited information on the incidence and prognostic impact of new-onset atrial fibrillation (NOAF) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD). This study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes. In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. Outcomes were analyzed according to the development of NOAF during the initial hospitalization following revascularization. Among 1,812 patients without atrial fibrillation on presentation, NOAF developed at a mean of 2.7 ± 2.5 days after revascularization in 162 patients (8.9%), including 161 of 893 (18.0%) CABG-treated patients and 1 of 919 (0.1%) PCI-treated patients (p < 0.0001). Older age, greater body mass index, and reduced left ventricular ejection fraction were independent predictors of NOAF in patients undergoing CABG. Patients with versus without NOAF had a significantly longer duration of hospitalization, were more likely to be discharged on anticoagulant therapy, and had an increased 30-day rate of Thrombolysis In Myocardial Infarction major or minor bleeding (14.2% vs. 5.5%; p < 0.0001). By multivariable analysis, NOAF after CABG was an independent predictor of 3-year stroke (6.6% vs. 2.4%; adjusted hazard ratio [HR]: 4.19; 95% confidence interval [CI]: 1.74 to 10.11; p = 0.001), death (11.4% vs. 4.3%; adjusted HR: 3.02; 95% CI: 1.60 to 5.70; p = 0.0006), and the primary composite endpoint of death, MI, or stroke (22.6% vs. 12.8%; adjusted HR: 2.13; 95% CI: 1.39 to 3.25; p = 0.0004). In patients with LMCAD undergoing revascularization in the EXCEL trial, NOAF was common after CABG but extremely rare after PCI. The development of NOAF was strongly associated with subsequent death and stroke in CABG-treated patients. Further studies are warranted to determine whether prophylactic strategies to prevent or treat atrial fibrillation may improve prognosis in patients with LMCAD who are undergoing CABG. (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776). Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

78 FR 76307 - Cardiovascular and Renal Drugs Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-17

...] Cardiovascular and Renal Drugs Advisory Committee; Notice of Meeting AGENCY: Food and Drug Administration, HHS...: Cardiovascular and Renal Drugs Advisory Committee. General Function of the Committee: To provide advice and... combined endpoint of cardiovascular death, MI, stroke, and urgent coronary revascularization. FDA intends...

Heart failure with preserved ejection fraction: comparison of patients with and without angina pectoris (from the Duke Databank for Cardiovascular Disease).

PubMed

Mentz, Robert J; Broderick, Samuel; Shaw, Linda K; Fiuzat, Mona; O'Connor, Christopher M

2014-01-28

This study investigated the characteristics and outcomes of patients with heart failure with preserved ejection fraction (HFpEF) and angina pectoris (AP). AP is a predictor of adverse events in patients with heart failure with reduced EF. The implications of AP in HFpEF are unknown. We analyzed HFpEF patients (EF ≥50%) who underwent coronary angiography at Duke University Medical Center from 2000 through 2010 with and without AP in the previous 6 weeks. Time to first event was examined using Kaplan-Meier methods for the primary endpoint of death/myocardial infarction (MI)/revascularization/stroke (i.e., major adverse cardiac events [MACE]) and secondary endpoints of death/MI/revascularization, death/MI/stroke, death/MI, death, and cardiovascular death/cardiovascular hospitalization. In the Duke Databank, 3,517 patients met criteria for inclusion and 1,402 (40%) had AP. Those with AP were older with more comorbidities and prior revascularization compared with non-AP patients. AP patients more often received beta-blockers, angiotensin-converting enzyme inhibitors, nitrates, and statins (all p < 0.05). In unadjusted analysis, AP patients had increased MACE and death/MI/revascularization (both p < 0.001), lower rates of death and death/MI (both p < 0.05), and similar rates of death/MI/stroke and cardiovascular death/cardiovascular hospitalization (both p > 0.1). After multivariable adjustment, those with AP remained at increased risk for MACE (hazard ratio [HR]: 1.30, 95% confidence interval [CI]: 1.17 to 1.45) and death/MI/revascularization (HR: 1.29, 95% CI: 1.15 to 1.43), but they were at similar risk for other endpoints (p > 0.06). AP in HFpEF patients with a history of coronary artery disease is common despite medical therapy and is independently associated with increased MACE due to revascularization with similar risk of death, MI, and hospitalization. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Off-Pump Versus On-Pump Coronary Artery Bypass Grafting-A Systematic Review and Analysis of Clinical Outcomes.

PubMed

Shaefi, Shahzad; Mittel, Aaron; Loberman, Dan; Ramakrishna, Harish

2018-04-04

Surgical coronary artery bypass grafting (CABG) is the standard of care for revascularization of left main or three-vessel coronary artery disease. The off-pump coronary artery bypass graft (OPCAB) procedure avoids the use of cardiopulmonary bypass. Theoretically, OPCAB may improve long-term outcomes by reducing the rates of perioperative myocardial injury, stroke, neurocognitive impairment, and cardiac-related mortality. Several high-quality clinical trials have been conducted since OPCAB became popular in the 1990s and have demonstrated no benefit of OPCAB over traditional CABG with respect to these outcomes despite favorable short-term reductions in transfusion requirements and other postoperative complications. Ultimately, OPCAB is associated with less effective myocardial revascularization and does not entirely prevent complications traditionally associated with cardiopulmonary bypass. This article reviews major high-quality trials of OPCAB versus traditional CABG with respect to both short- and long-term clinical outcomes. Copyright © 2018 Elsevier Inc. All rights reserved.

Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease.

PubMed

Stone, Gregg W; Sabik, Joseph F; Serruys, Patrick W; Simonton, Charles A; Généreux, Philippe; Puskas, John; Kandzari, David E; Morice, Marie-Claude; Lembo, Nicholas; Brown, W Morris; Taggart, David P; Banning, Adrian; Merkely, Béla; Horkay, Ferenc; Boonstra, Piet W; van Boven, Ad J; Ungi, Imre; Bogáts, Gabor; Mansour, Samer; Noiseux, Nicolas; Sabaté, Manel; Pomar, José; Hickey, Mark; Gershlick, Anthony; Buszman, Pawel; Bochenek, Andrzej; Schampaert, Erick; Pagé, Pierre; Dressler, Ovidiu; Kosmidou, Ioanna; Mehran, Roxana; Pocock, Stuart J; Kappetein, A Pieter

2016-12-08

Patients with obstructive left main coronary artery disease are usually treated with coronary-artery bypass grafting (CABG). Randomized trials have suggested that drug-eluting stents may be an acceptable alternative to CABG in selected patients with left main coronary disease. We randomly assigned 1905 eligible patients with left main coronary artery disease of low or intermediate anatomical complexity to undergo either percutaneous coronary intervention (PCI) with fluoropolymer-based cobalt-chromium everolimus-eluting stents (PCI group, 948 patients) or CABG (CABG group, 957 patients). Anatomic complexity was assessed at the sites and defined by a Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score of 32 or lower (the SYNTAX score reflects a comprehensive angiographic assessment of the coronary vasculature, with 0 as the lowest score and higher scores [no upper limit] indicating more complex coronary anatomy). The primary end point was the rate of a composite of death from any cause, stroke, or myocardial infarction at 3 years, and the trial was powered for noninferiority testing of the primary end point (noninferiority margin, 4.2 percentage points). Major secondary end points included the rate of a composite of death from any cause, stroke, or myocardial infarction at 30 days and the rate of a composite of death, stroke, myocardial infarction, or ischemia-driven revascularization at 3 years. Event rates were based on Kaplan-Meier estimates in time-to-first-event analyses. At 3 years, a primary end-point event had occurred in 15.4% of the patients in the PCI group and in 14.7% of the patients in the CABG group (difference, 0.7 percentage points; upper 97.5% confidence limit, 4.0 percentage points; P=0.02 for noninferiority; hazard ratio, 1.00; 95% confidence interval, 0.79 to 1.26; P=0.98 for superiority). The secondary end-point event of death, stroke, or myocardial infarction at 30 days occurred in 4.9% of the patients in the PCI group and in 7.9% in the CABG group (P<0.001 for noninferiority, P=0.008 for superiority). The secondary end-point event of death, stroke, myocardial infarction, or ischemia-driven revascularization at 3 years occurred in 23.1% of the patients in the PCI group and in 19.1% in the CABG group (P=0.01 for noninferiority, P=0.10 for superiority). In patients with left main coronary artery disease and low or intermediate SYNTAX scores by site assessment, PCI with everolimus-eluting stents was noninferior to CABG with respect to the rate of the composite end point of death, stroke, or myocardial infarction at 3 years. (Funded by Abbott Vascular; EXCEL ClinicalTrials.gov number, NCT01205776 .).

Comparative effectiveness of coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) in elderly patients with diabetes.

PubMed

Shah, Ruchit; Yang, Yi; Bentley, John P; Banahan, Benjamin F

2016-11-01

To compare the relative effectiveness of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) among elderly patients with diabetes regarding acute myocardial infarction (AMI), stroke, repeat revascularization, and all-cause mortality. A retrospective cohort study was conducted using the 2006-2008 5% national sample of Medicare claims data. Elderly (≥65 years) beneficiaries with at least two claims of diabetes separated by ≥30 days and who had at least one inpatient claim for multi-vessel CABG or PCI between 1 July 2006 and 30 June 2008 were identified. The date of beneficiary's first CABG or PCI was defined as the index date. All patients were followed from the index date to 31 December 2008 for outcomes. CABG and PCI patients were 1:1 matched on propensity scores and index dates. Cox proportional hazards models were used to compare postoperative outcomes between patients undergoing CABG versus PCI. The matched sample consisted of 4430 patients (2215 in each group). The Cox proportional hazards models showed that, compared to patients undergoing PCI, CABG was associated with a lower risk of postoperative AMI (hazard ratio [HR]: 0.494; 95% CI: 0.396-0.616; p < .0001), repeat revascularization (HR: 0.194; 95% CI: 0.149-0.252; p < .0001), the composite outcome (HR: 0.523; 95% CI: 0.460-0.595; p < .0001), and all-cause mortality (HR: 0.775; 95% CI: 0.658-0.914; p = .0024); postoperative risk of stroke was not significantly different between the two groups (HR: 0.965; 95% CI: 0.812-1.148; p = .691). CABG appears to be the preferred revascularization strategy for elderly patients with diabetes and coronary heart disease. However, this result should be interpreted considering study limitations, for example, several patient clinical variables and physician-related factors which may affect procedure outcomes are not available in the data. Clinical decisions should be individualized considering all patient- and physician-related factors.

Darapladib for preventing ischemic events in stable coronary heart disease.

PubMed

White, Harvey D; Held, Claes; Stewart, Ralph; Tarka, Elizabeth; Brown, Rebekkah; Davies, Richard Y; Budaj, Andrzej; Harrington, Robert A; Steg, P Gabriel; Ardissino, Diego; Armstrong, Paul W; Avezum, Alvaro; Aylward, Philip E; Bryce, Alfonso; Chen, Hong; Chen, Ming-Fong; Corbalan, Ramon; Dalby, Anthony J; Danchin, Nicolas; De Winter, Robbert J; Denchev, Stefan; Diaz, Rafael; Elisaf, Moses; Flather, Marcus D; Goudev, Assen R; Granger, Christopher B; Grinfeld, Liliana; Hochman, Judith S; Husted, Steen; Kim, Hyo-Soo; Koenig, Wolfgang; Linhart, Ales; Lonn, Eva; López-Sendón, José; Manolis, Athanasios J; Mohler, Emile R; Nicolau, José C; Pais, Prem; Parkhomenko, Alexander; Pedersen, Terje R; Pella, Daniel; Ramos-Corrales, Marco A; Ruda, Mikhail; Sereg, Mátyás; Siddique, Saulat; Sinnaeve, Peter; Smith, Peter; Sritara, Piyamitr; Swart, Henk P; Sy, Rody G; Teramoto, Tamio; Tse, Hung-Fat; Watson, David; Weaver, W Douglas; Weiss, Robert; Viigimaa, Margus; Vinereanu, Dragos; Zhu, Junren; Cannon, Christopher P; Wallentin, Lars

2014-05-01

Elevated lipoprotein-associated phospholipase A2 activity promotes the development of vulnerable atherosclerotic plaques, and elevated plasma levels of this enzyme are associated with an increased risk of coronary events. Darapladib is a selective oral inhibitor of lipoprotein-associated phospholipase A2. In a double-blind trial, we randomly assigned 15,828 patients with stable coronary heart disease to receive either once-daily darapladib (at a dose of 160 mg) or placebo. The primary end point was a composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included the components of the primary end point as well as major coronary events (death from coronary heart disease, myocardial infarction, or urgent coronary revascularization for myocardial ischemia) and total coronary events (death from coronary heart disease, myocardial infarction, hospitalization for unstable angina, or any coronary revascularization). During a median follow-up period of 3.7 years, the primary end point occurred in 769 of 7924 patients (9.7%) in the darapladib group and 819 of 7904 patients (10.4%) in the placebo group (hazard ratio in the darapladib group, 0.94; 95% confidence interval [CI], 0.85 to 1.03; P=0.20). There were also no significant between-group differences in the rates of the individual components of the primary end point or in all-cause mortality. Darapladib, as compared with placebo, reduced the rate of major coronary events (9.3% vs. 10.3%; hazard ratio, 0.90; 95% CI, 0.82 to 1.00; P=0.045) and total coronary events (14.6% vs. 16.1%; hazard ratio, 0.91; 95% CI, 0.84 to 0.98; P=0.02). In patients with stable coronary heart disease, darapladib did not significantly reduce the risk of the primary composite end point of cardiovascular death, myocardial infarction, or stroke. (Funded by GlaxoSmithKline; STABILITY ClinicalTrials.gov number, NCT00799903.).

Does stent strut design impact clinical outcomes: comparative safety and efficacy of Endeavor Resolute versus Resolute Integrity zotarolimus-eluting stents.

PubMed

Di Santo, Pietro; Simard, Trevor; Ramirez, F Daniel; Pourdjabbar, Ali; Harnett, David T; Singh, Kuljit; Moreland, Robert; Chong, Aun-Yeong; Dick, Alexander; Labinaz, Marino; Froeschl, Michael; Froeschl, Michael; Le May, Michael R; So, Derek Y; Hibbert, Benjamin

2015-10-07

Percutaneous coronary intervention is the most commonly performed method of revascularizing obstructive coronary artery disease. The impact of stent strut design on clinical outcomes remains unclear. The Endeavour Resolute (ER-ZES) and the Resolute Integrity (RI-ZES) zotarolimus-eluting stents utilize identical polymers and anti-proliferative agents, differing only in their respective strut design. This study assessed the comparative safety and efficacy of these two stents in unrestricted contemporary real-world practice. A total of 542 patients were identified, corresponding to 340 ER-ZES and 480 RI-ZES. The primary endpoint was major adverse cardiac events (MACE) defined by a composite of death, nonfatal myocardial infarction and stroke. Secondary endpoints included post-procedural length of stay, in-stent restenosis, target lesion revascularization, target vessel revascularization, coronary artery bypass grafting and stent thrombosis. MACE occurred in 3.2% of the ER-ZES cohort and 5.0% of the RI-ZES cohort (p= 0.43). Adjusted analysis utilizing propensity score-adjusted odds ratio for MACE, was 1.37 (95% CI 0.46-4.07, p=0.57). The mortality rate (0.9% ER-ZES vs. 1.9% RI-ZES, p=0.59), non-fatal MI (2.3% ER-ZES vs. 3.1% RI-ZES, p=0.75) and stroke (0.0% ER-ZES vs. 0.3% RI-ZES, p=0.85) were not different. Additionally, there was no difference in any of secondary outcomes. The clinical performance and safety of both ER-ZES and RI-ZES were not statistically different, despite differences in stent strut design.

Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and Multivessel Disease

PubMed Central

Gershlick, Anthony H.; Khan, Jamal Nasir; Kelly, Damian J.; Greenwood, John P.; Sasikaran, Thiagarajah; Curzen, Nick; Blackman, Daniel J.; Dalby, Miles; Fairbrother, Kathryn L.; Banya, Winston; Wang, Duolao; Flather, Marcus; Hetherington, Simon L.; Kelion, Andrew D.; Talwar, Suneel; Gunning, Mark; Hall, Roger; Swanton, Howard; McCann, Gerry P.

2015-01-01

Background The optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction is uncertain. Objectives CvLPRIT (Complete versus Lesion-only Primary PCI trial) is a U.K. open-label randomized study comparing complete revascularization at index admission with treatment of the infarct-related artery (IRA) only. Methods After they provided verbal assent and underwent coronary angiography, 296 patients in 7 U.K. centers were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤3 h or >3 h). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months. Results Patient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days). Although there was no significant reduction in death or MI, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups. Conclusions In patients presenting for P-PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival. (Complete Versus Lesion-only Primary PCI Pilot Study [CvLPRIT]; ISRCTN70913605) PMID:25766941

Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents in patients with multivessel coronary artery disease compared to coronary artery bypass surgery five-years after intervention

PubMed Central

Krenn, Lisa; Kopp, Christoph; Glogar, Dietmar; Lang, Irene M; Delle-Karth, Georg; Neunteufl, Thomas; Kreiner, Gerhard; Kaider, Alexandra; Bergler-Klein, Jutta; Khorsand, Aliasghar; Nikfardjam, Mariam; Laufer, Günther; Maurer, Gerald; Gyöngyösi, Mariann

2014-01-01

Objectives Cost-effectiveness of percutaneous coronary intervention (PCI) using drug-eluting stents (DES), and coronary artery bypass surgery (CABG) was analyzed in patients with multivessel coronary artery disease over a 5-year follow-up. Background DES implantation reducing revascularization rate and associated costs might be attractive for health economics as compared to CABG. Methods Consecutive patients with multivessel DES-PCI (n = 114, 3.3 ± 1.2 DES/patient) or CABG (n = 85, 2.7 ± 0.9 grafts/patient) were included prospectively. Primary endpoint was cost-benefit of multivessel DES-PCI over CABG, and the incremental cost-effectiveness ratio (ICER) was calculated. Secondary endpoint was the incidence of major adverse cardiac and cerebrovascular events (MACCE), including acute myocardial infarction (AMI), all-cause death, revascularization, and stroke. Results Despite multiple uses for DES, in-hospital costs were significantly less for PCI than CABG, with 4551 €/patient difference between the groups. At 5-years, the overall costs remained higher for CABG patients (mean difference 5400 € between groups). Cost-effectiveness planes including all patients or subgroups of elderly patients, diabetic patients, or Syntax score >32 indicated that CABG is a more effective, more costly treatment mode for multivessel disease. At the 5-year follow-up, a higher incidence of MACCE (37.7% vs. 25.8%; log rank P = 0.048) and a trend towards more AMI/death/stroke (25.4% vs. 21.2%, log rank P = 0.359) was observed in PCI as compared to CABG. ICER indicated 45615 € or 126683 € to prevent one MACCE or AMI/death/stroke if CABG is performed. Conclusions Cost-effectiveness analysis of DES-PCI vs. CABG demonstrated that CABG is the most effective, but most costly, treatment for preventing MACCE in patients with multivessel disease. © 2014 Wiley Periodicals, Inc. PMID:24403120

Determinants and Outcomes of Stroke Following Percutaneous Coronary Intervention by Indication.

PubMed

Myint, Phyo Kyaw; Kwok, Chun Shing; Roffe, Christine; Kontopantelis, Evangelos; Zaman, Azfar; Berry, Colin; Ludman, Peter F; de Belder, Mark A; Mamas, Mamas A

2016-06-01

Stroke after percutaneous coronary intervention (PCI) is a serious complication, but its determinants and outcomes after PCI in different clinical settings are poorly documented. The British Cardiovascular Intervention Society (BCIS) database was used to study 560 439 patients who underwent PCI in England and Wales between 2006 and 2013. We examined procedural-type specific determinants of ischemic and hemorrhagic stroke and the likelihood of subsequent 30-day mortality and in-hospital major adverse cardiovascular events (a composite of in-hospital mortality, myocardial infarction or reinfarction, and repeat revascularization). A total of 705 stroke cases were recorded (80% ischemic). Stroke after an elective PCI or PCI for acute coronary syndrome indications was associated with a higher risk of adverse outcomes compared with those without stroke; 30-day mortality and major adverse cardiovascular events outcomes in fully adjusted model were odds ratios 37.90 (21.43-67.05) and 21.05 (13.25-33.44) for elective and 5.00 (3.96-6.31) and 6.25 (5.03-7.77) for acute coronary syndrome, respectively. Comparison of odds of these outcomes between these 2 settings showed no differences; corresponding odds ratios were 1.24 (0.64-2.43) and 0.63 (0.35-1.15), respectively. Hemorrhagic and ischemic stroke complications are uncommon, but serious complications can occur after PCI and are independently associated with worse mortality and major adverse cardiovascular events outcomes in both the elective and acute coronary syndrome setting irrespective of stroke type. Our study provides a better understanding of the risk factors and prognosis of stroke after PCI by procedure type, allowing physicians to provide more informed advice around stroke risk after PCI and counsel patients and their families around outcomes if such neurological complications occur. © 2016 American Heart Association, Inc.

Long-term outcomes of coronary artery bypass grafting versus stent-PCI for unprotected left main disease: a meta-analysis.

PubMed

De Rosa, Salvatore; Polimeni, Alberto; Sabatino, Jolanda; Indolfi, Ciro

2017-09-06

Coronary artery bypass graft (CABG) surgery has traditionally represented the standard of care for left main coronary artery (LMCA) disease. However, percutaneous coronary intervention with stent implantation (PCI) has more recently emerged as a valuable alternative. The long-time awaited results of the largest randomized trials on the long-term impact of PCI versus CABG in LMCA disease, the newly published NOBLE and EXCEL studies, revealed contrasting results. Thus, aim of the present meta-analysis was to review the most robust evidence from randomized comparisons of CABG versus PCI for revascularization of LMCA. Randomized studies comparing long-term clinical outcomes of CABG or Stent-PCI for the treatment of LMCA disease were searched for in PubMed, the Chochrane Library and Scopus electronic databases. A total of 5 randomized studies were selected, including 4499 patients. No significant difference between CABG and PCI was found in the primary analysis on the composite endpoint of death, stroke and myocardial infarction (OR = 1·06 95% CI 0·80-1·40; p = 0·70). Similarly, no differences were observed between CABG and PCI for all-cause death (OR = 1·03 95% CI 0·81-1·32; p = 0·81). Although not statistically significant, a lower rate of stroke was registered in the PCI arm (OR = 0·86; p = 0·67), while a lower rate of myocardial infarction was found in the CABG arm (OR = 1·43; p = 0·17). On the contrary, a significantly higher rate of repeat revascularization was registered in the PCI arm (OR = 1·76 95% CI 1·45-2·13; p < 0·001). The present meta-analysis, the most comprehensive and updated to date, including 5 randomized studies and 4499 patients, demonstrates no difference between Stent-PCI and CABG for the treatment of LMCA disease in the composite endpoint of death, stroke and myocardial infarction. Hence, a large part of patients with unprotected left main coronary artery disease can be managed equally well by means of both these revascularization strategies.

Cost-effectiveness of percutaneous coronary intervention with drug-eluting stents versus bypass surgery for patients with 3-vessel or left main coronary artery disease: final results from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial.

PubMed

Cohen, David J; Osnabrugge, Ruben L; Magnuson, Elizabeth A; Wang, Kaijun; Li, Haiyan; Chinnakondepalli, Khaja; Pinto, Duane; Abdallah, Mouin S; Vilain, Katherine A; Morice, Marie-Claude; Dawkins, Keith D; Kappetein, A Pieter; Mohr, Friedrich W; Serruys, Patrick W

2014-09-30

The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial demonstrated that in patients with 3-vessel or left main coronary artery disease, coronary artery bypass graft surgery (CABG) was associated with a lower rate of cardiovascular death, myocardial infarction, stroke, or repeat revascularization compared with percutaneous coronary revascularization with drug-eluting stents (DES-PCI)). The long-term cost-effectiveness of these strategies is unknown. Between 2005 and 2007, 1800 patients with left main or 3-vessel coronary artery disease were randomized to CABG (n=897) or DES-PCI (n=903). Costs were assessed from a US perspective, and health state utilities were evaluated with the EuroQOL questionnaire. A patient-level microsimulation model based on the 5-year in-trial data was used to extrapolate costs, life expectancy, and quality-adjusted life expectancy over a lifetime horizon. Although initial procedural costs were $3415 per patient lower with CABG, total hospitalization costs were $10 036 per patient higher. Over the next 5 years, follow-up costs were higher with DES-PCI as a result of more frequent hospitalizations, revascularization procedures, and higher medication costs. Over a lifetime horizon, CABG remained more costly than DES-PCI, but the incremental cost-effectiveness ratio was favorable ($16 537 per quality-adjusted life-year gained) and remained <$20 000 per quality-adjusted life-year in most bootstrap replicates. Results were consistent across a wide range of assumptions about the long-term effect of CABG versus DES-PCI on events and costs. In patients with left main disease or a SYNTAX score ≤22, however, DES-PCI was economically dominant compared with CABG, although these findings were less certain. For most patients with 3-vessel or left main coronary artery disease, CABG is a clinically and economically attractive revascularization strategy compared with DES-PCI. However, among patients with less complex disease, DES-PCI may be preferred on both clinical and economic grounds. www.clinicaltrials.gov. Unique identifier: NCT00114972. © 2014 American Heart Association, Inc.

Percutaneous Coronary Intervention Is More Beneficial Than Optimal Medical Therapy in Elderly Patients with Angina Pectoris.

PubMed

Won, Hoyoun; Her, Ae Young; Kim, Byeong Keuk; Kim, Yong Hoon; Shin, Dong Ho; Kim, Jung Sun; Ko, Young Guk; Choi, Donghoon; Kwon, Hyuck Moon; Jang, Yangsoo; Hong, Myeong Ki

2016-03-01

Data comparing the clinical benefits of medical treatment with those of percutaneous coronary intervention (PCI) in an elderly population with angina pectoris are limited. Therefore, we evaluated the efficacy of elective PCI versus optimal medical treatment (OMT) in elderly patients (between 75 and 84 years old) with angina pectoris. One hundred seventy-seven patients with significant coronary artery stenosis were randomly assigned to either the PCI group (n=90) or the OMT group (n=87). The primary outcome was a composite of major adverse events in the 1-year follow-up period that included cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and stroke. Major adverse events occurred in 5 patients (5.6%) of the PCI group and in 17 patents (19.5%) of the OMT group (p=0.015). There were no significant differences between the PCI group and the OMT group in cardiac death [hazard ratio (HR) for the PCI group 0.454; 95% confidence interval (CI) 0.041-5.019, p=0.520], myocardial infarction (HR 0.399; 95% CI 0.039-4.050, p=0.437), or stroke (HR 0.919; 95% CI 0.057-14.709, p=0.952). However, the PCI group showed a significant preventive effect of the composite of major adverse events (HR 0.288; 95% CI 0.106-0.785, p=0.015) and against the need for coronary revascularization (HR 0.157; 95% CI 0.035-0.703, p=0.016). Elective PCI reduced major adverse events and was found to be an effective treatment modality in elderly patients with angina pectoris and significant coronary artery stenosis, compared to OMT.

Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease.

PubMed

Sanchez, Carlos E; Dota, Anthony; Badhwar, Vinay; Kliner, Dustin; Smith, A J Conrad; Chu, Danny; Toma, Catalin; Wei, Lawrence; Marroquin, Oscar C; Schindler, John; Lee, Joon S; Mulukutla, Suresh R

2016-10-01

To evaluate how a comprehensive evidence-based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons-derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization. Decision-making regarding the use of revascularization for coronary artery disease has come under major scrutiny due to inappropriate overuse of revascularization. There is little data in routine clinical practice evaluating how a structured, multidisciplinary heart team approach may be used in combination with the Appropriate Use Criteria for revascularization. From May 1, 2012 to January 1, 2015, multidisciplinary revascularization heart team meetings were convened to discuss evidence-based management of 301 patients with complex coronary artery disease. Heart team recommendations were adjudicated with the Appropriate Use Criteria for coronary revascularization for each clinical scenario using the Society for Cardiovascular Angiography and Interventions' Quality Improvement Toolkit (SCAI-QIT) Appropriate Use Criteria App. Concordance of the Heart Team to Appropriate Use Criteria had a 99.3% appropriate primary indication for coronary revascularization. Among patients who underwent percutaneous revascularization, 34.9% had an inappropriate or uncertain indication as recommended by the Heart Team. Patients with uncertain or inappropriate percutaneous coronary interventions had significantly higher SYNTAX score (27.3 ± 6.6; 28.5 ± 5.5; 19.2 ± 6; P < 0.0001) and Society of Thoracic Surgeons-Predicted Risk of Mortality (6.1% ± 4.7%; 8.1% ± 6.3%; 3.7% ± 4.1%; P < 0.0081) compared to appropriate indications, frequently had concomitant forms of advanced comorbidities and frailty in the setting of symptomatic coronary artery disease. A formal, multidisciplinary revascularization heart team can provide proper validation for clinical decisions and should be considered in combination with the Appropriate Use Criteria for coronary revascularization to formulate revascularization strategies for individuals in a patient-centered fashion. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.

High event rate after a first percutaneous coronary intervention in patients with diabetes mellitus: results from the Swedish coronary angiography and angioplasty registry.

PubMed

Ritsinger, Viveca; Saleh, Nawsad; Lagerqvist, Bo; Norhammar, Anna

2015-06-01

Patients with diabetes mellitus have reduced longevity after acute coronary syndromes and revascularization. However, knowledge of the long-term complication rates and patterns from an everyday life setting is lacking. Consecutive patients undergoing percutaneous coronary intervention included in the Swedish Coronary Angiography Angioplasty Registry (SCAAR) between 2006 and 2010 and with no previous revascularization were prospectively followed up for combined cardiovascular events (first of all-cause mortality, myocardial infarction, stroke, and heart failure) until December 31, 2010. The mean follow-up period was 920 days (SD, 530 days). Differences in background and procedural characteristics were adjusted for in a multivariate Cox regression model. Of 58 891 patients, mean age 67 years, 19% had diabetes mellitus; 27% of them were on diet treatment, 33% on oral glucose lowering, and 40% on insulin treatment. At admission, cardiovascular risk factors, multiple coronary vessel, and left main stem disease were more frequent in patients with diabetes mellitus and their revascularization was less often complete. The adjusted risk for combined cardiovascular events was higher in patients on insulin (hazard ratio [95% confidence interval], 1.63 [1.55-1.72]), on oral treatment (1.23 [1.15-1.31]), and on diet alone (1.21 [1.12-1.29]) compared with patients without diabetes mellitus. Insulin-treated patients ran an increased risk of restenosis (1.54 [1.39-1.71]) and stent thrombosis (1.56 [1.25-1.96]). The prognosis after a first percutaneous coronary intervention is more severe in patients with diabetes mellitus, in particular, in patients treated with insulin, with higher rates of mortality, cardiovascular events, and stent thrombosis over the following 5 years. © 2015 American Heart Association, Inc.

Current status of hybrid coronary revascularization.

PubMed

Jaik, Nikhil P; Umakanthan, Ramanan; Leacche, Marzia; Solenkova, Natalia; Balaguer, Jorge M; Hoff, Steven J; Ball, Stephen K; Zhao, David X; Byrne, John G

2011-10-01

Hybrid coronary revascularization combines coronary artery bypass surgery with percutaneous coronary intervention techniques to treat coronary artery disease. The potential benefits of such a technique are to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery. Hybrid coronary revascularization has resulted in the establishment of new 'hybrid operating suites', which incorporate and integrate the capabilities of a cardiac surgery operating room with that of an interventional cardiology laboratory. Hybrid coronary revascularization has greatly augmented teamwork and cooperation between both fields and has demonstrated encouraging as well as good initial outcomes.

A comparison of hybrid coronary revascularization and off-pump coronary revascularization.

PubMed

Umakanthan, Ramanan; Leacche, Marzia; Gallion, Anna H; Byrne, John G

2013-04-01

Minimally invasive approaches to treat vascular disease have been accruing significant popularity over the last several decades. Due to progressive advances in technology, a variety of techniques are being now utilized in the field of cardiovascular surgery. The objectives of minimally invasive techniques are to curtail operative trauma and minimize perioperative morbidity without decreasing the quality of the treatment. The standard surgical approach for the treatment of coronary artery disease has traditionally been coronary artery bypass grafting surgery via median sternotomy. Off-pump coronary artery bypass grafting surgery offers a less invasive alternative and enables coronary revascularization to be performed without cardiopulmonary bypass. Hybrid coronary revascularization offers an even less invasive option in which minimally invasive direct coronary artery bypass can be combined with percutaneous coronary intervention. In this article, the authors review a recent publication comparing hybrid coronary revascularization and off-pump coronary artery bypass grafting surgery.

Staged Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With ST-Segment-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis.

PubMed

Villablanca, Pedro A; Olmedo, Wilman; Weinreich, Michael; Gupta, Tanush; Mohananey, Divyanshu; Albuquerque, Felipe N; Kassas, Ibrahim; Briceño, David; Sanina, Cristina; Brevik, Thomas A; Ong, Emily; Ramakrishna, Harish; Attubato, Michael; Menegus, Mark; Wiley, Jose; Kalra, Ankur

2018-04-13

Studies have shown that chronic total occlusion (CTO) in a noninfarct-related artery in patients with ST-segment-elevation myocardial infarction is linked to increased mortality. It remains unclear whether staged revascularization of a noninfarct-related artery CTO in patients with ST-segment-elevation myocardial infarction translates to improved outcomes. We performed a meta-analysis to compare outcomes between patients presenting with ST-segment-elevation myocardial infarction with concurrent CTO who underwent percutaneous coronary intervention of noninfarct-related artery CTO versus those who did not. We conducted an electronic database search of all published data. The primary end point was major adverse cardiovascular events. Secondary end points were all-cause mortality, cardiovascular mortality, myocardial infarction, repeat revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, stroke, and heart failure readmission. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed. Random effects model was used and heterogeneity was considered if I 2 >25. Six studies (n=1253 patients) were included in the analysis. There was a significant difference in major adverse cardiovascular events (OR, 0.54; 95% CI, 0.32-0.91), cardiovascular mortality (OR, 0.43; 95% CI, 0.20-0.95), and heart failure readmissions (OR, 0.57; 95% CI, 0.36-0.89), favoring the patients in the CTO percutaneous coronary intervention group. No significant differences were observed between the 2 groups for all-cause mortality (OR, 0.47; 95% CI, 0.22-1.00), myocardial infarction (OR, 0.78; 95% CI, 0.41-1.46), repeat revascularization (OR, 1.13; 95% CI, 0.56-2.27), and stroke (OR, 0.51; 95% CI, 0.20-1.33). In this meta-analysis, CTO percutaneous coronary intervention of the noninfarct-related artery in patients presenting with ST-segment-elevation myocardial infarction was associated with a significant reduction in major adverse cardiovascular events, cardiovascular mortality, and heart failure readmissions. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

2-year results of the AUTAX (Austrian Multivessel TAXUS-Stent) registry beyond the SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) study.

PubMed

Gyöngyösi, Mariann; Christ, Günter; Lang, Irene; Kreiner, Gerhard; Sochor, Heinz; Probst, Peter; Neunteufl, Thomas; Badr-Eslam, Rosa; Winkler, Susanne; Nyolczas, Noemi; Posa, Aniko; Leisch, Franz; Karnik, Ronald; Siostrzonek, Peter; Harb, Stefan; Heigert, Matthias; Zenker, Gerald; Benzer, Werner; Bonner, Gerhard; Kaider, Alexandra; Glogar, Dietmar

2009-08-01

The multicenter AUTAX (Austrian Multivessel TAXUS-Stent) registry investigated the 2-year clinical/angiographic outcomes of patients with multivessel coronary artery disease after implantation of TAXUS Express stents (Boston Scientific, Natick, Massachusetts), in a "real-world" setting. The AUTAX registry included patients with 2- or 3-vessel disease, with/without previous percutaneous coronary intervention (PCI) and concomitant surgery. Patients (n = 441, 64 +/- 12 years, 78% men) (n = 1,080 lesions) with possible complete revascularization by PCI were prospectively included. Median clinical follow-up was 753 (quartiles 728 to 775) days after PCI in 95.7%, with control angiography of 78% at 6 months. The primary end point was the composite of major adverse cardiac (nonfatal acute myocardial infarction [AMI], all-cause mortality, target lesion revascularization [TLR]) and cerebrovascular events (MACCE). Potential risk factor effects on 2-year MACCE were evaluated using Cox regression. Complete revascularization was successful in 90.5%, with left main PCI of 6.8%. Rates of acute, subacute, and late stent thrombosis were 0.7%, 0.5%, and 0.5%. Two-year follow-up identified AMI (1.4%), death (3.6%), stroke (0.2%), and TLR (13.1%), for a composite MACCE of 18.3%. The binary restenosis rate was 10.8%. The median of cumulative SYNTAX score was 23.0 (range 12.0 to 56.5). The SYNTAX score did not predict TLR or MACCE, due to lack of scoring of restenotic or bypass stenoses (29.8%). Age (hazard ratio [HR]: 1.03, p = 0.019) and acute coronary syndrome (HR: 2.1, p = 0.001) were significant predictors of 2-year MACCE. Incomplete revascularization predicted death or AMI (HR: 3.84, p = 0.002). With the aim of complete revascularization, TAXUS stent implantations can be safe for patients with multivessel disease. The AUTAX registry including patients with post-PCI lesions provides additional information to the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) study. (Austrian Multivessel TAXUS-Stent Registry; NCT00738686).

Neuroimaging patterns of cerebral hyperperfusion

NASA Astrophysics Data System (ADS)

Semenov, S.; Portnov, Yu; Semenov, A.; Korotkevich, A.; Kokov, A.

2017-08-01

Cerebral hyperperfusion syndrome (CHS) after revascularization is a rare phenomenon associated with post-ischemic (reactive) hyperemia and acute pathological hyperperfusion. First described on perfusion CT as a very often moderate CBF increase, MTT/TTP decrease within 30% like a temporary effect, according to a short-time deterioration of neurological symptoms (vestibular ataxia - 58%, vegetative dysfunction - 100%, asthenic syndrome - 100%) in early postoperative period in patients with cardiac ischemia who had undergone coronary artery bypass surgery. The acute pathological hyperperfusion carotid revascularization is a casuistic phenomenon with two- or three-fold CBV and MTT/TTP increase and high hemorrhage risk. Besides, we detected similar exchanges via perfusion CT called benign hyperemia, which marks extension of MTT/TTP and an increase of CBV from 27% to 48% (average 30%), but with normal CBF-parameters, indicating that venous stasis in acute venous ischemic stroke due cerebral venous sinus-trombosis (68%), only 6% in cardioembolic stroke and appears never in arterial stroke. Territorial coincidence registered for perifocal of necrosis zones of benign hyperemia and vasogenic edema accompanied on MRI (DWI, ADC). Secondary hemorrhagic transformation registered for primary non-hemorrhagic venous stroke in 27%, only in 9% for arterial stroke and in 60% for cardioembolic stroke. Probably, congestion is an increasingly predisposing factor secondary hemorrhaging than necrosis.

Quality-of-Life After Everolimus-Eluting Stents or Bypass Surgery for Left-Main Disease: Results From the EXCEL Trial.

PubMed

Baron, Suzanne J; Chinnakondepalli, Khaja; Magnuson, Elizabeth A; Kandzari, David E; Puskas, John D; Ben-Yehuda, Ori; van Es, Gerrit-Anne; Taggart, David P; Morice, Marie-Claude; Lembo, Nicholas J; Brown, W Morris; Banning, Adrian; Simonton, Charles A; Kappetein, A Pieter; Sabik, Joseph F; Serruys, Patrick W; Stone, Gregg W; Cohen, David J

2017-12-26

The EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial compared outcomes in patients with unprotected left main coronary artery disease (LMCAD) treated with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) using everolimus-eluting stents. Whereas rates of death, stroke, and myocardial infarction were similar at 36 months, event timing and repeat revascularization rates differed by treatment group. To understand the effects of revascularization strategy from the patient's perspective, a prospective quality of life (QoL) substudy was performed alongside the EXCEL trial. Between September 2010 and March 2014, 1,905 patients with LMCAD were randomized to undergo CABG or PCI, of whom 1,788 participated in the QoL substudy. QoL was assessed at baseline and 1, 12, and 36 months using the Seattle Angina Questionnaire, the 12-Item Short Form Health Survey, the Rose Dyspnea Scale, the Patient Health Questionnaire-8, and the EQ-5D. Differences between PCI and CABG were assessed using longitudinal random-effect growth curve models. Over 36 months, both PCI and CABG were associated with significant improvements in QoL compared with baseline. At 1 month, PCI was associated with better QoL than CABG. By 12 months though, these differences were largely attenuated, and by 36 months, there were no significant QoL differences between PCI and CABG. Among selected patients with LMCAD, both PCI and CABG result in similar QoL improvement through 36 months, although a greater early benefit is seen with PCI. Taken together with the 3-year clinical results of EXCEL, these findings suggest that PCI and CABG provide similar intermediate-term outcomes for patients with LMCAD. (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776). Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

On-pump versus off-pump coronary artery bypass graft surgery among patients with type 2 diabetes in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial†

PubMed Central

Singh, Ashima; Schaff, Hartzell V.; Mori Brooks, Maria; Hlatky, Mark A.; Wisniewski, Stephen R.; Frye, Robert L.; Sako, Edward Y.

2016-01-01

OBJECTIVES Conclusive evidence is lacking regarding the benefits and risks of performing off-pump versus on-pump coronary artery bypass graft (CABG) for patients with diabetes. This study aims to compare clinical outcomes after off-pump and on-pump procedures for patients with diabetes. METHODS The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial enrolled patients with type 2 diabetes and documented coronary artery disease, 615 of whom underwent CABG during the trial. The procedural complications, 30-day outcomes, long-term clinical and functional outcomes were compared between the off-pump and on-pump groups overall and within a subset of patients matched on propensity score. RESULTS On-pump CABG was performed in 444 (72%) patients, and off-pump CABG in 171 (28%). The unadjusted 30-day rate of death/myocardial infarction (MI)/stroke was significantly higher after off-pump CABG (7.0 vs 2.9%, P = 0.02) despite fewer complications (10.3 vs 20.7%, P = 0.003). The long-term risk of death [adjusted hazard ratio (aHR): 1.41, P = 0.2197] and major cardiovascular events (death, MI or stroke) (aHR: 1.47, P = 0.1061) did not differ statistically between the off-pump and on-pump patients. Within the propensity-matched sample (153 pairs), patients who underwent off-pump CABG had a higher risk of the composite outcome of death, MI or stroke (aHR: 1.83, P = 0.046); the rates of procedural complications and death did not differ significantly, and there were no significant differences in the functional outcomes. CONCLUSIONS Patients with diabetes had greater risk of major cardiovascular events long-term after off-pump CABG than after on-pump CABG. PMID:25968885

Variation in Management of Patients With Obstructive Coronary Artery Disease: Insights From the Veterans Affairs Clinical Assessment and Reporting Tool (VA CART) Program.

PubMed

Sandhu, Amneet; Stanislawski, Maggie A; Grunwald, Gary K; Guinn, Kathryn; Valle, Javier; Matlock, Daniel; Ho, P Michael; Maddox, Thomas M; Bradley, Steven M

2017-09-12

Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

New-generation stents compared with coronary bypass surgery for unprotected left main disease: A word of caution.

PubMed

Benedetto, Umberto; Taggart, David P; Sousa-Uva, Miguel; Biondi-Zoccai, Giuseppe; Di Franco, Antonino; Ohmes, Lucas B; Rahouma, Mohamed; Kamel, Mohamed; Caputo, Massimo; Girardi, Leonard N; Angelini, Gianni D; Gaudino, Mario

2018-05-01

With the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials. All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable. The introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Percutaneous coronary intervention vs coronary artery bypass grafting for left main coronary artery disease? A systematic review and meta-analysis of randomized controlled trials.

PubMed

Sharma, Sharan P; Dahal, Khagendra; Khatra, Jaspreet; Rosenfeld, Alan; Lee, Juyong

2017-06-01

It is not clear whether percutaneous coronary intervention (PCI) is as effective and safe as coronary artery bypass grafting (CABG) for left main coronary artery disease. We aimed to perform a systematic review and meta-analysis of all randomized controlled trials (RCTs) that compared PCI and CABG in left main coronary disease. We searched PubMed, EMBASE, Cochrane, Scopus and relevant references for RCTs (inception through, November 20, 2016 without language restrictions) and performed meta-analysis using random-effects model. All-cause mortality, myocardial infarction, revascularization rate, stroke, and major adverse cardiac and cerebrovascular events (MACCE) were the measured outcomes. Six RCTs with a total population of 4700 were analyzed. There was no difference in all-cause mortality at 30-day, one-year, and five-year (1.8% vs 1.1%; OR 0.60; 95% CI: 0.26-1.39; P=.23; I 2 =9%) follow-up between PCI and CABG. CABG group had less myocardial infarction (MI) at five-year follow-up than PCI (5% vs 2.5%; OR 2.04; CI: 1.30-3.19; P=.002; I 2 =1%). Revascularization rate favored CABG in one-year (8.6% vs 4.5%; OR 2; CI: 1.46-2.73; P<.0001; I 2 =45%) and five-year (15.9% vs 9.9%; OR 1.73; CI: 1.36-2.20; P<.0001; I 2 =0%) follow-up. Although stroke rate was lower in PCI group at 1 year, there was no difference in longer follow-up. MACCE at 5 years favored CABG (24% vs 18%; OR 1.45; CI: 1.19-1.76; P=.0001; I 2 =0%). On subgroup analysis, MACCE were not different between two groups in low-to-intermediate SYNTAX group while it was higher for PCI group with high SYNTAX group. Percutaneous coronary intervention could be as safe and effective as CABG in a select group of left main coronary artery disease patients. © 2017 John Wiley & Sons Ltd.

Clinical outcomes of hybrid coronary revascularization versus coronary artery bypass surgery in patients with diabetes mellitus.

PubMed

Harskamp, Ralf E; Walker, Patrick F; Alexander, John H; Xian, Ying; Liberman, Henry A; de Winter, Robbert J; Vassiliades, Thomas A; Peterson, Eric D; Puskas, John D; Halkos, Michael E

2014-10-01

Hybrid coronary revascularization (HCR) involves minimally invasive left internal mammary artery to left anterior descending coronary artery grafting combined with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. The safety and efficacy of HCR among diabetic patients are unknown. Patients with diabetes were included who underwent HCR at a US academic center between October 2003 and September 2013. These patients were matched 1:5 to similar patients treated with coronary artery bypass grafting (CABG) using a propensity score (PS)-matching algorithm. Conditional logistic regression and Cox regression stratified on matched pairs were performed to evaluate the association between HCR and inhospital complications, a composite measure of 30-day mortality, myocardial infarction and stroke, and up to 3-year all-cause mortality. Of 618 patients (HCR = 103; CABG = 515) in the PS-matched cohort, the 30-day composite of death, MI, or stroke after HCR and CABG was 4.9% and 3.9% (odds ratio: 1.25; 95% CI [0.47-3.33]; P = .66). Compared with CABG, HCR also had similar need for reoperation (7.6% versus 6.3%; P = .60) and renal failure (4.2% versus 4.9%; P = .76) but required less blood products (31.4% versus. 65.8%; P < .0001), lower chest tube drainage (655 mL [412-916] versus 898 mL [664-1240]; P < .0001), and shorter length of stay (<5 days: 48.3% versus 25.3%; P < .0001). Over a 3-year follow-up period, mortality was similar after HCR and CABG (12.3% versus 14.9%, hazard ratio: 0.94, 95% CI [0.47-1.88]; P = .86). Among diabetic patients, the use of HCR appears to be safe and has similar longitudinal outcomes but is associated with less blood product usage and faster recovery than conventional CABG surgery. Copyright © 2014 Mosby, Inc. All rights reserved.

Hybrid coronary revascularization in the era of drug-eluting stents.

PubMed

Murphy, Gavin J; Bryan, Alan J; Angelini, Gianni D

2004-11-01

Left internal mammary artery to left anterior descending coronary artery bypass grafting integrated with percutaneous coronary angioplasty (hybrid procedure) offers multivessel revascularization with minimal morbidity in high-risk patients. This is caused in part by the avoidance of cardiopulmonary bypass-related morbidity and manipulation of the aorta coupled with minimally invasive techniques. Hybrid revascularization is currently reserved for particularly high-risk patients or those with favorable anatomic variants however, largely because of the emergence of off-pump coronary artery bypass grafting, which permits more complete multivessel revascularization, with low morbidity in high-risk groups. The wider introduction of hybrid revascularization is limited chiefly by the high number of repeat interventions compared with off-pump coronary artery bypass grafting, which occurs because of the target vessel failure rate of percutaneous coronary intervention. Other demerits are the costs and logistic problems associated with performing two procedures with differing periprocedural management protocols. Recently, drug-eluting stents have reduced the need for repeat intervention after percutaneous coronary intervention, and this has raised the possibility that the results of hybrid revascularization may now equal or even better those of off-pump coronary artery bypass grafting. Although undoubtedly effective at reducing in-stent restenosis, drug-eluting stents will not address the issues of incomplete revascularization or the logistic problems associated with hybrid. Uncertainty regarding the long-term effectiveness of drug-eluting stents in many patients, as well as their high cost when compared with those of off-pump coronary artery bypass grafting surgery, also militates against the wider introduction of hybrid revascularization.

Effects of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and major morbidity in myocardial infarction survivors: a randomized trial.

PubMed

Armitage, Jane M; Bowman, Louise; Clarke, Robert J; Wallendszus, Karl; Bulbulia, Richard; Rahimi, Kazem; Haynes, Richard; Parish, Sarah; Sleight, Peter; Peto, Richard; Collins, Rory

2010-06-23

Blood homocysteine levels are positively associated with cardiovascular disease, but it is uncertain whether the association is causal. To assess the effects of reducing homocysteine levels with folic acid and vitamin B(12) on vascular and nonvascular outcomes. Double-blind randomized controlled trial of 12,064 survivors of myocardial infarction in secondary care hospitals in the United Kingdom between 1998 and 2008. 2 mg folic acid plus 1 mg vitamin B(12) daily vs matching placebo. First major vascular event, defined as major coronary event (coronary death, myocardial infarction, or coronary revascularization), fatal or nonfatal stroke, or noncoronary revascularization. Allocation to the study vitamins reduced homocysteine by a mean of 3.8 micromol/L (28%). During 6.7 years of follow-up, major vascular events occurred in 1537 of 6033 participants (25.5%) allocated folic acid plus vitamin B(12) vs 1493 of 6031 participants (24.8%) allocated placebo (risk ratio [RR], 1.04; 95% confidence interval [CI], 0.97-1.12; P = .28). There were no apparent effects on major coronary events (vitamins, 1229 [20.4%], vs placebo, 1185 [19.6%]; RR, 1.05; 95% CI, 0.97-1.13), stroke (vitamins, 269 [4.5%], vs placebo, 265 [4.4%]; RR, 1.02; 95% CI, 0.86-1.21), or noncoronary revascularizations (vitamins, 178 [3.0%], vs placebo, 152 [2.5%]; RR, 1.18; 95% CI, 0.95-1.46). Nor were there significant differences in the numbers of deaths attributed to vascular causes (vitamins, 578 [9.6%], vs placebo, 559 [9.3%]) or nonvascular causes (vitamins, 405 [6.7%], vs placebo, 392 [6.5%]) or in the incidence of any cancer (vitamins, 678 [11.2%], vs placebo, 639 [10.6%]). Substantial long-term reductions in blood homocysteine levels with folic acid and vitamin B(12) supplementation did not have beneficial effects on vascular outcomes but were also not associated with adverse effects on cancer incidence. isrctn.org Identifier: ISRCTN74348595.

Rationale and design of the coronary artery bypass grafting surgery off or on pump revascularization study: a large international randomized trial in cardiac surgery.

PubMed

Lamy, Andre; Devereaux, Philip J; Prabhakaran, Dorairaj; Hu, Shengshou; Piegas, Leopoldo S; Straka, Zbynek; Paolasso, Ernesto; Taggart, David; Lanas, Fernando; Akar, A Ruchan; Jain, Anil; Noiseux, Nicolas; Ou, Yongning; Chrolavicius, Susan; Ng, Jennifer; Yusuf, Salim

2012-01-01

Uncertainty remains regarding the benefits and risks of the technique of operating on a beating heart (off pump) for coronary artery bypass grafting (CABG) surgery versus on-pump CABG. Prior trials had few events and relatively short follow-up. There is a need for a large randomized, controlled trial with long-term follow-up to inform both the short- and long-term impact of the 2 approaches to CABG. We plan to randomize 4,700 patients in whom CABG is planned to undergo the procedure on pump or off pump. The coprimary outcomes are a composite of total mortality, myocardial infarction (MI), stroke, and renal failure at 30 days and a composite of total mortality, MI, stroke, renal failure, and repeat revascularization at 5 years. We will also undertake a cost-effectiveness analysis at 30 days and 5 years after CABG surgery. Other outcomes include neurocognitive dysfunction, recurrence of angina, cardiovascular mortality, blood transfusions, and quality of life. As of May 3, 2011, CORONARY has recruited >3,884 patients from 79 centers in 19 countries. Currently, patient's mean age is 67.6 years, 80.7% are men, 47.0% have a history of diabetes, 51.4% have a history of smoking, and 34.4% had a previous MI. In addition, 20.9% of patients have a left main disease, and 96.6% have double or triple vessel disease. CORONARY is the largest trial yet conducted comparing off-pump CABG to on-pump CABG. Its results will lead to a better understanding of the safety and efficacy of off-pump CABG. Copyright © 2012 Mosby, Inc. All rights reserved.

Predictors of stroke associated with coronary artery bypass grafting in patients with diabetes mellitus and multivessel coronary artery disease.

PubMed

Domanski, Michael J; Farkouh, Michael E; Zak, Victor; Feske, Steven; Easton, Donald; Weinberger, Jesse; Hamon, Martial; Escobedo, Jorge; Shrader, Peter; Siami, Flora S; Fuster, Valentin

2015-05-15

This study assesses demographic and clinical variables associated with perioperative and late stroke in diabetes mellitus patients after multivessel coronary artery bypass grafting (CABG). Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) is the largest randomized trial of diabetic patients undergoing multivessel CABG. FREEDOM patients had improved survival free of death, myocardial infarction, or stroke and increased overall survival after CABG compared to percutaneous intervention. However, the stroke rate was greater following CABG than percutaneous intervention. We studied predictors of stroke in CABG-treated patients analyzing separately overall, perioperative (≤30 days after surgery), and late (>30 days after surgery) stroke. For long-term outcomes (overall stroke and late stroke), Cox proportional hazards regression was used, accounting for time to event, and logistic regression was used for perioperative stroke. Independent perioperative stroke predictors were previous stroke (odds ratio [OR] 6.96, 95% confidence interval [CI] 1.43 to 33.96; p = 0.02), warfarin use (OR 10.26, 95% CI 1.10 to 96.03; p = 0.02), and surgery outside the United States or Canada (OR 9.81, 95% CI 1.28 to 75.40; p = 0.03). Independent late stroke predictors: renal insufficiency (hazard ratio [HR] 3.57, 95% CI 1.01 to 12.64; p = 0.048), baseline low-density lipoprotein ≥105 mg/dl (HR 3.28, 95% CI 1.19 to 9.02; p = 0.02), and baseline diastolic blood pressure (each 1 mm Hg increase reduces stroke hazard by 5%; HR 0.95, 95% CI 0.91 to 0.99; p = 0.03). There was no overlap between predictors of perioperative versus late stroke. In conclusion, late post-CABG strokes were associated with well-described risk factors. Nearly half of the strokes were perioperative. Independent risk factors for perioperative stroke: previous stroke, previous warfarin use, and CABG performed outside the United States or Canada. Copyright © 2015 Elsevier Inc. All rights reserved.

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.

PubMed

Patel, Manesh R; Calhoon, John H; Dehmer, Gregory J; Grantham, James Aaron; Maddox, Thomas M; Maron, David J; Smith, Peter K

2017-10-01

The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes and stable ischemic heart disease (SIHD) were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing SIHD and acute coronary syndromes individually. This document presents the AUC for SIHD.Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status; risk level as assessed by noninvasive testing; coronary disease burden; and, in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy, are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.

Coronary angiography and myocardial revascularization following the first acute myocardial infarction in Norway during 2001-2009: Analyzing time trends and educational inequalities using data from the CVDNOR project.

PubMed

Sulo, Enxhela; Nygård, Ottar; Vollset, Stein Emil; Igland, Jannicke; Sulo, Gerhard; Ebbing, Marta; Egeland, Grace M; Hawkins, Nathaniel M; Tell, Grethe S

2016-06-01

We analyzed trends in the utilization of coronary angiography and revascularization - including percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) - related to the first AMI and explored potential educational inequalities in such procedures. All first AMI patients aged 35-89, hospitalized during 2001-2009 were retrieved from 'The Cardiovascular Disease in Norway' project. Information on education was obtained from The Norwegian Education Database. Gender and age group-specific trends in coronary procedures were analyzed using Joinpoint regression. Educational inequalities were explored using multivariable Poisson regression and reported as incidence rate ratios (IRR). A total of 104 836 patients (37.3% women) were included. Revascularization rates increased on average 9.0% and 15.4% per year among younger (35-64years) and older (65-89years) men. Corresponding increases among women were 5.6% and 16.6%. Compared to patients with primary education only, those with secondary and tertiary education had 8% (IRR=1.08, 95% CI; 1.06-1.10) and 12% (IRR=1.12, 95% CI; 1.09-1.14) higher revascularization rates. Educational inequalities were entirely driven by educational differences in receiving coronary angiography (IRR=1.10, 95% CI; 1.08-1.11 for secondary versus primary and IRR=1.14, 95% CI; 1.12-1.16 for tertiary versus primary education level.) Among diagnosed patients, no educational differences were observed in coronary revascularization rates. Revascularization rates increased whereas educational differences in revascularization decreased among AMI patients in Norway during 2001-2009. Lower coronary revascularization rates among patients with low education were explained by educational differences in receiving coronary angiography. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Fractional flow reserve by computerized tomography and subsequent coronary revascularization

PubMed Central

Packard, René R. Sevag; Li, Dong; Budoff, Matthew J.; Karlsberg, Ronald P.

2017-01-01

Aims Fractional flow reserve by computerized tomography (FFR-CT) provides non-invasive functional assessment of the hemodynamic significance of coronary artery stenosis. We determined the FFR-CT values, receiver operator characteristic (ROC) curves, and predictive ability of FFR-CT for actual standard of care guided coronary revascularization. Methods and results Consecutive outpatients who underwent coronary CT angiography (coronary CTA) followed by invasive angiography over a 24-month period from 2012 to 2014 were identified. Studies that fit inclusion criteria (n = 75 patients, mean age 66, 75% males) were sent for FFR-CT analysis, and results stratified by coronary artery calcium (CAC) scores. Coronary CTA studies were re-interpreted in a blinded manner, and baseline FFR-CT values were obtained retrospectively. Therefore, results did not interfere with clinical decision-making. Median FFR-CT values were 0.70 in revascularized (n = 69) and 0.86 in not revascularized (n = 138) coronary arteries (P < 0.001). Using clinically established significance cut-offs of FFR-CT ≤0.80 and coronary CTA ≥70% stenosis for the prediction of clinical decision-making and subsequent coronary revascularization, the positive predictive values were 74 and 88% and negative predictive values were 96 and 84%, respectively. The area under the curve (AUC) for all studied territories was 0.904 for coronary CTA, 0.920 for FFR-CT, and 0.941 for coronary CTA combined with FFR-CT (P = 0.001). With increasing CAC scores, the AUC decreased for coronary CTA but remained higher for FFR-CT (P < 0.05). Conclusion The addition of FFR-CT provides a complementary role to coronary CTA and increases the ability of a CT-based approach to identify subsequent standard of care guided coronary revascularization. PMID:27469588

Coronary Computed Tomographic Angiography-Derived Fractional Flow Reserve for Therapeutic Decision Making.

PubMed

Tesche, Christian; Vliegenthart, Rozemarijn; Duguay, Taylor M; De Cecco, Carlo N; Albrecht, Moritz H; De Santis, Domenico; Langenbach, Marcel C; Varga-Szemes, Akos; Jacobs, Brian E; Jochheim, David; Baquet, Moritz; Bayer, Richard R; Litwin, Sheldon E; Hoffmann, Ellen; Steinberg, Daniel H; Schoepf, U Joseph

2017-12-15

This study investigated the performance of coronary computed tomography angiography (cCTA) with cCTA-derived fractional flow reserve (CT-FFR) compared with invasive coronary angiography (ICA) with fractional flow reserve (FFR) for therapeutic decision making in patients with suspected coronary artery disease (CAD). Seventy-four patients (62 ± 11 years, 62% men) with at least 1 coronary stenosis of ≥50% on clinically indicated dual-source cCTA, who had subsequently undergone ICA with FFR measurement, were retrospectively evaluated. CT-FFR values were computed using an on-site machine-learning algorithm to assess the functional significance of CAD. The therapeutic strategy (optimal medical therapy alone vs revascularization) and the appropriate revascularization procedure (percutaneous coronary intervention vs coronary artery bypass grafting) were selected using cCTA-CT-FFR. Thirty-six patients (49%) had a functionally significant CAD based on ICA-FFR. cCTA-CT-FFR correctly identified a functionally significant CAD and the need of revascularization in 35 of 36 patients (97%). When revascularization was deemed indicated, the same revascularization procedure (32 percutaneous coronary interventions and 3 coronary artery bypass grafting) was chosen in 35 of 35 patients (100%). Overall, identical management strategies were selected in 73 of the 74 patients (99%). cCTA-CT-FFR shows excellent performance to identify patients with and without the need for revascularization and to select the appropriate revascularization strategy. cCTA-CT-FFR as a noninvasive "one-stop shop" has the potential to change diagnostic workflows and to directly inform therapeutic decision making in patients with suspected CAD. Copyright © 2017 Elsevier Inc. All rights reserved.

B-Type Natriuretic Peptide Assessment in Patients Undergoing Revascularization for Left Main Coronary Artery Disease: Analysis from the EXCEL Trial.

PubMed

Redfors, Björn; Chen, Shmuel; Crowley, Aaron; Ben-Yehuda, Ori; Gersh, Bernard J; Lembo, Nicholas J; Brown, W Morris; Banning, Adrian P; Taggart, David P; Serruys, Patrick W; Kappetein, Arie Pieter; Sabik, Joseph F; Stone, Gregg W

2018-04-17

Background -Elevated B-type natriuretic peptide (BNP) is reflective of impaired cardiac function and is associated with worse prognosis among patients with coronary artery disease (CAD). We sought to assess the association between baseline BNP, adverse outcomes, and the relative efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with left main (LM) CAD. Methods -The EXCEL trial randomized patients with LMCAD and low or intermediate SYNTAX scores to PCI with everolimus-eluting stents versus CABG. The primary endpoint was the composite of all-cause death, myocardial infarction (MI) or stroke. We used multivariable Cox proportional hazards regression to assess the associations between normal versus elevated BNP (≥100 pg/mL), randomized treatment, and the 3-year risk of adverse events. Results -BNP at baseline was elevated in 410 of 1037 (39.5%) patients enrolled in EXCEL. Patients with elevated BNP levels were older and more frequently had additional cardiovascular risk factors and lower LVEF than those with normal BNP, but had similar SYNTAX scores. Patients with elevated BNP had significantly higher 3-year rates of the primary endpoint (18.6% vs. 11.7%, adjusted HR 1.62, 95% CI 1.16-2.28, P=0.005), and higher mortality (11.5% vs. 3.9%, adjusted HR 2.49, 95% CI 1.48-4.19, P=0.0006), both from cardiovascular and non-cardiovascular causes. In contrast, there were no significant differences in the risks of MI, stroke, ischemia-driven revascularization, stent thrombosis, graft occlusion, or major bleeding. A significant interaction (P interaction =0.03) was present between elevated versus normal BNP and treatment with PCI versus CABG for the adjusted risk of the primary composite endpoint at 3 years among patients with elevated BNP (adjusted HR for PCI versus CABG 1.54, 95% CI 0.96-2.47) versus normal BNP (adjusted HR 0.74, 95% CI 0.46-1.20). This interaction was stronger when log(BNP) was modeled as a continuous variable (P interaction =0.002). Conclusions -In the EXCEL trial, elevated baseline BNP levels in patients with LMCAD undergoing revascularization were independently associated with long-term mortality but not non-fatal adverse ischemic or bleeding events. The relative long-term outcomes after PCI vs. CABG for revascularization of LMCAD may be conditioned by the baseline BNP level. Clinical Trial Registration -URL: http://www.clinicaltrials.gov. Unique identifier: NCT01205776.

A randomized trial of therapies for type 2 diabetes and coronary artery disease.

PubMed

Frye, Robert L; August, Phyllis; Brooks, Maria Mori; Hardison, Regina M; Kelsey, Sheryl F; MacGregor, Joan M; Orchard, Trevor J; Chaitman, Bernard R; Genuth, Saul M; Goldberg, Suzanne H; Hlatky, Mark A; Jones, Teresa L Z; Molitch, Mark E; Nesto, Richard W; Sako, Edward Y; Sobel, Burton E

2009-06-11

Optimal treatment for patients with both type 2 diabetes mellitus and stable ischemic heart disease has not been established. We randomly assigned 2368 patients with both type 2 diabetes and heart disease to undergo either prompt revascularization with intensive medical therapy or intensive medical therapy alone and to undergo either insulin-sensitization or insulin-provision therapy. Primary end points were the rate of death and a composite of death, myocardial infarction, or stroke (major cardiovascular events). Randomization was stratified according to the choice of percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG) as the more appropriate intervention. At 5 years, rates of survival did not differ significantly between the revascularization group (88.3%) and the medical-therapy group (87.8%, P=0.97) or between the insulin-sensitization group (88.2%) and the insulin-provision group (87.9%, P=0.89). The rates of freedom from major cardiovascular events also did not differ significantly among the groups: 77.2% in the revascularization group and 75.9% in the medical-treatment group (P=0.70) and 77.7% in the insulin-sensitization group and 75.4% in the insulin-provision group (P=0.13). In the PCI stratum, there was no significant difference in primary end points between the revascularization group and the medical-therapy group. In the CABG stratum, the rate of major cardiovascular events was significantly lower in the revascularization group (22.4%) than in the medical-therapy group (30.5%, P=0.01; P=0.002 for interaction between stratum and study group). Adverse events and serious adverse events were generally similar among the groups, although severe hypoglycemia was more frequent in the insulin-provision group (9.2%) than in the insulin-sensitization group (5.9%, P=0.003). Overall, there was no significant difference in the rates of death and major cardiovascular events between patients undergoing prompt revascularization and those undergoing medical therapy or between strategies of insulin sensitization and insulin provision. (ClinicalTrials.gov number, NCT00006305.) 2009 Massachusetts Medical Society

Applying the payoff time framework to carotid artery disease management.

PubMed

Yuo, Theodore H; Roberts, Mark S; Braithwaite, R Scott; Chang, Chung-Chou H; Kraemer, Kevin L

2013-11-01

and Asymptomatic stenosis of the carotid arteries is associated with stroke. Carotid revascularization can reduce the future risk of stroke but can also trigger an immediate stroke. The objective was to model the generic relationship between immediate risk, long-term benefit, and life expectancy for any one-time prophylactic treatment and then apply the model to the use of revascularization in the management of asymptomatic carotid disease. In the "payoff time" framework, the possibility of losing quality-adjusted life-years (QALYs) because of revascularization failure is conceptualized as an "investment" that is eventually recouped over time, on average. Using this framework, we developed simple mathematical forms that define relationships between the following: perioperative probability of stroke (P); annual stroke rate without revascularization (r0); annual stroke rate after revascularization, conditional on not having suffered perioperative stroke (r1); utility levels assigned to the asymptomatic state (ua) and stroke state (us); and mortality rates (λ). In patients whose life expectancy is below a critical life expectancy (CLE = P/(1-P)r0-r1, the "investment" will never pay off, and revascularization will lead to loss of QALYs, on average. CLE is independent of utilities assigned to the health states if a rank ordering exists in which ua > us. For clinically relevant values (P = 3%, r0 = 1%, r1 = 0.5%), the CLE is approximately 6.4 years, which is longer than published guidelines regarding patient selection for revascularization. In managing asymptomatic carotid disease, the payoff time framework specifies a CLE beneath which patients, on average, will not benefit from revascularization. This formula is suitable for clinical use at the patient's bedside and can account for patient variability, the ability of clinicians who perform revascularization, and the particular revascularization technology that is chosen.

Weighting Composite Endpoints in Clinical Trials: Essential Evidence for the Heart Team

PubMed Central

Tong, Betty C.; Huber, Joel C.; Ascheim, Deborah D.; Puskas, John D.; Ferguson, T. Bruce; Blackstone, Eugene H.; Smith, Peter K.

2013-01-01

Background Coronary revascularization trials often use a composite endpoint of major adverse cardiac and cerebrovascular events (MACCE). The usual practice in analyzing data with a composite endpoint is to assign equal weights to each of the individual MACCE elements. Non-inferiority margins are used to offset effects of presumably less important components, but their magnitudes are subject to bias. This study describes the relative importance of MACCE elements from a patient perspective. Methods A discrete choice experiment was conducted. Survey respondents were presented with a scenario that would make them eligible for the SYNTAX 3-Vessel Disease cohort. Respondents chose among pairs of procedures that differed on the 3-year probability of MACCE, potential for increased longevity, and procedure/recovery time. Conjoint analysis derived relative weights for these attributes. Results In all, 224 respondents completed the survey. The attributes did not have equal weight. Risk of death was most important (relative weight 0.23), followed by stroke (.18), potential increased longevity and recovery time (each 0.17), MI (0.14) and risk of repeat revascularization (0.11). Applying these weights to the SYNTAX 3-year endpoints resulted in a persistent, but decreased margin of difference in MACCE favoring CABG compared to PCI. When labeled only as “Procedure A” and “B,” 87% of respondents chose CABG over PCI. When procedures were labeled as “Coronary Stent” and “Coronary Bypass Surgery,” only 73% chose CABG. Procedural preference varied with demographics, gender and familiarity with the procedures. Conclusions MACCE elements do not carry equal weight in a composite endpoint, from a patient perspective. Using a weighted composite endpoint increases the validity of statistical analyses and trial conclusions. Patients are subject to bias by labels when considering coronary revascularization. PMID:22795064

Incidence and outcome of surgical procedures after coronary artery bypass grafting compared with those after percutaneous coronary intervention: a report from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2.

PubMed

Tokushige, Akihiro; Shiomi, Hiroki; Morimoto, Takeshi; Ono, Koh; Furukawa, Yutaka; Nakagawa, Yoshihisa; Kadota, Kazushige; Ando, Kenji; Shizuta, Satoshi; Tada, Tomohisa; Tazaki, Junichi; Kato, Yoshihiro; Hayano, Mamoru; Abe, Mitsuru; Hamasaki, Shuichi; Ohishi, Mitsuru; Nakashima, Hitoshi; Mitsudo, Kazuaki; Nobuyoshi, Masakiyo; Kita, Toru; Imoto, Yutaka; Sakata, Ryuzo; Okabayashi, Hitoshi; Hanyu, Michiya; Shimamoto, Mitsuomi; Nishiwaki, Noboru; Komiya, Tatsuhiko; Kimura, Takeshi

2014-08-01

Noncardiac surgery after percutaneous coronary intervention (PCI) has been reported to be carrying high risk for both ischemic and bleeding complications. However, there has been no report comparing the incidence and outcomes of surgical procedures after coronary artery bypass grafting (CABG) with those after PCI. Among 14 383 patients undergoing first coronary revascularization (PCI, n=12 207; CABG, n=2176) enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) PCI/CABG Registry Cohort-2, surgical procedures were performed more frequently after CABG (n=560) than after PCI (n=2398; cumulative 3-year incidence: 27% versus 22%; unadjusted P<0.0001), particularly <6 months of coronary revascularization. The risk for the primary ischemic outcome measure (death/myocardial infarction) at 30-day postsurgical procedures was not significantly different between the CABG and PCI groups (cumulative incidence: 3.1% versus 3.2%; unadjusted P=0.9; adjusted hazard ratio, 0.97; 95% confidence interval, 0.47-1.89; P=0.9). The risk for the primary bleeding outcome measure (moderate or severe bleeding by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries classification) was lower in the CABG groups than in the PCI group (cumulative incidence: 1.3% versus 2.6%; unadjusted P=0.07; adjusted hazard ratio, 0.36; 95% confidence interval, 0.12-0.87; P=0.02). There were no interactions between the timing of surgery and the types of coronary revascularization (CABG/PCI) for both ischemic and bleeding outcomes. Surgical procedures were performed significantly more frequently after CABG than after PCI, particularly <6 months after coronary revascularization. Surgical procedures after CABG as compared with those after PCI were associated with similar risk for ischemic events and lower risk for bleeding events, regardless of the timing after coronary revascularization. © 2014 American Heart Association, Inc.

Developing a new hybrid revascularization program: a road map for hospital managers and physician leaders.

PubMed

Harjai, Kishore J; Samy, Sanjay; Pennypacker, Barbara; Onofre, Bonnie; Stanfield, Pamela; Yaeger, Lynne; Stapleton, Dwight; Esrig, Barry C

2012-12-01

Hybrid coronary revascularization, which involves minimally invasive direct coronary artery bypass surgery using the left internal mammary artery to left anterior descending and percutaneous coronary intervention using drug-eluting stents for the remaining diseased coronary vessels, is an innovative approach to decrease the morbidity of conventional surgery. Little information is available to guide hospital managers and physician leaders in implementing a hybrid revascularization program. In this article, we describe the people-process-technology issues that managers and leaders are likely to encounter as they develop a hybrid revascularization program in their practice. ©2012, Wiley Periodicals, Inc.

Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials

PubMed Central

2018-01-01

Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials. PMID:29856140

Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials.

PubMed

Al-Hijji, Mohammed; El Sabbagh, Abdallah; Holmes, David R

2018-06-01

Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials. Copyright © 2018. The Korean Society of Cardiology.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with end-stage renal disease requiring dialysis (5-year outcomes of the CREDO-Kyoto PCI/CABG Registry Cohort-2).

PubMed

Marui, Akira; Kimura, Takeshi; Nishiwaki, Noboru; Mitsudo, Kazuaki; Komiya, Tatsuhiko; Hanyu, Michiya; Shiomi, Hiroki; Tanaka, Shiro; Sakata, Ryuzo

2014-08-15

Ischemic heart disease is a major risk factor for morbidity and mortality in patients with end-stage renal disease. However, long-term benefits of percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in those patients is still unclear in the drug-eluting stent era. We identified 388 patients with multivessel and/or left main disease with end-stage renal disease requiring dialysis among 15,939 patients undergoing first coronary revascularization enrolled in the Coronary REvascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (PCI: 258 patients and CABG: 130 patients). The CABG group included more patients with 3-vessel (38% vs 57%, p <0.001) and left main disease (10% vs 34%, p <0.001). Preprocedural Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score in the CABG group was significantly higher than that in the PCI group (23.5 ± 8.7 vs 29.4 ± 11.0, p <0.001). Unadjusted 30-day mortality was 2.7% for PCI and 5.4% for CABG. Cumulative 5-year all-cause mortality was 52.3% for PCI and 49.9% for CABG. Propensity score-adjusted all-cause mortality was not different between PCI and CABG (hazard ratio [HR] 1.33, 95% confidence interval [CI] 0.85 to 2.09, p = 0.219). However, the excess risk of PCI relative to CABG for cardiac death was significant (HR 2.10, 95% CI 1.11 to 3.96, p = 0.02). The risk of sudden death was also higher after PCI (HR 4.83, 95% CI 1.01 to 23.08, p = 0.049). The risk of myocardial infarction after PCI tended to be higher than after CABG (HR 3.30, 95% CI 0.72 to 15.09, p = 0.12). The risk of any coronary revascularization after PCI was markedly higher after CABG (HR 3.78, 95% CI 1.91 to 7.50, p <0.001). Among the 201 patients who died during the follow-up, 94 patients (47%) died from noncardiac morbidities such as stroke, respiratory failure, and renal failure. In patients with multivessel and/or left main disease undergoing dialysis, 5-year outcomes revealed that CABG relative to PCI reduced the risk of cardiac death, sudden death, myocardial infarction, and any revascularization. However, the risk of all-cause death was not different between PCI and CABG. Copyright © 2014 Elsevier Inc. All rights reserved.

Is there an additional benefit from coronary revascularization in diabetic patients with acute coronary syndromes or stable angina who are already on optimal medical treatment?

PubMed Central

Athyros, Vasilios G.; Gossios, Thomas D.; Tziomalos, Konstantinos; Florentin, Matilda; Karagiannis, Asterios

2011-01-01

Cardiovascular disease (CVD) is common in patients with diabetes mellitus (DM) and related clinical outcomes are worse compared with non-diabetics. The optimal treatment in diabetic patients with coronary heart disease (CHD) is currently not established. We searched MEDLINE (1975-2010) using the key terms diabetes mellitus, coronary heart disease, revascularization, coronary artery bypass, angioplasty, coronary intervention and medical treatment. Most studies comparing different revascularization procedures in patients with CHD favoured coronary artery bypass graft (CABG) surgery in patients with DM. However, most of this evidence comes from subgroup analyses. Recent evidence suggests that advanced percutaneous coronary intervention (PCI) techniques along with best medical treatment may be non-inferior and more cost-effective compared with CABG. Treatment of vascular risk factors is a key option in terms of improving CVD outcomes in diabetic patients with CHD. The choice between medical therapy and revascularization warrants further assessment. PMID:22328892

Benefits of off-pump coronary artery bypass grafting in high-risk patients.

PubMed

Marui, Akira; Okabayashi, Hitoshi; Komiya, Tatsuhiko; Tanaka, Shiro; Furukawa, Yutaka; Kita, Toru; Kimura, Takeshi; Sakata, Ryuzo

2012-09-11

The benefits of off-pump coronary artery bypass graft (OPCAB) compared with conventional on-pump coronary artery bypass graft (CCAB) remain controversial. Thus, it is important to investigate which patient subgroups may benefit the most from OPCAB rather than CCAB. Among the patients undergoing first coronary revascularization enrolled in the CREDO-Kyoto Registry (a registry of first-time percutaneous coronary intervention and coronary artery bypass graft patients in Japan), 2468 patients undergoing coronary artery bypass graft were entered into the study (mean age, 67 ± 9 years). Predicted risk of operative mortality (PROM) of each patient was calculated by logistic EuroSCORE. Patients were divided into tertile based on their PROM. Mortality rates and the incidences of cardiovascular events were compared between CCAB and OPCAB within each PROM tertile using propensity score analysis. A total of 1377 patients received CCAB whereas 1091 received OPCAB. Adjusted 30-day mortality was not significantly different between CCAB and OPCAB patients regardless of their PROM range. However, the odds ratio of 30-day stroke in CCAB compared with OPCAB in the high-risk tertile was 8.30 (95% confidence interval, 2.25-30.7; P<0.01). Regarding long-term outcomes, hazard ratio of stroke in CCAB compared with OPCAB in the high-risk tertile was 1.80 (95% confidence interval, 1.07-3.02; P=0.03). Nevertheless, hazard ratio of overall mortality in the high-risk tertile was 1.44 (95% confidence interval, 0.98-2.11; P=0.06), indicating no statistically significant difference between the 2 procedures. OPCAB as opposed to CCAB is associated with short-term and long-term benefits in stroke prevention in patients at higher risk as estimated by EuroSCORE. No survival benefit of OPCAB was shown regardless of preoperative risk level.

Clinical relevance of coronary angiography at the time of percutaneous closure of a patent foramen ovale.

PubMed

Wahl, Andreas; Praz, Fabien; Seiler, Christian; Windecker, Stephan; Meier, Bernhard

2007-11-01

The value of incidental coronary angiography during percutaneous shunt closure to screen for asymptomatic coronary artery disease (CAD) is unknown. On the occasion of percutaneous closure of patent foramen ovale (PFO), incidental coronary angiography routinely offered to men >40 and women >50 years, or younger patients with particular risk patterns, was performed in 575 patients (64% men, mean age 55 +/- 10 years, mean 1.5 +/- 1.1 cardiovascular risk factors) without overt history, signs, or symptoms of CAD. CAD was found in 164 patients (29%); 53 (9%) had >or=50% diameter stenoses. Thirty patients (5%) had one-vessel, 13 (2%) two-vessel, and 10 (2%) three-vessel disease. Patients with CAD (n = 164) were older (60 +/- 9 vs. 53 +/- 10 years; P < 0.0001), more frequently male (76% vs. 59%; P = 0.0002), and had a higher body mass index (26.5 +/- 4.0 vs. 25.4 +/- 4.6; P = 0.006) and more cardiovascular risk factors (2.0 +/- 1.1 vs. 1.2 +/- 1.0; P < 0.0001). There were six procedural complications (1%). Two were unequivocally related to coronary angiography: one minor stroke (diplopia), and one iatrogenic dissection of the right coronary ostium requiring stenting. Furthermore, four arteriovenous fistulae at the puncture site requiring elective surgical closure were possibly related to coronary angiography. Forty-five patients (8% of total) underwent percutaneous (n = 43) or surgical (n = 2) revascularization. In selected asymptomatic patients referred for percutaneous PFO closure, incidental coronary angiography discloses a rather high prevalence of clinically unsuspected CAD. These findings are relevant not only for timely revascularization but also for maintenance of long-term antiplatelet therapy beyond the few months recommended after PFO closure. (c) 2007 Wiley-Liss, Inc.

ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography.

PubMed

Patel, Manesh R; Dehmer, Gregory J; Hirshfeld, John W; Smith, Peter K; Spertus, John A

2012-02-28

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally,percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography.

PubMed

Patel, Manesh R; Dehmer, Gregory J; Hirshfeld, John W; Smith, Peter K; Spertus, John A; Masoudi, Frederick A; Dehmer, Gregory J; Patel, Manesh R; Smith, Peter K; Chambers, Charles E; Ferguson, T Bruce; Garcia, Mario J; Grover, Frederick L; Holmes, David R; Klein, Lloyd W; Limacher, Marian C; Mack, Michael J; Malenka, David J; Park, Myung H; Ragosta, Michael; Ritchie, James L; Rose, Geoffrey A; Rosenberg, Alan B; Russo, Andrea M; Shemin, Richard J; Weintraub, William S; Wolk, Michael J; Bailey, Steven R; Douglas, Pamela S; Hendel, Robert C; Kramer, Christopher M; Min, James K; Patel, Manesh R; Shaw, Leslee; Stainback, Raymond F; Allen, Joseph M

2012-04-01

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

Current indications for left thoracotomy in coronary revascularization and valvular procedures.

PubMed

Pratt, J W; Williams, T E; Michler, R E; Brown, D A

2000-10-01

Left thoracotomy is infrequently used for cardiac procedures, but its application in reoperative and minimally invasive coronary revascularization and in valvular procedures has been reported recently. Three case reports and a review of the current literature illustrate the unique benefits of this approach for myocardial revascularization and valve replacement. Reoperative coronary revascularization of the left anterior descending and circumflex coronary arteries was performed off-pump via a left posterolateral thoracotomy. For the second case, this approach was used for coronary artery bypass grafting of the right coronary and left anterior descending arteries with femoral-femoral cardiopulmonary bypass in a patient with congestive heart failure and coronary artery disease who also required closure of a patent ductus arteriosus. In the third case, mitral valve replacement using femoral venous and aortic cannulation for cardiopulmonary bypass was performed via a left thoracotomy to avoid a retrosternal gastric conduit in a patient with severe mitral stenosis and congestive heart failure. All patients returned to normal activity and are asymptomatic. These case reports and a comprehensive review of the literature demonstrate the utility of left thoracotomy as an alternative approach to standard median sternotomy in selected cases of revascularization and valvular procedures.

Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes.

PubMed

Valgimigli, Marco; Frigoli, Enrico; Leonardi, Sergio; Rothenbühler, Martina; Gagnor, Andrea; Calabrò, Paolo; Garducci, Stefano; Rubartelli, Paolo; Briguori, Carlo; Andò, Giuseppe; Repetto, Alessandra; Limbruno, Ugo; Garbo, Roberto; Sganzerla, Paolo; Russo, Filippo; Lupi, Alessandro; Cortese, Bernardo; Ausiello, Arturo; Ierna, Salvatore; Esposito, Giovanni; Presbitero, Patrizia; Santarelli, Andrea; Sardella, Gennaro; Varbella, Ferdinando; Tresoldi, Simone; de Cesare, Nicoletta; Rigattieri, Stefano; Zingarelli, Antonio; Tosi, Paolo; van 't Hof, Arnoud; Boccuzzi, Giacomo; Omerovic, Elmir; Sabaté, Manel; Heg, Dik; Jüni, Peter; Vranckx, Pascal

2015-09-10

Conflicting evidence exists on the efficacy and safety of bivalirudin administered as part of percutaneous coronary intervention (PCI) in patients with an acute coronary syndrome. We randomly assigned 7213 patients with an acute coronary syndrome for whom PCI was anticipated to receive either bivalirudin or unfractionated heparin. Patients in the bivalirudin group were subsequently randomly assigned to receive or not to receive a post-PCI bivalirudin infusion. Primary outcomes for the comparison between bivalirudin and heparin were the occurrence of major adverse cardiovascular events (a composite of death, myocardial infarction, or stroke) and net adverse clinical events (a composite of major bleeding or a major adverse cardiovascular event). The primary outcome for the comparison of a post-PCI bivalirudin infusion with no post-PCI infusion was a composite of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events. The rate of major adverse cardiovascular events was not significantly lower with bivalirudin than with heparin (10.3% and 10.9%, respectively; relative risk, 0.94; 95% confidence interval [CI], 0.81 to 1.09; P=0.44), nor was the rate of net adverse clinical events (11.2% and 12.4%, respectively; relative risk, 0.89; 95% CI, 0.78 to 1.03; P=0.12). Post-PCI bivalirudin infusion, as compared with no infusion, did not significantly decrease the rate of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events (11.0% and 11.9%, respectively; relative risk, 0.91; 95% CI, 0.74 to 1.11; P=0.34). In patients with an acute coronary syndrome, the rates of major adverse cardiovascular events and net adverse clinical events were not significantly lower with bivalirudin than with unfractionated heparin. The rate of the composite of urgent target-vessel revascularization, definite stent thrombosis, or net adverse clinical events was not significantly lower with a post-PCI bivalirudin infusion than with no post-PCI infusion. (Funded by the Medicines Company and Terumo Medical; MATRIX ClinicalTrials.gov number, NCT01433627.).

Percutaneous Coronary Intervention in Severely Calcified Unprotected Left Main Coronary Artery Disease: Initial Experience With Orbital Atherectomy.

PubMed

Lee, Michael S; Shlofmitz, Evan; Kaplan, Barry; Shlofmitz, Richard

2016-04-01

We report the clinical outcomes of patients who underwent percutaneous coronary intervention (PCI) with orbital atherectomy for severely calcified unprotected left main coronary artery (ULMCA) disease. Although surgical revascularization is the gold standard for patients with ULMCA disease, not all patients are candidates for this. PCI is increasingly used to treat complex coronary artery disease, including ULMCA disease. The presence of severely calcified lesions increases the complexity of PCI. Orbital atherectomy can be used to facilitate stent delivery and expansion in severely calcified lesions. The clinical outcomes of patients treated with orbital atherectomy for severely calcified ULMCA disease have not been reported. From May 2014 to July 2015, a total of 14 patients who underwent PCI with orbital atherectomy for ULMCA disease were retrospectively evaluated. The primary endpoint was major cardiac and cerebrovascular event (cardiac death, myocardial infarction, stroke, and target-lesion revascularization) at 30 days. The mean age was 78.2 ± 5.8 years. The mean ejection fraction was 41.8 ± 19.8%. Distal bifurcation disease was present in 9 of 14 patients. Procedural success was achieved in all 14 patients. The 30-day major adverse cardiac and cerebrovascular event rate was 0%. One patient had coronary dissection that was successfully treated with stenting. No patient had perforation, slow flow, or thrombosis. Orbital atherectomy in patients with severely calcified ULMCA disease is feasible, even in high-risk patients who were considered poor surgical candidates. Randomized trials are needed to determine the role of orbital atherectomy in ULMCA disease.

Evaluation of Mediterranean diet adherence in patients with a history of coronary revascularization.

PubMed

Acar, B; Gucuk Ipek, E; Unal, S; Yayla, C; Karanfil, M; Burak, C; Kara, M; Bayraktar, F; Kuyumcu, M S; Aydogdu, S

Lifestyle modification is an important component of the secondary prevention strategies; and a healthy diet is one of the cornerstones in management of the coronary heart disease. We aimed to investigate the dietary habits of the patients with history of coronary revascularization, characteristics of the ones with good adherence by using alternate MedDiet questionnaire. We included outpatients who had a history of coronary revascularization at least 6 months prior to enrollment. Each participant filled out a questionnaire to collect the data of demographics and clinical characteristics. Alternate MedDiet score was calculated to evaluate the Mediterranean style dietary adherence. Alternate MedDiet was originally based on 14-item questionnaire; we adjusted it to our population (max 13 points). We enrolled 226 consecutive outpatients (age 61.7±10.9 years, 72% males). The median duration after revascularization was 60 months. A total of 112 (49.6%) patients had previous percutaneous coronary intervention (PCI), 77 (34.1%) had coronary by-pass graft surgery (CABG), and 36 (15.9%) had both revascularization procedures. The median MedDiet score was 6. Patients were stratified into two subgroups (MedDiet score ≥7 vs. <7). A total of 61 (26.9%) patients had MedDiet score ≥7. By univariate analysis, good MedDiet scores were associated with older age, waist circumference, body mass index, high education level, regular follow-up, duration after first revascularization and revascularization with CABG+PCI. In the multivariate analysis, high education level (P=.002, OR=8.212, 95%CI: 2.155-31.291) and duration after revascularization (P=.034, OR=1.007, 95%CI: 1.001-1.013) were independent predictors of good MedDiet scores. The adherence rate to a healthy diet was low in patients with previous coronary revascularization. MedDiet score seems to be practical and useful item to evaluate the dietary habits in outpatient setting. Mediterranean diet adherence rates were associated with high education level, and duration after revascularization. Copyright © 2018 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.

Differential Event Rates and Independent Predictors of Long-Term Major Cardiovascular Events and Death in 5795 Patients With Unprotected Left Main Coronary Artery Disease Treated With Stents, Bypass Surgery, or Medication: Insights From a Large International Multicenter Registry.

PubMed

Kang, Se Hun; Ahn, Jung-Min; Lee, Cheol Hyun; Lee, Pil Hyung; Kang, Soo-Jin; Lee, Seung-Whan; Kim, Young-Hak; Lee, Cheol Whan; Park, Seong-Wook; Park, Duk-Woo; Park, Seung-Jung

2017-07-01

Identifying predictive factors for major cardiovascular events and death in patients with unprotected left main coronary artery disease is of great clinical value for risk stratification and possible guidance for tailored preventive strategies. The Interventional Research Incorporation Society-Left MAIN Revascularization registry included 5795 patients with unprotected left main coronary artery disease (percutaneous coronary intervention, n=2850; coronary-artery bypass grafting, n=2337; medication alone, n=608). We analyzed the incidence and independent predictors of major adverse cardiac and cerebrovascular events (MACCE; a composite of death, MI, stroke, or repeat revascularization) and all-cause mortality in each treatment stratum. During follow-up (median, 4.3 years), the rates of MACCE and death were substantially higher in the medical group than in the percutaneous coronary intervention and coronary-artery bypass grafting groups ( P <0.001). In the percutaneous coronary intervention group, the 3 strongest predictors for MACCE were chronic renal failure, old age (≥65 years), and previous heart failure; those for all-cause mortality were chronic renal failure, old age, and low ejection fraction. In the coronary-artery bypass grafting group, old age, chronic renal failure, and low ejection fraction were the 3 strongest predictors of MACCE and death. In the medication group, old age, low ejection fraction, and diabetes mellitus were the 3 strongest predictors of MACCE and death. Among patients with unprotected left main coronary artery disease, the key clinical predictors for MACCE and death were generally similar regardless of index treatment. This study provides effect estimates for clinically relevant predictors of long-term clinical outcomes in real-world left main coronary artery patients, providing possible guidance for tailored preventive strategies. URL: https://clinicaltrials.gov. Unique identifier: NCT01341327. © 2017 American Heart Association, Inc.

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.

PubMed

Patel, Manesh R; Calhoon, John H; Dehmer, Gregory J; Grantham, James Aaron; Maddox, Thomas M; Maron, David J; Smith, Peter K

2017-04-01

The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes (ACS) and stable ischemic heart disease were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and in an effort to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing ACS and stable ischemic heart disease individually. This document presents the AUC for ACS. Clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, presence of clinical instability or ongoing ischemic symptoms, prior reperfusion therapy, risk level as assessed by noninvasive testing, fractional flow reserve testing, and coronary anatomy. This update provides a reassessment of clinical scenarios that the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range (4 to 6) indicate that coronary revascularization may be appropriate for the clinical scenario. Seventeen clinical scenarios were developed by a writing committee and scored by the rating panel: 10 were identified as appropriate, 6 as may be appropriate, and 1 as rarely appropriate. As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction were considered appropriate. Likewise, clinical scenarios with unstable angina and intermediate- or high-risk features were deemed appropriate. Additionally, the management of nonculprit artery disease and the timing of revascularization are now also rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.

Translation, adaptation and validation of the Coronary Revascularization Outcome Questionnaire into Greek.

PubMed

Takousi, Maria G; Schmeer, Stefanie; Manaras, Irene; Olympios, Christoforos D; Fakiolas, Constantine N; Makos, Georgios; Troop, Nick A

2016-04-01

Evaluating the impact of coronary revascularization on patients' health related quality of life with a patient-based and disease-specific tool is important for drawing conclusions about treatment and outcomes. This study reports on the translation, adaptation and psychometric evaluation of a Greek version of the Coronary Revascularization Outcome Questionnaire (CROQ-Gr). A total of 609 (81.7% male) patients who had undergone coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting) were recruited from four hospitals in Athens. After translating the CROQ into Greek, a preliminary qualitative study and a pilot quantitative study were conducted. A full psychometric evaluation was carried out on the main study's data. The psychometric evaluation demonstrated that the CROQ-Gr is acceptable to patients (high response rate, low missing data) and has a good level of reliability (internal consistency >0.70, test-retest reliability >0.90) and validity (both content and construct validity). The results of this study show the CROQ-Gr to be a psychometrically rigorous patient-based measure of outcomes of coronary revascularization. It would be appropriate for use in evaluative research as well as a routine clinical tool to aid cardiologists in monitoring the outcomes of care. © The European Society of Cardiology 2015.

Likelihood of myocardial infarction during stroke rehabilitation preceded by cardiovascular screening and an exercise tolerance test: the Locomotor Experience Applied Post-Stroke (LEAPS) trial.

PubMed

Nadeau, Stephen E; Rose, Dorian Kay; Dobkin, Bruce; Wu, Samuel S; Dai, Yufeng E; Schofield, Richard; Duncan, Pamela W

2014-12-01

Coronary artery disease is highly prevalent in patients with stroke, but because revascularization does not improve major clinical outcomes in patients with stable coronary artery disease relative to intensive medical therapy, routine evaluation for this disease is not warranted in stroke patients. However, it might be warranted in patients destined to undergo vigorous physical therapy. The Locomotor Experience Applied Post-Stroke study, a randomized controlled trial of 408 participants that tested the relative efficacy of two rehabilitation techniques on functional walking level, provided the opportunity to address this question. The study aims to test the efficacy of screening for cardiovascular disease and an exercise tolerance test in assuring safety among patients undergoing vigorous rehabilitation for gait impairment. All participants were screened for serious cardiovascular and pulmonary conditions. At six-weeks poststroke, they also completed a cardiovascular screening inventory and underwent an exercise tolerance test involving bicycle ergometry. Participants received 36, 90-min sessions of a prescribed physical therapy (three per week), initiated at either two-months or six-months poststroke. Twenty-nine participants were excluded on the basis of the cardiac screening questionnaire, and 15 failed the exercise tolerance test for cardiovascular reasons. No participant experienced a cardiac event during a treatment session. Two participants experienced myocardial infarctions, but continued in the trial. In three additional participants, myocardial infarctions caused or contributed to death. The combination of a negative cardiac screen and the absence of exercise tolerance test failure appeared to have a high negative predictive value for cardiac events during treatment, despite the likelihood of a high prevalence of coronary artery disease in our population. © 2014 World Stroke Organization.

Carotid arterial wall characteristics are associated with incident ischemic stroke but not coronary heart disease in the ARIC Study

PubMed Central

Yang, Eric Y.; Chambless, Lloyd; Sharrett, A. Richey; Virani, Salim S.; Liu, Xiaoxi; Tang, Zhengzheng; Boerwinkle, Eric; Ballantyne, Christie M.; Nambi, Vijay

2011-01-01

Background and Purpose Ultrasound measurements of arterial stiffness are associated with atherosclerosis risk factors, but limited data exist on their association with incident cardiovascular events. We evaluated the association of carotid ultrasound derived arterial stiffness measures with incident coronary heart disease (CHD) and ischemic stroke in the ARIC study. Methods Carotid arterial strain (CAS) and compliance (AC), distensibility (AD) and stiffness indices (SI), pressure-strain (Ep) and Young’s elastic moduli (YEM) were measured in 10,407 individuals using ultrasound. Hazard ratios for incident CHD (myocardial infarction [MI], fatal CHD, coronary revascularization) and stroke in minimally adjusted (age, sex, center, race) and fully adjusted models (minimally adjusted model + diabetes, height, weight, total cholesterol, high-density lipoprotein cholesterol, tobacco use, systolic blood pressure, antihypertensive medication use, and carotid intima-media thickness (CIMT) were calculated. Results The mean age was 55.3 years. Over a mean follow up of 13.8 years, 1,267 incident CHD and 383 ischemic stroke events occurred. After full adjustment for risk factors and CIMT, all arterial stiffness parameters [CAS HR (95% confidence interval [CI]) =1.14 (1.02, 1.28); AD HR=1.19 (1.02, 1.39); SI HR=1.14 (1.04, 1.25); Ep HR=1.17 (1.06, 1.28); YEM HR=1.13 (1.03, 1.24)], except arterial compliance HR=1.02 (0.90, 1.16), were significantly associated with incident stroke but not with CHD. Conclusions After adjusting for cardiovascular risk factors, ultrasound measures of carotid arterial stiffness are associated with incident ischemic stroke but not incident CHD events, despite that the 2 outcomes sharing similar risk factors. PMID:22033999

Management and decision-making process leading to coronary angiography and revascularization in octogenarians with coronary artery disease: Insights from a large single-center registry.

PubMed

Martin, Anne-Céline; Dumas, Florence; Spaulding, Christian; Manzo-Silberman, Stéphane

2015-05-01

Cardiovascular diseases remain the most common cause of death in older adults. Guidelines state that advanced age alone should not limit the use of invasive therapy. However, coronary angiograms and subsequent revascularization are often not carried out in octogenarians. The benefit/risk balance of an invasive strategy and the decision-making process are not clearly defined. The aim of the present study was to assess the decision-making process, and the in-hospital and long-term mortality based on the clinical presentation, the diagnostic approach (coronary angiogram or conservative) and the therapeutic management (revascularization or not). The present study was a single-center retrospective analysis. A total of 522 patients aged ≥80 years, with a diagnosis of coronary disease were included from 2003 to 2009. The mean age was 82 ± 2.6 years. A total of 195 of 522 (37%) presented with a ST segment elevation myocardial infarction (STEMI). A coronary angiogram was carried out in 316 patients (60.5%) and 71% were treated by percutaneous coronary revascularization. A total of 39.5% were considered ineligible for a coronary angiogram due to cardiological reasons or comorbidities. Excluding cardiogenic shock, overall in-hospital mortality was 4.9%. Clinical presentation strongly influenced both in-hospital and 6-month mortality rates (cardiogenic shock 20% and 28.7%, stable angina 1% and 4.1%, respectively, P < 0.001). Long-term mortality was reduced in the coronary angiography arm compared with the conservative group (14.3% vs 20.9%, P = 0.04) whether or not revascularization was carried out. In the present study, in octogenarians, long-term mortality was lower in the group of patients who underwent a coronary angiogram, regardless of revascularization. The selection process for coronary angiography and angioplasty was mostly influenced by the existence of age-associated comorbidities. Risk prediction models are required to reduce age-dependent biases. © 2014 Japan Geriatrics Society.

Combining PCI and CABG: the role of hybrid revascularization.

PubMed

Green, Kelly D; Lynch, Donald R; Chen, Tyffany P; Zhao, David

2013-04-01

Hybrid coronary revascularization combines the benefits of both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the treatment of multivessel coronary artery disease (CAD) by combining the benefits of the LIMA-to-LAD graft and drug eluting stent (DES) to non-LAD regions. Through this approach, a patient receives the long-term benefit of the LIMA graft and avoids the morbidity of a full sternotomy and saphenous vein grafts. Available data related to outcomes following hybrid revascularization is limited to small studies. In this review we seek to provide an overview of hybrid revascularization in the era of modern drug eluting stent technology, discuss appropriate patient selection, and comment on future trial design. Additionally, we review the recent literature pertaining to the hybrid approach.

Neuropsychological outcome after percutaneous coronary intervention or coronary artery bypass grafting: results from the Stent or Surgery (SoS) Trial.

PubMed

Währborg, Peter; Booth, Jean E; Clayton, Tim; Nugara, Fiona; Pepper, John; Weintraub, William S; Sigwart, Ulrich; Stables, Rod H

2004-11-30

Coronary artery bypass surgery (CABG) has been associated with a range of neurological and neuropsychological complications from stroke to cognitive problems such as memory and problem solving disturbance. However, little is known about the impact of percutaneous coronary intervention (PCI) on neuropsychological outcome. In the Stent or Surgery Trial (SoS), 988 patients were randomized in equal proportions between PCI supported by stent implantation and CABG. As a substudy of this trial, we undertook an evaluation of neurological and neuropsychological outcomes after intervention. A clinical examination and neuropsychological assessment consisting of 5 tests (Digit Span Forwards and Backwards, Visual Reproduction, Bourdon, and Block Design) were performed at baseline and 6 and 12 months after the procedure. A total of 145 patients were included in the substudy analysis: 77 in the PCI group and 68 in the CABG group. One patient in the PCI arm had a stroke. There was no significant difference between treatment groups at 6 and 12 months for any of the 5 tests. The mean change from baseline was also similar in both groups. We were not able to demonstrate an important and significant difference in neuropsychological outcome in patients treated with different revascularization strategies. This important finding needs to be examined in further research.

Outcomes in Diabetic Patients Undergoing Orbital Atherectomy System.

PubMed

Lee, Michael S; Shlofmitz, Evan; Nguyen, Heajung; Shlofmitz, Richard A

2016-10-01

We evaluated the angiographic and clinical outcomes of orbital atherectomy to treat severely calcified coronary lesions in diabetic and non-diabetic patients. Diabetics have increased risk for death, myocardial infarction, and target vessel revascularization after percutaneous coronary intervention. Severely calcified coronary lesions are associated with increased cardiac events. Orbital atherectomy facilitates stent delivery and optimizes stent expansion by modifying severely calcified plaque. Outcomes in diabetic patients who undergo orbital atherectomy have not been reported. Our retrospective multicenter registry included 458 consecutive real-world patients with severely calcified coronary arteries who underwent orbital atherectomy. The primary safety endpoint was the rate of major adverse cardiac and cerebrovascular events at 30 days. Diabetics represented 42.1% (193/458) of the entire cohort. The primary endpoint was similar in diabetics and non-diabetics (1.0% vs. 3.0%%, P = 0.20), as were 30-day rates of death (0.5% vs. 1.9%, P = 0.41), myocardial infarction (0.5% vs. 1.5%, P = 0.40), target vessel revascularization (0% vs. 0%, P = 1), and stroke (0% vs. 0.4%, P > 0.9). Angiographic complications and stent thrombosis rate were low and did not differ between the 2 groups. Diabetics represented a sizeable portion of patients who underwent orbital atherectomy. Diabetics who had severely calcified coronary arteries and underwent orbital atherectomy had low event rates that were similar to non-diabetics. Orbital atherectomy appears to be a viable treatment strategy for diabetic patients. Randomized trials with longer-term follow-up are needed to determine the ideal treatment strategy for diabetics. © 2016, Wiley Periodicals, Inc.

Revascularization with percutaneous coronary intervention does not affect androgen status in males with chronic stable angina pectoris.

PubMed

Gosai, J N; Charalampidis, P; Nikolaidou, T; Parviz, Y; Morris, P D; Channer, K S; Jones, T H; Grech, E D

2016-05-01

There is a clear association between low serum testosterone and coronary artery disease (CAD) in men. Hypotestosteronaemia is associated with accelerated atherosclerosis and a quarter of men with CAD are biochemically hypogonadal. Amongst those with CAD, hypotestosteronaemia is associated with increased mortality. Testosterone vasodilates coronary arteries, and exogenous testosterone reduces ischaemia. Whether hypotestosteronaemia is a cause or a consequence of CAD remains unanswered. The aim of this prospective observational study was to investigate whether coronary revascularization affected androgen status in men with stable angina pectoris. Twenty five men (mean age 62.7, SD 9.18) with angiographically significant CAD and symptomatic angina underwent full coronary revascularization by percutaneous coronary intervention. Androgen status and symptoms of angina, stress, depression and sexual function were assessed before, and at one and 6 months after the coronary revascularization. All patients underwent complete revascularization which was associated with a significant reduction in angina symptoms and ischaemia. No significant difference was seen in total testosterone (11.33 nmol/L baseline; 12.56, 1 month post; 13.04 at 6 months; p = 0.08). A significant and sustained rise in sex hormone-binding globulin was seen (33.99 nm/L baseline; 36.11 nm/L 1 month post PCI; 37.94 nm/L at 6 months; p = 0.03) Overall, there was no significant alteration in any other marker of androgen status including free testosterone or bioavailable testosterone. There was no change in symptoms of anxiety, depression or sexual function. Coronary revascularization has no sustained effect on androgen status. This supports the hypothesis that hypotestosteronaemia is not a consequence of angina pectoris or myocardial ischaemia. © 2016 American Society of Andrology and European Academy of Andrology.

Long-term benefit of statin therapy initiated during hospitalization for an acute coronary syndrome: a systematic review of randomized trials.

PubMed

Bavry, Anthony A; Mood, Girish R; Kumbhani, Dharam J; Borek, Peter P; Askari, Arman T; Bhatt, Deepak L

2007-01-01

This study sought to determine if the initiation of statin (HMG-CoA reductase inhibitor) therapy during acute coronary syndromes reduces long-term mortality and other adverse cardiac outcomes. Initiation of statin therapy during acute coronary syndromes has not been shown to reduce mortality, myocardial infarction or stroke within 4 months of follow-up. Clinical trials that randomized patients with acute coronary syndromes to early statin therapy compared with less intensive lipid reduction (placebo/lower-dose statin/usual care), and reported long-term outcomes were included for analysis. In all, there were seven studies (L-CAD, PTT, FLORIDA, Colivicchi et al., PROVE-IT, ESTABLISH, and A-to-Z) with 9553 patients who started statin therapy within 12 days of hospital presentation. The incidence of all-cause mortality was 3.4% in the statin group versus 4.6% in the less intensive lipid reduction group over a weighted mean follow-up of 22.9 months (relative risk [RR] 0.74; 95% CI 0.61, 0.90; p = 0.003). The number of patients needed to treat to prevent one death was 84 patients. Similarly, the incidence of cardiovascular mortality in the statin versus the less intensive lipid reduction group was 2.4% versus 3.3% (RR 0.74; 95% CI 0.58, 0.93; p = 0.010), unstable angina 4.1% versus 5.0% (RR 0.81; 95% CI 0.68, 0.98; p = 0.027), revascularization 11.2% versus 12.9% (RR 0.86; 95% CI 0.78, 0.96; p = 0.006), stroke 1.1% versus 1.2% (RR 0.90; 95% CI 0.62, 1.30; p = 0.56), and myocardial infarction 6.6% versus 7.0% (RR 0.94; 95% CI 0.81, 1.09; p = 0.41). The benefit of early initiation of statin therapy during acute coronary syndromes slowly accrues over time so that a survival advantage is seen around 24 months. Relatively few patients need to be treated to prevent one death over this time period. Furthermore, this approach significantly reduces unstable angina and the need for revascularization.

International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial: Rationale and design.

PubMed

Maron, David J; Hochman, Judith S; O'Brien, Sean M; Reynolds, Harmony R; Boden, William E; Stone, Gregg W; Bangalore, Sripal; Spertus, John A; Mark, Daniel B; Alexander, Karen P; Shaw, Leslee; Berger, Jeffrey S; Ferguson, T Bruce; Williams, David O; Harrington, Robert A; Rosenberg, Yves

2018-07-01

Prior trials comparing a strategy of optimal medical therapy with or without revascularization have not shown that revascularization reduces cardiovascular events in patients with stable ischemic heart disease (SIHD). However, those trials only included participants in whom coronary anatomy was known prior to randomization and did not include sufficient numbers of participants with significant ischemia. It remains unknown whether a routine invasive approach offers incremental value over a conservative approach with catheterization reserved for failure of medical therapy in patients with moderate or severe ischemia. The ISCHEMIA trial is a National Heart, Lung, and Blood Institute supported trial, designed to compare an initial invasive or conservative treatment strategy for managing SIHD patients with moderate or severe ischemia on stress testing. Five thousand one-hundred seventy-nine participants have been randomized. Key exclusion criteria included estimated glomerular filtration rate (eGFR) <30 mL/min, recent myocardial infarction (MI), left ventricular ejection fraction <35%, left main stenosis >50%, or unacceptable angina at baseline. Most enrolled participants with normal renal function first underwent blinded coronary computed tomography angiography (CCTA) to exclude those with left main coronary artery disease (CAD) and without obstructive CAD. All randomized participants receive secondary prevention that includes lifestyle advice and pharmacologic interventions referred to as optimal medical therapy (OMT). Participants randomized to the invasive strategy underwent routine cardiac catheterization followed by revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery, when feasible, as selected by the local Heart Team to achieve optimal revascularization. Participants randomized to the conservative strategy undergo cardiac catheterization only for failure of OMT. The primary endpoint is a composite of cardiovascular (CV) death, nonfatal myocardial infarction (MI), hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest. Assuming the primary endpoint will occur in 16% of the conservative group within 4 years, estimated power exceeds 80% to detect an 18.5% reduction in the primary endpoint. Major secondary endpoints include the composite of CV death and nonfatal MI, net clinical benefit (primary and secondary endpoints combined with stroke), angina-related symptoms and disease-specific quality of life, as well as a cost-effectiveness assessment in North American participants. Ancillary studies of patients with advanced chronic kidney disease and those with documented ischemia and non-obstructive coronary artery disease are being conducted concurrently. ISCHEMIA will provide new scientific evidence regarding whether an invasive management strategy improves clinical outcomes when added to optimal medical therapy in patients with SIHD and moderate or severe ischemia. Copyright © 2018 Elsevier Inc. All rights reserved.

Percutaneous Coronary Intervention of Left Main Disease: Pre- and Post-EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) Era.

PubMed

Park, Duk-Woo; Park, Seung-Jung

2017-06-01

For nearly half a century, coronary artery bypass grafting has been the standard treatment for patients with obstructive left main coronary artery (LMCA) disease. However, there has been considerable evolution in the field of percutaneous coronary intervention, and especially, percutaneous coronary intervention for LMCA disease has been rapidly expanded with adoption of drug-eluting stents. Some, but not all randomized trials, have shown that percutaneous coronary intervention with drug-eluting stents might be a suitable alternative for selected patients with LMCA disease instead of bypass surgery. However, none of previous trials involving early-generation drug-eluting stents was sufficiently powered and comparative trials using contemporary drug-eluting stents were limited. Recently, primary results of 2 new trials of EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) were reported. However, these trials showed conflicting results, which might pose uncertainty on the optimal revascularization strategy for LMCA disease. In this article, with the incorporation of a key review on evolution of LMCA treatment, we summarize the similarity or disparity of the EXCEL and NOBLE trials, focus on how they relate to previous trials in the field, and finally speculate on how the treatment strategy may be changed or recommended for LMCA treatment. © 2017 American Heart Association, Inc.

The impact of ICD-9 revascularization procedure codes on estimates of racial disparities in ischemic stroke.

PubMed

Boan, Andrea D; Voeks, Jenifer H; Feng, Wuwei Wayne; Bachman, David L; Jauch, Edward C; Adams, Robert J; Ovbiagele, Bruce; Lackland, Daniel T

2014-01-01

The use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) diagnostic codes can identify racial disparities in ischemic stroke hospitalizations; however, inclusion of revascularization procedure codes as acute stroke events may affect the magnitude of the risk difference. This study assesses the impact of excluding revascularization procedure codes in the ICD-9 definition of ischemic stroke, compared with the traditional inclusive definition, on racial disparity estimates for stroke incidence and recurrence. Patients discharged with a diagnosis of ischemic stroke (ICD-9 codes 433.00-434.91 and 436) were identified from a statewide inpatient discharge database from 2010 to 2012. Race-age specific disparity estimates of stroke incidence and recurrence and 1-year cumulative recurrent stroke rates were compared between the routinely used traditional classification and a modified classification of stroke that excluded primary ICD-9 cerebral revascularization procedures codes (38.12, 00.61, and 00.63). The traditional classification identified 7878 stroke hospitalizations, whereas the modified classification resulted in 18% fewer hospitalizations (n = 6444). The age-specific black to white rate ratios were significantly higher in the modified than in the traditional classification for stroke incidence (rate ratio, 1.50; 95% confidence interval [CI], 1.43-1.58 vs. rate ratio, 1.24; 95% CI, 1.18-1.30, respectively). In whites, the 1-year cumulative recurrence rate was significantly reduced by 46% (45-64 years) and 49% (≥ 65 years) in the modified classification, largely explained by a higher rate of cerebral revascularization procedures among whites. There were nonsignificant reductions of 14% (45-64 years) and 19% (≥ 65 years) among blacks. Including cerebral revascularization procedure codes overestimates hospitalization rates for ischemic stroke and significantly underestimates the racial disparity estimates in stroke incidence and recurrence. Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Increased Arterial Stiffness after Coronary Artery Revascularization Correlates with Serious Coronary Artery Lesions and Poor Clinical Outcomes in Patients with Chronic Kidney Disease

PubMed Central

Zhu, Zhengbin; Yan, Zijun; Zhang, Lin; Du, Run; Zhu, Jinzhou; Zuo, Junli; Chu, Shaoli; Shen, Weifeng; Zhang, Ruiyan

2014-01-01

Objectives This study aimed to clarify the relationship between arterial stiffness and coronary artery lesions as well as their influence on long-term outcomes after coronary artery revascularization in patients with chronic kidney disease (CKD). Methods A total of 205 patients who had a coronary angiography and received coronary artery revascularization on demand were enrolled and followed up for 5 years. Demographic and clinical indicators, arterial stiffness indexes, angiographic characteristics and the Gensini score (GS) were recorded at baseline. Major adverse cardiac events (MACE), including cardiac death and repeat coronary artery revascularization, that occurred during the 5 years of follow-up were also recorded. Results All indexes reflecting the degree of arterial stiffness, including PWV, C1, C2, CSBP, CDBP, AP and Aix, were significantly higher in CKD than in non-CKD patients (all p < 0.05). Patients with CKD also had a higher rate of coronary artery disease and a higher GS (p < 0.05 and p < 0.01, respectively). Logistic regression analysis revealed CKD to be an independent risk factor for increased arterial stiffness (OR = 2.508, 95% CI 1.308-4.808, p = 0.006). During follow-up, CKD patients with PWV >13 m/s or Aix@75 >30 had a significantly higher MACE occurrence rate after coronary artery revascularization (both p < 0.05). Conclusion These results highlight that CKD and arterial stiffness correlate with the severity of coronary artery lesions. CKD patients with impaired arterial stiffness have poor clinical outcomes, suggesting a further clinical use of the arterial stiffness index as a surrogate of worse cardiovascular prognosis in CKD than in non-CKD patients. PMID:25737692

Optimal percutaneous coronary intervention in patients with ST-elevation myocardial infarction and multivessel disease: An updated, large-scale systematic review and meta-analysis.

PubMed

Nguyen, An Vu; Thanh, Le Van; Kamel, Mohamed Gomaa; Abdelrahman, Sara Attia Mahmoud; El-Mekawy, Mohamed; Mokhtar, Mohamed Ashraf; Ali, Aya Ashraf; Hoang, Nam Nguyen Nho; Vuong, Nguyen Lam; Abd-Elhay, Fatma Abd-Elshahed; Omer, Omer Abdelbagi; Mohamed, Ahmed Abdou; Hirayama, Kenji; Huy, Nguyen Tien

2017-10-01

Our study aimed to compare three different percutaneous coronary intervention (PCI) approaches: culprit-only (COR) and complete (CR) revascularization - categorizing into immediate (ICR) or staged (SCR). We searched 13 databases for randomized controlled trials. Articles were included if they compared at least two strategies. To have more studies in each analysis, an adjusted analysis was performed using person-years to incorporate follow-up durations and obtain pooled rate ratios (RR), with their corresponding 95% confidence interval. Thirteen trials were included with a population of 2830 patients. COR significantly increased major adverse cardiac event (MACE) (adjusted RR 1.67, 95% CI: 1.27-2.19) and repeat revascularization (2.12, 1.67-2.69), which was driven by repeat PCI, without any difference in all-cause mortality and myocardial infarction (MI) compared to CR. When categorizing CR into SCR and ICR, the trend repeated with COR increased MACE (1.99, 1.53-2.6 for ICR), cardiovascular mortality (2.06, 1.07-3.96 for ICR), MI for ICR (1.72, 1.04-2.86), repeat revascularization and repeat PCI for both ICR and SCR. Non-cardiovascular mortality, stroke, nephropathy, re-hospitalization, stent thrombosis and bleeding were similar among all approaches. In MVD-STEMI patients, CR is better than COR in terms of MACE, cardiovascular mortality, repeat revascularization with no difference in safety outcomes. There was a trend towards to a reduction of cardiovascular mortality and MI in ICR compared to SCR when each matched with COR; even though there is no statistically significant difference between ICR and SCR when compared together. Copyright © 2017 Elsevier B.V. All rights reserved.

[Immediate and remote results of endovascular treatment of patients with postinfarction cardiosclerosis].

PubMed

Patrikeev, A V; Rudman, V Ia; Maksimkin, D A; Baranovich, V Iu; Faĭbushevich, A G; Veretnik, G I; Mambetov, A V; Shugushev, Z Kh

2015-01-01

Two approaches in treatment of 131 patients with postinfarction cardiosclerosis are compared in the work. Tactics of "total" myocardial revascularization means restoration of coronary blood flow in all arteries with hemodynamically significant lesion while "selective" revascularization provides restoration of coronary blood flow only in those arteries which have a viable myocardium in their pool. It was concluded that restoration of coronary blood flow in patients after myocardial infarction permits to prevent postinfarction heart remodeling, development of heart failure thereby affecting on the prognosis. Evaluation of myocardial viability in the area of suggested surgery increases efficiency of revascularization, reduces number of implantable stents and decreases frequency of unfounded coronary interventions. Elimination of ischemia in the area of hibernation provides a rapid restoration of myocardial contractility in most of left ventricle segments with initially impaired kinetics. It was revealed that terms of contractility restoration of hibernating myocardium depend on duration of hibernation period up to revascularization.

Steroids and statins: an old and a new anti-inflammatory strategy compared.

PubMed

Vukovic, Petar M; Maravic-Stojkovic, Vera R; Peric, Miodrag S; Jovic, Miomir Dj; Cirkovic, Milan V; Gradinac, Sinisa Dj; Djukanovic, Bosko P; Milojevic, Predrag S

2011-01-01

This study compared the anti-inflammatory effects of methylprednisolone (MP) and atorvastatin and analysed their influences on clinical variables in patients undergoing coronary revascularization. Ninety patients with compromised left ventricular ejection fraction (≤30%) undergoing elective coronary surgery were equally randomized to one of three groups: statin group, treatment with atorvastatin (20 mg/day) 3 weeks before surgery; methylprednisolone group, a single shot of methylpredniosolone (10mg/kg); and control group. Postoperative IL-6 was higher in the control group when compared to the methylprednisolone and statin groups (p<0.01). IL-6 was higher in the statin-treated patients (p<0.05 versus methylprednisolone). Administration of methylprednisolone as well as statin treatment increased postoperative cardiac index, left ventricular stroke work index, decreased postoperative atrial fibrilation rate and reduced ICU stay (p<0.05 versus control). The number of patients requiring inotropic support was lower in the methylprednisolone group when compared with the other two groups (p<0.01). Tracheal intubation time was reduced in patients who received methylprednisolone (p<0.01 versus control). Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.

Cardiovascular Risk Assessment and Management in Prerenal Transplantation Candidates.

PubMed

Lindley, Eric M; Hall, Amanda K; Hess, Jordan; Abraham, Jo; Smith, Brigham; Hopkins, Paul N; Shihab, Fuad; Welt, Frederick; Owan, Theophilus; Fang, James C

2016-01-01

Cardiovascular (CV) assessment in prerenal transplant patients varies by center. Current guidelines recommend stress testing for candidates if ≥ 3 CV risk factors exist. We evaluated the CV assessment and management in 685 patients referred for kidney transplant over a 7-year period. All patients had CV risk factors, and the most common cause of end-stage renal disease was diabetes. Thirty-three percent (n = 229) underwent coronary angiography. The sensitivity of stress testing to detect obstructive coronary artery disease (CAD) was poor (0.26). Patients who had no CAD, nonobstructive CAD, or CAD with intervention had significantly higher event-free survival compared with patients with obstructive CAD without intervention. There were no adverse clinical events (death, myocardial infarction, stroke, revascularization, and graft failure) within 30 days post-transplant in patients who had preoperative angiography (n = 77). Of the transplanted patients who did not have an angiogram (n = 289), there were 8 clinical events (6 myocardial infarctions) in the first 30 days. In conclusion, our results indicate that stress testing and usual risk factors were poor predictors of obstructive CAD and that revascularization may prove beneficial in these patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Parameters influencing the physical activity of patients with a history of coronary revascularization.

PubMed

Acar, Burak; Yayla, Cagri; Gucuk Ipek, Esra; Unal, Sefa; Ertem, Ahmet Goktug; Burak, Cengiz; Senturk, Bihter; Bayraktar, Fatih; Kara, Meryem; Demirkan, Burcu; Guray, Yesim

2017-10-01

Coronary artery disease is the leading cause of mortality worldwide. Regular physical activity is part of a comprehensive management strategy for these patients. We investigated the parameters that influence physical activity in patients with a history of coronary revascularization. We included outpatients with a history of coronary revascularization at least six months prior to enrollment. Data on physical activity, demographics, and clinical characteristics were collected via a questionnaire. A total of 202 consecutive outpatients (age 61.3±11.2 years, 73% male) were enrolled. One hundred and four (51%) patients had previous percutaneous coronary intervention, 67 (33%) had coronary bypass graft surgery, and 31 (15%) had both procedures. Only 46 patients (23%) engaged in regular physical activity. Patients were classified into two subgroups according to their physical activity. There were no significant differences between subgroups in terms of age, comorbid conditions or revascularization type. Multivariate regression analysis revealed that low education level (OR=3.26, 95% CI: 1.31-8.11, p=0.01), and lack of regular follow-up (OR=2.95, 95% CI: 1.01-8.61, p=0.04) were independent predictors of non-adherence to regular physical activity among study subjects. Regular exercise rates were lower in outpatients with previous coronary revascularization. Education level and regular follow-up visits were associated with adherence to physical activity in these patients. Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

The feasibility and safety of off-pump coronary bypass surgery in emergency revascularization

PubMed Central

Joo, Hyun-Chel; Youn, Young-Nam; Chang, Byung-Chul

2018-01-01

Background The efficacy and safety of off-pump coronary artery bypass grafting (OPCAB) in emergency revascularization remains controversial despite its widespread use. The aim of our study was to examine the applicability and safety of OPCAB in patients who were indicated for emergency surgery. Methods This single-center study reviewed the indication, operative data, and early and long-term outcomes of 113 patients (mean age, 67.2±9.0 years; logistic EuroSCORE, 14.3±13.5) who underwent emergency OPCAB from January 2003 to December 2014 and were followed up (94.6% completion rate) for a mean 51.1±40.3 (range, 1–135) months. Results Emergency OPCAB was associated with favorable surgical outcomes (number of distal anastomoses per patient, 3.04±0.87; internal thoracic artery (IMA) use, 98.2%; complete revascularization, 79.6%) and in-hospital outcomes (mortality, 5.3%; low cardiac output syndrome, 5.3%; stroke, 2.7%; pulmonary complications, 8.8%; renal failure, 11.5%). Only five patients (4.4%) required on-pump conversion. The 10-year outcomes were also acceptable (survival, 75.4%±5.6%; major cerebral and cardiovascular events, 52.1%±1.8%). The multivariate risk factors for late mortality were peripheral vascular disease (HR 2.95, 95% CI: 1.11–11.83), cardiogenic shock (HR 3.67, 95% CI: 1.35–9.96), and incomplete revascularization (HR 3.41, 95% CI: 1.06–14.26). When patients were separated by whether the procedure was performed early (<2010) or late (≥2010) in the study period, the late period cohort had better outcomes despite containing higher-risk patients. Conclusions Our study suggests that emergency OPCAB can be performed safely and effectively with good hospital outcomes and adequate long-term results. OPCAB strategy can be considered as a good option in emergency revascularization. PMID:29850131

Surgical myocardial revascularization in patients with reduced systolic left ventricular function.

PubMed

Bruno, Piergiorgio; Iafrancesco, Mauro; Massetti, Massimo

2018-04-20

Surgical myocardial revascularization in patients with reduced left ventricular function has been a matter of debate for decades. Recently published 10-years extension follow-up of the STICH trial have conclusively demonstrated benefit of surgical myocardial revascularization in patients with significant coronary artery disease and low left ventricular ejection fraction. However, selection of patients for surgery remains challenging as well as decision to perform percutaneous rather than surgical revascularization in this class of patients. New evidence helped to clarify the role of preoperative patients' characteristics as risk factors for surgery and to identify those patients who may benefit the most from surgery. Focus of this review is to review epidemiology, aetiology and pathophysiology of coronary artery disease in patients with reduced left ventricular function, role of viability and results of observational and investigational studies on revascularization in patients with reduced left ventricular function with a particular emphasis on relative indication of coronary artery bypass grafting and percutaneous coronary intervention and the surgical implications of development of ischemic mitral regurgitation or ischemic left ventricular aneurysm.

Coronary Revascularization in Children at a Mexican Cardiac Center: Thirteen-Year Outcomes.

PubMed

Ramírez-Marroquín, Samuel E; Iturriaga-Hernández, Alejandra; Calderón-Colmenero, Juan; Benita-Bordes, Antonio; Cervantes-Salazar, Jorge L

2017-09-01

The indications for pediatric coronary revascularization are diverse. There are a large proportion of patients with sequelae of severe inflammatory diseases such as Kawasaki disease, and other less common causes. Retrospective review of ten pediatric patients undergoing coronary artery bypass surgery from January 2004 to December 2016. Ten children and adolescents ranging in age from 2 to 17 (median, 6) years at operation were followed up for as long as 13 years with a median follow-up of 2 years. The surgical indications include ischemia symptoms and/or coronary stenosis angiographically documented. Diagnoses include Kawasaki disease, anomalous origin of the left coronary artery from the pulmonary artery, and iatrogenic lesion of the right coronary artery. All the surgical procedures were performed with cardiopulmonary bypass with crystalloid cardioplegic arrest. The number of distal anastomoses was 1.6 per patient, and the left internal thoracic artery was used in one patient, the right internal thoracic artery in four patients, bilateral internal thoracic artery in four patients, and bilateral internal thoracic artery plus left radial artery in one patient, most frequently for right coronary artery revascularization. The patients underwent noninvasive diagnostic study during follow-up to evaluate their coronary status. The ten patients had no symptoms, and there was no mortality. Although survival was excellent after pediatric coronary bypass in our center, we need to continue the follow-up. Coronary revascularization by means of arterial grafting is a safe and reliable surgical modality for coronary disease in children.

Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial.

PubMed

Morice, Marie-Claude; Serruys, Patrick W; Kappetein, A Pieter; Feldman, Ted E; Ståhle, Elisabeth; Colombo, Antonio; Mack, Michael J; Holmes, David R; Choi, James W; Ruzyllo, Witold; Religa, Grzegorz; Huang, Jian; Roy, Kristine; Dawkins, Keith D; Mohr, Friedrich

2014-06-10

Current guidelines recommend coronary artery bypass graft surgery (CABG) when treating significant de novo left main coronary artery (LM) stenosis; however, percutaneous coronary intervention (PCI) has a class IIa indication for unprotected LM disease in selected patients. This analysis compares 5-year clinical outcomes in PCI- and CABG-treated LM patients in the Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) trial, the largest trial in this group to date. The SYNTAX trial randomly assigned 1800 patients with LM or 3-vessel disease to receive either PCI (with TAXUS Express paclitaxel-eluting stents) or CABG. The unprotected LM cohort (N=705) was predefined and powered. Major adverse cardiac and cerebrovascular event rates at 5 years was 36.9% in PCI patients and 31.0% in CABG patients (hazard ratio, 1.23 [95% confidence interval, 0.95-1.59]; P=0.12). Mortality rate was 12.8% and 14.6% in PCI and CABG patients, respectively (hazard ratio, 0.88 [95% confidence interval, 0.58-1.32]; P=0.53). Stroke was significantly increased in the CABG group (PCI 1.5% versus CABG 4.3%; hazard ratio, 0.33 [95% confidence interval, 0.12-0.92]; P=0.03) and repeat revascularization in the PCI arm (26.7% versus 15.5%; hazard ratio, 1.82 [95% confidence interval, 1.28-2.57]; P<0.01). Major adverse cardiac and cerebrovascular events were similar between arms in patients with low/intermediate SYNTAX scores but significantly increased in PCI patients with high scores (≥33). At 5 years, no difference in overall major adverse cardiac and cerebrovascular events was found between treatment groups. PCI-treated patients had a lower stroke but a higher revascularization rate versus CABG. These results suggest that both treatments are valid options for LM patients. The extent of disease should accounted for when choosing between surgery and PCI, because patients with high SYNTAX scores seem to benefit more from surgery compared with those in the lower tertiles. http://www.clinicaltrials.gov. Unique identifier: NCT00114972. © 2014 American Heart Association, Inc.

Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non-ST Elevation Myocardial Infarction: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (NCDR ACTION Registry-GWTG).

PubMed

Pandey, Ambarish; McGuire, Darren K; de Lemos, James A; Das, Sandeep R; Berry, Jarett D; Brilakis, Emmanouil S; Banerjee, Subhash; Marso, Steven P; Barsness, Gregory W; Simon, DaJuanicia N; Roe, Matthew; Goyal, Abhinav; Kosiborod, Mikhail; Amsterdam, Ezra A; Kumbhani, Dharam J

2016-05-01

Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non-ST-segment-elevation myocardial infarction. Using Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non-ST-segment-elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; Ptrend=0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; ptrend=0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; P value <0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure. Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST-segment-elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years. © 2016 American Heart Association, Inc.

Predictors of Functional Dependence Despite Successful Revascularization in Large-Vessel Occlusion Strokes

PubMed Central

Shi, Zhong-Song; Liebeskind, David S.; Xiang, Bin; Ge, Sijian Grace; Feng, Lei; Albers, Gregory W.; Budzik, Ronald; Devlin, Thomas; Gupta, Rishi; Jansen, Olav; Jovin, Tudor G.; Killer-Oberpfalzer, Monika; Lutsep, Helmi L.; Macho, Juan; Nogueira, Raul G.; Rymer, Marilyn; Smith, Wade S.; Wahlgren, Nils; Duckwiler, Gary R.

2014-01-01

Background and Purpose High revascularization rates in large-vessel occlusion strokes treated by mechanical thrombectomy are not always associated with good clinical outcomes. We evaluated predictors of functional dependence despite successful revascularization among patients with acute ischemic stroke treated with thrombectomy. Methods We analyzed the pooled data from the Multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke (TREVO), and TREVO 2 trials. Successful revascularization was defined as thrombolysis in cerebral infarction score 2b or 3. Functional dependence was defined as a score of 3 to 6 on the modified Rankin Scale at 3 months. We assessed relationship of demographic, clinical, angiographic characteristics, and hemorrhage with functional dependence despite successful revascularization. Results Two hundred and twenty-eight patients with successful revascularization had clinical outcome follow-up. The rates of functional dependence with endovascular success were 48.6% for Trevo thrombectomy and 58.0% for Merci thrombectomy. Age (odds ratio, 1.04; 95% confidence interval, 1.02–1.06 per 1-year increase), National Institutes of Health Stroke Scale score (odds ratio, 1.08; 95% confidence interval, 1.02–1.15 per 1-point increase), and symptom onset to endovascular treatment time (odds ratio, 1.11; 95% confidence interval, 1.01–1.22 per 30-minute delay) were predictors of functional dependence despite successful revascularization. Symptom onset to reperfusion time beyond 5 hours was associated with functional dependence. All subjects with symptomatic intracranial hemorrhage had functional dependence. Conclusions One half of patients with successful mechanical thrombectomy do not have good outcomes. Age, severe neurological deficits, and delayed endovascular treatment were associated with functional dependence despite successful revascularization. Our data support efforts to minimize delays to endovascular therapy in patients with acute ischemic stroke to improve outcomes. PMID:24876082

What’s Age Got to do with it? A Review of Contemporary Revascularization in the Elderly

PubMed Central

Vandermolen, Sebastian; Abbott, Jane; Silva, Kalpa De

2015-01-01

Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes. PMID:25329923

The Effects of Intra-Aortic Balloon Pumps on Mortality in Patients Undergoing High-Risk Coronary Revascularization: A Meta-Analysis of Randomized Controlled Trials of Coronary Artery Bypass Grafting and Stenting Era

PubMed Central

Wan, You-Dong; Sun, Tong-Wen; Kan, Quan-Cheng; Guan, Fang-Xia; Liu, Zi-Qi; Zhang, Shu-Guang

2016-01-01

Background Intra-aortic balloon pumps (IABP) have generally been used for patients undergoing high-risk mechanical coronary revascularization. However, there is still insufficient evidence to determine whether they can improve outcomes in reperfusion therapy patients, mainly by percutaneous coronary intervention (PCI) with stenting or coronary artery bypass graft (CABG). This study was designed to determine the difference between high-risk mechanical coronary revascularization with and without IABPs on mortality, by performing a meta-analysis on randomized controlled trials of the current era. Methods Pubmed and Embase databases were searched from inception to May 2015. Unpublished data were obtained from the investigators. Randomized clinical trials of IABP and non-IABP in high-risk coronary revascularization procedures (PCI or CABG) were included. In the case of PCI procedures, stents should be used in more than 80% of patients. Numbers of events at the short-term and long-term follow-up were extracted. Results A total of 12 randomized trials enrolling 2155 patients were included. IABPs did not significantly decrease short-term mortality (relative risk (RR) 0.66; 95% CI, 0.42–1.01), or long-term mortality (RR 0.79; 95% CI, 0.47–1.35), with low heterogeneity across the studies. The findings remained stable in patients with acute myocardial infarction with or without cardiogenic shock. But in high-risk CABG patients, IABP was associated with reduced mortality (71 events in 846 patients; RR 0.40; 95%CI 0.25–0.67). Conclusion In patients undergoing high-risk coronary revascularization, IABP did not significantly decrease mortality. But high-risk CABG patients may be benefit from IABP. Rigorous criteria should be applied to the use of IABPs. PMID:26784578

Coronary revascularization and adverse events in joint arthroplasty.

PubMed

Tabatabaee, Reza Mostafavi; Rasouli, Mohammad R; Rezapoor, Maryam; Maltenfort, Mitchell G; Ong, Alvin C; Parvizi, Javad

2015-09-01

There is a paucity of literature about outcome of total joint arthroplasty in patients with the history of angioplasty and/or stent or coronary artery bypass graft (CABG). The present study aimed to evaluate perioperative complications and mortality in these patients. We used the Nationwide Inpatient Sample data from 2002-2011. Using the Ninth Revision of the International Classification of Disease, Clinical Modification codes for disorders and procedures, we identified patients with a history of coronary revascularization (angioplasty and/or stent or CABG) and compared the inhospital adverse events in these patients with patients without a history of coronary revascularization. Cardiac complications occurred in 1.06% patients with a history of CABG; 0.95% of patients with a coronary angioplasty and/or stent and 0.82% of the control patients. In the multivariate analysis, neither the history of CABG (P = 0.07) nor the history of angioplasty and/or stenting (P = 0.86) was associated with a higher risk of cardiac complications. However, myocardial infarction occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio, 1.24, P = 0.001) and coronary angioplasty and/or stenting (0.67%, odds ratio, 1.96, P < 0.001) compared with that in the controls (0.27%). History of coronary revascularization did not increase the risk of respiratory, renal, and wound complications, surgical site infection, and mortality. Based on the findings of this study, it appears that there is no increased risk of inhospital mortality and complications (except for myocardial infarction) in patients with a history of coronary artery revascularization undergoing total joint arthroplasty. We also found perioperative cardiac arrhythmia, particularly atrial fibrillation, to be an independent predictor of inhospital adverse events. Copyright © 2015 Elsevier Inc. All rights reserved.

Early and mid-term results of off-pump endarterectomy of the left anterior descending artery

PubMed Central

Takahashi, Mitsuko; Gohil, Sunir; Tong, Bonnie; Lento, Patrick; Filsoufi, Farzan; Reddy, Ramachandra C.

2013-01-01

OBJECTIVES Many patients referred for coronary artery bypass surgery (CABG) today have diffusely diseased coronary vessels, and some of them may require coronary endarterectomy to provide adequate revascularization. Most reports of coronary endarterectomy describe an on-pump procedure. As off-pump coronary artery bypass graft has become safer and more routine, there is renewed interest in off-pump coronary endarterectomy. We report on our series of patients who underwent off-pump coronary endarterectomy of the left anterior descending (LAD) artery using an open endarterectomy technique. METHODS All patients undergoing open heart surgery at The Mount Sinai Medical Center are entered into a state-mandated, audited database. A retrospective review of this database revealed 12 patients between January 2008 and June 2012 who underwent off-pump endarterectomy of the LAD as part of their coronary revascularization. Additional data were collected from a review of the patients' charts. RESULTS There were a total of 12 patients, with a mean age of 72 ± 4 years. Nine (75%) were male and 3 (25%) were female. Comorbidities included hypertension in 11 (92%) patients, dyslipidaemia in 10 (83%), diabetes in 8 (67%), renal failure in 6 (50%) and stroke in 1 (8%). The mean number of diseased coronary territories was 3 ± 0.4 (range 2–3), and the mean number of coronary bypass grafts performed was 4 ± 0.8 (range 2–5). Eight patients required transfusion with packed red blood cells (67%). One (8%) patient was converted from off-pump to on-pump. The mean intensive care unit stay was 3 ± 2.8 (range 1–8 days), and the mean hospital length of stay was 15 ± 13 (range 4–54 days). Postoperative follow-up (mean 24 ± 19 months, range 1–53) is complete, and no ischaemic events have occurred in the early and mid-term follow-up period. CONCLUSIONS We conclude that off-pump endarterectomy of the LAD is a viable option for patients with diffuse LAD disease. PMID:23190620

Comparison of one-year outcomes of percutaneous coronary intervention versus coronary artery bypass grafting in patients with unprotected left main coronary artery disease and acute coronary syndromes (from the CUSTOMIZE Registry).

PubMed

Caggegi, Anna; Capodanno, Davide; Capranzano, Piera; Chisari, Alberto; Ministeri, Margherita; Mangiameli, Andrea; Ronsivalle, Giuseppe; Ricca, Giovanni; Barrano, Giombattista; Monaco, Sergio; Di Salvo, Maria Elena; Tamburino, Corrado

2011-08-01

Uncertainty surrounds the optimal revascularization strategy for patients with left main coronary artery disease presenting with acute coronary syndromes (ACSs), and adequately sized specific comparisons of percutaneous and surgical revascularization in this scenario are lacking. The aim of this study was to evaluate the incidence of 1-year major adverse cardiac events (MACEs) in patients with left main coronary artery disease and ACS treated with percutaneous coronary intervention (PCI) and drug-eluting stent implantation or coronary artery bypass grafting (CABG). A total of 583 patients were included. At 1 year, MACEs were significantly higher in patients treated with PCI (n = 222) compared to those treated with CABG (n = 361, 14.4% vs 5.3%, p <0.001), driven by a higher rate of target lesion revascularization (8.1% vs 1.7%, p = 0.001). This finding was consistent after statistical adjustment for MACEs (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.2 to 5.9, p = 0.01) and target lesion revascularization (adjusted HR 8.0, 95% CI 2.2 to 28.7, p = 0.001). No statistically significant differences between PCI and CABG were noted for death (adjusted HR 1.1, 95% CI 0.4 to 3.0, p = 0.81) and myocardial infarction (adjusted HR 4.8, 95% CI 0.3 to 68.6, p = 0.25). No interaction between clinical presentation (ST-segment elevation myocardial infarction or unstable angina/non-ST-segment elevation myocardial infarction) and treatment (PCI or CABG) was observed (p for interaction = 0.68). In conclusion, in patients with left main coronary artery disease and ACS, PCI is associated with similar safety compared to CABG but higher risk of MACEs driven by increased risk of repeat revascularization. Copyright © 2011 Elsevier Inc. All rights reserved.

Achievement of optimal medical therapy goals for U.S. adults with coronary artery disease: results from the REGARDS Study (REasons for Geographic And Racial Differences in Stroke).

PubMed

Brown, Todd M; Voeks, Jenifer H; Bittner, Vera; Brenner, David A; Cushman, Mary; Goff, David C; Glasser, Stephen; Muntner, Paul; Tabereaux, Paul B; Safford, Monika M

2014-04-29

In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial. In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures. The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure <130 mm Hg and diastolic blood pressure <85 mm Hg (<80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol <85 mg/dl, high-density lipoprotein cholesterol >40 mg/dl, and triglycerides <150 mg/dl; 4) fasting glucose <126 mg/dl; 5) nonsmoking status; 6) body mass index <25 kg/m(2); and 7) exercise ≥4 days per week. The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals. There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Orbital atherectomy for treating de novo, severely calcified coronary lesions: 3-year results of the pivotal ORBIT II trial.

PubMed

Lee, Michael; Généreux, Philippe; Shlofmitz, Richard; Phillipson, Daniel; Anose, Bynthia M; Martinsen, Brad J; Himmelstein, Stevan I; Chambers, Jeff W

2017-06-01

The presence of heavy coronary artery calcification increases the complexity of percutaneous coronary intervention (PCI) and increases the incidence of major adverse cardiac events (MACE): death, myocardial infarction (MI), target vessel revascularization (TVR), and stent thrombosis. The ORBIT II (Evaluate the Safety and Efficacy of OAS in Treating Severely Calcified Coronary Lesions) trial reported low rates of procedural, 30-day, 1-year, and 2-year ischemic complications after treatment of de novo, severely calcified lesions with the Diamondback 360° Coronary Orbital Atherectomy System (OAS) (Cardiovascular Systems, Inc.). ORBIT II was a single-arm trial that enrolled 443 patients at 49U.S. sites; in this study, de novo, severely calcified coronary lesions were treated with OAS prior to stenting. The primary safety endpoint was 30-day MACE: the composite of cardiac death, MI, and TVR (inclusive of target lesion revascularization (TLR)). The primary efficacy endpoint was procedural success: stent delivery with a residual stenosis of <50% without the occurrence of in-hospital MACE.The present analysis reports the final, 3-year follow-up results from ORBIT II. The majority of subjects (88.2%) underwent PCI with drug-eluting stents after orbital atherectomy. There were 360 (81.3%) subjects who completed the protocol-mandated 3-year visit.The overall cumulative rate of 3-year MACE was 23.5%, including cardiac death (6.7%), MI (11.2%), and TVR (10.2%). The 3-year target lesion revascularization rate was 7.8%. In the final 3-year analysis of the ORBIT II trial, orbital atherectomy of severely calcified coronary lesions followed by stenting resulted in a low rate of adverse ischemic events compared with historical controls.Orbital atherectomy represents a safe and effective revascularization strategy for patients with severely calcified coronary lesions. The ORBIT II trial enrolled 443 subjects to study orbital atherectomy followed by stenting for de novo severely calcified coronary lesions. The overall cumulative 3-year MACE rate was 23.5%, including cardiac death (6.7%), MI (11.2%), and TVR (10.2%); the 3-year target lesion revascularization rate was 7.8%. Orbital atherectomy of heavily calcified coronary lesions followed by stenting results in a low rate of adverse ischemic events compared with historical controls; it represents a reasonable revascularization strategy for patients with severely calcified coronary lesions. Copyright © 2017 Elsevier Inc. All rights reserved.

Anticoagulant and antiplatelet therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention.

PubMed

Goto, Koji; Nakai, Kentaro; Shizuta, Satoshi; Morimoto, Takeshi; Shiomi, Hiroki; Natsuaki, Masahiro; Yahata, Mitsuhiko; Ota, Chihiro; Ono, Koh; Makiyama, Takeru; Nakagawa, Yoshihisa; Furukawa, Yutaka; Kadota, Kazushige; Takatsu, Yoshiki; Tamura, Takashi; Takizawa, Akinori; Inada, Tsukasa; Doi, Osamu; Nohara, Ryuji; Matsuda, Mitsuo; Takeda, Teruki; Kato, Masayuki; Shirotani, Manabu; Eizawa, Hiroshi; Ishii, Katsuhisa; Lee, Jong-Dae; Takahashi, Masaaki; Horie, Minoru; Takahashi, Mamoru; Miki, Shinji; Aoyama, Takeshi; Suwa, Satoru; Hamasaki, Shuichi; Ogawa, Hisao; Mitsudo, Kazuaki; Nobuyoshi, Masakiyo; Kita, Toru; Kimura, Takeshi

2014-07-01

The prevalence, intensity, safety, and efficacy of oral anticoagulation (OAC) in addition to dual antiplatelet therapy (DAPT) in "real-world" patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not yet been fully evaluated. In the Coronary REvascularization Demonstrating Outcome Study in Kyoto registry cohort-2, a total of 1,057 patients with AF (8.3%) were identified among 12,716 patients undergoing first PCI. Cumulative 5-year incidence of stroke was higher in patients with AF than in no-AF patients (12.8% vs 5.8%, p <0.0001). Although most patients with AF had CHADS2 score ≥2 (75.2%), only 506 patients (47.9%) received OAC with warfarin at hospital discharge. Cumulative 5-year incidence of stroke in the OAC group was not different from that in the no-OAC group (13.8% vs 11.8%, p = 0.49). Time in therapeutic range (TTR) was only 52.6% with an international normalized ratio of 1.6 to 2.6, and only 154 of 409 patients (37.7%) with international normalized ratio data had TTR ≥65%. Cumulative 5-year incidence of stroke in patients with TTR ≥65% was markedly lower than that in patients with TTR <65% (6.9% vs 15.1%, p = 0.01). In a 4-month landmark analysis in the OAC group, there was a trend for higher cumulative incidences of stroke and major bleeding in the on-DAPT (n = 286) than in the off-DAPT (n = 173) groups (15.1% vs 6.7%, p = 0.052 and 14.7% vs 8.7%, p = 0.10, respectively). In conclusion, OAC was underused and its intensity was mostly suboptimal in real-world patients with AF undergoing PCI, which lead to inadequate stroke prevention. Long-term DAPT in patients receiving OAC did not reduce stroke incidence. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

The Effect of Previous Coronary Artery Revascularization on the Adverse Cardiac Events Ninety days After Total Joint Arthroplasty.

PubMed

Feng, Bin; Lin, Jin; Jin, Jin; Qian, Wenwei; Cao, Shiliang; Weng, Xisheng

2018-01-01

Although coronary artery revascularization therapies are effective for treating coronary artery disease (CAD), these patients may be more susceptible to adverse cardiac events during later non-cardiac surgeries. The purpose of this study is to evaluate post-operative 90-day complications of total joint arthroplasty (TJA) in CAD patients with a history of CAD and to study the risk factors for cardiac complications. We performed a retrospective analysis of TJA patients between 2005 and 2015 at our institute by summarizing the history of CAD, cardiac revascularization, and cardiac complications within 90 days after the operation. Multivariate logistic regression was performed to identify the factors that predicted cardiac complications within 90 days after the operation. A total of 4414 patients were included; of these, 64 underwent cardiac revascularization and 201 CAD patients underwent medical therapy other than revascularization. All the revascularization had history of myocardial infarction (MI). The rate of cardiac complications within 90 days for the CAD with revascularization was 18.7%, 18.4% for the CAD without revascularization, and 2.0% for the non-CAD group. A history of CAD and revascularization, bilateral TJA, general anesthesia, body mass index ≥30 kg/m 2 , and history of MI were associated with a higher risk of cardiac complications. Patients who underwent TJA within 2 years after cardiac revascularization had a significantly higher cardiac complication rate, and the risk decreased with time. There is an increased risk of cardiac complications within 90 days after the operation among TJA patients with a history of CAD. Revascularization cannot significantly reduce the risk of cardiac complications after TJA for CAD patients. However, the risk decreased as the interval between revascularization and TJA increased. Copyright © 2017 Elsevier Inc. All rights reserved.

Efficacy of Calcium Channel Blockers on Major Cardiovascular Outcomes for the Treatment of Hypertension in Asian Populations: A Meta-analysis.

PubMed

Tran, Karen C; Leung, Alexander A; Tang, Karen L; Quan, Hude; Khan, Nadia A

2017-05-01

Whether calcium channel blockers exert a greater effect on cardiovascular risk reduction in Asian populations than other antihypertensive agents is unclear. We conducted a meta-analysis of hypertension trials of dihydropyridine calcium channel blockers in Asian populations to clarify this association. EMBASE, MEDLINE, and Cochrane databases were searched (from inception to August 2016) for randomized controlled trials on cardiovascular death, major adverse cardiovascular events, stroke, congestive heart failure, and coronary revascularization in Asian persons with hypertension. We identified 9 trials that reported data specific to Asian populations (N = 29,643). These trials included 1 placebo-controlled trial and 8 active comparator trials; of these, 5 had angiotensin receptor blockers as the active comparator. One placebo-controlled trial (n = 9711) showed significantly reduced cardiovascular mortality, major adverse cardiovascular events, and stroke with calcium channel blockers. Among 8 active comparator trials (n = 19,932), there were no significant differences in mortality (relative risk [RR], 1.10; 95% confidence interval [CI], 0.72-1.67; I 2  = 0.0%), major adverse cardiovascular events (RR, 1.02; 95% CI, 0.90-1.15; I 2  = 0.0%), stroke (RR, 0.97; 95% CI, 0.80-1.17; I 2  = 0.0%), congestive heart failure (RR, 1.01; 95% CI, 0.51-2.00; I 2  = 53.7), or coronary revascularization rates (RR, 0.98; 95% CI, 0.76-1.25; I 2  = 0.0%) in the calcium channel blocker group compared with other antihypertensive agents. When restricting the meta-analysis to angiotensin receptor blocker comparators (n = 10,384), there were no significant differences in cardiovascular outcomes. There is no evidence that dihydropyridine calcium channel blockers are superior to other antihypertensive agents in Asian populations for the treatment of hypertension. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

A Randomized Factorial Trial of Vitamins C, E, and Beta-Carotene in the Secondary Prevention of Cardiovascular Events in Women

PubMed Central

Cook, Nancy R.; Albert, Christine M.; Gaziano, J. Michael; Zaharris, Elaine; MacFadyen, Jean; Danielson, Eleanor; Buring, Julie E.; Manson, JoAnn E.

2007-01-01

Background Randomized trials have largely failed to support an effect of antioxidant vitamins on risk of cardiovascular disease (CVD). Few trials have examined interactions among antioxidants, and no previous trial has examined the individual effect of vitamin C on CVD. Methods WACS tested the effects of vitamins C (500 mg daily), E (600 IU every other day), and beta-carotene (50 mg every other day) on the combined outcome of myocardial infarction (MI), stroke, coronary revascularization, or CVD death among 8,171 female health professionals at increased risk in a 2×2×2 factorial design. Participants were 40 years or older with a prior history of CVD or three or more CVD risk factors, and were followed an average 9.4 years, from 1995-96 to 2005. Results 1,450 women experienced one or more CVD outcomes. There was no overall effect of vitamin C (RR=1.02, 95% CI=0.92-1.13, p=0.71), vitamin E (RR=0.94, 95% CI=0.85-1.04, p=0.23), or beta-carotene (RR=1.02, 95% CI=0.92-1.13, p=0.71) on the primary combined endpoint, or on the individual secondary outcomes of MI, stroke, coronary revascularization, or CVD death. A marginally significant reduction in the primary outcome with active vitamin E was observed among the pre-specified subgroup of women with prior CVD (RR=0.89, 95% CI=0.79-1.00, p=0.04; p-interaction=0.07). There were no significant interactions between agents for the primary endpoint, but those randomized to both active vitamin C and E experienced fewer strokes (p for interaction=0.03). Conclusion There were no overall effects of vitamins C, E or beta-carotene on cardiovascular events among women at high risk for CVD. Trial Registration clinicaltrials.gov Identifier: NCT00000541 PMID:17698683

Symptom Expression in Coronary Heart Disease and Revascularization Recommendations for Black and White Patients

PubMed Central

Hravnak, Marilyn; Whittle, Jeff; Kelley, Mary E.; Sereika, Susan; Good, Chester B.; Ibrahim, Said A.; Conigliaro, Joseph

2007-01-01

Objectives. We examined whether symptoms of coronary heart disease vary between Black and White patients with coronary heart disease, whether presenting symptoms affect physicians’ revascularization recommendations, and whether the effect of symptoms upon recommendations differs in Black and White patients. Methods. We interviewed Black and White patients in Pittsburgh in 1997 to 1999 who were undergoing elective coronary catheterization. We interviewed them regarding their symptoms, and we interviewed their cardiologist decision-makers regarding revascularization recommendations. We obtained coronary catheterization results by chart review. Results. Black and White patients (N=1196; 9.7% Black) expressed similar prevalence of chest pain, angina equivalent, fatigue, and other symptoms, but Black patients had more shortness of breath (87% vs 72%, P=.001). When we considered only those patients with significant stenosis (n=737, 7.1% Black) and controlled for race, age, gender, and number of stenotic vessels, those who expressed shortness of breath were less likely to be recommended for revascularization (odds ratio=0.535; 95% confidence interval=0.375, 0.762; P<.001), but there was no significant interaction with race. Conclusions. Black patients reported shortness of breath more frequently than did White subjects. Shortness of breath was a negative predictor for revascularization for all patients with significant stenosis, but there was no difference in the recommendations by symptom by race. PMID:17329655

Generalizability of EXCEL and NOBLE results to a large registry population with unprotected left main coronary artery disease.

PubMed

Lee, Pil Hyung; Kang, Se Hun; Han, Seungbong; Ahn, Jung-Min; Bae, Jae Seok; Lee, Cheol Hyun; Kang, Soo-Jin; Lee, Seung-Whan; Kim, Young-Hak; Lee, Cheol Whan; Park, Seong-Wook; Park, Duk-Woo; Park, Seung-Jung

2017-12-01

The aim of this study was to determine how trial-based findings of EXCEL and NOBLE might be interpreted and generalizable in 'real-world' settings with comparison of data from the large-scaled, all-comer Interventional Research Incorporation Society-Left MAIN Revascularization (IRIS-MAIN) registry. We compared baseline clinical and procedural characteristics and also determined how the relative treatment effect of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) was different in EXCEL and NOBLE, compared with those of the multicenter, IRIS-MAIN registry (n=2481). The primary outcome for between-study comparison was a composite of death, myocardial infarction (MI), or stroke. There were between-study differences in patient risk profiles (age, BMI, diabetes, and clinical presentation), lesion complexities, and procedural characteristics (stent type, the use of off-pump surgery, and radial artery); the proportion of diabetes and acute coronary syndrome was particularly lower in NOBLE than in other studies. Although there was interstudy heterogeneity for the protocol definition of MI, the risks for serious composite outcome of death, MI, or stroke were similar between PCI and CABG in EXCEL [hazard ratio (HR): 1.00; 95% confidence interval (CI): 0.79-1.26; P=0.98] and in the matched cohort of IRIS-MAIN (HR: 1.08; 95%CI: 0.85-1.38; P=0.53), whereas it was significantly higher after PCI than after CABG in NOBLE (HR: 1.47; 95%CI: 1.06-2.05; P=0.02), which was driven by more common MI and stroke after PCI. In the comparison of a large-sized, all-comer registry, the EXCEL trial might represent better generalizability with respect to baseline characteristics and observed clinical outcomes compared with the NOBLE trial.

Mortality and morbidity during and after Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial: results by sex.

PubMed

Oparil, Suzanne; Davis, Barry R; Cushman, William C; Ford, Charles E; Furberg, Curt D; Habib, Gabriel B; Haywood, L Julian; Margolis, Karen; Probstfield, Jeffrey L; Whelton, Paul K; Wright, Jackson T

2013-05-01

To determine whether an angiotensin-converting enzyme inhibitor (lisinopril) or calcium channel blocker (amlodipine) is superior to a diuretic (chlorthalidone) in reducing cardiovascular disease incidence in sex subgroups, we carried out a prespecified subgroup analysis of 15 638 women and 17 719 men in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Total follow-up (active treatment + passive surveillance using national administrative databases to ascertain deaths and hospitalizations) was 8 to 13 years. The primary outcome was fatal coronary heart disease or nonfatal myocardial infarction. Secondary outcomes included all-cause mortality, stroke, combined cardiovascular disease (coronary heart disease death, nonfatal myocardial infarction, stroke, angina, coronary revascularization, heart failure [HF], or peripheral vascular disease), and end-stage renal disease. In-trial rates of HF, stroke, and combined cardiovascular disease were significantly higher for lisinopril compared with chlorthalidone, and rates of HF were significantly higher for amlodipine compared with chlorthalidone in both men and women. There were no significant treatment sex interactions. These findings did not persist through the extension period with the exception of the HF result for amlodipine versus chlorthalidone, which did not differ significantly by sex. For both women and men, rates were not lower in the amlodipine or lisinopril groups than in the chlorthalidone group for either the primary coronary heart disease outcome or any other cardiovascular disease outcome, and chlorthalidone-based treatment resulted in the lowest risk of HF. Neither lisinopril nor amlodipine is superior to chlorthalidone for initial treatment of hypertension in either women or men. Clinical Trial Registration- clinicaltrials.gov; Identifier: NCT00000542.

Prognostic Value of Transthoracic Doppler Echocardiography Coronary Flow Velocity Reserve in Patients with Nonculprit Stenosis of Intermediate Severity Early after Primary Percutaneous Coronary Intervention.

PubMed

Tesic, Milorad; Djordjevic-Dikic, Ana; Giga, Vojislav; Stepanovic, Jelena; Dobric, Milan; Jovanovic, Ivana; Petrovic, Marija; Mehmedbegovic, Zlatko; Milasinovic, Dejan; Dedovic, Vladimir; Zivkovic, Milorad; Juricic, Stefan; Orlic, Dejan; Stojkovic, Sinisa; Vukcevic, Vladan; Stankovic, Goran; Nedeljkovic, Milan; Ostojic, Miodrag; Beleslin, Branko

2018-04-03

Treatment of nonculprit coronary stenosis during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction may be beneficial, but the mode and timing of the intervention are still controversial. The aim of this study was to examine the significance and prognostic value of preserved coronary flow velocity reserve (CFVR) in patients with nonculprit intermediate stenosis early after primary percutaneous coronary intervention. Two hundred thirty patients with remaining intermediate (50%-70%) stenosis of non-infarct-related arteries, in whom CFVR was performed within 7 days after primary percutaneous coronary intervention, were prospectively enrolled. Twenty patients with reduced CFVR and positive results on stress echocardiography or impaired fractional flow reserve underwent revascularization and were not included in further analysis. The final study population of 210 patients (mean age, 58 ± 10 years; 162 men) was divided into two groups on the basis of CFVR: group 1, CFVR > 2 (n = 174), and group 2, CFVR ≤ 2 (n = 36). Cardiac death, nonfatal myocardial infarction, and revascularization of the evaluated vessel were considered adverse events. Mean follow-up duration was 47 ± 16 months. Mean CFVR for the whole group was 2.36 ± 0.40. There were six adverse events (3.4%) related to the nonculprit coronary artery in group 1, including one cardiac death, one ST-segment elevation myocardial infarction, and four revascularizations. In group 2, there were 30 adverse events (83.3%, P < .001 vs group 1), including two cardiac deaths, two ST-segment elevation myocardial infarctions, and 26 revascularizations. In patients with CFVR > 2 of the intermediate nonculprit coronary lesion, deferral of revascularization is safe and associated with excellent long-term clinical outcomes. Copyright © 2018 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Early risk of mortality after coronary artery revascularization in patients with left ventricular dysfunction and potential role of the wearable cardioverter defibrillator.

PubMed

Zishiri, Edwin T; Williams, Sarah; Cronin, Edmond M; Blackstone, Eugene H; Ellis, Stephen G; Roselli, Eric E; Smedira, Nicholas G; Gillinov, A Marc; Glad, Jo Ann; Tchou, Patrick J; Szymkiewicz, Steven J; Chung, Mina K

2013-02-01

Implantation of implantable cardioverter defibrillator for prevention of sudden cardiac death is deferred for 90 days after coronary revascularization, but mortality may be highest early after cardiac procedures in patients with ventricular dysfunction. We determined mortality risk in postrevascularization patients with left ventricular ejection fraction ≤35% and compared survival with those discharged with a wearable cardioverter defibrillator (WCD). Hospital survivors after surgical (coronary artery bypass graft surgery) or percutaneous (percutaneous coronary intervention [PCI]) revascularization with left ventricular ejection fraction ≤35% were included from Cleveland Clinic and national WCD registries. Kaplan-Meier, Cox proportional hazards, propensity score-matched survival, and hazard function analyses were performed. Early mortality hazard was higher among 4149 patients discharged without a defibrillator compared with 809 with WCDs (90-day mortality post-coronary artery bypass graft surgery 7% versus 3%, P=0.03; post-PCI 10% versus 2%, P<0.0001). WCD use was associated with adjusted lower risks of long-term mortality in the total cohort (39%, P<0.0001) and both post-coronary artery bypass graft surgery (38%, P=0.048) and post-PCI (57%, P<0.0001) cohorts (mean follow-up, 3.2 years). In propensity-matched analyses, WCD use remained associated with lower mortality (58% post-coronary artery bypass graft surgery, P=0.002; 67% post-PCI, P<0.0001). Mortality differences were not attributable solely to therapies for ventricular arrhythmia. Only 1.3% of the WCD group had a documented appropriate therapy. Patients with left ventricular ejection fraction ≤35% have higher early compared to late mortality after coronary revascularization, particularly after PCI. As early hazard seemed less marked in WCD users, prospective studies in this high-risk population are indicated to confirm whether WCD use as a bridge to left ventricular ejection fraction improvement or implantable cardioverter defibrillator implantation can improve outcomes after coronary revascularization.

Utilization of cardiac computed tomography angiography and outpatient invasive coronary angiography in Ontario, Canada.

PubMed

Roifman, Idan; Rezai, Mohammad R; Wijeysundera, Harindra C; Chow, Benjamin J W; Wright, Graham A; Tu, Jack V

2015-01-01

Cardiac computed tomography angiography (coronary CTA) has emerged as a non-invasive method of diagnosing coronary artery disease. The extent of utilization and uptake of this technology since initiation of its funding by the government of Ontario is unknown. The aim of our study was to examine coronary CTA utilization and the rates of elective invasive coronary angiography and revascularization before and after funding initiation. We studied all coronary CTAs performed on adults in Ontario after initiation of funding. We also used an interrupted time series analysis to compare the average monthly rates of invasive angiography and revascularization before and after initiation of funding. There was an initial steep increase in age-and sex-standardized rates of coronary CTA from 5.0 to 11.4/100,000 over the first two quarters after funding initiation. Afterwards, there was a gradual increase in utilization from 11.4 to 17.1/100,000 over two subsequent calendar years. There was a significant reduction in both the mean monthly outpatient invasive coronary angiography (from 20.7 to 19.9 per 100,000 (p = 0.0004)) and revascularization (from 4.9 to 4.4 per 100,000 (p < 0.0001)) rates in the three years following introduction of the coronary CTA billing code as compared to the three prior to its introduction. Since the introduction of coronary CTA funding in Ontario, there has been a steady and controlled increase in its utilization. The increasing use of coronary CTA was associated with a reduction in both the rates of invasive angiography and revascularization. Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Clinical outcome following conservative vs revascularization therapy in patients with stable coronary artery disease and borderline fractional flow reserve measurements.

PubMed

Lindstaedt, Michael; Halilcavusogullari, Yasemin; Yazar, Aydan; Holland-Letz, Tim; Bojara, Waldemar; Mügge, Andreas; Germing, Alfried

2010-02-01

Fractional flow reserve (FFR) measurements in the so-called gray-zone range of > or = 0.75 and < or =0.80 are associated with uncertainty concerning the guidance of patient therapy. It is unclear whether any difference in clinical outcome exists when revascularization treatment of FFR-evaluated lesions in this borderline range is deferred or performed. The objective of this study is to compare the clinical outcome of these patients with respect to their recommended treatment strategy. Out of a single center database of 900 consecutive patients with stable coronary artery disease, 97 patients with borderline FFR measurements were identified and included in the study. The rate of major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), coronary revascularization) and the presence of angina were evaluated at follow-up. A total of 48 patients were deferred from revascularization and 49 patients underwent revascularization. There was no difference in risk profile between these groups. At a mean follow-up of 24+/-16 months, event-free survival in the deferred group was significantly better regarding overall MACE, combined rate of cardiac death, and MI, as well as MACE related to the FFR-evaluated vessel. No difference with regard to the presence of angina was observed. Patients with coronary lesions in the borderline FFR range can be deferred from revascularization without putting them at increased risk for major adverse events. Revascularization may be considered in the course of therapy on an individual basis if typical angina persists or worsens despite maximal medical treatment. Copyright 2010 Wiley Periodicals, Inc.

Transcatheter aortic valve implantation and off-pump coronary artery bypass surgery: an effective hybrid procedure in selected patients.

PubMed

Mayr, Benedikt; Firschke, Christian; Erlebach, Magdalena; Bleiziffer, Sabine; Krane, Markus; Joner, Michael; Herold, Ulf; Nöbauer, Christian; Lange, Rüdiger; Deutsch, Marcus-André

2018-02-26

Simultaneous surgical off-pump coronary revascularization and transcatheter aortic valve implantation (TAVI) as a hybrid procedure may be a therapeutic option for patients with a TAVI indication who are not suitable for percutaneous coronary intervention and for patients who have an indication for combined surgical aortic valve implantation and coronary artery bypass grafting but present with a porcelain aorta. Early outcomes of these patients are analysed in this study. From February 2011 to April 2017, hybrid TAVI/off-pump coronary artery bypass (OPCAB) was performed in 12 (60%) patients, hybrid TAVI/minimally invasive direct coronary artery bypass in 6 (30%) patients and staged TAVI/OPCAB in 2 (10%) patients. Endpoints of this study were 30-day mortality, device success and postoperative adverse events as defined by the updated Valve Academic Research Consortium (VARC-2). The median age at the time of surgery was 77 years [interquartile range (IQR), 70-81] with a median logistic EuroSCORE and Society of Thoracic Surgeons' Predicted Risk score of 16.1% (IQR, 9.3-28.1) and 3.9% (IQR, 2.2-5.6), respectively. The median Synergy between PCI with Taxus and Cardiac Surgery score was 16.5 (IQR, 9.8-22.8). TAVI implantation routes were transaortic in 9 (45%) patients, transapical and transfemoral in 5 (25%) patients each and transsubclavian in 1 (5%) patient. Complete myocardial revascularization was achieved in 75% of patients. Device success rate was 100%. Paravalvular aortic regurgitation did not exceed mild in any patient. Stroke/transient ischaemic attack, vascular complications and myocardial infarction were not observed. Re-exploration for bleeding was required in 1 (5%) patient. Thirty-day mortality was 0%. Hybrid OPCAB/MIDCAB and TAVI prove to be a safe and effective alternative treatment option in selected higher risk patients.

Does off-pump coronary surgery reduce morbidity and mortality?

PubMed

Sabik, Joseph F; Gillinov, A Marc; Blackstone, Eugene H; Vacha, Catherine; Houghtaling, Penny L; Navia, Jose; Smedira, Nicholas G; McCarthy, Patrick M; Cosgrove, Delos M; Lytle, Bruce W

2002-10-01

To compare hospital outcomes of on-pump and off-pump coronary artery bypass surgery. From 1997 to 2000, primary coronary artery bypass grafting was performed in 481 patients off pump and in 3231 patients on pump. Hospital outcomes were compared between propensity-matched pairs of 406 on-pump and 406 off-pump patients. The 2 groups were similar in age (P =.9), left ventricular function (P =.7), extent of coronary artery disease (P =.5), carotid artery disease (P =.4), and chronic obstructive pulmonary disease (P =.5). However, off-pump patients had more previous strokes (P =.05) and peripheral vascular disease (P =.02); on-pump patients had a higher preoperative New York Heart Association class (P =.01). In the matched pairs the mean number of bypass grafts was 2.8 +/- 1.0 in off-pump patients and 3.5 +/- 1.1 in on-pump patients (P <.001). Fewer grafts were performed to the circumflex (P <.001) and right coronary (P =.006) artery systems in the off-pump patients. Postoperative mortality, stroke, myocardial infarction, and reoperation for bleeding were similar in the 2 groups. There was more encephalopathy (P =.02), sternal wound infection (P =.04), red blood cell use (P =.002), and renal failure requiring dialysis (P =.03) in the on-pump patients. Both off- and on-pump procedures produced excellent early clinical results with low mortality. An advantage of an off-pump operation was less postoperative morbidity; however, less complete revascularization introduced uncertainty about late results. A disadvantage of on-pump bypass was higher morbidity that seemed attributable to cardiopulmonary bypass.

Coronary revascularization and mortality in men with congestive heart failure or prior myocardial infarction who receive androgen deprivation.

PubMed

Nguyen, Paul L; Chen, Ming H; Goldhaber, Samuel Z; Martin, Neil E; Beard, Clair J; Dosoretz, Daniel E; Katin, Michael J; Ross, Rudi; Salenius, Sharon A; D'Amico, Anthony V

2011-01-15

A study was undertaken to determine the impact of prior coronary revascularization (angioplasty, stent, or coronary artery bypass graft) on the risk of all-cause mortality after neoadjuvant hormonal therapy (HT) for prostate cancer (PC) in men with a history of coronary artery disease (CAD)-induced congestive heart failure (CHF) or myocardial infarction (MI). Among 7839 men who received radiation with or without a median of 4 months of HT for PC from 1991 to 2006, 495 (6.3%) had CAD-induced CHF or MI and formed the study cohort. Of these men, 250 (50.5%) had been revascularized before treatment for PC. Cox regression was used to determine whether HT increased the risk of all-cause mortality, and whether revascularization altered this risk, after adjusting for known PC prognostic factors and a propensity score for revascularization. Median follow-up was 4.1 years. Neoadjuvant HT was associated with an increased risk of all-cause mortality (28.9% vs 15.7% at 5 years; adjusted hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.13-2.64; P = .01). Men who received HT without revascularization had the highest risk of all-cause mortality (33.3%; adjusted HR, 1.48; 95% CI, 1.01-2.18; P = .047), whereas men who were revascularized and did not receive HT had the lowest risk of all-cause mortality (9.4%; adjusted HR, 0.51; 95% CI, 0.28-0.93; P = .028). The reference group had an intermediate risk of all-cause mortality (23.4%) and was comprised of men in whom HT use and revascularization were either both given or both withheld. In men with a history of CAD-induced CHF or MI, neoadjuvant HT is associated with an excess risk of mortality, which appears to be reduced but not eliminated by prior revascularization. Copyright © 2010 American Cancer Society.

Coronary revascularization vs. medical therapy following coronary-computed tomographic angiography in patients with low-, intermediate- and high-risk coronary artery disease: results from the CONFIRM long-term registry

PubMed Central

Schulman-Marcus, Joshua; Lin, Fay Y.; Gransar, Heidi; Berman, Daniel; Callister, Tracy; DeLago, Augustin; Hadamitzky, Martin; Hausleiter, Joerg; Al-Mallah, Mouaz; Budoff, Matthew; Kaufmann, Philipp; Achenbach, Stephan; Raff, Gilbert; Chinnaiyan, Kavitha; Cademartiri, Filippo; Maffei, Erica; Villines, Todd; Kim, Yong-Jin; Leipsic, Jonathon; Feuchtner, Gudrun; Rubinshtein, Ronen; Pontone, Gianluca; Andreini, Daniele; Marques, Hugo; Chang, Hyuk-Jae; Chow, Benjamin J.W.; Cury, Ricardo C.; Dunning, Allison; Shaw, Leslee; Min, James K.

2017-01-01

Abstract Aims To identify the effect of early revascularization on 5-year survival in patients with CAD diagnosed by coronary-computed tomographic angiography (CCTA). Methods and results We examined 5544 stable patients with suspected CAD undergoing CCTA who were followed a median of 5.5 years in a large international registry. Patients were categorized as having low-, intermediate-, or high-risk CAD based on CCTA findings. Two treatment groups were defined: early revascularization within 90 days of CCTA (n = 1171) and medical therapy (n = 4373). To account for the non-randomized referral to revascularization, we developed a propensity score by logistic regression. This score was incorporated into Cox proportional hazard models to calculate the effect of revascularization on all-cause mortality. Death occurred in 363 (6.6%) patients and was more frequent in medical therapy. In multivariable models, when compared with medical therapy, the mortality benefit of revascularization varied significantly over time and by CAD risk (P for interaction 0.04). In high-risk CAD, revascularization was significantly associated with lower mortality at 1 year (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.11–0.47) and 5 years (HR 0.31, 95% CI 0.18–0.54). For intermediate-risk CAD, revascularization was associated with reduced mortality at 1 year (HR 0.45, 95% CI 0.22–0.93) but not 5 years (HR 0.63, 95% CI 0.33–1.20). For low-risk CAD, there was no survival benefit at either time point. Conclusions Early revascularization was associated with reduced 1-year mortality in intermediate- and high-risk CAD detected by CCTA, but this association only persisted for 5-year mortality in high-risk CAD. PMID:28329294

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

PubMed Central

Boukhris, Marouane; Tomasello, Salvatore Davide; Azzarelli, Salvatore; Elhadj, Zied Ibn; Marzà, Francesco; Galassi, Alfredo Ruggero

2015-01-01

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization. PMID:26136637

Cardioprotection during cardiac surgery

PubMed Central

Hausenloy, Derek J.; Boston-Griffiths, Edney; Yellon, Derek M.

2012-01-01

Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide. For a large number of patients with CHD, coronary artery bypass graft (CABG) surgery remains the preferred strategy for coronary revascularization. Over the last 10 years, the number of high-risk patients undergoing CABG surgery has increased significantly, resulting in worse clinical outcomes in this patient group. This appears to be related to the ageing population, increased co-morbidities (such as diabetes, obesity, hypertension, stroke), concomitant valve disease, and advances in percutaneous coronary intervention which have resulted in patients with more complex coronary artery disease undergoing surgery. These high-risk patients are more susceptible to peri-operative myocardial injury and infarction (PMI), a major cause of which is acute global ischaemia/reperfusion injury arising from inadequate myocardial protection during CABG surgery. Therefore, novel therapeutic strategies are required to protect the heart in this high-risk patient group. In this article, we review the aetiology of PMI during CABG surgery, its diagnosis and clinical significance, and the endogenous and pharmacological therapeutic strategies available for preventing it. By improving cardioprotection during CABG surgery, we may be able to reduce PMI, preserve left ventricular systolic function, and reduce morbidity and mortality in these high-risk patients with CHD. PMID:22440888

Left main coronary artery disease: pathophysiology, diagnosis, and treatment.

PubMed

Collet, Carlos; Capodanno, Davide; Onuma, Yoshinobu; Banning, Adrian; Stone, Gregg W; Taggart, David P; Sabik, Joseph; Serruys, Patrick W

2018-06-01

The advent of coronary angiography in the 1960s allowed for the risk stratification of patients with stable angina. Patients with unprotected left main coronary artery disease have an increased risk of death related to the large amount of myocardium supplied by this vessel. Although coronary angiography remains the preferred imaging modality for the evaluation of left main coronary artery stenosis, this technique has important limitations. Angiograms of the left main coronary artery segment can be difficult to interpret, and almost one-third of patients can be misclassified when fractional flow reserve is used as the reference. In patients with clinically significant unprotected left main coronary artery disease, surgical revascularization was shown to improve survival compared with medical therapy and has been regarded as the treatment of choice for unprotected left main coronary artery disease. Two large-scale clinical trials published in 2016 support the usefulness of catheter-based revascularization in selected patients with unprotected left main coronary artery disease. In this Review, we describe the pathophysiology of unprotected left main coronary artery disease, discuss diagnostic approaches in light of new noninvasive and invasive imaging techniques, and detail risk stratification models to aid the Heart Team in the decision-making process for determining the best revascularization strategy for these patients.

Body-Weight Fluctuations and Outcomes in Coronary Disease.

PubMed

Bangalore, Sripal; Fayyad, Rana; Laskey, Rachel; DeMicco, David A; Messerli, Franz H; Waters, David D

2017-04-06

Body-weight fluctuation is a risk factor for death and coronary events in patients without cardiovascular disease. It is not known whether variability in body weight affects outcomes in patients with coronary artery disease. We determined intraindividual fluctuations in body weight from baseline weight and follow-up visits and performed a post hoc analysis of the Treating to New Targets trial, which involved assessment of the efficacy and safety of lowering low-density lipoprotein cholesterol levels with atorvastatin. The primary outcome was any coronary event (a composite of death from coronary heart disease, nonfatal myocardial infarction, resuscitated cardiac arrest, revascularization, or angina). Secondary outcomes were any cardiovascular event (a composite of any coronary event, a cerebrovascular event, peripheral vascular disease, or heart failure), death, myocardial infarction, or stroke. Among 9509 participants, after adjustment for risk factors, baseline lipid levels, mean body weight, and weight change, each increase of 1 SD in body-weight variability (measured according to average successive variability and used as a time-dependent covariate) was associated with an increase in the risk of any coronary event (2091 events; hazard ratio, 1.04; 95% confidence interval [CI], 1.01 to 1.07; P=0.01), any cardiovascular event (2727 events; hazard ratio, 1.04; 95% CI, 1.02 to 1.07; P<0.001), and death (487 events; hazard ratio,1.09; 95% CI, 1.07 to 1.12; P<0.001). Among patients in the quintile with the highest variation in body weight, the risk of a coronary event was 64% higher, the risk of a cardiovascular event 85% higher, death 124% higher, myocardial infarction 117% higher, and stroke 136% higher than it was among those in the quintile with the lowest variation in body weight in adjusted models. Among participants with coronary artery disease, fluctuation in body weight was associated with higher mortality and a higher rate of cardiovascular events independent of traditional cardiovascular risk factors. (Funded by Pfizer; ClinicalTrials.gov number, NCT00327691 .).

Rationale and design of the Cardiovascular Inflammation Reduction Trial: a test of the inflammatory hypothesis of atherothrombosis.

PubMed

Everett, Brendan M; Pradhan, Aruna D; Solomon, Daniel H; Paynter, Nina; Macfadyen, Jean; Zaharris, Elaine; Gupta, Milan; Clearfield, Michael; Libby, Peter; Hasan, Ahmed A K; Glynn, Robert J; Ridker, Paul M

2013-08-01

Inflammation plays a fundamental role in atherothrombosis. Yet, whether direct inhibition of inflammation will reduce the occurrence of adverse cardiovascular outcomes is not known. The Cardiovascular Inflammation Reduction Trial (CIRT) (ClinicalTrials.govNCT01594333) will randomly allocate 7,000 patients with prior myocardial infarction (MI) and either type 2 diabetes or the metabolic syndrome to low-dose methotrexate (target dose 15-20 mg/wk) or placebo over an average follow-up period of 3 to 5 years. Low-dose methotrexate is a commonly used anti-inflammatory regimen for the treatment of rheumatoid arthritis and lacks significant effects on lipid levels, blood pressure, or platelet function. Both observational and mechanistic studies suggest that low-dose methotrexate has clinically relevant antiatherothrombotic effects. The CIRT primary end point is a composite of nonfatal MI, nonfatal stroke, and cardiovascular death. Secondary end points are all-cause mortality, coronary revascularization plus the primary end point, hospitalization for congestive heart failure plus the primary end point, all-cause mortality plus coronary revascularization plus congestive heart failure plus the primary end point, incident type 2 diabetes, and net clinical benefit or harm. CIRT will use standardized central methodology designed to ensure consistent performance of all dose adjustments and safety interventions at each clinical site in a manner that protects the blinding to treatment but maintains safety for enrolled participants. CIRT aims to test the inflammatory hypothesis of atherothrombosis in patients with prior MI and either type 2 diabetes or metabolic syndrome, conditions associated with persistent inflammation. If low-dose methotrexate reduces cardiovascular events, CIRT would provide a novel therapeutic approach for the secondary prevention of heart attack, stroke, and cardiovascular death. Copyright © 2013 Mosby, Inc. All rights reserved.

Bone marrow mononuclear cell implantation in myocardial laser channels in the ischemic heart disease surgery. Long-term results

NASA Astrophysics Data System (ADS)

Chernyavskiy, Alexander; Fomichev, Alexey; Minin, Stanislav; Nikitin, Nikita

2017-10-01

Background: The problem of incomplete myocardial revascularization for diffuse and distal lesions of the myocardium is still relevant. We assessed the clinical and instrumental long-term results of autologous bone marrow cell (BMC) implantation in laser channels in ischemic heart disease with diffuse and distal coronary disease. 35 coronary heart disease (CHD) patients with diffuse and distal coronary disease during coronary artery bypass grafting (CABG) underwent BMC implantation in laser channels. The control group consisted of 29 patients. All patients in this group underwent only CABG. Clinical and instrumental assessment of the method's effect was carried out at two weeks, six months, and six years after surgery. Indirect revascularization showed more significant decreasing of the functional class (FC) New York Heart Association (NYHA), myocardial perfusion and contractility improvement. Autologous BMC implantation in laser channels is an effective method of CHD surgical treatment if it is impossible to perform direct myocardial revascularization. The indirect revascularization effect is formed in the first six months after surgery and remains at the same level for six years.

Gender-Specific Differences in All-Cause Mortality Between Incomplete and Complete Revascularization in Patients With ST-Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease.

PubMed

Dimitriu-Leen, Aukelien C; Hermans, Maaike P J; van Rosendael, Alexander R; van Zwet, Erik W; van der Hoeven, Bas L; Bax, Jeroen J; Scholte, Arthur J H A

2018-03-01

The best revascularization strategy (complete vs incomplete revascularization) in patients with ST-elevation myocardial infarction (STEMI) is still debated. The interaction between gender and revascularization strategy in patients with STEMI on all-cause mortality is uncertain. The aim of the present study was to evaluate gender-specific difference in all-cause mortality between incomplete and complete revascularization in patients with STEMI and multi-vessel coronary artery disease. The study population consisted of 375 men and 115 women with a first STEMI and multi-vessel coronary artery disease without cardiogenic shock at admission or left main stenosis. The 30-day and 5-year all-cause mortality was examined in patients categorized according to gender and revascularization strategy (incomplete and complete revascularization). Within the first 30 days, men and women with incomplete revascularization were associated with higher mortality rates compared with men with complete revascularization. However, the gender-strategy interaction variable was not independently associated with 30-day mortality after STEMI when corrected for baseline characteristics and angiographic features. Within the survivors of the first 30 days, men with incomplete revascularization (compared with men with complete revascularization) were independently associated with all-cause mortality during 5 years of follow-up (hazard ratios 3.07, 95% confidence interval 1.24;7.61, p = 0.016). In contrast, women with incomplete revascularization were not independently associated with 5-year all-cause mortality (hazard ratios 0.60, 95% confidence interval 0.14;2.51, p = 0.48). In conclusion, no gender-strategy differences occurred in all-cause mortality within 30 days after STEMI. However, in the survivors of the first 30 days, incomplete revascularization in men was independently associated with all-cause mortality during 5-year follow-up, but this was not the case in women. Copyright © 2017 Elsevier Inc. All rights reserved.

Implementation of a cardiac PET stress program: comparison of outcomes to the preceding SPECT era.

PubMed

Knight, Stacey; Min, David B; Le, Viet T; Meredith, Kent G; Dhar, Ritesh; Biswas, Santanu; Jensen, Kurt R; Mason, Steven M; Ethington, Jon-David; Lappe, Donald L; Muhlestein, Joseph B; Anderson, Jeffrey L; Knowlton, Kirk U

2018-05-03

Cardiac positron emission testing (PET) is more accurate than single photon emission computed tomography (SPECT) at identifying coronary artery disease (CAD); however, the 2 modalities have not been thoroughly compared in a real-world setting. We conducted a retrospective analysis of 60-day catheterization outcomes and 1-year major adverse cardiovascular events (MACE) after the transition from a SPECT- to a PET-based myocardial perfusion imaging (MPI) program. MPI patients at Intermountain Medical Center from January 2011-December 2012 (the SPECT era, n = 6,777) and January 2014-December 2015 (the PET era, n = 7,817) were studied. Outcomes studied were 60-day coronary angiography, high-grade obstructive CAD, left main/severe 3-vessel disease, revascularization, and 1-year MACE-revascularization (MACE-revasc; death, myocardial infarction [MI], or revascularization >60 days). Patients were 64 ± 13 years old; 54% were male and 90% were of European descent; and 57% represented a screening population (no prior MI, revascularization, or CAD). During the PET era, compared with the SPECT era, a higher percentage of patients underwent coronary angiography (13.2% vs. 9.7%, P < 0.0001), had high-grade obstructive CAD (10.5% vs. 6.9%, P < 0.0001), had left main or severe 3-vessel disease (3.0% vs. 2.3%, P = 0.012), and had coronary revascularization (56.7% vs. 47.1%, P = 0.0001). Similar catheterization outcomes were seen when restricted to the screening population. There was no difference in 1-year MACE-revasc (PET [5.8%] vs. SPECT [5.3%], P = 0.31). The PET-based MPI program resulted in improved identification of patients with high-grade obstructive CAD, as well as a larger percentage of revascularization, thus resulting in fewer patients undergoing coronary angiography without revascularization. This observational study was funded using internal departmental funds.

Effect of pravastatin on cardiovascular events and mortality in 1516 women with coronary heart disease: results from the Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) study.

PubMed

Hague, Wendy; Forder, Peta; Simes, John; Hunt, David; Tonkin, Andrew

2003-04-01

The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) study showed that cholesterol-lowering therapy prevented further events in patients with coronary heart disease and average cholesterol levels. The aim of this subgroup analysis was to assess the effects of pravastatin in women. A total of 1516 women (756 assigned to take pravastatin) in a cohort of 9014 patients with previous myocardial infarction or unstable angina and a baseline plasma cholesterol level of 4.0 to 7.0 mmol/L (155-271 mg/dL) were assigned to receive pravastatin (40 mg/d) or placebo. Major cardiovascular disease events in 6 years were measured. Women were at a lesser risk than men for death from any cause (10.3% vs 14.8%, P <.01), death from coronary heart disease (6.6% vs 8.6%, P =.04), and coronary revascularization (13.6% vs 16.2%, P =.05) and at a similar risk of myocardial infarction (9.2% vs 10.5%, P =.26), stroke (3.6% vs 4.7%, P =.11), and hospitalization for unstable angina (25.1% vs 24.5%, P = 0.90). Pravastatin significantly reduced the risk of all prespecified cardiovascular events in all LIPID patients. Relative treatment effects in women did not differ significantly from those in men (P >.05) for any events except hospitalization for unstable angina. There were too few events to demonstrate separately significant effects in women; the estimated relative risk reduction with pravastatin was 11% (95% CI -18%-33%) for coronary heart disease death or nonfatal myocardial infarction, 18% (95% CI -25%-46%) for coronary heart disease death, 16% (95% CI -19%-41%) for myocardial infarction, and 17% (95% CI -2%-33%) for coronary heart disease death, myocardial infarction, or coronary revascularization. The study had the largest secondary-prevention female cohort studied thus far, but was not adequately powered to show separate effects in women. Nevertheless, the results were consistent with the main results of this and other trials in showing reduced risks with cholesterol-lowering treatment.

PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock.

PubMed

Thiele, Holger; Akin, Ibrahim; Sandri, Marcus; Fuernau, Georg; de Waha, Suzanne; Meyer-Saraei, Roza; Nordbeck, Peter; Geisler, Tobias; Landmesser, Ulf; Skurk, Carsten; Fach, Andreas; Lapp, Harald; Piek, Jan J; Noc, Marko; Goslar, Tomaž; Felix, Stephan B; Maier, Lars S; Stepinska, Janina; Oldroyd, Keith; Serpytis, Pranas; Montalescot, Gilles; Barthelemy, Olivier; Huber, Kurt; Windecker, Stephan; Savonitto, Stefano; Torremante, Patrizia; Vrints, Christiaan; Schneider, Steffen; Desch, Steffen; Zeymer, Uwe

2017-12-21

In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial. In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke. At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups. Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI. (Funded by the European Union 7th Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases.

PubMed

Bradshaw, Rhiannon J; Ahanchi, S Sadie; Powell, Obie; Larion, Sebastian; Brandt, Colin; Soult, Michael C; Panneton, Jean M

2017-05-01

The best management strategy for the left subclavian artery (LSA) in pathologic processes of the aorta requiring zone 2 thoracic endovascular aortic repair (TEVAR) remains controversial. We compared LSA coverage with or without revascularization as well as the different means of LSA revascularization. A retrospective chart review was conducted of patients with any aortic diseases who underwent zone 2 TEVAR deployment from 2007 to 2014. Primary end points included 30-day stroke and 30-day spinal cord injury (SCI). Secondary end points were 30-day procedure-related reintervention, freedom from aorta-related reintervention, aorta-related mortality, and all-cause mortality. We identified 96 patients with zone 2 TEVAR who met our inclusion criteria. The mean age of the patients was 62 years, with 61.5% male. Diseases included acute aortic dissections (n = 25), chronic aortic dissection with aneurysmal degeneration (n = 22), primary aortic aneurysms (n = 21), penetrating aortic ulcers/intramural hematomas (n = 17), and traumatic aortic injuries (n = 11). Strategies for the LSA included coverage with revascularization (n = 54) or without revascularization (n = 42). Methods of LSA revascularization included laser fenestration with stenting (n = 33) and surgical revascularization: transposition (n = 10) or bypass (n = 11). Of the 54 patients with LSA revascularization, 44 (81.5%) underwent LSA intervention at the time of TEVAR and 10 (18.5%) at a mean time of 33 days before TEVAR (range, 4-63 days). For the entire cohort, the overall incidence of 30-day stroke was 7.3%; of 30-day SCI, 2.1%; and of procedure-related reintervention, 5.2%. At a mean follow-up of 24 months (range, 1-79 months), aorta-related reintervention was 15.6%, aorta-related mortality was 12.5%, and all-cause mortality was 29.2%. The 30-day stroke rate was highest for LSA coverage without revascularization (6/42 [14.3%]) compared with any form of LSA revascularization (1/54 [1.9%]; P = .020), with no difference between LSA interventions done synchronously with TEVAR (1/44 [2.3%]) vs metachronously with TEVAR (0/10 [0%]; P = .63). There was no significant difference in 30-day SCI in LSA coverage without revascularization (2/42 [4.8%]) vs with revascularization (0/54 [0%]; P = .11). There was no difference in aorta-related reintervention, aorta-related mortality, or all-cause mortality in coverage without revascularization (5/42 [11.9%], 6/42 [14.3%], and 14/42 [33.3%]) vs with revascularization (10/54 [18.5%; P = .376], 6/54 [11.1%; P = .641], and 14/54 [25.9%; P = .43], respectively). After univariate and multivariable analysis, we identified LSA coverage without revascularization as associated with a higher rate of 30-day stroke (hazard ratio, 17.2; 95% confidence interval, 1.3-220.4; P = .029). Our study suggests that coverage of the LSA without revascularization increases the risk of stroke and possibly SCI. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Outcomes of a contemporary cohort of 536 consecutive patients with acute ischemic stroke treated with endovascular therapy.

PubMed

Abilleira, Sònia; Cardona, Pere; Ribó, Marc; Millán, Mònica; Obach, Víctor; Roquer, Jaume; Cánovas, David; Martí-Fàbregas, Joan; Rubio, Francisco; Alvarez-Sabín, José; Dávalos, Antoni; Chamorro, Angel; de Miquel, Maria Angeles; Tomasello, Alejandro; Castaño, Carlos; Macho, Juan M; Ribera, Aida; Gallofré, Miquel

2014-04-01

We sought to assess outcomes after endovascular treatment/therapy of acute ischemic stroke, overall and by subgroups, and looked for predictors of outcome. We used data from a mandatory, population-based registry that includes external monitoring of completeness, which assesses reperfusion therapies for consecutive patients with acute ischemic stroke since 2011. We described outcomes overall and by subgroups (age ≤ or >80 years; onset-to-groin puncture ≤ or >6 hours; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization), and determined independent predictors of good outcome (modified Rankin Scale score ≤2) and mortality at 3 months by multivariate modeling. We analyzed 536 patients, of whom 285 received previous IV recombinant tissue-type plasminogen activator. Overall, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%, 5.6% developed symptomatic intracerebral hemorrhages, 43.3% achieved good functional outcome, and 22.2% were dead at 90 days. Adjusted comparisons by subgroups systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome). Multivariate analyses confirmed the independent protective effect of revascularization. Additionally, age >80 years, stroke severity, hypertension (deleterious), atrial fibrillation, and onset-to-groin puncture ≤6 hours (protective) also predicted good outcome, whereas lack of previous disability and anterior circulation strokes (protective) as well as and hypertension (deleterious) independently predicted mortality. This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.

Impact of cardiac hybrid imaging-guided patient management on clinical long-term outcome.

PubMed

Benz, Dominik C; Gaemperli, Lara; Gräni, Christoph; von Felten, Elia; Giannopoulos, Andreas A; Messerli, Michael; Buechel, Ronny R; Gaemperli, Oliver; Pazhenkottil, Aju P; Kaufmann, Philipp A

2018-06-15

Although randomized trials have provided evidence for invasive fractional flow reserve to guide revascularization, evidence for non-invasive imaging is less well established. The present study investigated whether hybrid coronary computed tomography (CCTA)/single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) can identify patients who benefit from early revascularization compared to medical therapy. This retrospective study consists of 414 patients referred for evaluation of known or suspected coronary artery disease (CAD) with CCTA/SPECT hybrid imaging. CCTA categorized patients into no CAD, non-high-risk CAD and high-risk CAD. In patients with CAD (n = 329), a matched finding (n = 75) was defined as a reversible perfusion defect in a territory subtended by a coronary artery with CAD. All other combinations of pathologic findings were classified as unmatched (n = 254). Death, myocardial infarction, unstable angina requiring hospitalization, and late coronary revascularization were defined as major adverse cardiac events (MACE). Cox hazards models included covariates age, male gender, more than two risk factors, previous CABG, high-risk CAD and early revascularization. During median follow-up of 6.0 years, 112 patients experienced a MACE (27%). Early revascularization (n = 50) was independently associated with improved outcome among patients with a matched finding (p < 0.001). There was no benefit among patients with an unmatched finding (p = 0.787), irrespective of presence (p = 0.505) or absence of high-risk CAD (p = 0.631). Early revascularization is associated with an outcome benefit in CAD patients with a matched finding documented by cardiac hybrid imaging while no benefit of revascularization was observed in patients with an unmatched finding. Copyright © 2018 Elsevier B.V. All rights reserved.

Disability pension after coronary revascularization: a prospective nationwide register-based Swedish cohort study.

PubMed

Zetterström, Katharina; Vaez, Marjan; Alexanderson, Kristina; Ivert, Torbjörn; Pehrsson, Kenneth; Hammar, Niklas; Voss, Margaretha

2015-03-01

Scientific knowledge on disability pension (DP) after revascularization by coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) is scarce. The aim was to study the incidence of and risk factors for being granted DP in the 5 years following a first CABG or PCI, accounting for socio-demographic and medical factors. This is a nationwide population-based study using Swedish registers including all patients 30-63 years of age (n = 34,643, 16.4% women) who had a first CABG (n = 14,107) or PCI (n = 20,536) during 1994-2003. All were alive and without reintervention 30 days after the procedure and were not on DP or old-age pension. Multivariable adjusted Cox proportional hazard ratios (HR) for DP were estimated with 95% confidence intervals (CI). In 5 years following revascularization, 32.4% had been granted DP and the hazard ratio (HR) was higher in women (HR 1.55, 95% CI 1.48-1.62), and in CABG patients compared with PCI patients (HR 1.35, 95% CI 1.30-1.40). Long-term sick leave in the year before intervention was the strongest predictor for DP following revascularization. After adjustments for socio-demographic factors and sick-leave days in the 12 months before revascularization, HR remained high in all patients with diabetes mellitus regardless of type of revascularization. DP after coronary revascularization was common, especially among women and CABG patients. Most studied medical covariates, including mental and musculoskeletal disorders, were risk factors for future DP, especially long-term sickness absence. © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Jeromel, Miran, E-mail: miran.jeromel@gmail.com; Milosevic, Z. V., E-mail: zoran.milosevic@guest.arnes.si; Kocijancic, I. J., E-mail: igor.kocijancic@gmail.com

BackgroundEndovascular mechanical revascularization (thrombectomy) is an increasingly used method for intracranial large vessel recanalization in acute stroke. The purpose of the study was to analyze the recanalization rate, clinical outcome, and complication rate in our stroke patients treated with mechanical revascularization. A total of 57 patients with large vessel stroke (within 3 h for anterior and 12 h for posterior circulation) were treated with mechanical revascularization at a single center during 24 months. The primary goal of endovascular treatment using different mechanical devices was recanalization of the occluded vessel. Recanalization rate (reported as thrombolysis in cerebral infarction [TICI] score), clinicalmore » outcome (reported as National Institutes of Health Stroke Scale [NIHSS] score and modified Rankin scale [mRS] score), as well as periprocedural complications were analyzed. The mean age of the patients was 63.1 {+-} 12.9 years, with baseline median NIHSS score of 14 (interquartile range, 9.5-19). Successful recanalization (TICI 2b or 3) was achieved in 41 (72 %) patients. Twenty patients (35 %) presented with favorable outcome (mRS {<=}2) 30 days after stroke. Overall, significant neurological improvement ({>=}4 NIHSS point reduction) occurred in 36 (63 %) patients. A clinically significant procedure-related adverse events (vessel disruption, peri/postprocedural intracranial bleeding) defined with decline in NIHSS of {>=}4 or death occurred in three (5 %) patients. The study showed a high recanalization rate with improved clinical outcome and a low rate of periprocedural complications in our stroke patients treated with mechanical revascularization. Therefore, we could conclude that endovascular revascularization (primary or in combination with a bridging thrombolysis) was an effective and safe procedure for intracranial large vessel recanalization in acute stroke.« less

Review of the treatment of acute coronary syndrome in elderly patients.

PubMed

Jokhadar, Maan; Wenger, Nanette K

2009-01-01

Advances in treatment and early revascularization have led to improved outcomes for patients with acute coronary syndrome (ACS). However, elderly ACS patients are less likely to receive evidence-based treatment, including revascularization therapy, due to uncertainty of the associated benefits and risks in this population. This article addresses key issues regarding medical and revascularization therapy in elderly ACS patients based on a review of the medical literature and in concordance with clinical practice guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

Electrical neuromodulation for disabling angina pectoris related to isolated stenoses of small epicardial coronary arteries.

PubMed

Jessurun, G A; Hautvast, R W; DeJongste, M J; Meyler, W J; van Boven AJ; Crijns, H J

1999-07-01

Patients with symptomatic small vessel coronary artery disease may be inadequate candidates for revascularization procedures. They may suffer from refractory angina, which does not respond to maximal anti-anginal drug therapy. In addition to patients with end stage coronary artery disease and syndrome X, this newly defined group of subjects with an isolated stenosis of a small coronary artery may benefit from electrical neurostimulation. We describe two patients with intractable angina caused by a significant narrowing of a diagonal branch. This treatment modality should be considered as an alternative method for unsatisfactory revascularization procedures.

[CARDIOREABILITATION PECULIARITIES AND CORRECTION OF VIOLATIONS OF SISTOLIC, DIASOLIC FUNCTION AND HEART RATE VARIABILITY IN PATIENTS WITH ACUTE CORONARY SYNDROME AND CORONARY ARTERY REVASCULARIZATION].

PubMed

Shved, M; Tsuglevych, L; Kyrychok, I; Levytska, L; Boiko, T; Kitsak, Ya

2017-04-01

In patients with acute coronary syndrome (ACS) who underwent coronary arteries revascularization, violations of hemodynamics, metabolism and heart rate variability often develop in the postoperative period, therefore, the goal of the study was to establish the features of disturbances and the effectiveness of correction of left ventricular systolic and diastolic dysfunction and heart rate variability in stages of cardiorehabilitation in patients with acute coronary syndrome who underwent coronary arteries revascularization. The experimental group included 40 patients with ACS in the postoperative period who underwent balloon angioplasty and stenting of the coronary arteries (25 patients with ST-segment elevation ACS and 15 patients without ST-segment elevation ACS). The age of examined patients was 37 to 74 years, an average of 52.6±6.7 years. The control group consisted of 20 patients, comparable in age and clinico-laboratory manifestations of ACS, who underwent drug treatment with direct anticoagulants, double antiplatelet therapy, β-blockers, ACE inhibitors and statins. Clinical efficacy of cardiorespiratory process in patients of both groups was assessed by the dynamics of general clinical symptoms and parameters of natriuretic propeptide, systolic and diastolic function of the left ventricle and heart rate variability. In the initial state, clinical and laboratory-instrumental signs of myocardial ischemia disappear in patients with ACS undergoing surgical revascularization of the coronary arteries, but clinical and subclinical manifestations of heart failure were diagnosed. The use of the accelerated program of cardiac rehabilitation already during the first month of studies leads to a decreasement of the signs of systolic and diastolic dysfunction, the level of NT-proBNP and improve in the variability of the heart rhythm wich significantly improves the life quality of patients with ACS. To monitor the effectiveness and safety of cardiac rehabilitation in patients with ACS who underwent coronary arteries revascularization, in addition to the generally accepted methods (determination of heart rate, blood pressure, a 6-minute test), it is advisable to diagnose the subclinical stage of heart failure by determining the level of NT-proBNP, Doppler echocardiogram, parameters of the left ventricular systolic and diastolic function and heart rate variability.

Pharmacological treatment and perceived health status during 1-year follow up in patients diagnosed with coronary artery disease, but ineligible for revascularization. Results from the Euro Heart Survey on Coronary Revascularization.

PubMed

Lenzen, Mattie; Scholte op Reimer, Wilma; Norekvål, Tone M; De Geest, Sabina; Fridlund, Bengt; Heikkilä, Johanna; Jaarsma, Tiny; Mårtensson, Jan; Moons, Philip; Smith, Karen; Stewart, Simon; Strömberg, Anna; Thompson, David R; Wijns, William

2006-06-01

It has been recognized that a clinically significant portion of patients with coronary artery disease (CAD) continue to experience anginal and other related symptoms that are refractory to the combination of medical therapy and revascularization. The Euro Heart Survey on Revascularization (EHSCR) provided an opportunity to assess pharmacological treatment and outcome in patients with proven CAD who were ineligible for revascularization. We performed a secondary analysis of EHS-CR data. After excluding patients with ST-elevation myocardial infarction and those in whom revascularization was not indicated, 4409 patients remained in the analyses. We selected two groups: (1) patients in whom revascularization was the preferred treatment option (n = 3777, 86%), and (2) patients who were considered ineligible for revascularization (n = 632, 14%). Patient ineligible for revascularization had a worse risk profile, more often had a total occlusion (59% vs. 37%, p < 0.001), were treated more often with ACE-inhibitors (65% vs. 55%, p < 0.001) but less likely with aspirin (83% vs. 88%, p < 0.001). Overall, they had higher case-fatality at 1-year (7.0% vs. 3.7%, p < 0.001). Regarding self-perceived health status, measured via the EuroQol 5D (EQ-5D) questionnaire, these same patients reported more problems on all dimensions of the EQ-5D. Furthermore, in the revascularization group we observed an increase between discharge and 1-year follow up (utility score from 0.85 to 1.00) whereas patients ineligible for revascularization did not improve over time (utility score remained 0.80) In this large cohort of European patients with CAD, those considered ineligible for revascularization had more co-morbidities and risk factors, and scored worse on self-perceived health status as compared to revascularized patients in the revascularization group. With the exception of ACE-inhibitors and aspirin, there were no major differences regarding drug treatment between the two groups. Given these clinically significant observations, there appears to be a role for nurse-led, multidisciplinary, rehabilitation teams that target clinically vulnerable patients whose symptoms remain refractory to standard medical care.

Reliability of clinical guideline development using mail-only versus in-person expert panels.

PubMed

Washington, Donna L; Bernstein, Steven J; Kahan, James P; Leape, Lucian L; Kamberg, Caren J; Shekelle, Paul G

2003-12-01

Clinical practice guidelines quickly become outdated. One reason they might not be updated as often as needed is the expense of collecting expert judgment regarding the evidence. The RAND-UCLA Appropriateness Method is one commonly used method for collecting expert opinion. We tested whether a less expensive, mail-only process could substitute for the standard in-person process normally used. We performed a 4-way replication of the appropriateness panel process for coronary revascularization and hysterectomy, conducting 3 panels using the conventional in-person method and 1 panel entirely by mail. All indications were classified as inappropriate or not (to evaluate overuse), and coronary revascularization indications were classified as necessary or not (to evaluate underuse). Kappa statistics were calculated for the comparison in ratings from the 2 methods. Agreement beyond chance between the 2 panel methods ranged from moderate to substantial. The kappa statistic to detect overuse was 0.57 for coronary revascularization and 0.70 for hysterectomy. The kappa statistic to detect coronary revascularization underuse was 0.76. There were no cases in which coronary revascularization was considered inappropriate by 1 method, but necessary or appropriate by the other. Three of 636 (0.5%) hysterectomy cases were categorized as inappropriate by 1 method but appropriate by the other. The reproducibility of the overuse and underuse assessments from the mail-only compared with the conventional in-person conduct of expert panels in this application was similar to the underlying reproducibility of the process. This suggests a potential role for updating guidelines using an expert judgment process conducted entirely through the mail.

[Revascularization of the carotid and vertebral arteries in the elderly].

PubMed

Illuminati, G; Bezzi, M; D'Urso, A; Giacobbi, D; Ceccanei, G; Vietri, F

2004-01-01

From January 1994 to July 2004, 323 patients underwent 348 revascularization of carotid bifurcation for atherosclerotic stenoses. Eighty eight patients (group A) were 75 year-old or older, whereas 235 (group B) were younger than 75 years. Postoperative mortality/neurologic morbidity rate was 1% in group A, and 1.4% in group B. At 5 years, patency and freedom from symptoms/stroke were, respectively, 91% and 92% in group A, and 89% and 91% in group B. None of these differences was statistically significant. In the same time period, 26 internal carotid arteries were revascularized in 24 patients, 75 or more aged, for a symptomatic kinking. Postoperative mortality/morbidity rate was absent, whereas, at 5 years, patency and freedom from symptoms/stroke were, respectively, 88% and 92%. Twelve vertebral arteries were revascularized in 12 patients, 75 or more aged, for invalidating symptoms of vertebrobasilar insufficiency. Postoperative mortality/neurologic morbidity rate was absent. In one case postoperative recurrence of symptoms occurred, despite a patent revascularization. Patency and freedom from symptoms/stroke were 84% and 75%, at 5 years. Revascularization of carotid and vertebral arteries in the elderly can be accomplished with good results, superposable to those of standard revascularization of carotid bifurcation in a younger patients' population.

Comparison of RISK-PCI, GRACE, TIMI risk scores for prediction of major adverse cardiac events in patients with acute coronary syndrome.

PubMed

Jakimov, Tamara; Mrdović, Igor; Filipović, Branka; Zdravković, Marija; Djoković, Aleksandra; Hinić, Saša; Milić, Nataša; Filipović, Branislav

2017-12-31

To compare the prognostic performance of three major risk scoring systems including global registry for acute coronary events (GRACE), thrombolysis in myocardial infarction (TIMI), and prediction of 30-day major adverse cardiovascular events after primary percutaneous coronary intervention (RISK-PCI). This single-center retrospective study involved 200 patients with acute coronary syndrome (ACS) who underwent invasive diagnostic approach, ie, coronary angiography and myocardial revascularization if appropriate, in the period from January 2014 to July 2014. The GRACE, TIMI, and RISK-PCI risk scores were compared for their predictive ability. The primary endpoint was a composite 30-day major adverse cardiovascular event (MACE), which included death, urgent target-vessel revascularization (TVR), stroke, and non-fatal recurrent myocardial infarction (REMI). The c-statistics of the tested scores for 30-day MACE or area under the receiver operating characteristic curve (AUC) with confidence intervals (CI) were as follows: RISK-PCI (AUC=0.94; 95% CI 1.790-4.353), the GRACE score on admission (AUC=0.73; 95% CI 1.013-1.045), the GRACE score on discharge (AUC=0.65; 95% CI 0.999-1.033). The RISK-PCI score was the only score that could predict TVR (AUC=0.91; 95% CI 1.392-2.882). The RISK-PCI scoring system showed an excellent discriminative potential for 30-day death (AUC=0.96; 95% CI 1.339-3.548) in comparison with the GRACE scores on admission (AUC=0.88; 95% CI 1.018-1.072) and on discharge (AUC=0.78; 95% CI 1.000-1.058). In comparison with the GRACE and TIMI scores, RISK-PCI score showed a non-inferior ability to predict 30-day MACE and death in ACS patients. Moreover, RISK-PCI was the only scoring system that could predict recurrent ischemia requiring TVR.

Comparison of RISK-PCI, GRACE, TIMI risk scores for prediction of major adverse cardiac events in patients with acute coronary syndrome

PubMed Central

Jakimov, Tamara; Mrdović, Igor; Filipović, Branka; Zdravković, Marija; Djoković, Aleksandra; Hinić, Saša; Milić, Nataša; Filipović, Branislav

2017-01-01

Aim To compare the prognostic performance of three major risk scoring systems including global registry for acute coronary events (GRACE), thrombolysis in myocardial infarction (TIMI), and prediction of 30-day major adverse cardiovascular events after primary percutaneous coronary intervention (RISK-PCI). Methods This single-center retrospective study involved 200 patients with acute coronary syndrome (ACS) who underwent invasive diagnostic approach, ie, coronary angiography and myocardial revascularization if appropriate, in the period from January 2014 to July 2014. The GRACE, TIMI, and RISK-PCI risk scores were compared for their predictive ability. The primary endpoint was a composite 30-day major adverse cardiovascular event (MACE), which included death, urgent target-vessel revascularization (TVR), stroke, and non-fatal recurrent myocardial infarction (REMI). Results The c-statistics of the tested scores for 30-day MACE or area under the receiver operating characteristic curve (AUC) with confidence intervals (CI) were as follows: RISK-PCI (AUC = 0.94; 95% CI 1.790-4.353), the GRACE score on admission (AUC = 0.73; 95% CI 1.013-1.045), the GRACE score on discharge (AUC = 0.65; 95% CI 0.999-1.033). The RISK-PCI score was the only score that could predict TVR (AUC = 0.91; 95% CI 1.392-2.882). The RISK-PCI scoring system showed an excellent discriminative potential for 30-day death (AUC = 0.96; 95% CI 1.339-3.548) in comparison with the GRACE scores on admission (AUC = 0.88; 95% CI 1.018-1.072) and on discharge (AUC = 0.78; 95% CI 1.000-1.058). Conclusions In comparison with the GRACE and TIMI scores, RISK-PCI score showed a non-inferior ability to predict 30-day MACE and death in ACS patients. Moreover, RISK-PCI was the only scoring system that could predict recurrent ischemia requiring TVR. PMID:29308832

Composite versus conventional coronary artery bypass grafting strategy for the anterolateral territory: study protocol for a randomized controlled trial

PubMed Central

2013-01-01

Background In severe coronary artery disease, coronary artery bypass grafting (CABG) surgery is indicated to re-establish an adequate blood supply to the ischemic myocardium. Effectiveness of CABG surgery for symptom relief and mortality decrease should therefore depend on bypass graft patency. As bypass using a left internal mammary artery (LIMA)-to-left anterior descending coronary artery (LAD) anastomosis allows the best results in terms of graft patency, we designed a new surgical technique using a saphenous vein graft as a venous bridge to distribute the LIMA flow to the cardiac anterolateral territory. This novel strategy could extend the patency benefits associated to the LIMA. Other potential benefits of this technique include easier surgical technique, possibility to use saphenous vein grafts as vein patch angioplasty, shorter saphenous vein grafts requirement and reduced or eliminated manipulations of the ascendant aorta (and associated stroke risk). Methods/Design Between July 2012 and 2016, 200 patients undergoing a primary isolated CABG surgery using cardiopulmonary bypass with a LAD bypass graft and at least another target on the anterolateral territory will be randomized (1:1) according to 1) the new composite strategy and 2) the conventional strategy with a LIMA-to-LAD anastomosis and revascularization of the other anterolateral target(s) with a separated aorto-coronary saphenous vein graft. The primary objective of the trial is to assess whether the composite strategy allows non-inferior anterolateral graft patency index (proportion of non-occluded CABGs out of the total number of CABGs) compared to the conventional technique. The primary outcome is the anterolateral graft patency index, evaluated at one year by 256-slice computed tomography angiography. Ten years of clinical follow-up is planned to assess clinical outcomes including death, myocardial infarction and need for revascularization. Discussion This non-inferiority trial has the potential to advance the adult cardiac surgery field, given the potential benefits associated with the composite grafting strategy. Trial registration ClinicalTrials.gov: NCT01585285. PMID:23971858

Functional Testing Underlying Coronary Revascularisation

ClinicalTrials.gov

2016-10-04

Multivessel Coronary Artery Disease; Vessel Disease; Stable Angina; Unstable Angina or Stabilized Non-ST Elevated Myocardial Infarction; Patients With ST-elevated Myocardial Infarction; Revascularization of Culprit Coronary Artery

Frequency, predictors, and consequences of crossing over to revascularization within 12 months of randomization to optimal medical therapy in the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.

PubMed

Spertus, John A; Maron, David J; Cohen, David J; Kolm, Paul; Hartigan, Pam; Weintraub, William S; Berman, Daniel S; Teo, Koon K; Shaw, Leslee J; Sedlis, Steven P; Knudtson, Merril; Aslan, Mihaela; Dada, Marcin; Boden, William E; Mancini, G B John

2013-07-01

In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, some patients with stable ischemic heart disease randomized to optimal medical therapy (OMT) crossed over to early revascularization. The predictors and outcomes of patients who crossed over from OMT to revascularization are unknown. We compared characteristics of OMT patients who did and did not undergo revascularization within 12 months and created a Cox regression model to identify predictors of early revascularization. Patients' health status was measured with the Seattle Angina Questionnaire. To quantify the potential consequences of initiating OMT without percutaneous coronary intervention, we compared the outcomes of crossover patients with a matched cohort randomized to immediate percutaneous coronary intervention. Among 1148 patients randomized to OMT, 185 (16.1%) underwent early revascularization. Patient characteristics independently associated with early revascularization were worse baseline Seattle Angina Questionnaire scores and healthcare system. Among 156 OMT patients undergoing early revascularization matched to 156 patients randomized to percutaneous coronary intervention, rates of mortality (hazard ratio=0.51 [0.13-2.1]) and nonfatal myocardial infarction (hazard ratio=1.9 [0.75-4.6]) were similar, as were 1-year Seattle Angina Questionnaire scores. OMT patients, however, experienced worse health status over the initial year of treatment and more unstable angina admissions (hazard ratio=2.8 [1.1-7.5]). Among COURAGE patients assigned to OMT alone, patients' angina, dissatisfaction with their current treatment, and, to a lesser extent, their health system were associated with early revascularization. Because early crossover was not associated with an increase in irreversible ischemic events or impaired 12-month health status, these findings support an initial trial of OMT in stable ischemic heart disease with close follow-up of the most symptomatic patients. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00007657.

Sex differences in left main coronary artery stenting: Different characteristics but similar outcomes for women compared with men.

PubMed

Shin, Eun-Seok; Lee, Cheol Whan; Ahn, Jung-Min; Lee, Pil Hyung; Chang, Mineok; Kim, Min-Ju; Yoon, Sung-Han; Park, Duk-Woo; Kang, Soo-Jin; Lee, Seung-Whan; Kim, Young-Hak; Park, Seong-Wook; Park, Seung-Jung

2018-02-15

The clinical outcomes for women compared with men undergoing left main PCI were sparse. We compared the characteristics and long-term outcomes in women versus men after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main CAD. We identified 2328 patients (545 women; 1783 men) with unprotected left main CAD who received PCI with DES between January 2007 and December 2013 in the Interventional Cardiology Research In-cooperation Society-left MAIN revascularization (IRIS-MAIN) registry. The primary outcome was a composite of death from any cause, myocardial infarction, or stroke. The median follow-up time was 2.9years (interquartile range: 1.0-4.1years). Women were older, had a higher incidence of insulin-requiring diabetes mellitus and hypertension, and more commonly presented with acute coronary syndrome than men. Left main ostial lesion was more common in women, whereas left main bifurcation lesion with more extensive CAD was more common in men. The incidence of primary outcome was similar between the two groups (10.8% vs. 10.8%, respectively, log-rank p=0.587). The results were similar after adjustment for baseline variables and consistent across major subgroups. The need for target lesion revascularization was significantly higher in women than in men (8.8% vs. 5.7%, respectively, p<0.05) but the sex bias was not confirmed after adjusting for confounders. Women, as compared to men, had different clinical and lesion characteristics but similar long-term outcomes after PCI with DES for left main CAD. Copyright © 2017 Elsevier B.V. All rights reserved.

[Relationship between hyperuricemia and prognosis in patients with heart failure of coronary heart disease after revascularization].

PubMed

Peng, D; Wang, S P; Zhao, D H; Fan, Q C; Shu, J; Liu, J H

2018-05-08

Objective: To explore the effect of hyperuricemia on prognosis in patients with heart failure of coronary heart disease (CHD) after revascularization. Methods: A single-center retrospective study of all subjects who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) as revascularization for CHD at Beijing Anzhen Hospital, Capital Medical University, between January 2005 and December 2014 was performed.Patients were divided into two groups by with or without hyperuricemia.The average follow-up was 1 818 d. Results: The Logistic regression analysis revealed that hyperuricemia was independent risk factors of readmission of heart failure( P =0.018, OR =1.499, 95% CI 1.071-2.098). The Cox regression analysis revealed that hyperuricemia was independent risk factor of all-cause mortality( P =0.002, RR =1.520, 95% CI 1.166-1.982), cardiovascular ( CV ) mortality( P =0.001, RR =1.811, 95% CI 1.279-2.566), heart failure mortality( P =0.006, RR =2.151, 95% CI 1.247-3.711). Conclusions: There is negative correlation between level of uric acid and left ventricular ejection fraction (LVEF). The patients with heart failure of coronary heart disease complicated with hyperuricemia have high risk of readmission of heart failure, all-cause mortality, CV mortality andheart failure mortality than patients with normal uric acid level. Hyperuricemia is an independent risk factor for patients with heart failure of coronary heart disease after revascularization.

Impact of Multiple Complex Plaques on Short-and Long-Term Clinical in Patients Presenting with ST-Segment Elevation Myocardial Infarction (From the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial)

PubMed Central

Keeley, Ellen C.; Mehran, Roxana; Brener, Sorin J.; Witzenbichler, Bernhard; Guagliumi, Giulio; Dudek, Dariusz; Kornowski, Ran; Dressler, Ovidiu; Fahy, Martin; Xu, Ke; Grines, Cindy L.; Stone, Gregg W.

2014-01-01

It is not known whether the extent and severity of non-culprit coronary lesions correlate with outcomes in patients with STEMI referred for primary PCI. We sought to quantify complex plaques in ST-segment elevation myocardial infarction (STEMI) patients referred for primary percutaneous coronary intervention (PCI) and to determine their effect on short- and long-term clinical outcomes by examining the core laboratory database for plaque analysis from the HORIZONS-AMI study. Baseline demographic, angiographic, and procedural details were compared between patients with single vs. multiple complex plaques undergoing single vessel PCI. Multivariable analysis was performed for predictors of long-term major adverse cardiac events (MACE), a combined end point of death, reinfarction, ischemic target vessel revascularization, or stroke, and for death alone. Single vessel PCI was performed in 3,137 patients (87%): 2,174 (69%) had multiple complex plaques and 963 (31%) had a single complex plaque. Compared to those with a single complex plaque, patients with multiple complex plaques were older (p<0.0001) and had more comorbidities. The presence of multiple complex plaques was an independent predictor of 3-year MACE (hazard ratio [HR]: 1.58; 95% confidence interval [CI]: 1.26–1.98, p<0.0001), and death alone (HR: 1.68; 95% CI: 1.05–2.70, p=0.03). In conclusion, multiple complex plaques are present in the majority of STEMI patients undergoing primary PCI and their presence is an independent predictor of short- and long-term MACE, including death. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI]; NCT00433966) PMID:24703369

Off-pump versus on-pump coronary artery bypass surgery in patients with actively treated diabetes and multivessel coronary disease.

PubMed

Benedetto, Umberto; Caputo, Massimo; Vohra, Hunaid; Davies, Alan; Hillier, James; Bryan, Alan; Angelini, Gianni D

2016-11-01

We conducted a single-center analysis on short-term outcomes and long-term survival in actively treated diabetic patients undergoing off-pump coronary artery bypass versus on-pump coronary artery bypass surgery. The final population consisted of 2450 patients with actively treated diabetes (mean age, 66 ± 9 years; female/male 545/1905, 22%). Of those, 1493 subjects were orally treated and 1011 subjects were taking insulin. Off-pump coronary artery bypass and on-pump coronary artery bypass were performed in 1253 and 1197 patients, respectively. Propensity score matching was used to compare the 2 matched groups. When compared with on-pump coronary artery bypass, off-pump coronary artery bypass was associated with a significant risk reduction for postoperative cerebrovascular accident (odds ratio, 0.49; 95% confidence interval [CI], 0.25-0.99; P = .04), need for postoperative intra-aortic balloon pump (odds ratio, 0.48; 95% CI, 0.30-0.77; P = .002), and reexploration for bleeding (odds ratio, 0.55; 95% CI, 0.33-0.94; P = .02). Off-pump coronary artery bypass did not significantly affect early (hazard ratio [HR], 1.32; 95% CI, 0.73-2.40; P = .36) and late (HR, 1.08; 95% CI, 0.92-1.28; P = .32) mortality. However, off-pump coronary artery bypass with incomplete revascularization was associated with reduced survival when compared with off-pump coronary artery bypass with complete revascularization (HR, 1.82; 95% CI, 1.34-2.46; P = .0002) and on-pump coronary artery bypass with complete revascularization (HR, 1.83; 95% CI, 1.36-2.47; P < .0001). Off-pump coronary artery bypass is a safe and feasible option for diabetic patients with multivessel disease, reduces the incidence of early complications including postoperative cerebrovascular events, and provides excellent long-term survival similar to on-pump coronary artery bypass surgery in case of complete revascularization. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Coronary Artery Bypass Surgery Versus Drug-Eluting Stent Implantation for Left Main or Multivessel Coronary Artery Disease: A Meta-Analysis of Individual Patient Data.

PubMed

Lee, Cheol Whan; Ahn, Jung-Min; Cavalcante, Rafael; Sotomi, Yohei; Onuma, Yoshinobu; Suwannasom, Pannipa; Tenekecioglu, Erhan; Yun, Sung-Cheol; Park, Duk-Woo; Kang, Soo-Jin; Lee, Seung-Whan; Kim, Young-Hak; Park, Seong-Wook; Serruys, Patrick W; Park, Seung-Jung

2016-12-26

The authors undertook a patient-level meta-analysis to compare long-term outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in 3,280 patients with left main or multivessel coronary artery disease (CAD). The relative efficacy and safety of CABG versus PCI with DES for left main or multivessel CAD remain controversial. Data were pooled from the BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery vs. Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trials. The primary outcome was a composite of all-cause death, myocardial infarction, or stroke. The median follow-up was 60 months, and follow-up was completed for 96.2% of patients. The rate of primary outcome was significantly lower with CABG than with PCI (13.0% vs. 16.0%; hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.69 to 1.00; p = 0.046). The difference was mainly driven by reduction in myocardial infarction (HR: 0.46; 95% CI: 0.33 to 0.64; p < 0.001). There was significant interaction between treatment effect and types of CAD, showing CABG to be superior compared with PCI with DES in patients with multivessel CAD (p = 0.001), but no between-group difference in those with left main CAD (p = 0.427). The rates for all-cause death and stroke were similar between the 2 groups. By contrast, the need for repeat revascularization was significantly lower in the CABG group compared with the PCI group. CABG, as compared with PCI with DES, reduced long-term rates of the composite of all-cause death, myocardial infarction, or stroke in patients with left main or multivessel CAD. The advantage of CABG over PCI with DES was particularly pronounced in those with multivessel CAD. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

1-Year Clinical Outcomes in Women After Transcatheter Aortic Valve Replacement: Results From the First WIN-TAVI Registry.

PubMed

Chieffo, Alaide; Petronio, Anna Sonia; Mehilli, Julinda; Chandrasekhar, Jaya; Sartori, Samantha; Lefèvre, Thierry; Presbitero, Patrizia; Capranzano, Piera; Tchetche, Didier; Iadanza, Alessandro; Sardella, Gennaro; Van Mieghem, Nicolas M; Meliga, Emanuele; Dumonteil, Nicholas; Fraccaro, Chiara; Trabattoni, Daniela; Mikhail, Ghada; Sharma, Samin; Ferrer, Maria Cruz; Naber, Christoph; Kievit, Peter; Baber, Usman; Snyder, Clayton; Sharma, Madhav; Morice, Marie Claude; Mehran, Roxana

2018-01-08

This study sought to examine the safety and performance of contemporary transcatheter aortic valve replacement (TAVR) in an exclusive all-women TAVR population, and to further investigate the potential impact of female sex-specific characteristics on composite 1-year clinical outcomes. Women comprise ≥50% patients undergoing TAVR. Several data have shown the noninferiority of TAVR compared with surgical aortic valve replacement for symptomatic significant aortic stenosis, but no study so far has been specifically powered to detect differences by sex. The WIN-TAVI (Women's INternational Transcatheter Aortic Valve Implantation) registry is a multinational, prospective, observational registry of women undergoing TAVR for significant aortic stenosis, across 18 sites in Europe and 1 site in the United States, between January 2013 and December 2015. The primary Valve Academic Research Consortium (VARC)-2 efficacy endpoint was a composite of mortality, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure or valve-related dysfunction beyond 30 days. Secondary endpoints included composite 1-year death or stroke. Predictors of 1-year outcomes were determined using Cox regression methods. A total of 1,019 intermediate to high-risk women, with mean age 82.5 ± 6.3 years, mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) I 17.8 ± 11.7% and mean Society of Thoracic Surgeons score 8.3 ± 7.4% were enrolled. TAVR was performed via transfemoral access in 90.6% and new-generation devices were used in 42.1%. The primary VARC-2 efficacy composite endpoint occurred in 111 (10.9%) patients beyond 30 days and in 167 (16.5%) patients at 1 year. The incidence of 1-year death or stroke was 13.9% (n = 141). Death occurred in 127 (12.5%) patients and stroke in 22 (2.2%) patients. Prior coronary revascularization (hazard ratio [HR]: 1.72; 95% confidence interval [CI]: 1.17 to 2.52; p = 0.006) and EuroSCORE I (HR: 1.02; 95% CI: 1.00 to 1.04; p = 0.027) were independent predictors of the VARC-2 efficacy endpoint. Similarly, EuroSCORE I (HR: 1.02; 95% CI: 1.00 to 1.04; p = 0.013), baseline atrial fibrillation (HR: 1.58; 95% CI: 1.07 to 2.33; p = 0.022), and prior percutaneous coronary intervention (HR: 1.50; 95% CI: 1.03 to 2.19; p = 0.035) were independent predictors of 1-year death or stroke. After adjustment, no significant association was observed between history of pregnancy or any sex-specific factors and 1-year TAVR outcomes. Intermediate to high-risk women enrolled in this first ever all-women contemporary TAVR registry experienced a 1-year VARC-2 composite efficacy endpoint of 16.5%, with a low incidence of 1-year mortality and stroke. Prior revascularization and EuroSCORE I were independent predictors of the VARC-2 efficacy endpoint, whereas EuroSCORE I, baseline atrial fibrillation, and prior percutaneous coronary intervention were independent predictors of the 1-year death or stroke. Copyright © 2018. Published by Elsevier Inc.

[Surgical angioplasty of the left main coronary artery].

PubMed

Vranes, Mile; Velinović, Milos; Kocica, Mladen; Mikić, Aleksandar; Velimirović, Dusan; Djukić, Petar

2010-01-01

The conventional treatment for isolated stenosis of the left main coronary artery is bypass surgery (myocardial revascularization). However, the process of atherosclerosis is not arrested by myocardial revascularization and it will lead to the occlusion of the left main coronary artery. Revascularization will establish retrograde perfusion for 50-70% of the myocardium of the left ventricle. Direct surgical angioplasty of the left main coronary artery enables normal physiological perfusion of the whole myocardium and better myocardial function. The aim of our study is to point out a new surgical approach of treating left main coronary artery stenosis. Between October 2002 and October 2003, direct surgical angioplasty of the main left coronary artery was performed on three patients with isolated stenosis of the left main coronary artery using the anterior approach and the pericardium as a patch. The procedure was performed under total endotracheal anaesthesia and standard cardiopulmonary circulation, moderate hypothermia, anterograde St. Tomas cardioplegia and local cooling. Patients were followed clinically, echocardiographically and by load-tests. All three patients were without complications. In postoperative follow-up (54-68 months) neither angina pectoris nor electrocardiographically registered ischaemic changes were found. Load-tests performed every six months on all three patients were negative. Surgical angioplasty of isolated stenosis of the left main coronary artery is a preferred method for treating this type of coronary disease. Contraindications for this type of treatment are stenosis of the left main coronary artery with bifurcation and advanced calcification of the left main coronary artery.

Relationship between CHA2DS2-VASc score, coronary artery disease severity, residual platelet reactivity and long-term clinical outcomes in patients with acute coronary syndrome.

PubMed

Scudiero, Fernando; Zocchi, Chiara; De Vito, Elena; Tarantini, Giuseppe; Marcucci, Rossella; Valenti, Renato; Migliorini, Angela; Antoniucci, David; Marchionni, Niccolò; Parodi, Guido

2018-07-01

The CHA 2 DS 2 -VASc score predicts stroke risk in patients with atrial fibrillation, but recently has been reported to have a prognostic role even in patients with ACS. We sought to assess the ability of the CHA 2 DS 2 -VASc score to predict the severity of coronary artery disease, high residual platelet reactivity and long-term outcomes in patients with acute coronary syndrome (ACS). Overall, 1729 consecutive patients with ACS undergoing invasive management were included in this prospective registry. We assessed platelet reactivity via light transmittance aggregometry after clopidogrel loading. Patients were divided according to the CHA 2 DS 2 -VASc score: group A = 0, B = 1, C = 2, D = 3, E = 4 and F ≥ 5. Patients with higher CHA 2 DS 2 -VASc score were more likely to have a higher rate of multivessel CAD (37%, 47%, 55%, 62%, 67 and 75% in Group A, B, C, D, E and F; p < 0.001); moreover, CHA 2 DS 2 -VASc score correlated linearly with residual platelet reactivity (R = 0.77; p < 0.001). At long-term follow-up, estimated adverse event rates (MACCE: cardiac death, MI, stroke or any urgent coronary revascularization) were 3%, 8%, 10%, 14%, 19% and 24% in group A, B, C, D, E and F; p < 0.001. Multivariable analysis demonstrated CHA 2 DS 2 -VASc to be an independent predictor of severity of coronary artery disease, of high residual platelet reactivity and of MACCE. In a cohort of patients with ACS, CHA 2 DS 2 -VASc score correlated with coronary disease severity and residual platelet reactivity, and therefore it predicted the risk of long-term adverse events. Copyright © 2018 Elsevier B.V. All rights reserved.

Incessant ventricular tachycardia early after acute myocardial infarction: efficacy of radiofrequency catheter ablation but not of optimal coronary revascularization.

PubMed

Bonanno, C; Ometto, R; Finocchi, G; Rulfo, F; La Vecchia, L; Vincenzi, M

1999-12-01

Incessant ventricular tachycardia is an arrhythmia refractory to conventional antiarrhythmic treatment. We describe the case of 55-year-old man who presented incessant ventricular tachycardia in the early post-acute phase of myocardial infarction. Optimal coronary revascularization was not effective, but radiofrequency catheter ablation was able to eliminate the anatomic substrate and clinical arrhythmic recurrence.

Comparison of the survival between coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with poor left ventricular function (ejection fraction <30%): a propensity-matched analysis.

PubMed

Shah, Shaneel; Benedetto, Umberto; Caputo, Massimo; Angelini, Gianni D; Vohra, Hunaid A

2018-06-22

Existing evidence comparing the outcomes of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with poor left ventricular function (LVF) is sparse and flawed. This is largely due to patients with poor LVF being underrepresented in major research trials and the outdated nature of some studies that do not consider drug-eluting stent PCI. Following strict inclusion criteria, 717 patients who underwent revascularization by CABG or PCI between 2002 and 2015 were enrolled. All patients had poor LVF (defined by ejection fraction <30%). By employing a propensity score analysis, 134 suitable matches (67 CABG and 67 PCI) were identified. Several outcomes were evaluated, in the matched population, using data extracted from national registry databases. CABG patients required a longer length of hospital stay post-revascularization compared to PCI in the propensity-matched population, 7 days (lower-upper quartile; 6-12) and 2 days (lower-upper quartile; 1-6), respectively (Mood's median test, P = 0.001). Stratified Cox-regression proportional-hazards analysis of the propensity-matched population found that PCI patients experienced a higher adjusted 8-year mortality rate (hazard ratio 3.291, 95% confidence interval 1.776-6.101; P < 0.001). This trend was consistent amongst urgent cases of revascularization: patients with 3 or more vessels with coronary artery disease and patients where complete revascularization was achieved. Although sub-analyses found no difference between survival distributions of on-pump versus off-pump CABG (log-rank P = 0.726), both modes of CABG were superior to PCI (stratified log-rank P = 0.002). Despite a longer length of hospital stay, patients with impaired LVF requiring intervention for coronary artery disease experienced a greater post-procedural survival benefit if they received CABG compared to PCI. We have demonstrated this at 30 days, 90 days, 1 year, 3 years, 5 years and 8 years following revascularization. At present, CABG remains a superior revascularization modality to PCI in patients with poor LVF.

Long-term mipomersen treatment is associated with a reduction in cardiovascular events in patients with familial hypercholesterolemia.

PubMed

Duell, P Barton; Santos, Raul D; Kirwan, Bridget-Anne; Witztum, Joseph L; Tsimikas, Sotirios; Kastelein, John J P

2016-01-01

Familial hypercholesterolemia (FH) is characterized by severely elevated LDL-cholesterol and up to a 20-fold increase in premature cardiovascular disease (CVD). Mipomersen has been shown to lower the levels of these atherogenic lipoproteins, but whether it lowers major adverse cardiac events (MACEs) has not been addressed. This post hoc analysis of prospectively collected data of three randomized trials and an open-label extension phase included patients that were exposed to ≥12 months of mipomersen. MACE rates that occurred during 24 months before randomization in the mipomersen group were compared to MACE rates after initiation of mipomersen. Data from the trials included in this report are registered in Clinicaltrials.gov (NCT00607373, NCT00706849, NCT00794664, NCT00694109). The occurrence of MACE events, defined as cardiovascular death, nonfatal acute myocardial infarction, hospitalization for unstable angina, coronary revascularization and nonfatal ischemic stroke, was obtained from medical history data pre-treatment and adjudicated by an independent adjudication committee for events occurring post-treatment with mipomersen. MACEs were identified in 61.5% of patients (64 patients with 146 events [39 myocardial infarctions, 99 coronary revascularizations, 5 unstable angina episodes, 3 ischemic strokes]) during 24 months before mipomersen treatment, and in 9.6% of patients (10 patients with 13 events [1 cardiovascular death, 2 myocardial infarctions, 6 coronary interventions, 4 unstable angina episodes]) during a mean of 24.4 months after initiation of mipomersen (MACE rate 25.7 of 1000 patient-months vs 3.9 of 1000 patient-months, OR = 0.053 [95% CI, 0.016-0.168], P < .0001 by the exact McNemar test). The reduction in MACE coincided with a mean absolute reduction in LDL-C of 70 mg/dL (-28%) and of non-HDL cholesterol of 74 mg/dL (-26%) as well as reduction in Lp(a) of 11 mg/dL (-17%). Long-term mipomersen treatment not only lowers levels of atherogenic lipoproteins but may also lead to a reduction in cardiovascular events in FH patients. Copyright © 2016 National Lipid Association. Published by Elsevier Inc. All rights reserved.

Impact of prasugrel pretreatment and timing of coronary artery bypass grafting on clinical outcomes of patients with non-ST-segment elevation myocardial infarction: From the A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST-Elevation Myocardial Infarction (ACCOAST) study.

PubMed

Dudek, Dariusz; Dziewierz, Artur; Widimsky, Petr; Bolognese, Leonardo; Goldstein, Patrick; Hamm, Christian; Tanguay, Jean-Francois; LeNarz, LeRoy; Miller, Debra L; Brown, Eileen; Ten Berg, Jurrien; Montalescot, Gilles

2015-11-01

We evaluated impact of timing of coronary artery bypass grafting (CABG) and prasugrel pretreatment in patients with non-ST-segment elevation myocardial infarction undergoing CABG in the ACCOAST study. Of 4033 enrolled patients, 314 (7.8%) underwent isolated CABG through 30 days. Primary efficacy end point for this analysis was any cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout through 30 days. More CABG versus percutaneous coronary intervention or medically managed patients were men, diabetic, or had peripheral arterial disease. Per randomization, 157 of 314 patients received a 30-mg prasugrel loading dose before CABG, and 157 of 314 received placebo. Patients were stratified by tertile of time from randomization to CABG: <2.98 days (n = 104), ≥2.98 and <6.95 days (n = 106), and ≥6.95 days (n = 104). Primary end point occurred in 12.5%, 4.7%, and 4.8%, respectively (<2.98 days vs other tertiles, hazard ratio [HR] = 2.80; P = .011). Similarly, the rate of all TIMI major bleeding was highest in the lowest tertile (26.0% vs 10.4% and 4.8%; P < .001), but no difference in all-cause death was observed through 30 days (3.9% vs 1.9% and 1.9%; P = .30). Time from randomization to CABG (HR = 0.84 for each day delay), left main disease (HR = 1.76), region of enrollment (Non-Eastern Europe vs Eastern Europe; HR = 3.83), but not prasugrel pretreatment and baseline troponin ≥3× upper limit of normal, were independent predictors of combined 30-day end point of all-cause death/myocardial infarction/stroke/TIMI major bleeding. In ACCOAST, early (<2.98 days) surgical revascularization carried increased risk of bleeding and ischemic complications without affecting all-cause mortality through 30 days. Baseline troponin and prasugrel pretreatment did not impact ischemic clinical outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Surgical management in patients with coexistent coronary and cerebrovascular disease. Long-term results.

PubMed

Kaul, T K; Fields, B L; Wyatt, D A; Jones, C R; Kahn, D R

1994-11-01

Between January 1980 and December 1992, 3% (210/6,862) of our patients undergoing myocardial revascularization (CABG) had high grade (> 80%) internal carotid stenosis (CS). One hundred seventy-five of these patients with complete follow up for a minimum of 18 months were studied. Bilateral internal CS was present in 60%, and 75% had other vascular lesions, mainly as peripheral vascular disease (PVD) of the lower limb (50.8%). All patients underwent CAE (carotid endarterectomy) followed by CABG under the same anesthesia. Peripheral vascular lesions, contralateral internal CS and recurrent (n = 43) and progressive vascular lesions (n = 50), were subsequently treated as staged procedures. Hospital mortality was 3.42%. By univariate analysis significant predictors of late mortality were congestive heart failure, COPD, PVD, postoperative myocardial infarction, postoperative stroke, and ischemic cardiomyopathy. Only the latter two were also significant by multivariate analysis. At 12 years, actuarial survival in the presence of these risk factors were 46%, 49%, 22%, 37%, 53%, and 27% respectively. All are significantly lower as compared with the corresponding subsets of patients with the risk factor absent. At 12 years, actuarial survival for the entire series was 65%. Cumulative incidence of postoperative strokes was higher in patients with bilateral internal CS than in patients with unilateral internal CS (p < 0.07) and in patients with neurologic symptoms than asymptomatic patients. At 12 years, actuarial freedom from all cardiac related events, postoperative stroke, and symptomatic PVD were 49%, 82%, and 76% respectively. After successful revascularization these patients should be carefully followed for recurrent and progressive vascular lesions.

Free Radical Damage in Ischemia-Reperfusion Injury: An Obstacle in Acute Ischemic Stroke after Revascularization Therapy

PubMed Central

Jin, Hang; Sun, Xin; Huang, Shuo; Zhang, Fu-Liang; Guo, Zhen-Ni

2018-01-01

Acute ischemic stroke is a common cause of morbidity and mortality worldwide. Thrombolysis with recombinant tissue plasminogen activator and endovascular thrombectomy are the main revascularization therapies for acute ischemic stroke. However, ischemia-reperfusion injury after revascularization therapy can result in worsening outcomes. Among all possible pathological mechanisms of ischemia-reperfusion injury, free radical damage (mainly oxidative/nitrosative stress injury) has been found to play a key role in the process. Free radicals lead to protein dysfunction, DNA damage, and lipid peroxidation, resulting in cell death. Additionally, free radical damage has a strong connection with inducing hemorrhagic transformation and cerebral edema, which are the major complications of revascularization therapy, and mainly influencing neurological outcomes due to the disruption of the blood-brain barrier. In order to get a better clinical prognosis, more and more studies focus on the pharmaceutical and nonpharmaceutical neuroprotective therapies against free radical damage. This review discusses the pathological mechanisms of free radicals in ischemia-reperfusion injury and adjunctive neuroprotective therapies combined with revascularization therapy against free radical damage. PMID:29770166

Risk model for estimating the 1-year risk of deferred lesion intervention following deferred revascularization after fractional flow reserve assessment.

PubMed

Depta, Jeremiah P; Patel, Jayendrakumar S; Novak, Eric; Gage, Brian F; Masrani, Shriti K; Raymer, David; Facey, Gabrielle; Patel, Yogesh; Zajarias, Alan; Lasala, John M; Amin, Amit P; Kurz, Howard I; Singh, Jasvindar; Bach, Richard G

2015-02-21

Although lesions deferred revascularization following fractional flow reserve (FFR) assessment have a low risk of adverse cardiac events, variability in risk for deferred lesion intervention (DLI) has not been previously evaluated. The aim of this study was to develop a prediction model to estimate 1-year risk of DLI for coronary lesions where revascularization was not performed following FFR assessment. A prediction model for DLI was developed from a cohort of 721 patients with 882 coronary lesions where revascularization was deferred based on FFR between 10/2002 and 7/2010. Deferred lesion intervention was defined as any revascularization of a lesion previously deferred following FFR. The final DLI model was developed using stepwise Cox regression and validated using bootstrapping techniques. An algorithm was constructed to predict the 1-year risk of DLI. During a mean (±SD) follow-up period of 4.0 ± 2.3 years, 18% of lesions deferred after FFR underwent DLI; the 1-year incidence of DLI was 5.3%, while the predicted risk of DLI varied from 1 to 40%. The final Cox model included the FFR value, age, current or former smoking, history of coronary artery disease (CAD) or prior percutaneous coronary intervention, multi-vessel CAD, and serum creatinine. The c statistic for the DLI prediction model was 0.66 (95% confidence interval, CI: 0.61-0.70). Patients deferred revascularization based on FFR have variation in their risk for DLI. A clinical prediction model consisting of five clinical variables and the FFR value can help predict the risk of DLI in the first year following FFR assessment. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Efficacy and safety of aspirin, clopidogrel, and warfarin after coronary artery stenting in Korean patients with atrial fibrillation.

PubMed

Suh, Soon Yong; Kang, Woong Chol; Oh, Pyung Chun; Choi, Hanul; Moon, Chan Il; Lee, Kyounghoon; Han, Seung Hwan; Ahn, Taehoon; Choi, In Suck; Shin, Eak Kyun

2014-09-01

There are limited data on the optimal antithrombotic therapy for patients with atrial fibrillation (AF) who undergoing coronary stenting. We reviewed 203 patients (62.6 % men, mean age 68.3 ± 10.1 years) between 2003 and 2012, and recorded clinical and demographic characteristics of the patients. Clinical follow-up included major adverse cardiac and cerebrovascular events (MACCE) (cardiac death, myocardial infarction, target lesion revascularization, and stroke), stent thrombosis, and bleeding. The most commonly associated comorbidities were hypertension (70.4 %), diabetes mellitus (35.5 %), and congestive heart failure (26.6 %). Sixty-three percent of patients had stroke risk higher than CHADS2 score 2. At discharge, dual-antiplatelet therapy (aspirin, clopidogrel) was used in 166 patients (81.8 %; Group I), whereas 37 patients (18.2 %) were discharged with triple therapy (aspirin, clopidogrel, warfarin; Group II). The mean follow-up period was 42.0 ± 29.0 months. The mean international normalized ratio (INR) in group II was 1.83 ± 0.41. The total MACCE was 16.3 %, with stroke in 3.4 %. Compared with the group II, the incidence of MACCE (2.7 % vs 19.3 %, P = 0.012) and cardiac death (0 % vs 11.4 %, P = 0.028) were higher in the group I. Major and any bleeding, however, did not differ between the two groups. In multivariate analysis, no warfarin therapy (odds ratio 7.8, 95 % confidence interval 1.02-59.35; P = 0.048) was an independent predictor of MACCE. By Kaplan-Meier survival analysis, warfarin therapy was associated with a lower risk of MACCE (P = 0.024). In patients with AF undergoing coronary artery stenting, MACCE were reduced by warfarin therapy without increased bleeding, which might be related to tighter control with a lower INR value.

Apixaban in patients with atrial fibrillation and prior coronary artery disease: insights from the ARISTOTLE trial.

PubMed

Bahit, Maria Cecilia; Lopes, Renato D; Wojdyla, Daniel M; Hohnloser, Stefan H; Alexander, John H; Lewis, Basil S; Aylward, Philip E; Verheugt, Freek W A; Keltai, Matyas; Diaz, Rafael; Hanna, Michael; Granger, Christopher B; Wallentin, Lars

2013-12-10

A substantial portion of patients with atrial fibrillation (AF) also have coronary artery disease (CAD) and are at risk for coronary events. Warfarin is known to reduce these events, but increase the risk of bleeding. We assessed the effects of apixaban compared with warfarin in AF patients with and without prior CAD. In ARISTOTLE, 18,201 patients with AF were randomized to apixaban or warfarin. History of CAD was defined as documented CAD, prior myocardial infarction, and/or history of coronary revascularization. We analyzed baseline characteristics and clinical outcomes of patients with and without prior CAD and compared outcomes by randomized treatment using Cox models. A total of 6639 (36.5%) patients had prior CAD. These patients were more often male, more likely to have prior stroke, diabetes, and hypertension, and more often received aspirin at baseline (42.2% vs. 24.5%). The effects of apixaban were similar among patients with and without prior CAD on reducing stroke or systemic embolism and death from any cause (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.71-1.27, P for interaction=0.12; HR 0.96, 95% CI 0.81-1.13, P for interaction=0.28). Rates of myocardial infarction were numerically lower with apixaban than warfarin among patients with and without prior CAD. The effect of apixaban on reducing major bleeding and intracranial hemorrhage was consistent in patients with and without CAD. In patients with AF, apixaban more often prevented stroke or systemic embolism and death and caused less bleeding than warfarin, regardless of the presence of prior CAD. Given the common occurrence of AF and CAD and the higher rates of cardiovascular events and death, our results indicate that apixaban may be a better treatment option than warfarin for these high-risk patients. © 2013.

Carotid and coronary disease management prior to open and endovascular aortic surgery. What are the current guidelines?

PubMed

Thompson, J P

2014-04-01

Several bodies produce broadly concurring and updated guidelines for the evaluation and treatment of cardiovascular disease in both surgical and non-surgical patients. Recent developments include revised recommendations on preoperative stress testing, referral for possible coronary revascularization and medical management. It is recognized that non-invasive cardiac tests are relatively poor at predicting perioperative risk, and "prophylactic" coronary revascularization has a limited role. The planned aortic intervention (open or endovascular repair) also influences preoperative management. Patients presenting for elective abdominal aortic aneurysm (AAA) repair should only be referred for cardiological testing if they have active symptoms of coronary artery disease (CAD), known CAD and poor functional exercise capacity, or multiple risk factors for CAD. Coronary revascularization before AAA surgery should be limited to patients with established indications, so cardiac stress testing should only be performed if it would change management i.e. the patient is a candidate for and would benefit from coronary revascularization. When endovascular aortic repair is planned, it is reasonable to proceed to surgery without further cardiac stress testing or evaluation unless otherwise indicated. All non-emergency patients require medical optimization, but perioperative beta blockade benefits only certain patients. Some of the data informing recent guidelines have been questioned and some guidelines are being revised. Current guidelines do not specifically address the management of patients with known or suspected carotid artery disease who may require aortic surgery. For these patients, an individualized approach is required. This review considers recent guidelines. Algorithms for investigation and management based on their recommendations are included.

Reduction in Total Cardiovascular Events With Ezetimibe/Simvastatin Post-Acute Coronary Syndrome: The IMPROVE-IT Trial.

PubMed

Murphy, Sabina A; Cannon, Christopher P; Blazing, Michael A; Giugliano, Robert P; White, Jennifer A; Lokhnygina, Yuliya; Reist, Craig; Im, KyungAh; Bohula, Erin A; Isaza, Daniel; Lopez-Sendon, Jose; Dellborg, Mikael; Kher, Uma; Tershakovec, Andrew M; Braunwald, Eugene

2016-02-02

Intensive low-density lipoprotein cholesterol therapy with ezetimibe/simvastatin in IMPROVE-IT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial) significantly reduced the first primary endpoint (PEP) in patients post-acute coronary syndrome (ACS) compared to placebo/simvastatin. This analysis tested the hypothesis that total events, including those beyond the first event, would also be reduced with ezetimibe/simvastatin therapy. All PEP events (cardiovascular [CV] death, myocardial infarction [MI], stroke, unstable angina [UA] leading to hospitalization, coronary revascularization ≥30 days post-randomization) during a median 6-year follow-up were analyzed in patients randomized to receive ezetimibe/simvastatin or placebo/simvastatin in IMPROVE-IT. Negative binomial regression was used for the primary analysis. Among 18,144 patients, there were 9,545 total PEP events (56% were first events and 44% subsequent events). Total PEP events were significantly reduced by 9% with ezetimibe/simvastatin vs placebo/simvastatin (incidence-rate ratio [RR]: 0.91; 95% confidence interval [CI]: 0.85 to 0.97; p = 0.007), as were the 3 pre-specified secondary composite endpoints and the exploratory composite endpoint of CV death, MI, or stroke (RR: 0.88; 95% CI: 0.81 to 0.96; p = 0.002). The reduction in total events was driven by decreases in total nonfatal MI (RR: 0.87; 95% CI: 0.79 to 0.96; p = 0.004) and total NF stroke (RR: 0.77; 95% CI: 0.65 to 0.93; p = 0.005). Lipid-lowering therapy with ezetimibe plus simvastatin improved clinical outcomes. Reductions in total PEP events, driven by reductions in MI and stroke, more than doubled the number of events prevented compared with examining only the first event. These data support continuation of intensive combination lipid-lowering therapy after an initial CV event. (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial [IMPROVE-IT]; NCT00202878). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Five-year outcomes of percutaneous versus surgical coronary revascularization in patients with diabetes mellitus (from the CREDO-Kyoto PCI/CABG Registry Cohort-2).

PubMed

Marui, Akira; Kimura, Takeshi; Nishiwaki, Noboru; Mitsudo, Kazuaki; Komiya, Tatsuhiko; Hanyu, Michiya; Shiomi, Hiroki; Tanaka, Shiro; Sakata, Ryuzo

2015-04-15

We investigated the impact of diabetes mellitus on long-term outcomes of percutaneous coronary intervention (PCI) in the drug-eluting stent era versus coronary artery bypass grafting (CABG) in a real-world population with advanced coronary disease. We identified 3,982 patients with 3-vessel and/or left main disease of 15,939 patients with first coronary revascularization enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (patients without diabetes: n = 1,984 [PCI: n = 1,123 and CABG: n = 861], and patients with diabetes: n = 1,998 [PCI: n = 1,065 and CABG: n = 933]). Cumulative 5-year incidence of all-cause death after PCI was significantly higher than after CABG both in patients without and with diabetes (19.8% vs 16.2%, p = 0.01, and 22.9% vs 19.0%, p = 0.046, respectively). After adjusting confounders, the excess mortality risk of PCI relative to CABG was no longer significant (hazard ratio [HR] 1.16; 95% confidence interval [CI] 0.88 to 1.54; p = 0.29) in patients without diabetes, whereas it remained significant (HR 1.31; 95% CI 1.01 to 1.70; p = 0.04) in patients with diabetes. The excess adjusted risks of PCI relative to CABG for cardiac death, myocardial infarction (MI), and any coronary revascularization were significant in both patients without (HR 1.59, 95% CI 1.01 to 2.51, p = 0.047; HR 2.16, 95% CI 1.20 to 3.87, p = 0.01; and HR 3.30, 95% CI 2.55 to 4.25, p <0.001, respectively) and with diabetes (HR 1.45, 95% CI 1.00 to 2.51, p = 0.047; HR 2.31, 95% CI 1.31 to 4.08, p = 0.004; and HR 3.70, 95% CI 2.91 to 4.69, p <0.001, respectively). There was no interaction between diabetic status and the effect of PCI relative to CABG for all-cause death, cardiac death, MI, and any revascularization. In conclusion, in both patients without and with diabetes with 3-vessel and/or left main disease, CABG compared with PCI was associated with better 5-year outcomes in terms of cardiac death, MI, and any coronary revascularization. There was no difference in the direction and magnitude of treatment effect of CABG relative to PCI regardless of diabetic status. Copyright © 2015 Elsevier Inc. All rights reserved.

Ad hoc vs. Non-ad hoc Percutaneous Coronary Intervention Strategies in Patients With Stable Coronary Artery Disease.

PubMed

Toyota, Toshiaki; Morimoto, Takeshi; Shiomi, Hiroki; Ando, Kenji; Ono, Koh; Shizuta, Satoshi; Kato, Takao; Saito, Naritatsu; Furukawa, Yutaka; Nakagawa, Yoshihisa; Horie, Minoru; Kimura, Takeshi

2017-03-24

Few studies have evaluated the prevalence and clinical outcomes of ad hoc percutaneous coronary intervention (PCI), performing diagnostic coronary angiography and PCI in the same session, in stable coronary artery disease (CAD) patients.Methods and Results:From the CREDO-Kyoto PCI/CABG registry cohort-2, 6,943 patients were analyzed as having stable CAD and undergoing first PCI. Ad hoc PCI and non-ad hoc PCI were performed in 1,722 (24.8%) and 5,221 (75.1%) patients, respectively. The cumulative 5-year incidence and adjusted risk for all-cause death were not significantly different between the 2 groups (15% vs. 15%, P=0.53; hazard ratio: 1.15, 95% confidence interval: 0.98-1.35, P=0.08). Ad hoc PCI relative to non-ad hoc PCI was associated with neutral risk for myocardial infarction, any coronary revascularization, and bleeding, but was associated with a trend towards lower risk for stroke (hazard ratio: 0.78, 95% confidence interval: 0.60-1.02, P=0.06). Ad hoc PCI in stable CAD patients was associated with at least comparable 5-year clinical outcomes as with non-ad hoc PCI. Considering patients' preference and the cost-saving, the ad hoc PCI strategy might be a safe and attractive option for patients with stable CAD, although the prevalence of ad hoc PCI was low in the current study population.

Antiplatelet Therapy and Clinical Outcomes Following Myocardial Infarction Among Patients in a U.S. Employer-Based Insurance Database.

PubMed

Patel, Mehul D; Wu, David; Chase, Monica Reed; Mavros, Panagiotis; Heithoff, Kim; Hanson, Mary E; Simpson, Ross J

2017-06-01

Estimates of residual cardiovascular risks among patients who have experienced a recent acute myocardial infarction (MI) are predominantly derived from secondary prevention trial populations, patient registries, and population-based cohorts. To generate real-world evidence of antiplatelet treatment and recurrent events following MI in patients on antiplatelet treatment among commercial, employer-based insured patients in a large administrative database. This was a retrospective cohort claims database study using the Truven Health MarketScan Commercial Claims and Encounters and Medicare Supplemental databases between 2007-2011. Patients with an acute MI hospitalization with a discharge date between 2008 and 2010 were included. Excluded were those patients with documentation of stroke, transient ischemic attack (TIA), or severe bleeding at or before index hospitalization and with concomitant use of anticoagulant therapy following index hospitalization. Patients treated with clopidogrel following the index MI hospitalization were followed up to 1 year for repeat MI, stroke, and coronary revascularization. Among 33,943 post-MI continuous clopidogrel users without history of stroke, TIA, or bleeding, 22% had diabetes, whereas angina and renal impairment were less prevalent (5% and 7%, respectively). Over the 1-year follow-up, 2.4% experienced a repeat MI or stroke, and 8.2% underwent coronary revascularization. Angina, diabetes, and renal impairment were associated with elevated 1-year risk of repeat MI or stroke. This study suggests that there is residual cardiovascular risk, although relatively low, in an insured, secondary prevention population on antiplatelet treatment following an MI. In patients with MI, identifying angina, diabetes, and renal impairment may aid risk stratification and guide the effective management of these higher-risk patients. Funding for this research was provided by Merck & Co. Although Merck & Co. formally reviewed a penultimate draft, the opinions expressed are those of the authorship and may not necessarily reflect those of the company. Reed Chase, Wu, Mavros, Heithoff, and Hanson are employees of Merck Sharp & Dohme, a subsidiary of Merck & Co., and may own stock and/or hold stock options in the company. Patel was an employee of Merck & Co. during the conduct of this study and preparation of the manuscript. Simpson is a paid consultant for Merck, Pfizer, and Amgen and has received speaker's fees from Merck and Pfizer. Study concept and design were contributed by all authors except Hanson. Heifhoff and Patel collected the data, and data interpretation was performed by Simpson, Mavros, Patel, Wu, and Hanson. The manuscript was written by Hanson, Mavros, and Patel and revised by Heithoff, Wu, Simpson, and Reed Chase.

EDTA Chelation Therapy Alone and in Combination with Oral High-Dose Multivitamins and Minerals for Coronary Disease: The Factorial Group Results of the Trial to Assess Chelation Therapy

PubMed Central

Lamas, Gervasio A.; Boineau, Robin; Goertz, Christine; Mark, Daniel B.; Rosenberg, Yves; Stylianou, Mario; Rozema, Theodore; Nahin, Richard L.; Chappell, L. Terry; Lindblad, Lauren; Lewis, Eldrin F.; Drisko, Jeanne; Lee, Kerry L.

2014-01-01

Background Disodium ethylene diamine tetraacetic acid (EDTA) reduced adverse cardiac outcomes in a factorial trial also testing oral vitamins. Objective This report describes the intent-to-treat comparison of the 4 factorial groups overall and in patients with diabetes. Methods Double-blind placebo-controlled 2 × 2 factorial multicenter randomized trial of 1708 post-MI patients ≥ 50 years and creatinine ≤2.0 mg/dL randomized to receive 40 EDTA chelation or placebo infusions plus 6 caplets daily of a 28-component multivitaminmultimineral mixture or placebo. Primary endpoint was a composite of total mortality, MI, stroke, coronary revascularization, or hospitalization for angina. Results Median age was 65 years, 18% female, 94% Caucasian, 37% diabetic, 83% prior coronary revascularization, and 73% on statins. Five-year Kaplan-Meier estimates for the primary endpoint in the chelation + high-dose vitamin group was 31.9%, in the chelation + placebo vitamin group 33.7%, in the placebo infusion + active vitamin group 36.6%, and in the placebo infusions + placebo vitamin group 40.2 %. The reduction in primary endpoint by double active treatment compared with double placebo was significant (HR 0.74, 95% CI (0.57,0.95); p=0.016). In patients with diabetes, the primary endpoint reduction of double active compared with double placebo was more pronounced (HR 0.49, 95% CI (0.33,0.75), p<0.001). Conclusions In stable post- MI patients on evidence-based medical therapy, the combination of oral high-dose vitamins and chelation therapy compared with double placebo reduced clinically important cardiovascular events to an extent that was both statistically significant and of potential clinical relevance. PMID:24952858

High-Dose Versus Low-Dose Pitavastatin in Japanese Patients With Stable Coronary Artery Disease (REAL-CAD): A Randomized Superiority Trial.

PubMed

Taguchi, Isao; Iimuro, Satoshi; Iwata, Hiroshi; Takashima, Hiroaki; Abe, Mitsuru; Amiya, Eisuke; Ogawa, Takanori; Ozaki, Yukio; Sakuma, Ichiro; Nakagawa, Yoshihisa; Hibi, Kiyoshi; Hiro, Takafumi; Fukumoto, Yoshihiro; Hokimoto, Seiji; Miyauchi, Katsumi; Yamazaki, Tsutomu; Ito, Hiroshi; Otsuji, Yutaka; Kimura, Kazuo; Takahashi, Jun; Hirayama, Atsushi; Yokoi, Hiroyoshi; Kitagawa, Kazuo; Urabe, Takao; Okada, Yasushi; Terayama, Yasuo; Toyoda, Kazunori; Nagao, Takehiko; Matsumoto, Masayasu; Ohashi, Yasuo; Kaneko, Tetsuji; Fujita, Retsu; Ohtsu, Hiroshi; Ogawa, Hisao; Daida, Hiroyuki; Shimokawa, Hiroaki; Saito, Yasushi; Kimura, Takeshi; Inoue, Teruo; Matsuzaki, Masunori; Nagai, Ryozo

2018-05-08

Current guidelines call for high-intensity statin therapy in patients with cardiovascular disease on the basis of several previous "more versus less statins" trials. However, no clear evidence for more versus less statins has been established in an Asian population. In this prospective, multicenter, randomized, open-label, blinded end point study, 13 054 Japanese patients with stable coronary artery disease who achieved low-density lipoprotein cholesterol (LDL-C) <120 mg/dL during a run-in period (pitavastatin 1 mg/d) were randomized in a 1-to-1 fashion to high-dose (pitavastatin 4 mg/d; n=6526) or low-dose (pitavastatin 1 mg/d; n=6528) statin therapy. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal ischemic stroke, or unstable angina requiring emergency hospitalization. The secondary composite end point was a composite of the primary end point and clinically indicated coronary revascularization excluding target-lesion revascularization at sites of prior percutaneous coronary intervention. The mean age of the study population was 68 years, and 83% were male. The mean LDL-C level before enrollment was 93 mg/dL with 91% of patients taking statins. The baseline LDL-C level after the run-in period on pitavastatin 1 mg/d was 87.7 and 88.1 mg/dL in the high-dose and low-dose groups, respectively. During the entire course of follow-up, LDL-C in the high-dose group was lower by 14.7 mg/dL than in the low-dose group ( P <0.001). With a median follow-up of 3.9 years, high-dose as compared with low-dose pitavastatin significantly reduced the risk of the primary end point (266 patients [4.3%] and 334 patients [5.4%]; hazard ratio, 0.81; 95% confidence interval, 0.69-0.95; P =0.01) and the risk of the secondary composite end point (489 patients [7.9%] and 600 patients [9.7%]; hazard ratio, 0.83; 95% confidence interval, 0.73-0.93; P =0.002). High-dose pitavastatin also significantly reduced the risks of several other secondary end points such as all-cause death, myocardial infarction, and clinically indicated coronary revascularization. The results for the primary and the secondary composite end points were consistent across several prespecified subgroups, including the low (<95 mg/dL) baseline LDL-C subgroup. Serious adverse event rates were low in both groups. High-dose (4 mg/d) compared with low-dose (1 mg/d) pitavastatin therapy significantly reduced cardiovascular events in Japanese patients with stable coronary artery disease. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01042730. © 2018 The Authors.

Comparison of everolimus- and paclitaxel-eluting stents in patients with acute and stable coronary syndromes: pooled results from the SPIRIT (A Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System) and COMPARE (A Trial of Everolimus-Eluting Stents and Paclitaxel-Eluting Stents for Coronary Revascularization in Daily Practice) Trials.

PubMed

Planer, David; Smits, Pieter C; Kereiakes, Dean J; Kedhi, Elvin; Fahy, Martin; Xu, Ke; Serruys, Patrick W; Stone, Gregg W

2011-10-01

This study sought to compare the clinical outcomes of everolimus-eluting stents (EES) versus paclitaxel-eluting stents (PES) in patients with acute coronary syndromes (ACS) and stable coronary artery disease (CAD). Although randomized trials have shown superiority of EES to PES, the safety and efficacy of EES in ACS is unknown. We performed a patient-level pooled analysis from the prospective, randomized SPIRIT (Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System) II, III, IV, and COMPARE (A Trial of Everolimus-Eluting Stents and Paclitaxel-Eluting Stents for Coronary Revascularization in Daily Practice) trials in which 2,381 patients with ACS and 4,404 patients with stable CAD were randomized to EES or to PES. Kaplan-Meier estimates of death, myocardial infarction (MI), ischemia-driven target lesion revascularization, and stent thrombosis were assessed at 2 years and stratified by clinical presentation (ACS vs. stable CAD). At 2 years, patients with ACS compared with stable CAD had higher rates of death (3.2% vs. 2.4%, hazard ratio [HR]: 1.37 [95% confidence interval (CI): 1.02 to 1.85], p = 0.04) and MI (4.9% vs. 3.4%, HR: 1.45 [95% CI: 1.14 to 1.85], p = 0.02). In patients with ACS, EES versus PES reduced the rate of death or MI (6.6% vs. 9.3%, HR: 0.70 [95% CI: 0.52 to 0.94], p = 0.02), stent thrombosis (0.7% vs. 2.9%, HR: 0.25 [95% CI: 0.12 to 0.52], p = 0.0002), and ischemia-driven target lesion revascularization (4.7% vs. 6.2%, HR: 0.69 [95% CI: 0.48 to 0.99], p = 0.04). In patients with stable CAD, EES reduced the rate of death or MI (4.5% vs. 7.1%, HR: 0.62 [95% CI: 0.48 to 0.80], p = 0.0002), stent thrombosis (0.7% vs. 1.8%, HR: 0.34 [95% CI: 0.19 to 0.62], p = 0.0002), and ischemia-driven target lesion revascularization (3.9% vs. 6.9%, HR: 0.55 [95% CI: 0.42 to 0.73], p < 0.0001). Treatment with EES versus PES provides enhanced safety and efficacy regardless of the acuity of the clinical syndrome being treated and appears to mitigate the increased risk of stent thrombosis associated with ACS. (A Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Patients With de Novo Native Coronary Artery Lesions [SPIRIT II]; NCT00180310; SPIRIT III: A Clinical Evaluation of the Investigational Device XIENCE V Everolimus Eluting Coronary Stent System [EECSS] in the Treatment of Subjects With de Novo Native Coronary Artery Lesions [SPIRIT III]; NCT00180479; SPIRIT IV Clinical Trial: Clinical Evaluation of the XIENCE V Everolimus Eluting Coronary Stent System in the Treatment of Subjects With de Novo Native Coronary Artery Lesions [SPIRIT IV]; NCT00307047; A Trial of Everolimus-Eluting Stents and Paclitaxel-Eluting Stents for Coronary Revascularization in Daily Practice: the COMPARE Trial [COMPARE]; NCT01016041). Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Minimized extracorporeal circulation system in coronary artery bypass surgery: a 10-year single-center experience with 2243 patients.

PubMed

Puehler, Thomas; Haneya, Assad; Philipp, Alois; Zausig, York A; Kobuch, Reinhard; Diez, Claudius; Birnbaum, Dietrich E; Schmid, Christof

2011-04-01

Coronary artery bypass grafting (CABG) is the gold standard for the surgical therapy of multivessel coronary artery disease. To reduce the side effects, associated with standard extracorporeal circulation (ECC), a concept of minimal extracorporeal circulation (MECC) was devised in our center. We report on our 10-year experience with the MECC for coronary revascularization. From January 1998 to August 2009, 2243 patients underwent CABG with MECC in our center. In a retrospective observational study, we analyzed indication, preoperative patient co-morbidity, postoperative clinical course, and perioperative outcome of all patients operated on with MECC. Furthermore, the risk factors for mortality in the MECC group were assessed. Patients showed a mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 4.5±0.1%. The mean age of the patients was 66.8±9.1 years. The overall 30-day mortality after CABG with MECC was 2.3%, ranging from 1.1% for elective to 13.0% for emergent patients and was significantly better than standard ECC. Only 15.3% (n=344) of patients with MECC required intra-operative blood transfusion. Postoperative catecholamine support, red blood cell transfusion, need for hemodialysis, release of creatinine kinase, incidence of stroke, and postoperative delirium were low after MECC revascularization. Ejection fraction below 30% (odds ratio (OR): 5.1), emergent operation (OR: 9.4), and high-dose catecholamine therapy (OR: 2.6) were associated predictors for mortality. MECC until now is an established concept and has become an alternative for ECC in routine CABG in our center. The use of the MECC system is associated with low mortality and conversion rate. Excellent survival rates and low transfusion requirements in the perioperative course were achieved. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Circulating Branched-Chain Amino Acids and Incident Cardiovascular Disease in a Prospective Cohort of US Women.

PubMed

Tobias, Deirdre K; Lawler, Patrick R; Harada, Paulo H; Demler, Olga V; Ridker, Paul M; Manson, JoAnn E; Cheng, Susan; Mora, Samia

2018-04-01

Circulating branched-chain amino acids (BCAAs; isoleucine, leucine, and valine) are strong predictors of type 2 diabetes mellitus (T2D), but their association with cardiovascular disease (CVD) is uncertain. We hypothesized that plasma BCAAs are positively associated with CVD risk and evaluated whether this was dependent on an intermediate diagnosis of T2D. Participants in the Women's Health Study prospective cohort were eligible if free of CVD at baseline blood collection (n=27 041). Plasma metabolites were measured via nuclear magnetic resonance spectroscopy. Multivariable Cox regression models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for BCAAs with incident CVD (myocardial infarction, stroke, and coronary revascularization). We confirmed 2207 CVD events over a mean 18.6 years of follow-up. Adjusting for age, body mass index, and other established CVD risk factors, total BCAAs were positively associated with CVD (per SD: HR, 1.13; 95% CI, 1.08-1.18), comparable to LDL-C (low-density lipoprotein cholesterol) with CVD (per SD: HR, 1.12; 95% CI, 1.07-1.17). BCAAs were associated with coronary events (myocardial infarction: HR, 1.16; 95% CI, 1.06-1.26; revascularization: HR, 1.17; 95% CI, 1.11-1.25), and borderline significant association with stroke (HR, 1.07; 95% CI, 0.99-1.15). The BCAA-CVD association was greater ( P interaction=0.036) among women who developed T2D before CVD (HR, 1.20; 95% CI, 1.08-1.32) versus women without T2D (HR, 1.08; 95% CI, 1.03-1.14). Adjusting for LDL-C, an established CVD risk factor, did not attenuate these findings; however, adjusting for HbA1c and insulin resistance eliminated the associations of BCAAs with CVD. Circulating plasma BCAAs were positively associated with incident CVD in women. Impaired BCAA metabolism may capture the long-term risk of the common cause underlying T2D and CVD. © 2018 American Heart Association, Inc.

Thrombogenicity and central pulse pressure to enhance prediction of ischemic event occurrence in patients with established coronary artery disease: The MAGMA-ischemia score.

PubMed

Bliden, Kevin P; Chaudhary, Rahul; Navarese, Eliano P; Sharma, Tushar; Kaza, Himabindu; Tantry, Udaya S; Gurbel, Paul A

2018-01-01

Conventional cardiovascular risk estimators based on clinical demographics have limited prediction of coronary events. Markers for thrombogenicity and vascular function have not been explored in risk estimation of high-risk patients with coronary artery disease. We aimed to develop a clinical and biomarker score to predict 3-year adverse cardiovascular events. Four hundred eleven patients, with ejection fraction ≥40% undergoing coronary angiography, and found to have a luminal diameter stenosis ≥50%, were included in the analysis. Thrombelastography indices and central pulse pressure (CPP) were determined at the time of catheterization. We identified predictors of death, myocardial infarction (MI) or stroke and developed a numerical ischemia risk score. The primary endpoint of cardiovascular death, MI or stroke occurred in 22 patients (5.4%). The factors associated with events were age, prior PCI or CABG, diabetes, CPP, and thrombin-induced platelet-fibrin clot strength, and were included in the MAGMA-ischemia score. The MAGMA-ischemia score showed a c-statistic of 0.85 (95% Confidence Interval [CI] 0.80-0.87; p<0.001) for the primary endpoint. In the subset of patients who underwent revascularization, the c-statistic was 0.90 (p<0.001). Patients with MAGMA-ischemia score greater than 5 had highest risk to develop clinical events, hazard ratio for the primary endpoint: 13.9 (95% CI 5.8-33.1, p<0.001) and for the secondary endpoint: 4.8 (95% CI 2.3-9.6, p<0.001). When compared to previous models, the MAGMA-ischemia score yielded a higher discrimination. Inclusion of CPP and assessment of thrombogenicity in a novel score for patients with documented CAD enhanced the prediction of events. Copyright © 2017 Elsevier B.V. All rights reserved.

Thrombin-receptor antagonist vorapaxar in acute coronary syndromes.

PubMed

Tricoci, Pierluigi; Huang, Zhen; Held, Claes; Moliterno, David J; Armstrong, Paul W; Van de Werf, Frans; White, Harvey D; Aylward, Philip E; Wallentin, Lars; Chen, Edmond; Lokhnygina, Yuliya; Pei, Jinglan; Leonardi, Sergio; Rorick, Tyrus L; Kilian, Ann M; Jennings, Lisa H K; Ambrosio, Giuseppe; Bode, Christoph; Cequier, Angel; Cornel, Jan H; Diaz, Rafael; Erkan, Aycan; Huber, Kurt; Hudson, Michael P; Jiang, Lixin; Jukema, J Wouter; Lewis, Basil S; Lincoff, A Michael; Montalescot, Gilles; Nicolau, José Carlos; Ogawa, Hisao; Pfisterer, Matthias; Prieto, Juan Carlos; Ruzyllo, Witold; Sinnaeve, Peter R; Storey, Robert F; Valgimigli, Marco; Whellan, David J; Widimsky, Petr; Strony, John; Harrington, Robert A; Mahaffey, Kenneth W

2012-01-05

Vorapaxar is a new oral protease-activated-receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation. In this multinational, double-blind, randomized trial, we compared vorapaxar with placebo in 12,944 patients who had acute coronary syndromes without ST-segment elevation. The primary end point was a composite of death from cardiovascular causes, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization. Follow-up in the trial was terminated early after a safety review. After a median follow-up of 502 days (interquartile range, 349 to 667), the primary end point occurred in 1031 of 6473 patients receiving vorapaxar versus 1102 of 6471 patients receiving placebo (Kaplan-Meier 2-year rate, 18.5% vs. 19.9%; hazard ratio, 0.92; 95% confidence interval [CI], 0.85 to 1.01; P=0.07). A composite of death from cardiovascular causes, myocardial infarction, or stroke occurred in 822 patients in the vorapaxar group versus 910 in the placebo group (14.7% and 16.4%, respectively; hazard ratio, 0.89; 95% CI, 0.81 to 0.98; P=0.02). Rates of moderate and severe bleeding were 7.2% in the vorapaxar group and 5.2% in the placebo group (hazard ratio, 1.35; 95% CI, 1.16 to 1.58; P<0.001). Intracranial hemorrhage rates were 1.1% and 0.2%, respectively (hazard ratio, 3.39; 95% CI, 1.78 to 6.45; P<0.001). Rates of nonhemorrhagic adverse events were similar in the two groups. In patients with acute coronary syndromes, the addition of vorapaxar to standard therapy did not significantly reduce the primary composite end point but significantly increased the risk of major bleeding, including intracranial hemorrhage. (Funded by Merck; TRACER ClinicalTrials.gov number, NCT00527943.).

Association of Coronary Artery Calcification with Estimated Coronary Heart Disease Risk from Prediction Models in a Community-Based Sample of Japanese Men: The Shiga Epidemiological Study of Subclinical Atherosclerosis (SESSA).

PubMed

Fujiyoshi, Akira; Arima, Hisatomi; Tanaka-Mizuno, Sachiko; Hisamatsu, Takahashi; Kadowaki, Sayaka; Kadota, Aya; Zaid, Maryam; Sekikawa, Akira; Yamamoto, Takashi; Horie, Minoru; Miura, Katsuyuki; Ueshima, Hirotsugu

2017-12-05

The clinical significance of coronary artery calcification (CAC) is not fully determined in general East Asian populations where background coronary heart disease (CHD) is less common than in USA/Western countries. We cross-sectionally assessed the association between CAC and estimated CHD risk as well as each major risk factor in general Japanese men. Participants were 996 randomly selected Japanese men aged 40-79 y, free of stroke, myocardial infarction, or revascularization. We examined an independent relationship between each risk factor used in prediction models and CAC score ≥100 by logistic regression. We then divided the participants into quintiles of estimated CHD risk per prediction model to calculate odds ratio of having CAC score ≥100. Receiver operating characteristic curve and c-index were used to examine discriminative ability of prevalent CAC for each prediction model. Age, smoking status, and systolic blood pressure were significantly associated with CAC score ≥100 in the multivariable analysis. The odds of having CAC score ≥100 were higher for those in higher quintiles in all prediction models (p-values for trend across quintiles ＜0.0001 for all models). All prediction models showed fair and similar discriminative abilities to detect CAC score ≥100, with similar c-statistics (around 0.70). In a community-based sample of Japanese men free of CHD and stroke, CAC score ≥100 was significantly associated with higher estimated CHD risk by prediction models. This finding supports the potential utility of CAC as a biomarker for CHD in a general Japanese male population.

Unanswered questions for management of acute coronary syndrome: risk stratification of patients with minimal disease or normal findings on coronary angiography.

PubMed

Bugiardini, Raffaele; Manfrini, Olivia; De Ferrari, Gaetano M

2006-07-10

The prognostic implication of chest pain associated with normal or near-normal findings on angiography is still unknown. We explored outcomes and methods of risk stratification in patients with nonobstructive coronary artery disease in the setting of non-ST-segment elevation acute coronary syndromes. Data were pooled from 3 Thrombolysis in Myocardial Infarction (TIMI) trials (TIMI 11B, TIMI 16, and TIMI 22). Angiographic data were available on 7656 patients with non-ST-segment elevation acute coronary syndromes. The primary end point of this analysis was the composite of the rates of death, myocardial infarction, unstable angina requiring rehospitalization, revascularization, and stroke at 1-year follow-up. Outcomes were evaluated by mean of the TIMI risk score for developing at least 1 component of the primary end point. Angiographic findings showed that 710 (9.1%) of 7656 patients had nonobstructive coronary artery disease; 48.7% of these had normal coronary arteries (0% stenosis), and 51.3% had mild coronary artery disease (>0% to <50% stenosis). A primary end-point event occurred in 101 patients (12.1%). It is noteworthy that a 2% event rate of deaths and myocardial infarctions had occurred in these patients at the 1-year follow-up. Event rates of death and myocardial infarction increased significantly as the TIMI risk score increased from 0.6% for a score of 1 to 4.0% for a score greater than 4. Patients with non-ST-segment elevation acute coronary syndromes with nonobstructive coronary artery disease detected by angiography have a substantial risk of subsequent coronary events within 1 year. The risk is not univariately high, and the TIMI risk score helps to reveal patients at high risk.

Evaluation of Revascularization Subtypes in Octogenarians Undergoing Coronary Artery Bypass Grafting

PubMed Central

Aziz, Abdulhameed; Lee, Anson M.; Pasque, Michael K.; Lawton, Jennifer S.; Moazami, Nader; Damiano, Ralph J.; Moon, Marc R.

2009-01-01

Background Recent data suggest that octogenarians’ long-term survival after complete CABG revascularization is superior to incomplete revascularization. Discriminating between variable definitions of “complete” complicates interpretation of survival data. We aimed to clarify octogenarian long-term survival rates by stratifying revascularization subtypes. Methods and Results From 1986 to 2007, 580 patients 80 to 94 years of age underwent CABG. Functional complete revascularization was defined as at least one graft to all diseased coronary vessels with greater than 50% stenosis. Traditional complete revascularization was defined as one graft to each major arterial system with at least 50% stenosis. Incomplete revascularization was defined as leaving diseased, ungrafted regions. Revascularization was functional in 279 (48%), traditional in 181 (31%), and incomplete in 120 (21%). Long-term survival was evaluated by Kaplan-Meier analysis. Of 537 operative survivors, there were 402 late deaths. Cumulative long-term survival totaled 2,890 patient-years. Late survival (Kaplan-Meier) was similar between functional (6.8 years, mean) and traditional (6.7 years) groups (p=0.51), but diminished with incomplete (4.2 years) revascularization (p=0.007). Survival by group at 5 years was: 59±3% functional, 57±4% traditional, and 45±5% incomplete. Survival at 8 years was: 40±3% functional, 37±4% traditional, and 26±5% incomplete. To minimize selection bias in patients with limited life expectancy, Kaplan-Meier analysis was repeated including only patients with survival greater than 12 months. Survival was again impaired with incomplete revascularization (p=0.04), and there was no difference between functional and traditional complete revascularization (p=0.73). Conclusions Bypassing all diseased arterial vessels after revascularization does not afford significant long-term survival advantage compared to a traditional approach. Incomplete revascularization, related to more extensive disease, is associated with an 18% decline in survival. These data suggest that it is important to avoid incomplete revascularization in octogenarians, but the supplementary endeavor required to perform functional complete revascularization does not improve survival. PMID:19752388

Challenges with Evidence-Based Management of Stable Ischemic Heart Disease.

PubMed

Patel, Amit V; Bangalore, Sripal

2017-02-01

Stable ischemic heart disease (SIHD) is a highly prevalent condition associated with increased costs, morbidity, and mortality. Management goals of SIHD can broadly be thought of in terms of improving prognosis and/or improving symptoms. Treatment options include medical therapy as well as revascularization, either with percutaneous coronary intervention or coronary artery bypass grafting. Herein, we will review the current evidence base for treatment of SIHD as well as its challenges and discuss ongoing studies to help address some of these knowledge gaps. There has been no consistent reduction in death or myocardial infarction (MI) with revascularization vs. medical therapy in patients with SIHD in contemporary trials. Angina and quality of life have been shown to be relieved more rapidly with revascularization vs. optimal medical therapy; however, the durability of these results is uncertain. There have been challenges and limitations in several of the trials addressing the optimal treatment strategy for SIHD due to potential selection bias (due to knowledge of coronary anatomy prior to randomization), patient crossover, and advances in medical therapy and revascularization strategies since trial completion. The challenges inherent to prior trials addressing the optimal management strategy for SIHD have impacted the generalizability of results to real-world cohorts. Until the results of additional ongoing trials are available, the decision for revascularization or medical therapy should be based on patients' symptoms, weighing the risks and benefits of each approach, and patient preference.

Determinants and Long-Term Outcomes of Percutaneous Coronary Interventions vs. Surgery for Multivessel Disease According to Clinical Presentation.

PubMed

Hong, Sung-Jin; Kim, Byeong-Keuk; Shin, Sanghoon; Suh, Yongsung; Kim, Seunghwan; Ahn, Chul-Min; Kim, Jung-Sun; Ko, Young-Guk; Choi, Donghoon; Hong, Myeong-Ki; Jang, Yangsoo

2018-03-23

The long-term outcome of percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG), particularly for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), remains controversial.Methods and Results:We retrospectively analyzed 2,827 patients (stable coronary artery disease [SCAD], n=1,601; NSTE-ACS, n=1,226) who underwent either PCI (n=1,732) or CABG (n=1,095). The 8-year composite of cardiac death and myocardial infarction (MI) was compared between PCI and CABG before and after propensity matching. For patients with NSTE-ACS, PCI was performed more frequently for those with higher Thrombolysis in Myocardial Infarction risk score and 3-vessel disease, and PCI led to significantly higher 8-year composite of cardiac death and MI than CABG (14.1% vs. 5.9%, hazard ratio [HR]=2.22, 95% confidence interval [CI]=1.37-3.58, P=0.001). There was a significant interaction between clinical presentation and revascularization strategy (P-interaction=0.001). However, after matching, the benefit of CABG vs. PCI was attenuated in patients with NSTE-ACS, whereas it was pronounced in those with SCAD. Interactions between clinical presentation and revascularization strategy were not observed (P-interaction=0.574). Although the determinants of PCI vs. CABG in real-world clinical practice differ according to the clinical presentation, a significant interaction between clinical presentation and revascularization strategy was not noted for long-term outcomes. The revascularization strategy for patients with NSTE-ACS can be based on the criteria applied to patients with SCAD.

Dual antiplatelet therapy versus oral anticoagulation plus dual antiplatelet therapy in patients with atrial fibrillation and low-to-moderate thromboembolic risk undergoing coronary stenting: design of the MUSICA-2 randomized trial.

PubMed

Sambola, Antonia; Montoro, J Bruno; Del Blanco, Bruno García; Llavero, Nadia; Barrabés, José A; Alfonso, Fernando; Bueno, Héctor; Cequier, Angel; Serra, Antonio; Zueco, Javier; Sabaté, Manel; Rodríguez-Leor, Oriol; García-Dorado, David

2013-10-01

Oral anticoagulation (OAC) is the recommended therapy for patients with atrial fibrillation (AF) because it reduces the risk of stroke and other thromboembolic events. Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention and stenting (PCI-S). In patients with AF requiring PCI-S, the association of DAPT and OAC carries an increased risk of bleeding, whereas OAC therapy or DAPT alone may not protect against the risk of developing new ischemic or thromboembolic events. The MUSICA-2 study will test the hypothesis that DAPT compared with triple therapy (TT) in patients with nonvalvular AF at low-to-moderate risk of stroke (CHADS2 score ≤2) after PCI-S reduces the risk of bleeding and is not inferior to TT for preventing thromboembolic complications. The MUSICA-2 is a multicenter, open-label randomized trial that will compare TT with DAPT in patients with AF and CHADS2 score ≤2 undergoing PCI-S. The primary end point is the incidence of stroke or any systemic embolism or major adverse cardiac events: death, myocardial infarction, stent thrombosis, or target vessel revascularization at 1 year of PCI-S. The secondary end point is the combination of any cardiovascular event with major or minor bleeding at 1 year of PCI-S. The calculated sample size is 304 patients. The MUSICA-2 will attempt to determine the most effective and safe treatment in patients with nonvalvular AF and CHADS2 score ≤2 after PCI-S. Restricting TT for AF patients at high risk for stroke may reduce the incidence of bleeding without increasing the risk of thromboembolic complications. © 2013.

The effects of sacubitril/valsartan on coronary outcomes in PARADIGM-HF.

PubMed

Mogensen, Ulrik M; Køber, Lars; Kristensen, Søren L; Jhund, Pardeep S; Gong, Jianjian; Lefkowitz, Martin P; Rizkala, Adel R; Rouleau, Jean L; Shi, Victor C; Swedberg, Karl; Zile, Michael R; Solomon, Scott D; Packer, Milton; McMurray, John J V

2017-06-01

Angiotensin converting enzyme inhibitors (ACE-I), are beneficial both in heart failure with reduced ejection fraction (HF-REF) and after myocardial infarction (MI). We examined the effects of the angiotensin-receptor neprilysin inhibitor sacubitril/valsartan, compared with the ACE-I enalapril, on coronary outcomes in PARADIGM-HF. We examined the effect of sacubitril/valsartan compared with enalapril on the following outcomes: i) the primary composite endpoint of cardiovascular (CV) death or HF hospitalization, ii) a pre-defined broader composite including, in addition, MI, stroke, and resuscitated sudden death, and iii) a post hoc coronary composite of CV-death, non-fatal MI, angina hospitalization or coronary revascularization. At baseline, of 8399 patients, 3634 (43.3%) had a prior MI and 4796 (57.1%) had a history of any coronary artery disease. Among all patients, compared with enalapril, sacubitril/valsartan reduced the risk of the primary outcome (HR 0.80 [0.73-0.87], P<.001), the broader composite (HR 0.83 [0.76-0.90], P<.001) and the coronary composite (HR 0.83 [0.75-0.92], P<.001). Although each of the components of the coronary composite occurred less frequently in the sacubitril/valsartan group, compared with the enalapril group, only CV death was reduced significantly. Compared with enalapril, sacubitril/valsartan reduced the risk of both the primary endpoint and a coronary composite outcome in PARADIGM-HF. Additional studies on the effect of sacubitril/valsartan on atherothrombotic outcomes in high-risk patients are merited. Copyright © 2017 Elsevier Inc. All rights reserved.

Meta-Analysis Comparing Complete Revascularization Versus Infarct-Related Only Strategies for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease.

PubMed

Shah, Rahman; Berzingi, Chalak; Mumtaz, Mubashir; Jasper, John B; Goswami, Rohan; Morsy, Mohamed S; Ramanathan, Kodangudi B; Rao, Sunil V

2016-11-15

Several recent randomized controlled trials (RCTs) demonstrated better outcomes with multivessel complete revascularization (CR) than with infarct-related artery-only revascularization (IRA-OR) in patients with ST-segment elevation myocardial infarction. It is unclear whether CR should be performed during the index procedure (IP) at the time of primary percutaneous coronary intervention (PCI) or as a staged procedure (SP). Therefore, we performed a pairwise meta-analysis using a random-effects model and network meta-analysis using mixed-treatment comparison models to compare the efficacies of 3 revascularization strategies (IRA-OR, CR-IP, and CR-SP). Scientific databases and websites were searched to find RCTs. Data from 9 RCTs involving 2,176 patients were included. In mixed-comparison models, CR-IP decreased the risk of major adverse cardiac events (MACEs; odds ratio [OR] 0.36, 95% CI 0.25 to 0.54), recurrent myocardial infarction (MI; OR 0.50, 95% CI 0.24 to 0.91), revascularization (OR 0.24, 95% CI 0.15 to 0.38), and cardiovascular (CV) mortality (OR 0.44, 95% CI 0.20 to 0.87). However, only the rates of MACEs, MI, and CV mortality were lower with CR-SP than with IRA-OR. Similarly, in direct-comparison meta-analysis, the risk of MI was 66% lower with CR-IP than with IRA-OR, but this advantage was not seen with CR-SP. There were no differences in all-cause mortality between the 3 revascularization strategies. In conclusion, this meta-analysis shows that in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease, CR either during primary PCI or as an SP results in lower occurrences of MACE, revascularization, and CV mortality than IRA-OR. CR performed during primary PCI also results in lower rates of recurrent MI and seems the most efficacious revascularization strategy of the 3. Published by Elsevier Inc.

Impact of minimally invasive surgery on medical spending and employee absenteeism.

PubMed

Epstein, Andrew J; Groeneveld, Peter W; Harhay, Michael O; Yang, Feifei; Polsky, Daniel

2013-07-01

As many surgical procedures have undergone a transition from a standard, open surgical approach to a minimally invasive one in the past 2 decades, the diffusion of minimally invasive surgery may have had sizeable but overlooked effects on medical expenditures and worker productivity. To examine the impact of standard vs minimally invasive surgery on health plan spending and workplace absenteeism for 6 types of surgery. Cross-sectional regression analysis. National health insurance claims data and matched workplace absenteeism data from January 1, 2000, to December 31, 2009. A convenience sample of adults with employer-sponsored health insurance who underwent either standard or minimally invasive surgery for coronary revascularization, uterine fibroid resection, prostatectomy, peripheral revascularization, carotid revascularization, or aortic aneurysm repair. Health plan spending and workplace absenteeism from 14 days before through 352 days after the index surgery. There were 321,956 patients who underwent surgery; 23,814 were employees with workplace absenteeism data. After multivariable adjustment, mean health plan spending was lower for minimally invasive surgery for coronary revascularization (-$30,850; 95% CI, -$31,629 to -$30,091), uterine fibroid resection (-$1509; 95% CI, -$1754 to -$1280), and peripheral revascularization (-$12,031; 95% CI, -$15,552 to -$8717) and higher for prostatectomy ($1350; 95% CI, $611 to $2212) and carotid revascularization ($4900; 95% CI, $1772 to $8370). Undergoing minimally invasive surgery was associated with missing significantly fewer days of work for coronary revascularization (mean difference, -37.7 days; 95% CI, -41.1 to -34.3), uterine fibroid resection (mean difference, -11.7 days; 95% CI, -14.0 to -9.4), prostatectomy (mean difference, -9.0 days; 95% CI, -14.2 to -3.7), and peripheral revascularization (mean difference, -16.6 days; 95% CI, -28.0 to -5.2). For 3 of 6 types of surgery studied, minimally invasive procedures were associated with significantly lower health plan spending than standard surgery. For 4 types of surgery, minimally invasive procedures were consistently associated with significantly fewer days of absence from work.

Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials.

PubMed

Hulten, Edward; Pickett, Christopher; Bittencourt, Marcio Sommer; Villines, Todd C; Petrillo, Sara; Di Carli, Marcelo F; Blankstein, Ron

2013-02-26

The aim of the study was to systematically review and perform a meta-analysis of randomized, controlled trials of coronary computed tomography angiography (CCTA) versus usual care (UC) triage of acute chest pain in the emergency department (ED). CCTA allows rapid evaluation of patients presenting to the ED with acute chest pain syndromes; however, the impact of such testing on patient management and downstream testing has emerged as a concern. We systematically searched for randomized, controlled trials of CCTA in the ED and performed a meta-analysis of clinical outcomes. Four randomized, controlled trials were included, with 1,869 patients undergoing CCTA and 1,397 undergoing UC. There were no deaths and no difference in the incidence of myocardial infarction, post-discharge ED visits, or rehospitalizations. Four studies reported decreased length of stay with CCTA and 3 reported cost savings; 8.4% of patients undergoing CCTA versus 6.3% of those receiving UC underwent invasive coronary angiography (ICA), whereas 4.6% of patients undergoing CCTA versus 2.6% of those receiving UC underwent coronary revascularization. The odds ratio of ICA for CCTA patients versus UC patients was 1.36 (95% confidence interval [CI]: 1.03 to 1.80, p = 0.030), and for revascularization, it was 1.81 (95% CI: 1.20 to 2.72, p = 0.004). The absolute increase in ICA after CCTA was 21 per 1,000 CCTA patients (95% CI: 1.8 to 44.9), and the number needed to scan was 48. The absolute increase in revascularization after CCTA was 20 per 1,000 patients (95% CI: 5.0 to 41.4); the number needed to scan was 50. Both percutaneous coronary intervention and coronary artery bypass graft surgery independently contributed to the significant increase in revascularization. Compared with UC, the use of CCTA in the ED is associated with decreased ED cost and length of stay but increased ICA and revascularization. Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Management of Chronic Total Coronary Occlusion in Stable Ischemic Heart Disease by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Versus Medical Therapy.

PubMed

Shuvy, Mony; Qiu, Feng; Chee-A-Tow, Alyssandra; Graham, John J; Abuzeid, Wael; Buller, Christopher; Strauss, Bradley H; Wijeysundera, Harindra C

2017-09-01

Coronary chronic total occlusions (CTOs) are found in approximately 20% of angiograms. We sought to assess the variation in the management of patients with CTOs and to compare the clinical outcomes of CTO lesions with those of non-CTO lesions. We conducted a population-based cohort study and included all patients with stable angina who underwent cardiac catheterization from October 1, 2012, to June 30, 2013, in Ontario, Canada. The primary outcome was a composite of mortality and hospitalization for myocardial infarction. A total of 7,864 patients were included, of whom 2,279 (29%) had a CTO. There were substantial differences in revascularization rates for patients with CTOs across hospitals in Ontario (44.9% to 94.1%). Revascularization was associated with improved outcomes in the overall cohort. Although the advantage of coronary artery bypass grafting over medical therapy was consistent in both patients with CTOs and patients without CTOs, the benefit of percutaneous coronary intervention (PCI) was limited to patients without CTOs (hazard ratio 0.56, 95% confidence interval 0.40- to 0.78), with no difference in patients with CTOs. The CTO lesion, however, was revascularized in few of the PCI cases (41.1%), with PCI limited to the non-CTO lesion in most patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Long term outcomes of new generation drug eluting stents versus coronary artery bypass grafting for multivessel and/or left main coronary artery disease. A Bayesian network meta-analysis of randomized controlled trials.

PubMed

Mina, George S; Watti, Hussam; Soliman, Demiana; Shewale, Anand; Atkins, Jessica; Reddy, Pratap; Dominic, Paari

2018-01-05

Most data guiding revascularization of multivessel disease (MVD) and/or left main disease (LMD) favor coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI). However, those data are based on trials comparing CABG to bare metal stents (BMS) or old generation drug eluting stents (OG-DES). Hence, it is essential to outcomes of CABG to those of new generation drug eluting stents (NG-DES). We searched PUBMED and Cochrane database for trials evaluating revascularization of MVD and/or LMD with CABG and/or PCI. A Bayesian network meta-analysis was performed to calculate odds ratios (OR) and 95% credible intervals (CrI). Primary outcome was major adverse cardiovascular events (MACE) at 3-5 years. Secondary outcomes were mortality, cerebrovascular accidents (CVA), myocardial infarction (MI) and repeat revascularization. We included 10 trials with a total of 9287 patients. CABG was associated with lower MACE when compared to BMS or OG-DES. However, MACE was not significantly different between CABG and NG-DES (OR 0.79, CrI 0.45-1.40). Moreover, there were no significant differences between CABG and NG-DES in mortality (OR 0.78, CrI 0.45-1.37), CVA (OR 0.93 CrI 0.35-2.2) or MI (OR 0.6, CrI 0.17-2.0). On the other hand, CABG was associated with lower repeat revascularization (OR 0.55, CrI 0.36-0.84). Our study suggests that NG-DES is an acceptable alternative to CABG in patients with MVD and/or LMD. However, repeat revascularization remains to be lower with CABG than with PCI. Copyright © 2018. Published by Elsevier Inc.

Association Between Clinical Pathways Leading to Medical Management and Prognosis in Patients With NSTEACS.

PubMed

Bueno, Héctor; Pocock, Stuart; Medina, Jesús; Danchin, Nicolas; Annemans, Lieven; Licour, Muriel; Gregson, John; Vega, Ana María; van de Werf, Frans

2017-10-01

A large proportion of patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) are initially selected for medical management (MM) and do not undergo coronary revascularization during or immediately after the index event. The aim of this study was to explore the clinical pathways leading to MM in NSTEACS patients and their influence on prognosis. Patient characteristics, pathways leading to MM, and 2-year outcomes were recorded in a prospective cohort of 5591 NSTEACS patients enrolled in 555 hospitals in 20 countries across Europe and Latin America. Cox models were used to assess the impact of hospital management on postdischarge mortality. Medical management was the selected strategy in 2306 (41.2%) patients, of whom 669 (29%) had significant coronary artery disease (CAD), 451 (19.6%) had nonsignificant disease, and 1186 (51.4%) did not undergo coronary angiography. Medically managed patients were older and had higher risk features than revascularized patients. Two-year mortality was higher in medically managed patients than in revascularized patients (11.0% vs 4.4%; P < .001), with higher mortality rates in patients who did not undergo angiography (14.6%) and in those with significant CAD (9.3%). Risk-adjusted mortality was highest for patients who did not undergo angiography (HR = 1.81; 95%CI, 1.23-2.65), or were not revascularized in the presence of significant CAD (HR = 1.90; 95%CI, 1.23-2.95) compared with revascularized patients. Medically managed NSTEACS patients represent a heterogeneous population with distinct risk profiles and outcomes. These differences should be considered when designing future studies in this population. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Lipoprotein(a) Levels and Recurrent Vascular Events After First Ischemic Stroke.

PubMed

Lange, Kristin S; Nave, Alexander H; Liman, Thomas G; Grittner, Ulrike; Endres, Matthias; Ebinger, Martin

2017-01-01

The association of elevated lipoprotein(a) (Lp(a)) levels and the incidence of cardiovascular disease, especially coronary heart disease and ischemic stroke, is well established. However, evidence on the association between Lp(a) levels and residual vascular risk in stroke survivors is lacking. We aimed to elucidate the risk for recurrent cardiovascular and cerebrovascular events in the patients with first-ever ischemic stroke with elevated Lp(a). All patients with acute ischemic stroke who participated in the prospective Berlin C&S study (Cream & Sugar) between January 2009 and August 2014 with available 12-month follow-up data and stored blood samples were eligible for inclusion. Lp(a) levels were determined in serum samples using an isoform-insensitive nephelometry assay. We assessed the risk for the composite vascular end point of ischemic stroke, transient ischemic attack, myocardial infarction, nonelective coronary revascularization, and cardiovascular death with elevated Lp(a) defined as >30 mg/dL using Cox regression analyses. Of 465 C&S study participants, 250 patients were included into this substudy with a median National Institutes of Health Stroke Scale score of 2 (1-4). Twenty-six patients (10%) experienced a recurrent vascular event during follow-up. Among patients with normal Lp(a) levels, 11 of 157 subjects (7%) experienced an event at a median time of 161 days (interquartile range, 19-196 days), whereas in patients with elevated Lp(a) levels, 15 of 93 subjects (16%) experienced an event at a median time of 48 days (interquartile range, 9-194 days; P=0.026). The risk for a recurrent event was significantly higher in patients with elevated Lp(a) levels after adjustment for potential confounders (hazard ratio, 2.60; 95% confidence interval, 1.19-5.67; P=0.016). Elevated Lp(a) levels are associated with a higher risk for combined vascular event recurrence in patients with acute, first-ever ischemic stroke. This finding should be validated in larger, multicenter trials. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01378468. © 2016 American Heart Association, Inc.

Coronary revascularization in Japan. Part 2: comparison of facilities between 1997 and 1999.

PubMed

Tsuchihashi, M; Tsutsui, H; Shihara, M; Shigematsu, H; Yamamoto, S; Koike, G; Kono, S; Takeshita, A

2001-12-01

A nation-wide survey on the procedures and facilities of coronary revascularization, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) conducted by the Japanese Coronary Intervention Study (JCIS) group during 1997 revealed that PCI is more often used than CABG and is mainly carried out in low-volume facilities without surgical backup. The present study aimed to investigate the temporal changes in the usage of revascularization therapies and facilities from 1997 to 1999. A questionnaire was mailed in 1998 to the delegates of 1,086 PCI and 582 CABG facilities identified by the previous survey, and 89% of PCIs surveyed and 94% of CABGs surveyed reported back. The number of PCI procedures had increased by 19% from 97,831 to 116,479 and that of CABG procedures also increased by 21% from 16,374 to 19,846. The ratio of PCI to CABG was 5.9 in 1999, showing no significant change from 6.0 in 1997. In parallel, the number of PCI and CABG facilities increased from 888 to 941 and from 442 to 453, respectively. The use of coronary stents and other interventional devices increased during these 2 years. Coronary stents were used regardless of the annual procedural volume of the facilities, whereas other interventional devices, directional and rotational coronary atherectomy, were used mainly in the high-volume laboratories (p<0.01). Beating-heart, off-pump CABG had increased from 2% to 11% of total cases. Continued monitoring of trends in PCI and CABG facilities and procedures will be needed for nation-wide assessment of the use of new technology.

Financial impact of coronary stenting in emergency for acute coronary syndromes.

PubMed

Nidegger, Delphine; Metz, Damien; Vacter, Christophe; Tassan-Mangina, Sophie; Deschildre, Alain; Gawron, Michel; Bourgeois, Jacqueline

2009-05-01

Since the prospective payment system, health institutions have only specific payments for the emergency care in the emergency room. The direct urgent admissions in coronary care units for acute coronary syndrome (ACS) do not collect this complementary refund. For the patient's stay, hospital is remunerated with fixed national prices which are similar even in case of emergent or planed coronary revascularization when realized. To analyze and compare the financial impact between emergent and planed coronary stenting in the setting of ACS. This retrospective study was based on patients suffering from ACS who experienced emergent coronary stenting during the year 2005. On 154 patients, 127 were age-, sex- and diagnosis-related group (called "groupe homogène de malades" in the French Health Care system)-matched with 127 suffering from same ACS but with planed "ad hoc" coronary stenting. The overall charges (medical and paramedical team, pharmacy, biology, implantable coronary devices, radiology) were compared between the two groups. Mean stay duration was 6.7 days and did not differ between the two groups. Mean financial retributions were significantly higher in the emergent group (7338 euro [6831-7846] IC95 vs 6509 euro [5994-7023]; p=0,02) but with a much more raised consumption (6810 euro [6283-7336] vs 5223 euro [4632-5814]; p=0,001). This overcost was due especially to drugs and biological expenses. The hospitalization payments did not cover the overall expenses for 25% of the patients' stays (N=64) among whom 39 have had emergent coronary stenting (30.7%, p=0.04). Among the different GHM, the most important difference was observed in non-STEMI without complication with a negative receipts/costs ratio for 37.8% of the stay with coronary stenting in emergency. The application of the recent guidelines for coronary revascularization in the management of ACS represents a financial venture for hospital institutions. The engaged charges for emergent coronary stenting are covered with difficulties contrary to planed revascularization.

Percutaneous coronary intervention in patients with multi-vessel coronary artery disease: a focus on physiology.

PubMed

Cho, Yun-Kyeong; Nam, Chang-Wook

2018-03-21

Multi-vessel coronary artery disease (MVD) frequently features ambiguous or intermediate lesions that may be both serial and complex, suggesting that multiple regions require revascularization. Percutaneous coronary intervention (PCI) is associated with various challenges such as appropriate identification of lesions that should be treated, the choice of an optimum revascularization method, and limitations of long-term outcomes. Optimal patient selection and careful targeting of lesions are key when planning treatment. Physiology-guided decision-making (based on the fractional flow reserve) can overcome the current limitations of PCI used to treat MVD regardless of clinical presentation or disease subtype, as confirmed in recent clinical trials. Here, we review the use of physiology-guided PCI for patients with MVD, and their early and late outcomes.

National trends in utilization and outcomes of coronary revascularization procedures among people with and without type 2 diabetes in Spain (2001–2011)

PubMed Central

2014-01-01

Background Diabetes is associated with a high risk of death due to coronary artery disease (CAD). People with diabetes suffering from CAD are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of coronary revascularization procedures in diabetic and non-diabetic patients in Spain between 2001 and 2011. Methods We identified all patients who had undergone coronary revascularization procedures, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. The incidence of discharges attributed to coronary revascularization procedures were calculated stratified by diabetes status. We calculated length of stay and in-hospital mortality (IHM). We apply joinpoint log-linear regression to identify the years in which changes in tendency occurred in the use of PCI and CABG in diabetic and non-diabetic patients. Multivariate analysis was adjusted by age, sex, year and comorbidity (Charlson comorbidity index). Results From 2001 to 2011, 434,108 PCIs and 79,986 CABGs were performed. According to the results of the joinpoint analysis, we found that sex and age-adjusted use of PCI increased by 31.4% per year from 2001 to 2003, by 15.9% per year from 2003 to 2006 and by 3.8% per year from 2006 to 2011 in patients with diabetes. IHM among patients with diabetes who underwent a PCI did not change significantly over the entire study period (OR 0.99; 95% CI 0.97-1.00). Among patients with diabetes who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 10.4% per year from 2001 to 2003, and then decreased by 1.1% through 2011. Diabetic patients who underwent a CABG had a 0.67 (95% CI 0.63-0.71) times lower probability of dying during hospitalization than those without diabetes. Conclusions The annual percent change in PCI procedures increased in diabetic and non-diabetic patients. Higher comorbidity and the female gender are associated with a higher IHM in PCI procedures. In diabetic and non-diabetic patients, we found a decrease in the use of CABG procedures. IHM was higher in patients without diabetes than in those with diabetes. PMID:24383412

The SPIRIT V study: a clinical evaluation of the XIENCE V everolimus-eluting coronary stent system in the treatment of patients with de novo coronary artery lesions.

PubMed

Grube, Eberhard; Chevalier, Bernard; Smits, Peter; Džavík, Vladimir; Patel, Tejas M; Mullasari, Ajit S; Wöhrle, Jochen; Stuteville, Marrianne; Dorange, Cécile; Kaul, Upendra

2011-02-01

The SPIRIT V (A Clinical Evaluation of the XIENCE V Everolimus-Eluting Coronary Stent System in the Treatment of Patients With De Novo Coronary Artery Lesions) study is a post-market surveillance experience of the XIENCE V (Abbott Vascular, Santa Clara, California) everolimus-eluting stent (EES) in patients with higher-risk coronary anatomy. Previous pre-approval studies have shown the safety and efficacy of EES in highly selected groups of patients. The SPIRIT V trial is a prospective, open label, single arm, multicenter study. Two thousand seven hundred patients with multiple de novo coronary artery lesions suitable for treatment with a planned maximum of 4 EES were enrolled at 93 centers in Europe, Asia Pacific, Canada, and South Africa. Lesions had a reference vessel diameter between 2.25 and 4.0 mm and a length of ≤ 28 mm by visual estimation. An independent clinical events committee adjudicated all end point-related events. The primary end point was the composite rate of all death, myocardial infarction (MI), and target vessel revascularization at 30 days. Secondary end points included stent thrombosis and acute success (clinical device and procedure success). At 30 days, the primary composite end point of all death, MI, and target vessel revascularization was 2.7%. At 1 year, rates of cardiac death, overall MI, and target lesion revascularization were 1.1%, 3.5%, and 1.8%, respectively. The cumulative rate of definite and probable stent thrombosis was low at 0.66% at 1 year. Use of EES in patients with multiple, complex de novo lesions yielded 1-year major adverse cardiac events, stent thrombosis, and target lesion revascularization rates that are comparable to those of the more controlled SPIRIT II and SPIRIT III trials-which included patients with restricted inclusion/exclusion criteria-and other all-comer population, physician-initiated studies like the X-SEARCH (Xience Stent Evaluated At Rotterdam Cardiology Hospital) and COMPARE (A Randomized Controlled Trial of Everolimus-eluting Stents and Paclitaxel-eluting Stents for Coronary Revascularization in Daily Practice) trials. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Anomalous Coronary Artery From the Opposite Sinus (ACAOS): Technical Challenges During Percutaneous Coronary Intervention.

PubMed

Sinha, Santosh Kumar; Razi, Mahmodula; Mahrotra, Anupam; Aggarwal, Puneet; Singh, Anupam; Rekwal, Lokendra; Tripathi, Sunil; Abhishekh, Nishant Kumar; Krishna, Vinay

2018-04-01

Anomalies of the coronary arteries are reported in 1-2% of patients among diagnostic angiogram. Ectopic origin of right coronary artery (RCA) from opposite sinus is one of the most common and they are mainly benign, but at times may be malignant. We report a case of a 69-year-old male who underwent early invasive percutaneous coronary intervention for non-ST-segment elevation myocardial infarction (NSTEMI) where RCA arising from left sinus at the root of left main artery was culprit and various technical challenges were encountered while intervening in form of cannulation to tracking of hardwares. RCA was cannulated with floating wire technique using hockey stick guide catheter and revascularized by deployment of 3.5 × 38 mm Promus Premier Everolimus eluting stent (Boston Scientific, USA). To the best of our knowledge, this is the first ever report of ectopic RCA being revascularized by using hockey stick catheter.

Gender-Based Differences in Outcomes After Orbital Atherectomy for the Treatment of De Novo Severely Calcified Coronary Lesions.

PubMed

Lee, Michael S; Shlofmitz, Evan; Mansourian, Pejman; Sethi, Sanjum; Shlofmitz, Richard A

2016-11-01

We evaluated the relationship between gender and angiographic and clinical outcomes in patients with severely calcified lesions who underwent orbital atherectomy. Female gender is associated with increased risk of adverse clinical events after percutaneous coronary intervention (PCI). Severe coronary artery calcification increases the complexity of PCI and increases the risk of adverse cardiac events. Orbital atherectomy is effective in plaque modification, which facilitates stent delivery and expansion. Whether gender differences exist after orbital atherectomy is unclear. Our analysis retrospectively analyzed 458 consecutive real-world patients (314 males and 144 females) from three centers who underwent orbital atherectomy. The primary endpoint was the major adverse cardiac and cerebrovascular event (MACCE) rate, defined as the composite of death, myocardial infarction (MI), target-vessel revascularization (TVR), and stroke, at 30 days. The primary endpoint of MACCE was low and similar in females and males (0.7% vs 2.9%; P=.14). The individual endpoints of death (0.7% vs 1.6%; P=.43), MI (0.7% vs 1.3%; P=.58), TVR (0% vs 0%; P>.99), and stroke (0% vs 0.3%; P=.50) were low in both groups and did not differ. Angiographic complications were low: perforation (0.8% vs 0.7%; P>.90), dissection (0.8% vs 1.1%; P=.80), and no-reflow (0.8% vs 0.7%; P>.90). Plaque modification with orbital atherectomy was safe and provided similar angiographic and clinical outcomes between females and males. Randomized trials with longer-term follow-up are needed to support our results.

The History of Primary Angioplasty and Stenting for Acute Myocardial Infarction.

PubMed

Smilowitz, Nathaniel R; Feit, Frederick

2016-01-01

The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.

Revascularization Treatment of Emergency Patients with Acute ST-Segment Elevation Myocardial Infarction in Switzerland: Results from a Nationwide, Cross-Sectional Study in Switzerland for 2010-2011.

PubMed

Berlin, Claudia; Jüni, Peter; Endrich, Olga; Zwahlen, Marcel

2016-01-01

Cardiovascular diseases are the leading cause of death worldwide and in Switzerland. When applied, treatment guidelines for patients with acute ST-segment elevation myocardial infarction (STEMI) improve the clinical outcome and should eliminate treatment differences by sex and age for patients whose clinical situations are identical. In Switzerland, the rate at which STEMI patients receive revascularization may vary by patient and hospital characteristics. To examine all hospitalizations in Switzerland from 2010-2011 to determine if patient or hospital characteristics affected the rate of revascularization (receiving either a percutaneous coronary intervention or a coronary artery bypass grafting) in acute STEMI patients. We used national data sets on hospital stays, and on hospital infrastructure and operating characteristics, for the years 2010 and 2011, to identify all emergency patients admitted with the main diagnosis of acute STEMI. We then calculated the proportion of patients who were treated with revascularization. We used multivariable multilevel Poisson regression to determine if receipt of revascularization varied by patient and hospital characteristics. Of the 9,696 cases we identified, 71.6% received revascularization. Patients were less likely to receive revascularization if they were female, and 80 years or older. In the multivariable multilevel Poisson regression analysis, there was a trend for small-volume hospitals performing fewer revascularizations but this was not statistically significant while being female (Relative Proportion = 0.91, 95% CI: 0.86 to 0.97) and being older than 80 years was still associated with less frequent revascularization. Female and older patients were less likely to receive revascularization. Further research needs to clarify whether this reflects differential application of treatment guidelines or limitations in this kind of routine data.

Six-month outcome in unstable angina patients without previous myocardial infarction according to the use of tertiary cardiologic resources. RESCATE Investigators. Recursos Empleados en el Síndrome Coronario Agudo y Tiempos de Espera.

PubMed

Lupón, J; Valle, V; Marrugat, J; Elosua, R; Serés, L; Pavesi, M; Freixa, R; Sanz, G; Masiá, R; Molina, L; Sala, J; Serra, J

1999-12-01

The study assessed whether varying accessibility of patients with unstable angina (UA) to coronary angiography and revascularization determined differing usages and outcomes. The appropriate use rate of coronary angiography and revascularization procedures in UA remains to be established. A total of 791 consecutive patients with UA without previous acute myocardial infarction (AMI) admitted to four reference teaching hospitals (one with tertiary facilities) were followed for six months. End points were six-month mortality and readmission for AMI, UA, heart failure, or severe ventricular arrhythmias. Patients admitted to the tertiary hospital were 3.27 (95% confidence interval [CI] 2.32 to 4.62) times more likely to undergo coronary angiography after adjustment for comorbidity and severity than were those admitted to nontertiary facilities (overall six-month use rates 70.1% and 48.3%, respectively). Revascularization procedures were performed in 36.2% of patients in the tertiary hospital and 24.6% in the others (p = 0.0007); adjusted relative risk (RR) 2.37 (95% CI 1.55 to 3.63). Median delay for urgent coronary angiography was shorter in the tertiary hospital (24 h vs. 4 days, p < 0.0002). Six-month mortality and readmission rates were similar in tertiary and nontertiary hospitals: 3.9% versus 5.3% and 16.9% versus 21.2%, respectively. Adjusted RR of death or readmission for the nontertiary hospitals was 1.23 (95% CI 0.57 to 2.67). The use of coronary angiography and revascularization procedures in UA patients with no previous AMI is higher in tertiary than in nontertiary hospitals, but the more selective use of these procedures in nontertiary centers does not imply worse outcome.

Concomitant Carotid and Coronary Artery Reconstruction

PubMed Central

Craver, Joseph M.; Murphy, Douglas A.; Jones, Ellis L.; Curling, Patrick E.; Bone, David K.; Smith, Robert B.; Perdue, Garland D.; Hatcher, Charles R.; Kandrach, Michael

1982-01-01

Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Rehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are; self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CECAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from CAB alone. PMID:7082063

Risk stratification for large artery or chronic coronary artery disease-related ischemic stroke in octogenarians undergoing exercise stress myocardial perfusion imaging: A cohort study.

PubMed

Katsikis, Athanasios; Theodorakos, Athanasios; Drosatos, Alexandros; Konstantinou, Konstantinos; Papaioannou, Spyridon; Koutelou, Maria

2017-04-01

To test, if in octogenarians, treadmill exercise with myocardial perfusion imaging (exercise-MPI) can risk stratify for large artery or chronic CAD-related ischemic stroke (LACCIS). Exercise-MPI-related data of 237 octogenarians (55% prior MI or revascularization) without previous stroke were registered and prospective follow-up was performed to document LACCIS. LACCIS was defined as acute onset of neurological symptoms with CT/MRI findings of non-lacunar-type infarcts in the absence of atrial fibrillation or intracardiac embolic sources. After 7.3 years, 10 LACCIS were documented. SSS [HR 1.08 (1.02-1.13 95% CIs), SDS [HR 1.1 (1.04-1.16 95% CIs)], and non-sustained VT or transient AV block during exercise [HR 3.9 (1.7-9.0 95% CIs)] were predictors of LACCIS (P < .01 for all). A SSS threshold of 16 had 81% specificity for identification of future LACCIS and risk groups formed according to this cut-off had significantly different LACCIS-free survival (P = .015). Exercise-MPI in octogenarians can provide risk stratification markers for LACCIS.

Revascularization of the internal carotid artery for isolated, stenotic, and symptomatic kinking.

PubMed

Illuminati, Giulio; Calió, Francesco G; Papaspyropoulos, Vassilios; Montesano, Giuseppe; D'Urso, Antonio

2003-02-01

The operation for isolated, stenotic, and symptomatic kinking of the internal carotid artery is safe and effective in preventing stroke and relieving the symptoms of cerebral ischemia. A consecutive sample clinical study with a mean follow-up of 44 months. The surgical department of an academic tertiary care center and an affiliated secondary care center. Fifty-four patients with a mean age of 67 years underwent 55 revascularizations of the internal carotid artery. The surgical procedures consisted of the following: shortening and reimplantation in the common carotid artery in 36 cases, bypass grafting in 15 cases, and transposition into the external carotid artery in 4 cases. Cumulative survival, primary patency, and stroke-free and neurologic symptom-free rates expressed by standard life-table analysis. No patients died in the postoperative period. The postoperative stroke rate was 1.8%. The cumulative rates (SEs) at 5 years were as follows: survival, 70% (10.2%); primary patency, 89% (7.8%); overall stroke free, 92% (6.8%); ipsilateral stroke free, 96% (5.3%); neurologic symptom free, 90% (7.5%); and ipsilateral symptom free, 93% (6.5%). Revascularization of the internal carotid artery for the treatment of isolated, stenotic, and symptomatic kinking is safe and effective in preventing stroke and relieving symptoms of cerebrovascular insufficiency.

Very late stent thrombosis and late target lesion revascularization after sirolimus-eluting stent implantation: five-year outcome of the j-Cypher Registry.

PubMed

Kimura, Takeshi; Morimoto, Takeshi; Nakagawa, Yoshihisa; Kawai, Kazuya; Miyazaki, Shunichi; Muramatsu, Toshiya; Shiode, Nobuo; Namura, Masanobu; Sone, Takahito; Oshima, Shigeru; Nishikawa, Hideo; Hiasa, Yoshikazu; Hayashi, Yasuhiko; Nobuyoshi, Masakiyo; Mitudo, Kazuaki

2012-01-31

There is a scarcity of long-term data from large-scale drug-eluting stent registries with a large enough sample to evaluate low-frequency events such as stent thrombosis (ST). Five-year outcomes were evaluated in 12 812 consecutive patients undergoing sirolimus-eluting stent (SES) implantation in the j-Cypher registry. Cumulative incidence of definite ST was low (30 day, 0.3%; 1 year, 0.6%; and 5 years, 1.6%). However, late and very late ST continued to occur without attenuation up to 5 years after sirolimus-eluting stent implantation (0.26%/y). Cumulative incidence of target lesion revascularization within the first year was low (7.3%). However, late target lesion revascularization beyond 1 year also continued to occur without attenuation up to 5 years (2.2%/y). Independent risk factors of ST were completely different according to the timing of ST onset, suggesting the presence of different pathophysiological mechanisms of ST according to the timing of ST onset: acute coronary syndrome and target of proximal left anterior descending coronary artery for early ST; side-branch stenting, diabetes mellitus, and end-stage renal disease with or without hemodialysis for late ST; and current smoking and total stent length >28 mm for very late ST. Independent risk factors of late target lesion revascularization beyond 1 year were generally similar to those risk factors identified for early target lesion revascularization. Late adverse events such as very late ST and late target lesion revascularization are continuous hazards, lasting at least up to 5 years after implantation of the first-generation drug-eluting stents (sirolimus-eluting stents), which should be the targets for developing improved coronary stents.

Efficiency of the Penumbra 5MAX ACE Reperfusion Catheter in Acute Ischemic Stroke Patients.

PubMed

Suzuki, Kentaro; Aoki, Junya; Sakamoto, Yuki; Kanamaru, Takuya; Abe, Arata; Suda, Satoshi; Okubo, Seiji; Kimura, Kazumi

2016-12-01

This study was performed to investigate whether the Penumbra 5MAX ACE is superior to other Penumbra systems. We performed a retrospective, single center analysis of patients with acute ischemic stroke with occlusion of the internal carotid artery or middle cerebral artery (M1 segment) who underwent endovascular therapy using a Penumbra system. The reperfusion success rate, puncture-to-revascularization time, and number of passes were assessed. Multivariate regression analysis was conducted to evaluate independent factors related to revascularization within 60 minutes. Successful revascularization was defined by a thrombolysis in cerebral infarction score ≥2b. The Penumbra 5MAX ACE was used in 24 of the 40 patients (60%). Although the revascularization success rate was similar between patient groups (P = .229), the number of passes was significantly lower (1.5 ± .8 versus 2.6 ± 1.3, P = .006) and the puncture-to-revascularization time was shorter (50 ± 26 minutes versus 116 ± 69 minutes, P = .002) in patients treated with the Penumbra 5MAX ACE. The Penumbra 5MAX ACE was identified as an independent factor for early revascularization (odds ratio, 5.80; P = .041). Among patients with a premorbid modified Rankin Scale score of 0-1, a modified Rankin Scale score of 0-2 at 3 months was observed in 15 of the 19 patients (79%) treated with the Penumbra 5MAX ACE and in 8 of the 16 (50%) who were not (P = .072). Acute revascularization therapy using the Penumbra 5MAX ACE can achieve rapid successful recanalization and tend to improve clinical outcomes. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

A randomized study to compare bioactive titanium stents and everolimus-eluting stents in diabetic patients (TITANIC XV): 1-year results.

PubMed

López-Mínguez, José R; Nogales-Asensio, Juan M; Doncel-Vecino, Luis J; Merchán-Herrera, Antonio; Pomar-Domingo, Francisco; Martínez-Romero, Pedro; Fernández-Díaz, José A; Valdesuso-Aguilar, Raúl; Moreu-Burgos, José; Díaz-Fernández, José

2014-07-01

Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients. A total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter < 2.5 mm or length > 28 mm in vessels < 3mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients). Baseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P < .0001). The everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis. Copyright © 2013 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

Comparing Coronary Atheroma Progression Rates and Coronary Events in the United States, Canada, Latin America, and Europe.

PubMed

Puri, Rishi; Nicholls, Stephen J; St John, Julie; Tuzcu, E Murat; Kapadia, Samir R; Uno, Kiyoko; Kataoka, Yu; Wolski, Kathy; Nissen, Steven E

2016-12-01

We explored for geographic variations in coronary atheroma progression rates in the United States compared to other world regions (Canada, Latin America, Western Europe, and Central-Eastern Europe) and sought to ascertain if this associated with regional differences in major adverse cardiovascular events (MACE; cardiovascular death, nonfatal myocardial infarction, coronary revascularization). Across 7 randomized trials with a global recruitment pattern, 5,451 participants with angiographic coronary disease underwent serial coronary intravascular ultrasonography during 18 or 24 months, with adjudicated MACE. Change in coronary percent atheroma volume (ΔPAV) and MACE in the United States versus other world regions were assessed. Despite similar baseline angiographic and plaque characteristics across participants and regions, following propensity-weighted and multivariate analysis, US (n = 3,706) versus non-US (n = 1,745) participants demonstrated marginal but significantly greater annualized ΔPAV (least-square means ± SE: 0.27 ± 0.14% vs 0.062 ± 0.14%, p = 0.005). However, MACE rates were disproportionately higher in US compared to non-US participants (23.5% vs 10.9%, p <0.001), driven by a doubling in crude rates of coronary revascularization procedures (16.1% vs 7.8%, p <0.001). The US participants hospitalized with unstable angina demonstrated more significant disease progression than their non-US counterparts (ΔPAV: 0.57 ± 0.19% vs -0.30 ± 0.36%, p = 0.033) and greater MACE (9.1% vs 4.8%, p <0.001). A US geographic disposition independently associated with MACE (hazard ratio 1.53, 95% confidence interval 1.22 to 1.92, p <0.001). In conclusion, in participants with stable coronary disease, coronary atheroma progression rates are modestly higher in US-based compared to non-US-based participants. Elective coronary revascularization rates however are disproportionately greater in US-based participants. Copyright © 2016 Elsevier Inc. All rights reserved.

[Oxygen-transporting function of the blood circulation system in sevoflurane anesthesia during myocardial revascularization under extracorporeal circulation].

PubMed

Skopets, A A; Lomivorotov, V V; Karakhalis, N B; Makarov, A A; Duman'ian, E S; Lomivorotova, L V

2009-01-01

The purpose of the study was to evaluate the efficiency of oxygen-transporting function of the circulatory system under sevoflurane anesthesia during myocardial revascularization operations under extracorporeal circulation. Twenty-five patients with coronary heart disease were examined. Mean blood pressure, heart rate, cardiac index, total peripheral vascular resistance index, pulmonary pressure, pulmonary wedge pressure, and central venous pressure were measured. Arterial and mixed venous blood oxygen levels, oxygen delivery and consumption index, arteriovenous oxygen difference, and glucose and lactate concentrations were calculated. The study has demonstrated that sevoflurane is an effective and safe anesthetic for myocardial revascularization operations in patients with coronary heart disease. The use of sevoflurane contributes to steady-state oxygen-transporting function of the circulatory system at all surgical stages.

Angiographic predictors of 3-year patency of bypass grafts implanted on the right coronary artery system: a prospective randomized comparison of gastroepiploic artery, saphenous vein, and right internal thoracic artery grafts.

PubMed

Glineur, David; D'hoore, William; de Kerchove, Laurent; Noirhomme, Philippe; Price, Joel; Hanet, Claude; El Khoury, Gebrine

2011-11-01

Saphenous vein, in situ right gastroepiploic artery, and right internal thoracic artery grafts are routinely used to revascularize the right coronary artery. Little is known about the predictive value of objective preoperative angiographic parameters on midterm graft patency. We prospectively enrolled 210 consecutive patients undergoing coronary revascularization. Revascularization of the right coronary artery was randomly performed with the saphenous vein grafts in 81 patients and the right gastroepiploic artery in 92 patients. During the same study period, 37 patients received right coronary artery revascularization with the right internal thoracic artery used in a Y-composite fashion. All patients underwent a protocol-driven coronary angiogram 3 years after surgery. Preoperative angiographic parameters included minimum lumen diameter percent stenosis measured by quantitative angiography. A graft was considered "not functional" with patency scores of 0 to 2 and "functional" with patency scores of 3 or 4. Angiographic follow-up was 100% complete. A significant difference in the distribution of flow patterns was observed in the 3 groups. In multivariate analysis, the use of a saphenous vein graft was associated with superior graft functionality compared with the other conduits (odds ratio, 6.1; 95% confidence interval, 2.4-15). Graft function was negatively influenced by the minimum lumen diameter (odds ratio, 0.11; confidence interval, 0.05-0.25). In the right gastroepiploic artery and right internal thoracic artery groups, the proportion of functional grafts was higher when the minimum lumen diameter was below a threshold value in the third minimum lumen diameter quartile (0.64-1.30 mm). Preoperative angiography predicts graft patency in the right gastroepiploic artery and right internal thoracic artery, whereas the flow pattern in saphenous vein grafts is significantly less influenced by quantitative angiographic parameters. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Antithrombotic therapy in patients with non-valvular atrial fibrillation undergoing percutaneous coronary intervention: should we change our practice after the PIONEER AF-PCI and RE-DUAL PCI trials?

PubMed

Duerschmied, D; Brachmann, J; Darius, H; Frey, N; Katus, H A; Rottbauer, W; Schäfer, A; Thiele, H; Bode, C; Zeymer, Uwe

2018-04-20

The number of patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) is increasing. Since these patients have a CHA 2 DS 2 -VASc score of 1 or higher, they should be treated with oral anticoagulation to prevent stroke. However, combination therapy with oral anticoagulation for prevention of embolic stroke and dual platelet inhibition for prevention of coronary thrombosis significantly increases bleeding complications. The optimal combination, intensity and duration of antithrombotic combination therapy is still not known. In the rather small randomized WOEST trial, the combination of a vitamin K antagonist (VKA) and clopidogrel decreased bleeding compared to the conventional triple therapy with VKA, clopidogrel and aspirin. In the PIONEER AF-PCI trial, two rivaroxaban-based treatment regimens significantly reduced bleeding complications compared to conventional triple therapy without increasing embolic or ischemic complications following PCI. Dual therapy with rivaroxaban and clopidogrel appeared to provide an optimal risk-benefit ratio. In the RE-DUAL PCI trial, dual therapy with dabigatran also reduced bleeding complications compared to conventional triple therapy. With respect to the composite efficacy end point of thromboembolic events (myocardial infarction, stroke, or systemic embolism), death, or unplanned revascularization dabigatran-based dual therapy was non-inferior to VKA-based triple therapy. The upcoming trials AUGUSTUS with apixaban and ENTRUST-PCI with edoxaban will further examine the use of NOACs in this setting. While recent guidelines recommend NOAC-based dual therapy in only a subset of patients (those who are at increased risk of bleeding), the available data now suggest that this should be the preferred choice for the majority of patients. Adding aspirin to this primary choice for up to 4 weeks in patients at especially high ischemic risk would likely prevent atherothrombotic events, but this needs further investigation. Taken together, it is time to adjust our practice and move to dual therapy consisting of a NOAC plus clopidogrel in most patients.

Role of Stress Myocardial Scintigraphy in the Evaluation of Incompletely Revascularized Post-PCI Patients

PubMed Central

Galassi, Alfredo R.; Marzá, Francesco; Azzarelli, Salvatore; Tomasello, Salvatore D.

2011-01-01

Percutaneous coronary intervention (PCI) is actually the most used method of revascularization. Although complete revascularization remains a desirable goal, it may not be possible or not easy to plan in many patients. Thus, incomplete revascularization might be a preferred treatment strategy in selected patient categories. Stress myocardial scintigraphy, because of its high diagnostic accuracy and prognostic value and its ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have uninterpretable electrocardiogram, is of paramount importance for clinical decision making in patients with multivessel disease and incomplete revascularization. PMID:21941646

Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: an expert consensus document from the Society for Cardiovascular Angiography and Interventions (SCAI).

PubMed

Moussa, Issam D; Klein, Lloyd W; Shah, Binita; Mehran, Roxana; Mack, Michael J; Brilakis, Emmanouil S; Reilly, John P; Zoghbi, Gilbert; Holper, Elizabeth; Stone, Gregg W

2014-01-01

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5) which are of uncertain prognostic importance. In addition, for both MI types cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than employing an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a "clinically relevant MI." The present document introduces a new definition for "clinically relevant MI" after coronary revascularization (PCI or CABG) which is applicable for use in clinical trials, patient care, and quality outcomes assessment. Copyright © 2013 Wiley Periodicals, Inc.

Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol.

PubMed

Gaudino, Mario; Alexander, John H; Bakaeen, Faisal G; Ballman, Karla; Barili, Fabio; Calafiore, Antonio Maria; Davierwala, Piroze; Goldman, Steven; Kappetein, Peter; Lorusso, Roberto; Mylotte, Darren; Pagano, Domenico; Ruel, Marc; Schwann, Thomas; Suma, Hisayoshi; Taggart, David P; Tranbaugh, Robert F; Fremes, Stephen

2017-12-01

The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Whole blood gene expression testing for coronary artery disease in nondiabetic patients: major adverse cardiovascular events and interventions in the PREDICT trial.

PubMed

Rosenberg, Steven; Elashoff, Michael R; Lieu, Hsiao D; Brown, Bradley O; Kraus, William E; Schwartz, Robert S; Voros, Szilard; Ellis, Stephen G; Waksman, Ron; McPherson, John A; Lansky, Alexandra J; Topol, Eric J

2012-06-01

The majority of first-time angiography patients are without obstructive coronary artery disease (CAD). A blood gene expression score (GES) for obstructive CAD likelihood was validated in the PREDICT study, but its relation to major adverse cardiovascular events (MACE) and revascularization was not assessed. Patients (N = 1,160) were followed up for MACE and revascularization 1 year post-index angiography and GES, with 1,116 completing follow-up. The 30-day event rate was 23% and a further 2.2% at 12 months. The GES was associated with MACE/revascularizations (p < 0.001) and added to clinical risk scores. Patients with GES >15 trended towards increased >30 days MACE/revascularization likelihood (odds ratio = 2.59, 95% confidence interval = 0.89-9.14, p = 0.082). MACE incidence overall was 1.5% (17 of 1,116) and 3 of 17 patients had GES ≤ 15. For the total low GES group (N = 396), negative predictive value was 90% for MACE/revascularization and >99% for MACE alone, identifying a group of patients without obstructive CAD and highly unlikely to suffer MACE within 12 months.

Elevated plasma lipoprotein(a) levels were associated with increased risk of cardiovascular events in Chinese patients with stable coronary artery disease.

PubMed

Dai, Wen; Long, Junke; Cheng, Ying; Chen, Yaqin; Zhao, Shuiping

2018-05-16

Recent studies have suggested that lipoprotein(a) [Lp(a)] is associated with cardiovascular disease (CVD). However, the contribution of Lp(a) to residual risk of CVD has not been determined in Chinese populations. We conducted a prospective study to evaluate the association between Lp(a) and the risk of major adverse cardiovascular events (MACEs) in patients with stable coronary artery disease (CAD) who received optimal medication treatment (OMT). The study enrolled 1602 patients with stable CAD from 5 hospitals in China. The baseline clinical characteristics and follow-up MACE data for the patients were recorded. Coronary lesion severity was assessed by the Gensini scoring system. All-cause death, non-fatal myocardial infarction, non-fatal stroke and unplanned coronary revascularization were considered MACEs. We found that plasma Lp(a) levels were positively associated with coronary lesion severity at baseline (p < 0.001). During a mean follow-up period of 39.6 months, 166 (10.4%) patients suffered MACEs. There were significant differences in the adjusted event-free survival rates among the Lp(a) quartile subgroups (p = 0.034). The hazard ratio for MACEs was 1.291 (95% confidence interval: 1.091-1.527, p = 0.003) per standardized deviation in the log-transformed Lp(a) level after adjustment for traditional cardiovascular risk factors. Therefore, Lp(a) was an independent predictor of MACEs in Chinese patients with stable CAD who received OMT.

Technical aspects and limitations of fractional flow reserve measurement.

PubMed

Jerabek, Stepan; Kovarnik, Tomas

2018-02-27

The only indication for coronary revascularization is elimination of ischaemia. Invasive hemodynamic methods (fractional flow reserve - FFR and instantaneous wave-free ratio (iFR) are superior to coronary angiography in detection of lesions causing myocardial ischaemia. Current European guidelines for myocardial revascularization recommend using of FFR for detection of functional assessment of lesions severity in category IA and number of these procedures increases. However, routine usage of these methods requires knowledge of technical requirements and limitations. The aim of the study is to summarise good clinical practice for FFR and iFR measurements with explanation of possible technical challenges, that are necessary for increasing of measurement accuracy. Authors describe frequent technical mistakes and malpractice during invasive assessment of lesion severity in coronary arteries.

First-in-Man Computed Tomography-Guided Percutaneous Revascularization of Coronary Chronic Total Occlusion Using a Wearable Computer: Proof of Concept.

PubMed

Opolski, Maksymilian P; Debski, Artur; Borucki, Bartosz A; Szpak, Marcin; Staruch, Adam D; Kepka, Cezary; Witkowski, Adam

2016-06-01

We report a case of successful computed tomography-guided percutaneous revascularization of a chronically occluded right coronary artery using a wearable, hands-free computer with a head-mounted display worn by interventional cardiologists in the catheterization laboratory. The projection of 3-dimensional computed tomographic reconstructions onto the screen of virtual reality glass allowed the operators to clearly visualize the distal coronary vessel, and verify the direction of the guide wire advancement relative to the course of the occluded vessel segment. This case provides proof of concept that wearable computers can improve operator comfort and procedure efficiency in interventional cardiology. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Effect of disodium EDTA chelation regimen on cardiovascular events in patients with previous myocardial infarction: The TACT Randomized Trial

PubMed Central

Lamas, Gervasio A.; Goertz, Christine; Boineau, Robin; Mark, Daniel B.; Rozema, Theodore; Nahin, Richard L.; Lindblad, Lauren; Lewis, Eldrin F.; Drisko, Jeanne; Lee, Kerry L.

2014-01-01

Context Chelation therapy with disodium ethylene diamine tetraacetic acid (EDTA) has been used for over 50 years to treat atherosclerosis without proof of efficacy. Objective To determine if an EDTA-based chelation regimen reduces cardiovascular events. Design and Setting Double-blind placebo-controlled 2×2 factorial multicenter randomized trial. NIH Funding was approved in August 2002. The first patient was enrolled in September 2003, and the last follow-up took place in October 2011. Median follow-up was 55 months. Participants were recruited from 134 US and Canadian clinical sites. Participants 1708 patients, age 50 or older and at least 6 weeks post myocardial infarction, with a serum creatinine <2.0 mg/dL. 289 patients (17% of total; 115 in the EDTA group and 174 in the placebo group) withdrew consent for continued follow-up over the course of the trial. Interventions Patients were randomized to receive 40 infusions of a 500 mL chelation solution (containing 3 grams of disodium EDTA, 7 grams of ascorbate, B-vitamins, electrolytes, procaine, and heparin) versus placebo, and to an oral vitamin and mineral regimen or an oral placebo. Infusions were administered weekly for 30 weeks, followed by 10 infusions 2 to 8 weeks apart. Patients received 55,222 infusions. 15% discontinued infusions for adverse events. Main outcome measure The pre-specified primary endpoint was a composite of total mortality, recurrent myocardial infarction, stroke, coronary revascularization, or hospitalization for angina. Followup for clinical events began upon randomization. This report describes the intent-to-treat comparison of EDTA chelation versus placebo. To account for multiple interim analyses, the significance threshold required at the final analysis was p=0.036. Results The qualifying myocardial infarction occurred a median of 4.6 years before enrollment. Median age was 65 years, 18% were female, 9% were nonwhite, 31% were diabetic. 83% had prior coronary revascularization, and 73% were on statins. The primary endpoint occurred in 222 (26%) of the chelation group and 261 (30%) of the placebo group (hazard ratio 0.82, 95% confidence interval 0.69–0.99, p=0.035). There was no effect on total mortality (chelation: 87 deaths (10%) placebo 93 (11%): hazard ratio (HR) 0.93, 95% confidence interval 0.70–1.25, p=0.64), but the study was not powered for this comparison. The effect of EDTA chelation on the components of the primary endpoint other than death was of similar magnitude as its overall effect (myocardial infarction HR 0.77 95% confidence interval (0.54,1.11); stroke HR 0.77 95% confidence interval (0.34, 1.76); coronary revascularization HR 0.81 95% confidence interval (0.64, 1.02); hospitalization for angina HR 0.72 95% confidence interval (0.35, 1.47). Extensive sensitivity analyses examining the effect of patient drop out and varying treatment compliance did not alter the study’s conclusions. Conclusions and Relevance In stable patients with a history of MI, the use of an intravenous chelation regimen with disodium EDTA, compared with placebo, modestly reduced the risk of a composite of adverse cardiovascular outcomes, many of which were revascularization procedures. These results provide evidence to guide further research but are not, by themselves, sufficient to support the routine use of chelation therapy for treatment of post-MI patients. PMID:23532240

Clinical indicators for recurrent cardiovascular events in acute coronary syndrome patients treated with statins under routine practice in Thailand: an observational study.

PubMed

Chinwong, Dujrudee; Patumanond, Jayanton; Chinwong, Surarong; Siriwattana, Khanchai; Gunaparn, Siriluck; Hall, John Joseph; Phrommintikul, Arintaya

2015-06-16

Acute coronary syndrome (ACS) patients are at very high cardiovascular risk and tend to have recurrent cardiovascular events. The clinical indicators for subsequent cardiovascular events are limited and need further investigation. This study aimed to explore clinical indicators that were associated with recurrent cardiovascular events following index hospitalization. The data of patients hospitalized with ACS at a tertiary care hospital in northern Thailand between January 2009 and December 2012 were retrospectively reviewed from medical charts and the electronic hospital database. The patients were classified into three groups based on the frequency of recurrent cardiovascular events (nonfatal ACS, nonfatal stroke, or all-cause death) they suffered: no recurrent events (0), single recurrent event (1), and multiple recurrent events (≥2). Ordinal logistic regression was performed to explore the clinical indicators for recurrent cardiovascular events. A total of 405 patients were included; 60 % were male; the average age was 64.9 ± 11.5 years; 40 % underwent coronary revascularization during admission. Overall, 359 (88.6 %) had no recurrent events, 36 (8.9 %) had a single recurrent event, and 10 (2.5 %) had multiple recurrent events. The significant clinical indicators associated with recurrent cardiovascular events were achieving an LDL-C goal of < 70 mg/dL (Adjusted OR = 0.43; 95 % CI = 0.27-0.69, p-value < 0.001), undergoing revascularization during admission (Adjusted OR = 0.44; 95 % CI = 0.24-0.81, p-value = 0.009), being male (Adjusted OR = 1.85; 95 % CI = 1.29-2.66, p-value = 0.001), and decrease estimated glomerular filtration rate (Adjusted OR = 2.46; 95 % CI = 2.21-2.75, p-value < 0.001). The routine clinical practice indicators assessed in ACS patients that were associated with recurrent cardiovascular events were that achieving the LDL-C goal and revascularization are protective factors, while being male and having decreased estimated glomerular filtration rate are risk factors for recurrent cardiovascular events. These clinical indicators should be used for routinely monitoring patients to prevent recurrent cardiovascular events in ACS patients.

Clinical Features and Gaps in the Management of Probable Familial Hypercholesterolemia and Cardiovascular Disease.

PubMed

Zafrir, Barak; Jubran, Ayman; Lavie, Gil; Halon, David A; Flugelman, Moshe Y; Shapira, Chen

2017-12-25

Familial hypercholesterolemia (FH) is associated with premature atherosclerotic cardiovascular disease (ASCVD). The introduction of potent therapeutic agents underlies the importance of improving clinical diagnosis and treatment gaps in FH.Methods and Results:A regional database of 1,690 adult patients with high-probability FH based on age-dependent peak-low-density lipoprotein cholesterol (LDL-C) cut-offs and exclusion of secondary causes of severe hypercholesterolemia, was examined to explore the clinical manifestations and current needs in the management of ASCVD, which was present in 248 patients (15%), of whom 83% had coronary artery disease (CAD); 19%, stroke; and 13%, peripheral artery disease. ASCVD was associated with male gender, higher peak LDL-C, lower high-density lipoprotein cholesterol (HDL-C), and traditional risk factor burden. Despite high-intensity statin (prescribed in 83% and combined with ezetimibe in 42%), attainment of LDL-C treatment goals was low, and associated with treatment intensity and drug adherence. Multivessel CAD (adjusted hazard ratios (HR), 3.05; 95% CI: 1.65-5.64), myocardial infarction, and the presence of ≥1 traditional risk factor (HR, 2.59; 95% CI: 1.42-4.71), were associated with repeat coronary revascularizations, in contrast with peak LDL-C >300 mg/dL (HR, 1.13; 95% CI: 0.66-1.91). Main manifestations of ASCVD in FH patients were premature, multivessel CAD with need for recurrent revascularization, associated with classical cardiovascular risk factors but not with peak LDL-C. In spite of intensive therapy with lipid-lowering agents, treatment gaps were significant, with low attainment of LDL-C treatment goals.

Coronary Artery Bypass Grafting for an Anomalous Left Coronary Artery from the Pulmonary Artery in a 73-Year-Old Female.

PubMed

Ishida, Narihiro; Shimabukuro, Katsuya; Ogura, Hiroki; Takemura, Hirofumi; Doi, Kiyoshi

2016-06-01

Anomalous left coronary artery from the pulmonary artery (ALCAPA) in adults is a rare congenital coronary abnormality. We report a case of ALCAPA in a 73-year-old female managed by total arterial revascularization. doi: 10.1111/jocs.12755 (J Card Surg 2016;31:380-382). © 2016 Wiley Periodicals, Inc.

Design and Methodology of the Trial to Assess Chelation Therapy (TACT)

PubMed Central

Lamas, Gervasio A.; Goertz, Christine; Boineau, Robin; Mark, Daniel B.; Rozema, Theodore; Nahin, Richard L.; Drisko, Jeanne A.; Lee, Kerry L.

2011-01-01

The Trial to Assess Chelation Therapy (TACT) is an NIH-sponsored, randomized, double blind, placebo-controlled, 2×2 factorial clinical trial testing the benefits and risks of 40 infusions of a multi-component Na2EDTA-chelation solution compared with placebo, and of an oral, high-dose multivitamin and mineral supplement. TACT has randomized and will follow 1708 patients for an average of approximately 4 years. The primary endpoint is a composite of all cause mortality, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina. A 900 patient substudy will examine quality of life outcomes. The trial is designed to have >85% power to detect a 25% relative reduction in the primary endpoint for each treatment factor. Enrollment began in September 2003 and completed in October 2010. PMID:22172430

[Angioplasty in native coronary circulation in patients treated with myocardial revascularization].

PubMed

Pimentel Filho, W A; Ascer, E; Büchler, J R; Assis, S F; Hirschfeld, R; Neves, M; Araújo, E C; Pinheiro, L F; Souza, J A; De Carvalho, V B

1992-05-01

To evaluate the clinical results after angioplasty in the native coronary vessels in patients who had undergone previous coronary artery surgery. From June 1987 to July 1990, 69 patients with previous coronary artery surgery underwent coronary angioplasty in the native arteries. Age ranged from 31 to 82 (mean = 57.5) years, fifty eight were males. Angina was present in all patients. The patients were classified in three groups according to the following criteria: group I--incomplete revascularization following bypass surgery (28 patients); group II--progression of the disease in ungrafted vessels (24 patients) and group III--progression of the disease in grafted vessels (17 patients). Primary success was achieved in 94% (65/69). Ninety-five percent in group I, 92% in group II and 94% in group III. Complications occurred in 4%; emergency surgery or deaths were not observed in this study. Forty patients (61%) repeated coronary arteriography an average follow-up of 4 months and restenosis was detected in 10 (25%); 8 of them were redilated. Survival rates was 95% and 75% of them were free of coronary events after an average follow-up of 13 months. Coronary angioplasty in these patients is a safe and effective interventional procedure in the treatment of coronary artery disease in native coronary vessels.

Design and rationale for a randomised comparison of everolimus-eluting stents and coronary artery bypass graft surgery in selected patients with left main coronary artery disease: the EXCEL trial.

PubMed

Kappetein, Arie Pieter; Serruys, Patrick W; Sabik, Joseph F; Leon, Martin B; Taggart, David P; Morice, Marie-Claude; Gersh, Bernard J; Pocock, Stuart J; Cohen, David J; Wallentin, Lars; Ben-Yehuda, Ori; van Es, Gerrit-Anne; Simonton, Charles A; Stone, Gregg W

2016-09-18

Coronary artery bypass graft (CABG) surgery is the standard of care for revascularisation of patients with left main coronary artery disease (LMCAD). Recent studies have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may provide comparable outcomes in selected patients with LMCAD without extensive CAD. We therefore designed a trial to investigate whether PCI with XIENCE cobalt-chromium everolimus-eluting stents (CoCr-EES) would result in non-inferior or superior clinical outcomes to CABG in selected patients with LMCAD. The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial is a prospective, open-label, multicentre, international study of 1,900 randomised subjects. Patients with significant LMCAD with a SYNTAX score ≤32 and local Heart Team consensus that the subject is appropriate for revascularisation by both PCI and CABG are consented and randomised 1:1 to undergo PCI using CoCr-EES or CABG. All patients undergo follow-up for five years. The primary endpoint is the three-year composite rate of death, stroke or myocardial infarction, assessed at a median follow-up of at least three years (with at least two-year follow-up in all patients), powered for sequential non-inferiority and superiority testing. The EXCEL study will define the contemporary roles of CABG and PCI using XIENCE CoCr-EES in patients with LMCAD disease with low and intermediate SYNTAX scores.

[Coronary artery disease--relevance of total coronary revascularization on the incidence of malignant arrhythmias].

PubMed

Brandt, A; Gulba, D C

2006-12-01

Myocardial ischemia induces redistribution of different ions (H(+), K(+), Na(+), Ca(++)) across the cardiomyocyte membrane, as well as the loss of intracellular ATP content. This results in changes in the electrical properties including shortening of the action potential, appearance of delayed afterpotentials, and a modified refractoriness of the cardiomyocyte. These changes may induce or support malignant cardiac arrhythmias. Supersensitivity of sympathetic denervated myocardium may further support the electrical instability of ischemic myocardium.Virtues of studies indicate that patients with coronary artery disease who develop complex arrhythmias during or after exercise bear a substantially increased risk for sudden cardiac death. Other studies report about arrhythmic stabilization and reduced mortality if patients with reversible myocardial ischemia receive complete revascularization. However, none of these studies is without methodological flaws. Due to the lack of methodologically sound studies in sufficiently large patient cohorts, the question whether complete coronary revascularisation improves the prognosis of patients with coronary artery disease and which strategy (medical, interventional, or surgical) warrants the best outcomes remains open.

Sex-related differences in coronary revascularization practices: the perspective from a Canadian queue management project.

PubMed

Naylor, C D; Levinton, C M

1993-10-01

To assess sex-related differences in coronary revascularization practices in a Canadian setting. Prospective analytic cohort study. Regional referral office in Toronto. A selected but consecutive group of 131 women and 440 men referred by cardiologists for revascularization procedures between Jan. 3, 1989, and June 30, 1991. Coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). Nurse-coordinators placed the referral with a surgeon or interventional cardiologist at one of three hospitals, who then communicated directly with the referring cardiologist. Symptom status at referral, procedures requested and performed, and time from referral to procedure. Although the women were more likely than the men to have unstable angina at the time of referral (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.38 to 3.79, p = 0.0006), more women than men (16.8% v. 12.1%) were turned down for a procedure. Significant sex-related differences in practice patterns (p < 0.001) persisted after controlling for age or for the referring cardiologists' perception of expected procedural risk. A stepwise multivariate model showed that anatomy was the main determinant of case management; sex was the only other significant variable (p = 0.016). The referring physicians requested CABG more often for men than for women (p = 0.009), and the men accepted for a procedure were much more likely to undergo CABG than the women (OR 2.40, CI 1.47 to 3.93, p = 0.0002). Although the women undergoing CABG waited shorter periods than the men (p = 0.0035), this difference was attributable to their more severe symptoms. In this selected group women had more serious symptoms before referral but were turned down for revascularization more often than men. Reduced use of CABG rather than PTCA largely accounted for the sex-related differences in revascularization. Once accepted for a procedure women had shorter waiting times, which was appropriate given their more severe symptoms.

Angina pectoris refractory for conventional therapy--is neurostimulation a possible alternative treatment?

PubMed

Hautvast, R W; DeJongste, M J; ter Horst, G J; Blanksma, P K; Lie, K I

1996-07-01

The treatment of angina pectoris as a symptom of coronary artery disease usually is focused on restoring the balance between oxygen demand and supply of the myocardium by administration of drugs interfering in heart rate, cardiac pre- and afterload, and coronary vascular tone. For nonresponders to drug therapy or for those with jeopardized myocardium, revascularization procedures such as coronary bypass surgery and percutaneous transluminal coronary angioplasty are at hand. However, the atherosclerotic process is not stopped by these therapies and, at longer terms, angina may recur. It is not always possible to revascularize all the patients who do not positively react to medical treatment. Those with angina, not responding to adequate medication and who are not suitable anymore for revascularization, are considered to suffer from refractory angina pectoris. This group of patients has a poor quality of life, for their exercise tolerance is severely afflicted. For these patients, neurostimulation has been described repeatedly as an effective and safe therapy. The mechanism of action of neurostimulation is not completely known, but recent studies suggest an anti-ischemic effect, exerted through changes in myocardial blood flow. As soon as its safety is sufficiently established, it may become a useful alternative in the treatment of refractory angina pectoris.

Invasive cardiac procedure use and mortality among South Asian and Chinese Canadians with coronary artery disease.

PubMed

Quan, Hude; Khan, Nadia; Li, Bing; Humphries, Karin H; Faris, Peter; Galbraith, P Diane; Graham, Michelle; Knudtson, Merril L; Ghali, William A

2010-01-01

Previous studies evaluated cardiac procedure use and outcome over the short term, with relatively few Asian patients included. To determine the likelihood of undergoing percutaneous coronary intervention and coronary artery bypass grafting, and survival during 10.5 years of follow-up after coronary angiography among South Asian, Chinese and other Canadian patients. Using prospective cohort study data from two large Canadian provinces, 3061 South Asian, 1473 Chinese and 77,314 other Canadian patients with angiographically proven coronary artery disease from 1995 to 2004 were assessed, and their revascularization and mortality rates during 10.5 years of follow-up were determined. Compared with other Canadian patients, South Asian and Chinese patients were slightly less likely to undergo revascularization (riskadjusted HR 0.94, 95% CI 0.90 to 0.98 for South Asian patients; and HR 0.94, 95% CI 0.88 to 1.00 for Chinese patients). However, South Asian patients underwent coronary artery bypass grafting (HR 1.00, 95% CI 0.94 to 1.07) and Chinese patients underwent percutaneous coronary intervention (HR 0.96, 95% CI 0.89 to 1.04) as frequently as other Canadian patients. Although the 30-day mortality rate was similar across the three ethnic groups, the mortality rate in the follow-up period was significantly lower for South Asian patients (HR 0.76, 95% CI 0.61 to 0.95) and marginally lower for Chinese patients (HR 0.80, 95% CI 0.60 to 1.07) compared with other Canadian patients. South Asian and Chinese patients used revascularization slightly less but had better survival outcomes than other Canadian patients. The factors underlying the better outcomes for South Asian and Chinese patients warrant further study.

[Revascularization of left anterior descending artery area using a skeletonized left internal mammary artery: a comparison between sequential and separate grafting].

PubMed

Shen, J Q; Ji, Q; Ding, W J; Xia, L M; Wei, L; Wang, C S

2018-03-13

Objective: To evaluate in-hospital and mid-term outcomes of sequential versus separate grafting of in situ skeletonized left internal mammary artery (LIMA) to the left coronary system in a single-center, propensity-matched study. Methods: After propensity score matching, 120 pairs of patients undergoing first, scheduled, isolated coronary artery bypass grafting (CABG) with in situ skeletonized LIMA grafting to the left anterior descending artery (LAD) territory were entered into a sequential group (sequential grafting of LIMA to the diagonal artery and then to the LAD) or a control group (separate grafting of LIMA to the LAD). The in-hospital and follow-up clinical outcomes and follow-up LIMA graft patency were compared. Results: The two propensity score-matched groups had similar in-hospital and follow-up clinical outcomes. The number of bypass conduits ranged from 3 to 6 (with a mean of 3.5), and 91.3%(219/240)of the included patients received off-pump CABG surgery. No significant differences were found between the two propensity score-matched groups in the in-hospital outcomes, including in-hospital death and the incidence of complications associated with CABG (prolonged ventilation, peroperative stroke, re-operation before discharge, and deep sternal wound infection). During follow-up, 9 patients (4 patients from the sequential group and 5 patients from the control group) died, and the all-cause mortality rate was 3.9%. No significant difference was found in the all-cause mortality rate between the 2 groups[3.4% (4/116) vs 4.3% (5/115), P =0.748]. During follow-up period, 99.1% (115/116) patency for the diagonal site and 98.3% (114/116) for the LAD site were determined by coronary computed tomographic angiography after sequential LIMA grafting, both of which were similar with graft patency of separate grafting of in situ skeletonized LIMA to the LAD. Conclusions: Revascularization of the left coronary system using a skeletonized LIMA resulted in excellent in-hospital and mid-term clinical outcomes and graft patency using sequential grafting.

The Use of Bilateral Internal Mammary Arteries for Coronary Revascularization in Patients with COPD: Is It a Good Idea?

PubMed

Hegazy, Yasser Yehia; Sodian, Ralf; Hassanein, Wael; Rayan, Amr; Ennker, Juergen

2016-10-31

The use of bilateral internal mammary arteries (BIMA) is limited worldwide, especially in patients with chronic obstructive pulmonary disease (COPD). Thus, we assessed the safety of the use of BIMA in COPD patients. From cohorts of 8846 patients operated on at our center for primary isolated multi-vessel coronary bypass operations between 2002 and 2012, we studied two propensity-matched groups of patients with COPD who received either single internal mammary artery and saphenous vein grafts (SIMA group: 137 patients) or exclusively BIMA (BIMA group: 137 patients). Preoperative data were similar regarding age (63.59 ± 10.62 versus 65.55 ± 9.61 years; P = .10), body mass index (BMI) (28.6 ± 4.71 versus 28.42 ± 3.86 kg/m2; P = .72), diabetes mellitus (32% versus 27%; P = .08), EuroSCORE (4.34 ± 2.23 versus 4.8 ± 2.52; P = .09) and ejection fraction (58.7 ± 13.08% versus 60.29 ± 14.13%; P = .32). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.07 ± 0.77 versus 3.06 ± 0.85; P = .90), total operation time (192.17 ± 43.06 versus 200.63 ± 39.24 min; P = .08), postoperative stroke (0.7% versus 0%; P = .29), myocardial infarction (2.92% versus 3.6%; P = .81), reintubation (2.9% versus 4.4%; P = .66), reexploration (0.7% versus 2.2%; P = .32), deep sternal wound infection (2.9% versus 3.6%; P = .81) and 30-day mortality (2.2% versus 2.9%; P = .77). However, postoperative blood loss (726.1 ± 468.35  versus 907 ± 890.58 mL; P = .03) was higher in the BIMA group. COPD patients can benefit from coronary artery revascularization with BIMA; however, postoperative blood loss can be higher using this technique.

Implementation of a Pilot ACO Payment Model and the Use of Discretionary and Non-Discretionary Cardiovascular Care

PubMed Central

Colla, Carrie. H.; Goodney, Philip P.; Lewis, Valerie A.; Nallamothu, Brahmajee K.; Gottlieb, Daniel J.; Meara, Ellen R.

2014-01-01

Background Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that ACO implementation would selectively limit utilization of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care such as non-discretionary cardiovascular imaging and procedures. Methods and Results The intervention group was composed of fee-for-service Medicare patients (n=819,779) from 10 groups participating in a Medicare pilot ACO, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934,621) from non-participating groups in the same regions. We compared utilization of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and non-discretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures, among patients of PGPD practices compared to patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% CI -0.51% to 0.85%, p=0.595) or discretionary coronary imaging (-0.19%; 95% CI -0.73% to 0.35%, p=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% CI -0.008% to 0.002%, p=0.705) and coronary revascularization (-0.02%, 95% CI -0.11% to 0.07%, p=0.06). The difference-in-difference associated with PGPD implementation was also essentially zero for non-discretionary cardiovascular imaging or procedures. Conclusions Implementation of a pilot ACO did not limit the utilization of discretionary or non-discretionary cardiovascular care in ten large health systems. PMID:25421044

Implementation of a pilot accountable care organization payment model and the use of discretionary and nondiscretionary cardiovascular care.

PubMed

Colla, Carrie H; Goodney, Philip P; Lewis, Valerie A; Nallamothu, Brahmajee K; Gottlieb, Daniel J; Meara, Ellen

2014-11-25

Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that accountable care organization implementation would selectively limit the use of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care, such as nondiscretionary cardiovascular imaging and procedures. The intervention group was composed of fee-for-service Medicare patients (n=819 779) from 10 groups participating in a Medicare pilot accountable care organization, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934 621) from nonparticipating groups in the same regions. We compared use of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and nondiscretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures among patients of PGPD practices compared with patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% confidence interval, -0.51% to 0.85%; P=0.595) or discretionary coronary imaging (-0.19%; 95% confidence interval, -0.73% to 0.35%; P=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% confidence interval, -0.008% to 0.002%; P=0.705) and coronary revascularization (-0.02%; 95% confidence interval, -0.11% to 0.07%; P=0.06). The difference-in-difference associated with PGPD implementation was also essentially 0 for nondiscretionary cardiovascular imaging or procedures. Implementation of a pilot accountable care organization did not limit the use of discretionary or nondiscretionary cardiovascular care in 10 large health systems. © 2014 American Heart Association, Inc.

EDTA chelation therapy alone and in combination with oral high-dose multivitamins and minerals for coronary disease: The factorial group results of the Trial to Assess Chelation Therapy.

PubMed

Lamas, Gervasio A; Boineau, Robin; Goertz, Christine; Mark, Daniel B; Rosenberg, Yves; Stylianou, Mario; Rozema, Theodore; Nahin, Richard L; Terry Chappell, L; Lindblad, Lauren; Lewis, Eldrin F; Drisko, Jeanne; Lee, Kerry L

2014-07-01

Disodium ethylenediaminetetraacetic acid (EDTA) reduced adverse cardiac outcomes in a factorial trial also testing oral vitamins. This report describes the intent-to-treat comparison of the 4 factorial groups overall and in patients with diabetes. This was a double-blind, placebo-controlled, 2 × 2 factorial multicenter randomized trial of 1,708 post-myocardial infarction (MI) patients ≥50 years of age and with creatinine ≤2.0 mg/dL randomized to receive 40 EDTA chelation or placebo infusions plus 6 caplets daily of a 28-component multivitamin-multimineral mixture or placebo. The primary end point was a composite of total mortality, MI, stroke, coronary revascularization, or hospitalization for angina. Median age was 65 years, 18% were female, 94% were Caucasian, 37% were diabetic, 83% had prior coronary revascularization, and 73% were on statins. Five-year Kaplan-Meier estimates for the primary end point was 31.9% in the chelation + high-dose vitamin group, 33.7% in the chelation + placebo vitamin group, 36.6% in the placebo infusion + active vitamin group, and 40.2% in the placebo infusions + placebo vitamin group. The reduction in primary end point by double active treatment compared with double placebo was significant (hazard ratio 0.74, 95% CI 0.57-0.95, P = .016). In patients with diabetes, the primary end point reduction of double active compared with double placebo was more pronounced (hazard ratio 0.49, 95% CI 0.33-0.75, P < .001). In stable post-MI patients on evidence-based medical therapy, the combination of oral high-dose vitamins and chelation therapy compared with double placebo reduced clinically important cardiovascular events to an extent that was both statistically significant and of potential clinical relevance. Copyright © 2014 The Authors. Published by Mosby, Inc. All rights reserved.

Long-term follow-up after near-infrared spectroscopy coronary imaging: Insights from the lipid cORe plaque association with CLinical events (ORACLE-NIRS) registry.

PubMed

Danek, Barbara Anna; Karatasakis, Aris; Karacsonyi, Judit; Alame, Aya; Resendes, Erica; Kalsaria, Pratik; Nguyen-Trong, Phuong-Khanh J; Rangan, Bavana V; Roesle, Michele; Abdullah, Shuaib; Banerjee, Subhash; Brilakis, Emmanouil S

Coronary lipid core plaque may be associated with the incidence of subsequent cardiovascular events. We analyzed outcomes of 239 patients who underwent near-infrared spectroscopy (NIRS) coronary imaging between 2009-2011. Multivariable Cox regression was used to identify variables independently associated with the incidence of major adverse cardiovascular events (MACE; cardiac mortality, acute coronary syndromes (ACS), stroke, and unplanned revascularization) during follow-up. Mean patient age was 64±9years, 99% were men, and 50% were diabetic, presenting with stable coronary artery disease (61%) or an acute coronary syndrome (ACS, 39%). Target vessel pre-stenting median lipid core burden index (LCBI) was 88 [interquartile range, IQR 50-130]. Median LCBI in non-target vessels was 57 [IQR 26-94]. Median follow-up was 5.3years. The 5-year MACE rate was 37.5% (cardiac mortality was 15.0%). On multivariable analysis the following variables were associated with MACE: diabetes mellitus, prior percutaneous coronary intervention performed at index angiography, and non-target vessel LCBI. Non-target vessel LCBI of 77 was determined using receiver-operating characteristic curve analysis to be a threshold for prediction of MACE in our cohort. The adjusted hazard ratio (HR) for non-target vessel LCBI ≥77 was 14.05 (95% confidence interval (CI) 2.47-133.51, p=0.002). The 5-year cumulative incidence of events in the above-threshold group was 58.0% vs. 13.1% in the below-threshold group. During long-term follow-up of patients who underwent NIRS imaging, high LCBI in a non-PCI target vessel was associated with increased incidence of MACE. Published by Elsevier Inc.

The effect of sex counselling in the sexual activity of acute myocardial infarction patients after primary percutaneous coronary intervention.

PubMed

Xu, Feng; Ming, Qiang; Hou, Lei

2015-08-01

Primary percutaneous coronary intervention has improved the outcome of acute myocardial infarction (AMI) patients. Counsel-guided sex rehabilitation efficacy in acute myocardial infarction patients receiving percutaneous coronary intervention remains unknown. The aim of the study was to study counsel-guided sex rehabilitation efficacy in AMI patients receiving percutaneous coronary intervention. 240 AMI patients who received percutaneous coronary intervention were randomly divided into a control and a counselling group. Control group patients were given written sex rehabilitation instruction before discharge, while counselling group patients were given written instruction before discharge and monthly counselling with healthcare providers. Before discharge, the first evaluation was performed for frequency of and satisfaction with sexual activity before AMI. At one year of follow-up, the time of resuming, frequency of and satisfaction with sexual activity was evaluated. The main adverse event rates were also investigated. No significant differences in age, sex, smoking status, hypertension, diabetes, PVD (peripheral vascular disease), EF (ejection fraction) or GRACE (Global Registry of Acute Coronary Events) score were found between the groups. Both groups suffered reduced frequency of and satisfaction with sexual activity after AMI as compared with prior to presentation with AMI. However, compared with controls, the counselling group had higher scores for frequency of and satisfaction with sexual activity after AMI. The time to resume sexual activity after AMI in the counselling group was significantly shorter than was found for the control group.There were no significant differences between the groups for recurrent AMI, non-fatal stroke, admitting the patient for angina, all-cause death or adverse events. Intermittent discussions between healthcare providers and AMI patients improved resumption of sexual activity. Encouraging patients who received complete coronary revascularization to resume sexual activity shortly after AMI was safe.

Excessive Daytime Sleepiness is Associated with Longer Culprit Lesion and Adverse Outcomes in Patients with Coronary Artery Disease

PubMed Central

Lee, Chi-Hang; Ng, Wai-Yee; Hau, William; Ho, Hee-Hwa; Tai, Bee-Choo; Chan, Mark Y.; Richards, A. Mark; Tan, Huay-Cheem

2013-01-01

Study Objectives: We assessed whether excessive daytime sleepiness was associated with coronary plaque phenotype and subsequent adverse cardiovascular events. Methods: Prospective cohort study. Intravascular ultrasound (IVUS) examination of the culprit coronary stenosis was performed. The Epworth Sleepiness Scale (ESS) questionnaire was administered, and the patients were divided into 2 groups—(1) sleepier and (2) less sleepy—based on the ESS score. Adverse cardiovascular outcomes were defined as cardiac death, myocardial infarction, stroke, unplanned revascularization, or heart failure admission. Results: One hundred seventeen patients undergoing urgent or non-urgent coronary angiography were recruited. Compared with the less sleepy group (ESS ≤ 10, n = 87), the sleepier group (ESS > 10, n = 30) had higher serum levels of total cholesterol and of low-density-lipoprotein cholesterols (p < 0.05 for both). The IVUS examinations indicated coronary stenoses were longer in the sleepier group than in the less sleepy group (p = 0.011). The cumulative incidence of adverse cardiovascular events at 16-month follow-up was higher in the sleepier than the less sleepy group (12.5% versus 6.9%, p = 0.03). Cox regression analysis adjusting for age and smoking showed increased hazard of adverse cardiovascular events in sleepier group as compared to less sleepy group (HR = 3.44, 95% CI 1.01-11.72). Conclusion: In patients presenting with coronary artery disease, excessive daytime sleepiness based on ESS > 10 was associated with longer culprit lesions and future adverse cardiovascular events. Citation: Lee CH; Ng WY; Hau W; Ho HH; Tai BC; Chan MY; Richards AM; Tan HC. Excessive daytime sleepiness is associated with longer culprit lesion and adverse outcomes in patients with coronary artery disease. J Clin Sleep Med 2013;9(12):1267-1272. PMID:24340288

[The value of SYNTAX score in predicting outcome patients undergoing percutaneous coronary intervention].

PubMed

Gao, Yue-chun; Yu, Xian-peng; He, Ji-qiang; Chen, Fang

2012-01-01

To assess the value of SYNTAX score to predict major adverse cardiac and cerebrovascular events (MACCE) among patients with three-vessel or left-main coronary artery disease undergoing percutaneous coronary intervention. 190 patients with three-vessel or left-main coronary artery disease undergoing percutaneous coronary intervention (PCI) with Cypher select drug-eluting stent were enrolled. SYNTAX score and clinical SYNTAX score were retrospectively calculated. Our clinical Endpoint focused on MACCE, a composite of death, nonfatal myocardial infarction (MI), stroke and repeat revascularization. The value of SYNTAX score and clinical SYNTAX score to predict MACCE were studied respectively. 29 patients were observed to suffer from MACCE, accounting 18.5% of the overall 190 patients. MACCE rates of low (≤ 20.5), intermediate (21.0 - 31.0), and high (≥ 31.5) tertiles according to SYNTAX score were 9.1%, 16.2% and 30.9% respectively. Both univariate and multivariate analysis showed that SYNTAX score was the independent predictor of MACCE. MACCE rates of low (≤ 19.5), intermediate (19.6 - 29.1), and high (≥ 29.2) tertiles according to clinical SYNTAX score were 14.9%, 9.8% and 30.6% respectively. Both univariate and multivariate analysis showed that clinical SYNTAX score was the independent predictor of MACCE. ROC analysis showed both SYNTAX score (AUC = 0.667, P = 0.004) and clinical SYNTAX score (AUC = 0.636, P = 0.020) had predictive value of MACCE. Clinical SYNTAX score failed to show better predictive ability than the SYNTAX score. Both SYNTAX score and clinical SYNTAX score could be independent risk predictors for MACCE among patients with three-vessel or left-main coronary artery disease undergoing percutaneous coronary intervention. Clinical SYNTAX score failed to show better predictive ability than the SYNTAX score in this group of patients.

Emergency Cardiac Surgery in Patients with Acute Coronary Syndromes: A Review of the Evidence and Perioperative Implications of Medical and Mechanical Therapeutics

PubMed Central

Brown, Charles; Joshi, Brijen; Faraday, Nauder; Shah, Ashish; Yuh, David; Rade, Jeffrey J.; Hogue, Charles W.

2011-01-01

Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly due to subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarcation. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly rFVIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk-stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes needs more stringent analysis. PMID:21385977

Outcomes in Elderly Patients With Severely Calcified Coronary Lesions Undergoing Orbital Atherectomy.

PubMed

Lee, Michael S; Shlofmitz, Evan; Lluri, Gentian; Shlofmitz, Richard A

2017-04-01

We evaluated the clinical outcomes of elderly patients who underwent orbital atherectomy for the treatment of severe coronary artery calcification (CAC) prior to stenting. Percutaneous coronary intervention (PCI) of severe CAC is associated with worse clinical outcomes including death, myocardial infarction (MI), and target vessel revascularization (TVR). The elderly represents a high-risk group of patients, often have more comorbid conditions, and have worse outcomes after PCI compared to younger patients. Clinical trials and a large multicenter registry have demonstrated the safety and efficacy of orbital atherectomy for the treatment of severe CAC. Clinical outcomes of elderly patients who undergo orbital atherectomy are unknown. Of the 458 patients, 229 were ≥75 years old (elderly) and 229 were <75 years old (younger). The primary endpoint was rate of 30-day major adverse cardiac and cerebrovascular events (MACCE), comprised of cardiac death, MI, TVR, and stroke. The primary endpoint was similar in the elderly and younger groups (2.2% vs. 2.2%, P = 1), as were the individual endpoints of death (2.2% vs. 0.4%, P = 0.1), MI (0.9% vs. 1.3%, P = 0.65), TVR (0% vs. 0%, P = 1), and stroke (0% vs. 0.4%, P = 0.32). The rates of angiographic complications and stent thrombosis were similarly low in both groups. The elderly represented a sizeable number of patients who underwent orbital atherectomy. It is a safe and effective treatment strategy for elderly patients with severe CAC as the clinical outcomes were similar to their younger counterparts. A randomized trial should further clarify the role of orbital atherectomy in these patients. © 2017, Wiley Periodicals, Inc.

Association of adiponectin with future cardiovascular events in patients after acute myocardial infarction.

PubMed

Huang, Shao-Sung; Huang, Po-Hsun; Chen, Ying-Hwa; Chiang, Kuang-Hsing; Chen, Jaw-Wen; Lin, Shing-Jong

2010-03-31

There is uncertainty about the association between circulating concentrations of adiponectin and coronary heart disease risk, particularly in patients after acute myocardial infarction (AMI). The goal of this study was to determine whether plasma adiponectin levels could predict future cardiovascular events in patients after AMI, and to elucidate the role of adiponectin in cardioprotection. A total of 102 patients with AMI were enrolled. Plasma adiponectin levels were examined from blood samples collected 18 months after AMI. All subjects were followed-up for 43+/-12 months. The primary endpoint was the combined occurrence of major adverse cardiovascular events (MACE), including rehospitalization due to unstable angina, nonfatal MI, revascularization with percutaneous coronary intervention or coronary artery bypass grafting, ischemic stroke, and cardiovascular death. A total of 30 MACE occurred, including one case of cardiovascular death, five cases of nonfatal MI, and nine cases of ischemic stroke. Patients with MACE had lower plasma adiponectin levels (p=0.013). In addition, adiponectin was positively associated with changes in left ventricular ejection fraction (p=0.005). All patients were divided into a high-adiponectin group (>or=6.46 microg/mL) and a low-adiponectin group (<6.46 microg/mL). The incidence of MACE was significantly reduced in the high-adiponectin group (p=0.021). In multivariate Cox regression analysis that included adiponectin, classical risk factors, and medications, adiponectin was an independent predictor of MACE in patients after AMI (HR, 0.821; 95% CI, 0.691 to 0.974; p=0.024). The results indicate a potential association between plasma adiponectin levels and future cardiovascular events in patients after AMI. Moreover, plasma adiponectin concentrations appear to play a pivotal role in atherothrombosis and cardioprotection.

The Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRA*CER) trial: study design and rationale.

PubMed

2009-09-01

The protease-activated receptor 1 (PAR-1), the main platelet receptor for thrombin, represents a novel target for treatment of arterial thrombosis, and SCH 530348 is an orally active, selective, competitive PAR-1 antagonist. We designed TRA*CER to evaluate the efficacy and safety of SCH 530348 compared with placebo in addition to standard of care in patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) and high-risk features. TRA*CER is a prospective, randomized, double-blind, multicenter, phase III trial with an original estimated sample size of 10,000 subjects. Our primary objective is to demonstrate that SCH 530348 in addition to standard of care will reduce the incidence of the composite of cardiovascular death, myocardial infarction (MI), stroke, recurrent ischemia with rehospitalization, and urgent coronary revascularization compared with standard of care alone. Our key secondary objective is to determine whether SCH 530348 will reduce the composite of cardiovascular death, MI, or stroke compared with standard of care alone. Secondary objectives related to safety are the composite of moderate and severe GUSTO bleeding and clinically significant TIMI bleeding. The trial will continue until a predetermined minimum number of centrally adjudicated primary and key secondary end point events have occurred and all subjects have participated in the study for at least 1 year. The TRA*CER trial is part of the large phase III SCH 530348 development program that includes a concomitant evaluation in secondary prevention. TRA*CER will define efficacy and safety of the novel platelet PAR-1 inhibitor SCH 530348 in the treatment of high-risk patients with NSTE ACS in the setting of current treatment strategies.

Outcomes of percutaneous coronary intervention in intermediate coronary artery disease: fractional flow reserve-guided versus intravascular ultrasound-guided.

PubMed

Nam, Chang-Wook; Yoon, Hyuck-Jun; Cho, Yun-Kyeong; Park, Hyoung-Seob; Kim, Hyungseop; Hur, Seung-Ho; Kim, Yoon-Nyun; Chung, In-Sung; Koo, Bon-Kwon; Tahk, Seung-Jae; Fearon, William F; Kim, Kwon-Bae

2010-08-01

This study sought to evaluate the long-term clinical outcomes of a fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) strategy compared with intravascular ultrasound (IVUS)-guided PCI for intermediate coronary lesions. Both FFR- and IVUS-guided PCI strategies have been reported to be safe and effective in intermediate coronary lesions. The study included 167 consecutive patients, with intermediate coronary lesions evaluated by FFR or IVUS (FFR-guided, 83 lesions vs. IVUS-guided, 94 lesions). Cutoff value of FFR in FFR-guided PCI was 0.80, whereas that for minimal lumen cross sectional area in IVUS-guided PCI was 4.0 mm(2). The primary outcome was defined as a composite of major adverse cardiac events including death, myocardial infarction, and ischemia-driven target vessel revascularization at 1 year after the index procedure. Baseline percent diameter stenosis and lesion length were similar in both groups (51 +/- 8% and 24 +/- 12 mm in the FFR group vs. 52 +/- 8% and 24 +/- 13 mm in the IVUS group, respectively). However, the IVUS-guided group underwent revascularization therapy significantly more often (91.5% vs. 33.7%, p < 0.001). No significant difference was found in major adverse cardiac event rates between the 2 groups (3.6% in FFR-guided PCI vs. 3.2% in IVUS-guided PCI). Independent predictors for performing intervention were guiding device: FFR versus IVUS (relative risk [RR]: 0.02); left anterior descending coronary artery versus non-left anterior descending coronary artery disease (RR: 5.60); and multi- versus single-vessel disease (RR: 3.28). Both FFR- and IVUS-guided PCI strategy for intermediate coronary artery disease were associated with favorable outcomes. The FFR-guided PCI reduces the need for revascularization of many of these lesions. Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Screening asymptomatic patients with diabetes for unknown coronary artery disease: does it reduce risk? An open-label randomized trial comparing a strategy based on exercise testing aimed at revascularization with management based on pharmacological/behavioural treatment of traditional risk factors. DADDY-D Trial (Does coronary Atherosclerosis Deserve to be Diagnosed and treated early in Diabetics?).

PubMed

Turrini, Fabrizio; Messora, Roberto; Giovanardi, Paolo; Tondi, Stefano; Magnavacchi, Paolo; Cavani, Rita; Tosoni, Giandomenico; Cappelli, Carlo; Pellegrini, Elisa; Romano, Stefania; Baldini, Augusto; Zennaro, Romeo Giulietto; Bondi, Marco

2009-12-23

Coronary artery disease is the leading cause of morbidity and mortality in patients with type 2 diabetes. Screening for asymptomatic coronary artery disease with treatment by means of revascularization seems to be an appealing option for prevention. The utility of such a strategy has never been challenged in a randomized trial. In the present study a cohort of diabetic patients without any symptoms and without known coronary artery disease will be screened at two diabetes outpatients services. Those with intermediate or high risk (equal or greater than 10% according to the Italian risk chart) will be asked to participate and enrolled. They will be seen and followed in order to provide the best adherence to medical therapy. Half of the patients will be randomized to undergo an exercise tolerance testing while the other group will continue to be regularly seen at diabetes outpatients services. Best medical/behavioral therapy will be offered to both groups. Those patients with a positive exercise tolerance testing will be studied by coronary angiography and treated according to the severity of coronary lesions by percutaneous stenting or surgery.The objective of the study is to evaluate the efficacy of the screening strategy aimed at revascularization. A cost-effectiveness analysis will be performed at the end of the follow up. The study will provide useful information about prevention and treatment of diabetic patients at high risk of coronary events. It will be made clearer if detection of silent coronary artery disease has to be recommended and followed by treatment. Given the simplicity of the study protocol, it will be easily transferable to the real world. (ClinicalTrials.gov): NCT00547872.

Screening asymptomatic patients with diabetes for unknown coronary artery disease: Does it reduce risk? An open-label randomized trial comparing a strategy based on exercise testing aimed at revascularization with management based on pharmacological/behavioural treatment of traditional risk factors. DADDY-D Trial (Does coronary Atherosclerosis Deserve to be Diagnosed and treated early in Diabetics?)

PubMed Central

2009-01-01

Background Coronary artery disease is the leading cause of morbidity and mortality in patients with type 2 diabetes. Screening for asymptomatic coronary artery disease with treatment by means of revascularization seems to be an appealing option for prevention. The utility of such a strategy has never been challenged in a randomized trial. Methods/Design In the present study a cohort of diabetic patients without any symptoms and without known coronary artery disease will be screened at two diabetes outpatients services. Those with intermediate or high risk (equal or greater than 10% according to the Italian risk chart) will be asked to participate and enrolled. They will be seen and followed in order to provide the best adherence to medical therapy. Half of the patients will be randomized to undergo an exercise tolerance testing while the other group will continue to be regularly seen at diabetes outpatients services. Best medical/behavioral therapy will be offered to both groups. Those patients with a positive exercise tolerance testing will be studied by coronary angiography and treated according to the severity of coronary lesions by percutaneous stenting or surgery. The objective of the study is to evaluate the efficacy of the screening strategy aimed at revascularization. A cost-effectiveness analysis will be performed at the end of the follow up. Discussion The study will provide useful information about prevention and treatment of diabetic patients at high risk of coronary events. It will be made clearer if detection of silent coronary artery disease has to be recommended and followed by treatment. Given the simplicity of the study protocol, it will be easily transferable to the real world. Trial registration (ClinicalTrials.gov): NCT00547872 PMID:20030830

A Numerical Multiscale Framework for Modeling Patient-Specific Coronary Artery Bypass Surgeries

NASA Astrophysics Data System (ADS)

Ramachandra, Abhay B.; Kahn, Andrew; Marsden, Alison

2014-11-01

Coronary artery bypass graft (CABG) surgery is performed to revascularize diseased coronary arteries, using arterial, venous or synthetic grafts. Vein grafts, used in more than 70% of procedures, have failure rates as high as 50% in less than 10 years. Hemodynamics is known to play a key role in the mechano-biological response of vein grafts, but current non-invasive imaging techniques cannot fully characterize the hemodynamic and biomechanical environment. We numerically compute hemodynamics and wall mechanics in patient-specific 3D CABG geometries using stabilized finite element methods. The 3D patient-specific domain is coupled to a 0D lumped parameter circulatory model and parameters are tuned to match patient-specific blood pressures, stroke volumes, heart rates and heuristic flow-split values. We quantify differences in hemodynamics between arterial and venous grafts and discuss possible correlations to graft failure. Extension to a deformable wall approximation will also be discussed. The quantification of wall mechanics and hemodynamics is a necessary step towards coupling continuum models in solid and fluid mechanics with the cellular and sub-cellular responses of grafts, which in turn, should lead to a more accurate prediction of the long term outcome of CABG surgeries, including predictions of growth and remodeling.

Experimental and clinical studies on transmyocardial laser revascularzation (TMLR)

NASA Astrophysics Data System (ADS)

Okada, Masayoshi

2005-07-01

The number of patients with coronary artery disease has been increasing in Japan and several kinds of treatments have been performed to reduce their cardiovascular diseases. In patients with small branches, or diffuse stenotic lesions of the coronary arteries, on whom coronary artery bypass grafting(CABG) and percutaneous coronary intervention (PCI) cannot be carried out, it has been hemodynamically demonstrated possible to supply arterial blood from the left ventricular cavity to the ischemic myocardium through laser channels. On the basis of excellent experimental studies using mongrel dogs, newly created laser channels 0.2 mm in diameter have been confirmed to be histologically patent even 3 years after transmyocardial revascularization(TMLR). Thus, this method could be applied as an alternative procedure of transmyocardial revascularization. First clinical procedure of TMLR alone was performed on 55 year-old male patient with severe angina pectoris who had undergone pericardiectomy 7 years ago. He had no candidate for percutaneous coronary intervention, or coronary artery bypass grafting, because his left venticle had severe adhesion to the left lung. Therefore, this method was finally carried out. He is getting well after this surgical intervention. This procedure should be recommended for the patient with end-stage coronary artery disease.

Relationship between systolic and diastolic function with improvements in forward stroke volume following reduction in mitral regurgitation

NASA Technical Reports Server (NTRS)

Firstenberg, M. S.; Greenberg, N. L.; Smedira, N. G.; McCarthy, P. M.; Garcia, M. J.; Thomas, J. D.

2001-01-01

Efforts to improve mitral regurgitation (MR) are often performed in conjunction with coronary revascularization. However, the independent effects of a reduced MR area (MRa) are difficult to quantify. Using a previously developed cardiovascular model, ventricular contractility (elastance 1-8 mmHg/ml) and relaxation (tau: 40-150 msec) were independently adjusted for four grades of MR orifice areas (0.0 to 0.8 cm2). Improvements in forward stroke volume (fSV) were determined for the permutations of reduced MRa. For all conditions, LV end-diastolic pressure and volumes ranged from 7.3-24.2 mmHg and 64.8-174.3 ml, respectively. Overall, fSV ranged from 36.0-89.4 (mean: 64.2 +/- 12.8) ml, improved between 6.4 and 35.3% (mean: 15.6 +/- 8.1%), and was best predicted by (r=0.97, p<0.01) %delta(fSV)[correction of fVS]=34[MRa initial] - 46[MRa final] -0.5[elastance]. Reduced MRa, independent of relaxation and minimally influence by contractility, yield improved fSVs.

5A.01: CORONARY ATHEROSCLEROSIS AND ADVERSE OUTCOME IN HYPERTENSIVE PATIENTS WITH RECENT-ONSET ATRIAL FIBRILLATION AND TROPONIN RISE.

PubMed

Conti, A; Angeli, E; Trausi, F; Grifoni, C; Lazzeretti, D; Bianchi, S; Catarzi, S; Covelli, A; Perrotta, M E; Lencioni, A M; Pisani, N; Bertolini, L

2015-06-01

Atrial fibrillation (AF), the most common cardiac-arrhythmia in critical-care, has reached a high prevalence in hypertensive patients. Prevention of systemic-embolism is mandatory; unfortunately, evidence to support the treatment of comorbidities as coronary artery disease (CAD) that contribute to excess mortality is lacking, and the mechanism underlying the troponin-rise during AF without acute coronary syndrome (ACS) is unclear. This study investigates the relationship between CAD, stroke and outcomes in patients with troponin-rise and AF. Patients with a recent-onset AF and without severe comorbidities were enrolled. Baseline characteristics in those with troponin-rise versus those without were adjusted with propensity-score-matching for possible confounders. SPSS-software allowed estimation of the propensity-score using logistic-regression and specifying nearest-neighbor matching in prior-stroke, heart-rate, hypertension, TIMI-risk-score, GRACE-score, CHA2DS2Vasc-score. Patients with a troponin-rise or cardiovascular event (CVE) were considered for angiography. The primary endpoint was the composite of ACS, revascularization (with critical CAD>/ = 70%) and cardiac-death at the follow-up; the secondary endpoint was stroke. Out of 6203 AF patients without severe comorbidities, 3541 with recent-onset AF completed the study; 202(6%) showed a troponin-rise, 91(3%) a CVE. After matching no difference existed in baseline characteristics. On multivariate analysis, in the entire cohort, troponin-rise, know-CAD and hypertension were predictors of the endpoint, whereas only troponin-rise (Odd Ratio, OR: 10, Confidence Interval 95%, CI: 4-22, p < 0.001) and TIMI-score > 2 (OR 4, CI 2-9, p < 0.001) in the matching cohort, suggesting the role of CAD in poor outcomes. Patients with or without troponin-rise achieved the endpoint in 38(19%) and 43(1%), respectively (p < 0.001). Stroke occurred in 4(2%) and 20 (1%), respectively (p = 0.018). Critical CAD account for 23(12%) and 15(1%), respectively (p < 0,001). In the matching cohort, only stroke did not reach the statistical significance. Interestingly, the best cut/off troponin level for decision-making was 0.30 ng/L which, on Receiver Operator Curve analysis, was associated with 68% of sensitivity and 60% specificity; the value > 0.50 ng/L with 55% and 75%, respectively. Patients with a recent-onset AF and troponin-rise showed a high prevalence of CVE but not stroke, thus CAD might have a role in poor outcomes.

Consideration of a new definition of clinically relevant myocardial infarction after coronary revascularization: an expert consensus document from the Society for Cardiovascular Angiography and Interventions (SCAI).

PubMed

Moussa, Issam D; Klein, Lloyd W; Shah, Binita; Mehran, Roxana; Mack, Michael J; Brilakis, Emmanouil S; Reilly, John P; Zoghbi, Gilbert; Holper, Elizabeth; Stone, Gregg W

2013-10-22

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5), which are of uncertain prognostic importance. In addition, for both the MI types, cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than using an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a "clinically relevant MI." The present document introduces a new definition for "clinically relevant MI" after coronary revascularization (PCI or CABG), which is applicable for use in clinical trials, patient care, and quality outcomes assessment. Copyright © 2013. Published by Elsevier Inc.

The Contemporary Use of Angiography and Revascularization Among Patients With Non-ST-Segment Elevation Myocardial Infarction in the United States Compared With South Korea.

PubMed

Kang, Hyun-Jae; Simon, Dajuanicia; Wang, Tracy Y; Alexander, Karen P; Jeong, Myung Ho; Kim, Hyo-Soo; Bates, Eric R; Henry, Timothy D; Peterson, Eric D; Roe, Matthew T

2015-12-01

Practice guidelines recommend an early invasive strategy for high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients, but international differences in the use of invasive strategies are unknown. Profiling NSTEMI patient management in the United States (U.S.) and South Korea could provide insight into how patients are triaged for an early invasive strategy in different health care environments and geographical regions. We evaluated the use of angiography and revascularization for NSTEMI patients treated at revascularization-capable hospitals (2007-2010) in both the ACTION Registry-GWTG (U.S.: n = 133,835; 433 hospitals) and KAMIR/KorMI Registry (South Korea: n = 7,901; 72 hospitals). Compared with South Korean patients, U.S. NSTEMI patients more commonly had established cardiovascular risk factors, disease, and prior cardiovascular events and procedures. From 2007-2010, the use of angiography for NSTEMI patients rose steadily in both countries, but the use of revascularization only rose in South Korea. Patients from South Korea more commonly underwent angiography and revascularization. Percutaneous coronary intervention was the most common type of revascularization in both countries, but coronary artery bypass grafting was less common in South Korea. The use of both angiography and revascularization was incrementally lower with a higher predicted mortality risk for patients from both countries, but greater differences between low- and high-risk patients occurred in the U.S. The profile, characteristics, and use of angiography and revascularization for NSTEMI patients in the U.S. vs South Korea differed substantially from 2007-2010, underscoring the heterogeneity of NSTEMI patients and treatment selection among different countries. © 2015 Wiley Periodicals, Inc.

Prospective, Multi-Centre, Single-Arm Study of Mechanical Thrombectomy using Solitaire FR in Acute Ischemic Stroke-STAR

PubMed Central

Pereira, Vitor M; Gralla, Jan; Davalos, Antoni; Bonafé, Alain; Castaño, Carlos; Chapot, Rene; Liebeskind, David S; Nogueira, Raul G; Arnold, Marcel; Sztajzel, Roman; Liebig, Thomas; Goyal, Mayank; Besselmann, Michael; Moreno, Alfredo; Schroth, Gerhard

2013-01-01

Background and Purpose Mechanical thrombectomy using stent retriever devices have been advocated to increase revascularization in intracranial vessel occlusion. We present the results of a large prospective study on the use of the Solitaire FR in patients with acute ischemic stroke. Methods STAR was an international, multicenter, prospective, single-arm study of Solitaire FR thrombectomy in patients with large vessel anterior circulation strokes treated within 8 hours of symptom onset. Strict criteria for site selection were applied. The primary endpoint was the revascularization rate (3TICI 2b) of the occluded vessel as determined by an independent core lab. The secondary endpoint was the rate of good functional outcome (defined as 90-day modified Rankin scale (mRS) 0–2). Results A total of 202 patients were enrolled across 14 comprehensive stroke centers in Europe, Canada and Australia. The median age was 72 years, 60% were female patients. The median National Institute of Health Stroke Scale (NIHSS) was 17. Most proximal intracranial occlusion was the internal carotid artery in 18%, the middle cerebral artery in 82%. Successful revascularization was achieved in 79.2% of patients. Device and/or procedure related severe adverse events were found in 7.4%. Favorable neurological outcome was found in 57.9%. The mortality rate was 6.9%. Any intracranial hemorrhagic transformation was found in 18.8% of patients, 1.5% were symptomatic. Conclusions In this single arm study, treatment with the Solitaire™ FR device in intracranial anterior circulation occlusions results in high rates of revascularization, low risk of clinically relevant procedural complications, and good clinical outcomes in combination with low mortality at 90 days. Clinical Trial Registration This study is registered with ClinicalTrials.gov, number NCT01327989. PMID:23908066

The role of niacin in raising high-density lipoprotein cholesterol to reduce cardiovascular events in patients with atherosclerotic cardiovascular disease and optimally treated low-density lipoprotein cholesterol: baseline characteristics of study participants. The Atherothrombosis Intervention in Metabolic syndrome with low HDL/high triglycerides: impact on Global Health outcomes (AIM-HIGH) trial.

PubMed

2011-03-01

The study aims to report the baseline characteristics of the fully randomized AIM-HIGH study population. Residual risk persists despite aggressive low-density lipoprotein cholesterol (LDL-C) reduction in patients with atherosclerotic cardiovascular (CV) disease, many of whom have atherogenic dyslipidemia (low levels of high-density lipoprotein cholesterol (HDL-C), elevated triglycerides, and small dense LDL particles). All study participants had established CV disease and atherogenic dyslipidemia. Participants received simvastatin (or simvastatin plus ezetimibe) at a dose sufficient to maintain LDL-C at 40 - 80 mg/dL (1.03-2.07 mmol/L) and were randomized to receive extended-release niacin or matching placebo. The primary end point is time to the first occurrence of coronary heart disease death, nonfatal myocardial infarction, ischemic stroke, hospitalization for acute coronary syndrome or symptom-driven coronary or cerebral revascularization with average follow-up of 4.1 years. Between 2006 and 2010, 8,162 individuals signed consent to be screened, 4,275 began study drug run-in, and 3,414 were randomized to treatment. Mean age at entry was 64 ± 9 years, 85% were men, and 92% were white. As expected, risk factors were prevalent with 34% having diabetes; 71%, hypertension; and 81%, metabolic syndrome. Most participants had coronary artery disease (92%), whereas 11% had peripheral arterial disease; and 12%, cerebrovascular disease. Previous coronary revascularization occurred in 82%, and 54% reported a prior myocardial infarction. Among participants on a statin at entry (94%), mean baseline LDL-C was 71 mg/dL (1.84 mmol/L); mean HDL-C, 34.9 mg/dL (0.90 mmol/L); and median triglycerides, 161 mg/dL (1.82 mmol/L). AIM-HIGH enrolled a high-risk group of patients with established atherosclerotic CV disease and atherogenic dyslipidemia. This study should determine whether there is incremental clinical benefit of niacin in reducing cardiovascular events in patients who have attained optimal on-treatment levels of LDL-C with a statin. Copyright © 2011 Mosby, Inc. All rights reserved.

Contemporary antithrombotic strategies in patients with acute coronary syndromes managed without revascularization: insights from the EYESHOT study.

PubMed

De Luca, Leonardo; Leonardi, Sergio; Smecca, Ignazio Maria; Formigli, Dario; Lucci, Donata; Gonzini, Lucio; Tuccillo, Bernardino; Olivari, Zoran; Gulizia, Michele Massimo; Bovenzi, Francesco Maria; De Servi, Stefano

2015-07-01

Patients with acute coronary syndromes (ACSs) who are managed without coronary revascularization represent a mixed and understudied population that seems to receive suboptimal pharmacological treatment. We assessed patterns of antithrombotic therapies employed during the hospitalization and in-hospital clinical events of medically managed patients with ACS enrolled in the prospective, multicentre, nationwide EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units) registry. Among the 2585 consecutive ACS patients enrolled in EYESHOT, 783 (30.3%) did not receive any revascularization during hospital admission. Of these, 478 (61.0%) underwent coronary angiography (CA), whereas 305 (39.0%) did not. The median GRACE and CRUSADE risk scores were significantly higher among patients who did not undergo CA compared with those who did (180 vs. 145, P < 0.0001 and 50 vs. 33, P < 0.0001, respectively). Antithrombotic therapies employed during hospitalization significantly differ between patients who received CA and those who did not with unfractioned heparin and novel P2Y12 inhibitors more frequently used in the first group, and low-molecular-weight heparins and clopidogrel in the latter group. During the index hospitalization, patients who did not receive CA presented a higher incidence of ischaemic cerebrovascular events and of mortality compared with those who underwent CA (1.6 vs. 0.2%, P = 0.04 and 7.9 vs. 2.7%, P = 0.0009, respectively). Almost one-third of ACS patients are managed without revascularization during the index hospitalization. In this population, a lower use of recommended antiplatelet therapy and worse clinical outcome were observed in those who did not undergo CA when compared with those who did. Unique identifier: NCT02015624, http://www.clinicaltrials.gov. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Six-month outcome in patients with myocardial infarction initially admitted to tertiary and nontertiary hospitals. RESCATE Investigators. Recursos Empleados en el Síndrome Coronario Agudo y Tiempos de Espera.

PubMed

Marrugat, J; Sanz, G; Masiá, R; Valle, V; Molina, L; Cardona, M; Sala, J; Serés, L; Szescielinski, L; Albert, X; Lupón, J; Alonso, J

1997-11-01

The aim of the present study was to ascertain whether the degree of accessibility to coronary angiography and revascularization results in differing usages or outcomes, or both, in the setting of a high coverage national health system. The selective use of coronary angiography and revascularization procedures in the management of acute myocardial infarction (MI) remains controversial. A cohort of 1,460 consecutive patients with a first MI admitted to four referral teaching hospitals (one with tertiary facilities) were followed up for 6 months after admission. Only patients initially admitted to each of the study hospitals were retained for analysis in the original hospital's cohort. End points were 6-month mortality and readmission for reinfarction, unstable angina, heart failure or severe ventricular arrhythmia. Patients admitted to the tertiary hospital were more likely to undergo coronary angiography (adjusted relative risk 4.22, 95% confidence interval [CI] 3.37 to 5.45) than those admitted to the nontertiary sites (use rate: 22.1% for nontertiary care, 55.5% for tertiary care). Revascularization procedures were performed in 21.2% of patients in the tertiary hospital and in 8.3% in the nontertiary hospitals (p < 0.0001). Median delay for emergency coronary angiography was shorter in the tertiary hospital (within 1 vs. 2 days, p < 0.0001). Six-month mortality or readmission rates were similar (23.7% and 24.7% for tertiary and nontertiary care, respectively). After adjustment for comorbidity and disease severity, the relative risk of death or readmission for the tertiary hospital was 1.03 (95% CI 0.69 to 1.53) times that of the nontertiary hospitals. Selective use of coronary angiography and revascularization procedures may be as effective as less restricted use in the management of acute MI.

Sodium bicarbonate does not prevent postoperative acute kidney injury after off-pump coronary revascularization: a double-blinded randomized controlled trial.

PubMed

Soh, S; Song, J W; Shim, J K; Kim, J H; Kwak, Y L

2016-10-01

Acute kidney injury (AKI) is a common morbidity after off-pump coronary revascularization. We investigated whether perioperative administration of sodium bicarbonate, which might reduce renal injury by alleviating oxidative stress in renal tubules, prevents postoperative AKI in off-pump coronary revascularization patients having renal risk factors. Patients (n=162) having at least one of the following AKI risk factors were enrolled: (i) age >70 yr; (ii) diabetes mellitus; (iii) chronic renal disease; (iv) congestive heart failure or left ventricular ejection fraction <35%; and (v) reoperation or emergency. Patients were evenly randomized to receive either sodium bicarbonate (0.5 mmol kg -1 for 1 h upon induction of anaesthesia followed by 0.15 mmol kg -1 h -1 for 23 h) or 0.9% saline. Acute kidney injury within 48 h after surgery was assessed using the Acute Kidney Injury Network criteria. The incidences of AKI were 21 and 26% in the bicarbonate and control groups, respectively (P=0.458). Serially measured serum creatinine concentrations and perioperative fluid balance were also comparable between the groups. The length of postoperative hospitalization and incidence of morbidity end points were similar between the groups, whereas significantly more patients in the bicarbonate group required prolonged mechanical ventilation (>24 h) relative to the control group (20 vs 6, P=0.003). Perioperative sodium bicarbonate administration did not decrease the incidence of AKI after off-pump coronary revascularization in high-risk patients and might even be associated with a need for prolonged ventilatory care. NCT01840241. © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Mortality of Department of Veterans Affairs patients undergoing coronary revascularization in private sector hospitals.

PubMed

Vaughan-Sarrazin, Mary S; Wakefield, Bonnie; Rosenthal, Gary E

2007-10-01

A limitation of studies comparing outcomes of Veterans Affairs (VA) and private sector hospitals is uncertainty about the methods of accounting for risk factors in VA populations. This study estimates whether use of VA services is a marker for increased risk by comparing outcomes of VA users and other patients undergoing coronary revascularization in private sector hospitals. Males 67 years and older undergoing coronary artery bypass graft (CABG; n=687,936) surgery or percutaneous coronary intervention (PCI; n=664,124) during 1996-2002 were identified from Medicare administrative data. Patients using VA services during the 2 years preceding the Medicare admission were identified using VA administrative files. Thirty-, 90-, and 365-day mortality were compared in patients who did and did not use VA services, adjusting for demographic and clinical risk factors using generalized estimating equations and propensity score analysis. Adjusted mortality after CABG was higher (p<.001) in VA users compared with nonusers at 30, 90, and 365 days: odds ratio (OR)=1.07 (95 percent confidence interval [CI], 1.03-1.11), 1.07 (95 percent CI, 1.04-1.10), and 1.09 (95 percent CI, 1.06-1.12), respectively. For PCI, mortality at 30 and 90 days was similar (p>.05) for VA users and nonusers, but was higher at 365 days (OR=1.09; 95 percent CI, 1.06-1.12). The increased risk of death in VA users was limited to patients with service-connected disabilities or low incomes. Odds of death for VA users were slightly lower using samples matched by propensity scores. A small difference in risk-adjusted outcomes for VA users and nonusers undergoing revascularization in private sector hospitals was found. This difference reflects unmeasured severity in VA users undergoing revascularization in private sector hospitals.

Immediate outcomes of eptifibatide therapy during intracoronary stent implantation.

PubMed

Shariati, Hooman; Sanei, Hamid; Pourmoghadas, Ali; Salehizadeh, Leila; Amirpour, Afshin

2016-01-01

The objective of the present study was to assess the major immediate outcomes of eptifibatide therapy during intracoronary stent implantation. In an interventional study, patients undergoing percutaneous coronary intervention (PCI) were randomized into either the eptifibatide ( n = 100) or the control ( n = 107) group. In each group, demographic and clinical characteristics such as cardiac death, stent thrombosis (ST), myocardial infarction (MI), rates of target lesion and vessel revascularization, cerebral vascular accident (CVA), and emergency coronary artery bypass grafting (CABG) were recorded. The overall rates of major adverse events such as mortality, Stent thrombosis (ST), Myocardial Infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), CVA, and emergency CABG within 24 h after stent implantation were low and comparable between the two groups; P > 0.05 considered significant for all comparisons. There were no statistical differences between the clinical outcomes of groups administered with single-dose intracoronary eptifibatide and control groups among patients undergoing PCI during stent implantation.

[Instantaneous wave-free ratio (iFR®) in patients with coronary artery disease].

PubMed

Baumann, S; Schaefer, A C; Hohneck, A; Mueller, K; Becher, T; Behnes, M; Renker, M; Borggrefe, M; Akin, I; Lossnitzer, D

2017-08-23

Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.

Transmyocardial Laser Revascularization as an Adjunct to Coronary Artery Bypass Grafting

PubMed Central

Frazier, O. H.; Tuzun, Egemen; Eichstadt, Harald; Boyce, Steven W.; Lansing, Allan M.; March, Robet J.; Satori, Michele; Kadipasaoglu, Kamuran A.

2004-01-01

We evaluated transmyocardial laser revascularization (TMLR) with coronary artery bypass grafting (CABG) versus CABG alone for severe coronary artery disease involving ≥1 myocardial region unsuited for CABG. At 4 centers, 44 consecutive patients were randomized for CABG+TMLR (n = 23) or CABG alone (n = 21). Operative and in-hospital mortality and morbidity rates were monitored. Clinical status was evaluated at hospital discharge, 1 year, and 4 years. Success was characterized by relief of angina and freedom from repeat revascularization and death. Preoperatively, 20 patients (47%) were at high risk. The CABG technique, number of grafts, and target vessels were similar in both groups. Patients undergoing CABG+ TMLR received 25 ± 11 laser channels. Their ≤30-day mortality was 13% (3/23) compared with 28% (6/21) after CABG alone (P = 0.21). There were no significant intergroup differences in the number of intraoperative or in-hospital adverse events. The follow-up period was 50.3 ± 17.8 months for CABG alone and 48.1 ± 16.8 months for CABG+TMLR. Both groups had substantially improved angina and functional status at 1 and 4 years, with no significant differences in cumulative 4-year mortality. The incidence of repeat revascularization was 24% after CABG alone versus none after CABG+ TMLR (P < 0.05). The 4-year event-free survival rate was 14% versus 39%, respectively (P < 0.064). In conclusion, CABG+TMLR appears safe and poses no additional threat for high-risk patients. Improved overall success and repeat revascularization rates may be due to better perfusion of ischemic areas not amenable to bypass. Further studies are warranted to determine whether these trends are indeed significant. PMID:15562842

Early Ventricular Tachycardia or Fibrillation in Patients With ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention and Impact on Mortality and Stent Thrombosis (from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction Trial).

PubMed

Kosmidou, Ioanna; Embacher, Monica; McAndrew, Thomas; Dizon, José M; Mehran, Roxana; Ben-Yehuda, Ori; Mintz, Gary S; Stone, Gregg W

2017-11-15

The prevalence and impact of early ventricular arrhythmias (ventricular tachycardia [VT]/ventricular fibrillation [VF]) occurring before mechanical revascularization for acute ST segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention are poorly understood. We sought to investigate the association between early VT/VF and long-term clinical outcomes using data from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Among 3,602 patients with STEMI, 108 patients (3.0%) had early VT/VF. Baseline clinical characteristics were similar in patients with versus without early VT/VF. Patients with early VT/VF had shorter symptom-to-balloon times and lower left ventricular ejection fraction and underwent more frequent thrombectomy compared with patients without early VT/VF. Adjusted 3-year rates of all-cause death (15.7% vs 6.5%; adjusted hazard ratio 2.62, 95% confidence interval 1.48 to 4.61, p <0.001) and stent thrombosis (13.7% vs 5.7%; adjusted hazard ratio 2.74, 95% confidence interval 1.52 to 4.93, p <0.001) were significantly higher in patients with early VT/VF compared with patients without early VT/VF. In conclusion, in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial, VT/VF occurring before coronary angiography and revascularization in patients with STEMI was strongly associated with increased 3-year rates of death and stent thrombosis. Further investigation into the mechanisms underlying the increased risk of early stent thrombosis in patients with early VT/VF is required. Copyright © 2017 Elsevier Inc. All rights reserved.

Culprit versus multivessel coronary intervention in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials.

PubMed

Vaidya, Satyanarayana R; Qamar, Arman; Arora, Sameer; Devarapally, Santhosh R; Kondur, Ashok; Kaul, Prashant

2018-03-01

The 2015 American College of Cardiology/American Heart Association update on primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) recommended PCI of the non-infarct-related artery at the time of primary PCI (class IIb recommendation). Despite evidence supporting complete revascularization in STEMI, its benefit on mortality rates is uncertain. We searched all available databases for randomized controlled trials comparing complete multivessel percutaneous coronary intervention (CMV PCI) with infarct-artery-only revascularization in patients with STEMI. Summary risk ratios and 95% confidence intervals (CIs) were calculated for both the efficacy and safety outcomes. Nine randomized controlled trials fulfilled the inclusion criteria, yielding 2991 patients. Follow-up periods ranged from 6 to 36 months. Compared with infarct-related artery-only PCI, CMV PCI was associated with significantly lower rates of major adverse cardiac events [relative risk (RR)=0.54, 95% CI=0.41-0.71; P<0.00001], cardiovascular mortality (RR=0.48, 95% CI=0.28-0.80; P=0.005), and repeat revascularization (RR=0.38, 95% CI=0.30-0.47; P<0.00001). Although, contrast-induced nephropathy and major bleed rates were comparable between both groups, CMV PCI failed to show any reduction in all-cause mortality (RR=0.75, 95% CI=0.53-1.07; P=0.11) and nonfatal myocardial infarction (RR=0.69, 95% CI=0.43-1.10; P=0.12). Our results suggest that in patients with STEMI and multivessel disease, complete revascularization is safe, and is associated with reduced risks of major adverse cardiac events and cardiac death along with a reduced need for repeat revascularization. However, it showed no beneficial effect on all-cause mortality and nonfatal myocardial infarction.

Temporal trends in revascularization and outcomes after acute myocardial infarction among the very elderly

PubMed Central

Pagé, Maude; Doucet, Michel; Eisenberg, Mark J.; Behlouli, Hassan; Pilote, Louise

2010-01-01

Background Few data are available on time-related changes in use and outcomes of invasive procedures after acute myocardial infarction in very elderly patients. Our objective was to describe trends in revascularization procedures and outcomes in a provincial cohort of very elderly patients who had experienced acute myocardial infarction. Methods We used a database of hospital discharge summaries to identify all patients aged 80 years or older admitted for acute myocardial infarction in Quebec. We used the provincial database of physicians’ services and medication claims to assess treatment and obtain data on survival. Results Between March 1996 and March 2007, 29 750 patients aged 80 years or older were admitted to hospital for acute myocardial infarction. During this period, use of percutaneous coronary interventions increased from 2.2% to 24.9%, and use of coronary artery bypass graft surgery increased from 0.8% to 3.1%. Evidence-based prescriptions of medication increased over time (p < 0.001). The prevalence of reported comorbidities was higher during the period of 2003–2006 than during the 1996–1999 period. One-year mortality improved over time (46.5% for 1996–1999 v. 40.9% for 2003–2006, p < 0.001) but remained unchanged in the subgroup of patients who did not undergo revascularization. Interpretation The use of revascularization, especially percutaneous coronary interventions, in the very elderly after acute myocardial infarction has been growing at a rapid pace, while the prevalence of reported comorbidities has been increasing in this population. Revascularization procedures are no longer restricted to younger patients. In the context of an aging population, it is imperative to determine whether these changes in practice are cost-effective. PMID:20682731

Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis.

PubMed

Teixeira, Pedro Gr; Woo, Karen; Beck, Adam W; Scali, Salvatore T; Weaver, Fred A

2017-12-01

Objectives Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair. Methods The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011-July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences. Results The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82-2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03-5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74-3.26), P = 0.244). Conclusion For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.

Orbital Atherectomy for Treating De Novo Severely Calcified Coronary Narrowing (1-Year Results from the Pivotal ORBIT II Trial).

PubMed

Généreux, Philippe; Lee, Arthur C; Kim, Christopher Y; Lee, Michael; Shlofmitz, Richard; Moses, Jeffrey W; Stone, Gregg W; Chambers, Jeff W

2015-06-15

Percutaneous coronary intervention of severely calcified lesions has historically been associated with major adverse cardiac event (MACE) rates as high as 30%. In the ORBIT II (Evaluate the Safety and Efficacy of OAS in Treating Severely Calcified Coronary Lesions) trial, treatment of de novo severely calcified lesions with the Diamondback 360° Coronary Orbital Atherectomy System (OAS) resulted in low rates of procedural and 30-day adverse ischemic events. The long-term results from this trial have not been reported. We sought to determine the 1-year outcomes after orbital atherectomy of severely calcified coronary lesions. ORBIT II was a single-arm trial enrolling 443 subjects at 49 US sites with severely calcified lesions usually excluded from randomized trials. OAS utilizes a centrifugal differential sanding mechanism of action for plaque modification prior to stent implantation. After OAS drug-eluting stents were implanted in 88.2% of the patients. The primary safety end point was 30-day MACE, the composite of cardiac death, myocardial infarction, or target vessel revascularization [TVR]. The present analysis reports the 1-year follow-up results from ORBIT II. One-year data were available in 433 of 443 patients (97.7%), with median follow-up time of 16.7 months. The 1-year MACE rate was 16.4%, including cardiac death (3.0%), myocardial infarction (9.7%), and target vessel revascularization (5.9%). The 1-year target lesion revascularization rate was 4.7%, and stent thrombosis occurred in 1 patient (0.2%). Independent predictors of 1-year MACE and target vessel revascularization were diameter stenosis at baseline and the use of bare-metal stents. In patients with severely calcified lesions who underwent percutaneous coronary intervention, the use of OAS was associated with low rates of 1-year adverse ischemic events compared with historical controls. This finding has important clinical implications for the selection of optimum treatment strategies for patients with severely calcified lesions. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Management of Patients With Cardiac Arrest Complicating Myocardial Infarction in New York Before and After Public Reporting Policy Changes.

PubMed

Strom, Jordan B; McCabe, James M; Waldo, Stephen W; Pinto, Duane S; Kennedy, Kevin F; Feldman, Dmitriy N; Yeh, Robert W

2017-05-01

In 2010, New York State began excluding selected patients with cardiac arrest and coma from publicly reported mortality statistics after percutaneous coronary intervention. We evaluated the effects of this exclusion on rates of coronary angiography, revascularization, and mortality among patients with acute myocardial infarction and cardiac arrest. Using statewide hospitalization files, we identified discharges for acute myocardial infarction and cardiac arrest January 2003 to December 2013 in New York and several comparator states. A difference-in-differences approach was used to evaluate the likelihood of coronary angiography, revascularization, and in-hospital mortality before and after 2010. A total of 26 379 patients with acute myocardial infarction and cardiac arrest (5619 in New York) were included. Of these, 17 141 (65%) underwent coronary angiography, 12 183 (46.2%) underwent percutaneous coronary intervention, and 2832 (10.7%) underwent coronary artery bypass grafting. Before 2010, patients with cardiac arrest in New York were less likely to undergo percutaneous coronary intervention compared with referent states (adjusted relative risk, 0.79; 95% confidence interval, 0.73-0.85; P <0.001). This relationship was unchanged after the policy change (adjusted relative risk, 0.82; 95% confidence interval, 0.76-0.89; interaction P =0.359). Adjusted risks of in-hospital mortality between New York and comparator states after 2010 were also similar (adjusted relative risk, 0.94; 95% confidence interval, 0.87-1.02; P =0.152 for post- versus pre-2010 in New York; adjusted relative risk, 0.88; 95% confidence interval, 0.84-0.92; P <0.001 for comparator states; interaction P =0.103). Exclusion of selected cardiac arrest cases from public reporting was not associated with changes in rates of percutaneous coronary intervention or in-hospital mortality in New York. Rates of revascularization in New York for cardiac arrest patients were lower throughout. © 2017 American Heart Association, Inc.

Carotid revascularization: risks and benefits

PubMed Central

O’Brien, Marlene; Chandra, Ankur

2014-01-01

Despite a decline during the recent decades in stroke-related death, the incidence of stroke has remained unchanged or slightly increased, and extracranial carotid artery stenosis is implicated in 20%–30% of all strokes. Medical therapy and risk factor modification are first-line therapies for all patients with carotid occlusive disease. Evidence for the treatment of patients with symptomatic carotid stenosis greater than 70% with either carotid artery stenting (CAS) or carotid endarterectomy (CEA) is compelling, and several trials have demonstrated a benefit to carotid revascularization in the symptomatic patient population. Asymptomatic carotid stenosis is more controversial, with the largest trials only demonstrating a 1% per year risk stroke reduction with CEA. Although there are sufficient data to advocate for aggressive medical therapy as the primary mode of treatment for asymptomatic carotid stenosis, there are also data to suggest that certain patient populations will benefit from a stroke risk reduction with carotid revascularization. In the United States, consensus and practice guidelines dictate that CEA is reasonable in patients with high-grade asymptomatic stenosis, a reasonable life expectancy, and perioperative risk of less than 3%. Regarding CAS versus CEA, the best-available evidence demonstrates no difference between the two procedures in early perioperative stroke, myocardial infarction, or death, and no difference in 4-year ipsilateral stroke risk. However, because of the higher perioperative risks of stroke in patients undergoing CAS, particularly in symptomatic, female, or elderly patients, it is difficult to recommend CAS over CEA except in populations with prohibitive cardiac risk, previous carotid surgery, or prior neck radiation. Current treatment paradigms are based on identifying the magnitude of perioperative risk in patient subsets and on using predictive factors to stratify patients with high-risk asymptomatic stenosis. PMID:25045271

Cost considerations in selecting coronary artery revascularization therapy in the elderly.

PubMed

Maziarz, David M; Koutlas, Theodore C

2004-01-01

This article presents some of the cost factors involved in selecting coronary artery revascularization therapy in an elderly patient. With the percentage of gross national product allocated to healthcare continuing to rise in the US, resource allocation has become an issue. Percutaneous coronary intervention continues to be a viable option for many patients, with lower initial costs. However, long-term angina-free results often require further interventions or eventual surgery. Once coronary artery revascularization therapy is selected, it is worthwhile to evaluate the cost considerations inherent to various techniques. Off-pump coronary artery bypass graft surgery has seen a resurgence, with improved technology and lower hospital costs than on-pump bypass surgery. Numerous factors contributing to cost in coronary surgery have been studied and several are documented here, including the potential benefits of early extubation and the use of standardized optimal care pathways. A wide range of hospital-level cost variation has been noted, and standardization issues remain. With the advent of advanced computer-assisted robotic techniques, a push toward totally endoscopic bypass surgery has begun, with the eventual hope of reducing hospital stays to a minimum while maximizing outcomes, thus reducing intensive care unit and stepdown care times, which contribute a great deal toward overall cost. At the present time, these techniques add a significant premium to hospital charges, outweighing any potential length-of-stay benefits from a cost standpoint. As our elderly population continues to grow, use of healthcare resource dollars will continue to be heavily scrutinized. Although the clinical outcome remains the ultimate benchmark, cost containment and optimization of resources will take on a larger role in the future. Copyright 2004 Adis Data Information BV

Effectiveness of Drug-Eluting Stents versus Bare-Metal Stents in Large Coronary Arteries in Patients with Acute Myocardial Infarction

PubMed Central

Sim, Doo Sun; Ahn, Youngkeun; Kim, Young Jo; Chae, Shung Chull; Hong, Taek Jong; Seong, In Whan; Chae, Jei Keon; Kim, Chong Jin; Cho, Myeong Chan; Seung, Ki Bae; Park, Seung Jung

2011-01-01

This study compared clinical outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in large coronary arteries in patients with acute myocardial infarction (MI). A total of 985 patients who underwent single-vessel percutaneous coronary intervention (PCI) in large coronary arteries (≥ 3.5 mm) in lesions < 25 mm were divided into DES group (n = 841) and BMS group (n = 144). Clinical outcomes during 12 months were compared. In-hospital outcome was similar between the groups. At six months, death/MI rate was not different. However, DES group had significantly lower rates of target-lesion revascularization (TLR) (1.7% vs 5.6%, P = 0.021), target-vessel revascularization (TVR) (2.2% vs 5.6%, P = 0.032), and total major adverse cardiac events (MACE) (3.4% vs 11.9%, P = 0.025). At 12 months, the rates of TLR and TVR remained lower in the DES group (2.5% vs 5.9%, P = 0.032 and 5.9% vs 3.1%, P = 0.041), but the rates of death/MI and total MACE were not statistically different. The use of DES in large vessels in the setting of acute MI is associated with lower need for repeat revascularization compared to BMS without compromising the overall safety over the course of one-year follow-up. PMID:21468259

Real‐World Multicenter Registry of Patients with Severe Coronary Artery Calcification Undergoing Orbital Atherectomy

PubMed Central

Shlofmitz, Evan; Kaplan, Barry; Alexandru, Dragos; Meraj, Perwaiz; Shlofmitz, Richard

2016-01-01

Objectives We evaluated the safety and efficacy of orbital atherectomy in real‐world patients with severe coronary artery calcification (CAC). Background The presence of severe CAC increases the complexity of percutaneous coronary intervention as it may impede stent delivery and optimal stent expansion. Atherectomy may be an indispensable tool for uncrossable or undilatable lesions by modifying severe CAC. Although the ORBIT I and II trials report that orbital atherectomy was safe and effective for the treatment of severe CAC, patients with kidney disease, recent myocardial infarction, long diffuse disease, severe left ventricular dysfunction, and unprotected left main disease were excluded. Methods This retrospective study included 458 consecutive patients with severe CAC who underwent orbital atherectomy followed by stenting from October 2013 to December 2015 at 3 centers. Results The primary endpoint of major adverse cardiac and cerebrovascular events at 30 days was 1.7%. Low rates of 30‐day all‐cause mortality (1.3%), myocardial infarction (1.1%), target vessel revascularization (0%), stroke (0.2%), and stent thrombosis (0.9%) were observed. Angiographic complications were low: perforation was 0.7%, dissection 0.9%, and no‐reflow 0.7%. Emergency coronary artery bypass graft surgery was performed in 0.2% of patients. Conclusion In the largest real‐world study of patients who underwent orbital atherectomy, including high‐risk patients who were not surgical candidates as well as those with very complex coronary anatomy, acute and short‐term adverse clinical event rates were low. A randomized clinical trial is needed to identify the ideal treatment strategy for patients with severe CAC. PMID:27358246

Plasma big endothelin-1 levels at admission and future cardiovascular outcomes: A cohort study in patients with stable coronary artery disease.

PubMed

Zhou, Bing-Yang; Guo, Yuan-Lin; Wu, Na-Qiong; Zhu, Cheng-Gang; Gao, Ying; Qing, Ping; Li, Xiao-Lin; Wang, Yao; Dong, Qian; Liu, Geng; Xu, Rui Xia; Cui, Chuan-Jue; Sun, Jing; Li, Jian-Jun

2017-03-01

Big endothelin-1 (ET-1) has been proposed as a novel prognostic indicator of acute coronary syndrome, while its predicting role of cardiovascular outcomes in patients with stable coronary artery disease (CAD) is unclear. A total of 3154 consecutive patients with stable CAD were enrolled and followed up for 24months. The outcomes included all-cause death, non-fatal myocardial infarction, stroke and unplanned revascularization (percutaneous coronary intervention and coronary artery bypass grafting). Baseline big ET-1 was measured using sandwich enzyme immunoassay method. Cox proportional hazard regression analysis and Kaplan-Meier analysis were used to evaluate the prognostic value of big ET-1 on cardiovascular outcomes. One hundred and eighty-nine (5.99%) events occurred during follow-up. Patients were divided into two groups: events group (n=189) and non-events group (n=2965). The results indicated that the events group had higher levels of big ET-1 compared to non-events group. Multivariable Cox proportional hazard regression analysis showed that big ET-1 was positively and statistically correlated with clinical outcomes (Hazard Ratio: 1.656, 95% confidence interval: 1.099-2.496, p=0.016). Additionally, the Kaplan-Meier analysis revealed that patients with higher big ET-1 presented lower event-free survival (p=0.016). The present study firstly suggests that big ET-1 is an independent risk marker of cardiovascular outcomes in patients with stable CAD. And more studies are needed to confirm our findings. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Cell biology, MRI and geometry: insight into a microscopic/macroscopic marriage.

PubMed

de Oliveira, Sérgio Almeida; Gowdak, Luís Henrique W; Buckberg, Gerald; Krieger, José Eduardo

2006-04-01

The concept of cell therapy as an adjunctive therapy to myocardial surgical revascularization for patients with severe coronary artery disease is illustrated by two case reports of ischemic cardiac disease that were unsuitable for revascularization by coronary grafting. The potential interaction of cell therapy, magnetic resonance imaging (MRI) of viability, and left ventricle (LV) restoration is described. Each patient had an ejection fraction below 30%, a relatively conical heart, and MRI gadolinium scan showing predominantly viable muscle. Intramyocardial injections of autologous bone marrow-derived cells (BMC) were performed along with either incomplete coronary artery bypass grafting (CABG) (to mother regions) or with transmyocardial laser revascularization (TMLR). An improvement in contractile function was seen at 6-12-month intervals after the procedure. The implications of possible underlying mechanisms of improvement in both myocardial perfusion and contractility suggest the striking importance of both micro- and macroenvironment for any cell-based therapeutic strategy. These observations imply that the interaction of cell biology, viability by MRI and geometry may be important in the future, as geometry can be restored surgically, and the new architectural form may develop enhanced function if it contains viable tissue and cell-based treatment can be delivered.

Orbital atherectomy for the treatment of severely calcified coronary lesions: evidence, technique, and best practices.

PubMed

Shlofmitz, Evan; Martinsen, Brad J; Lee, Michael; Rao, Sunil V; Généreux, Philippe; Higgins, Joe; Chambers, Jeffrey W; Kirtane, Ajay J; Brilakis, Emmanouil S; Kandzari, David E; Sharma, Samin K; Shlofmitz, Richard

2017-11-01

The presence of severe coronary artery calcification is associated with higher rates of angiographic complications during percutaneous coronary intervention (PCI), as well as higher major adverse cardiac events compared with non-calcified lesions. Incorporating orbital atherectomy (OAS) for effective preparation of severely calcified lesions can help maximize the benefits of PCI by attaining maximal luminal gain (or stent expansion) and improve long-term outcomes (by reducing need for revascularization). Areas covered: In this manuscript, the prevalence, risk factors, and impact of coronary artery calcification on PCI are reviewed. Based on current data and experience, the authors review orbital atherectomy technique and best practices to optimize lesion preparation. Expert Commentary: The coronary OAS is the only device approved for use in the U.S. as a treatment for de novo, severely calcified coronary lesions to facilitate stent delivery. Advantages of the device include its ease of use and a mechanism of action that treats bi-directionally, allowing for continuous blood flow during treatment, minimizing heat damage, slow flow, and subsequent need for revascularization. The OAS technique tips reviewed in this article will help inform interventional cardiologists treating patients with severely calcified lesions.

On pump versus off pump coronary artery bypass grafting in patients with end-stage renal disease and coronary artery disease - A nation-wide, propensity score matched database analyses.

PubMed

Chen, Jien-Jiun; Lin, Lian-Yu; Yang, Yao-Hsu; Hwang, Juey-Jen; Chen, Pau-Chung; Lin, Jiunn-Lee; Chi, Nai-Hsin

2017-01-15

The usage of on or off cardiopulmonary bypass in patients with coronary artery disease receiving coronary artery bypass grafting (CABG) surgery had been debated and had not yet been investigated thoroughly in patients with end-stage renal disease (ESRD). We aimed to study cardiovascular outcomes and total mortality in these patients by using our National Health Insurance (NHI) database. By using our NHI ESRD claim database, we searched ESRD patients aged more than 18years, who received CABG and divided them into on pump and off pump groups. Baseline characteristics and underlying comorbidities were identified from the database. Propensity score (PS) method was used to match all the potential confounders between patients. Outcomes including mortality, myocardial infarction, stroke and repeat revascularization within 30days, 1year and whole follow-up period were also obtained. A total of 134,410 ESRD patients were identified in the database. We included 341 patients and 543 patients who received off pump and on pump CABG respectively. The hazard ratios of different outcomes at 30days, 1year and a median of 745days after CABG did not show significant different between on, or off pump groups before and after PS match. ESRD patients with CAD undergoing either on pump or off pump CABG surgery showed similar outcomes in 30days, 1year and whole follow-up period. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Clinical outcomes in metabolic syndrome.

PubMed

Bhatheja, Rohit; Bhatt, Deepak L

2006-01-01

Metabolic syndrome is a clustering of cardiovascular risk factors. Its definition is the presence of any 3 of the following: obesity, hypertriglyceridemia, low high-density lipoprotein, hypertension, and impaired fasting glucose. The development of coronary artery disease is the most dreaded complication of this disease. In the United States, Mexican Americans and African American women are the most affected. Management of this syndrome includes physical exercise, weight loss, and effective drug treatment of dyslipidemia, high blood pressure, and impaired fasting blood glucose. Because of the increasing prevalence of obesity and diabetes, there is a rise in fatal and nonfatal cardiovascular events. With the development of effective antiplatelet medication and newer drug-eluting stents, percutaneous coronary intervention has become an effective revascularization strategy for those with coronary artery disease. Rates of stent restenosis and target-lesion revascularization have been reduced. Oral hypoglycemic drugs like thiazolidinediones improve insulin resistance and may have a favorable effect in those with metabolic syndrome. Diagnosis and appropriate management of metabolic syndrome are challenges as the presence of risk factors predates the coronary event.

Fractional flow reserve guided revascularization in daily practice: clinical judgment does not always meet science.

PubMed

Rubinshtein, Ronen; Jaffe, Ronen

2013-09-01

Measurement of the fractional flow reserve (FFR) during invasive coronary angiography is the accepted ''gold standard'' for assessing the functional significance of coronary artery lesions by determination of the characteristics of blood flow proximal and distal to a coronary stenosis during pharmacologically-mediated hyperemia. Abnormal FFR is associated with higher cardiac event rate if the coronary lesion is left untreated. On the other hand, it was shown that patients derived no clinical benefit from revascularization of angiographically obstructive lesions which were hemodynamically insignificant according to FFR (>0.8). This editorial comment refers to an observational cohort study which reported that in approximately 20% of real world patients the treatment strategy chosen was discordant with FFR findings. Our comment discusses these findings and concludes that while the standard of care is to treat patients in accordance with their FFR results (when available), it should be recognized that there are some clinical scenarios that may require a treatment strategy that is discordant with FFR result.

[Management of coronary artery disease in diabetic patients with lower limb critical ischaemia: assessment of operational risk, drug therapy and indications for interventions].

PubMed

Dedov, I I; Kalashnikov, V Iu; Terekhin, S A; Melkozerov, K V

2012-01-01

Despite obvious progress in management of diabetes mellitus, the DM-related complications rate remains inadmissibly high. Macroangiopathy is known to rank first amongst complications of diabetes mellitus, and coronary artery disease remains to be the major cause of death. Analysed herein are peculiarities of the clinical course in diabetic patients presenting with coronary artery disease and lower limb critical ischaemia, followed by discussing the issues concerning drug therapy, preoperative examination, and methods of diagnosis in this cohort of patients prior to vascular operations, assessment of the preoperative risk, indications for coronarography and myocardial revascularization. Also presented are the results of the main clinical trials dedicated to preoperative myocardial revascularization, including those in diabetic patients with limb critical ischaemia, and finally highlighting current importance of optimizing approaches to managing and working out algorithms of treatment policy for diabetic patients with a combination of coronary artery disease, diabetes mellitus, and critical limb ischaemia.

On- or off-pump coronary artery bypass grafting for octogenarians: A meta-analysis of comparative studies involving 27,623 patients.

PubMed

Khan, Habib; Uzzaman, Mohsin; Benedetto, Umberto; Butt, Salman; Raja, Shahzad G

2017-11-01

Coronary artery bypass grafting (CABG) is being increasingly offered to octogenarians. Both on- and off-pump CABG are reported as effective surgical revascularization strategies for octogenarians by single institution studies. However, the issue of superiority of one strategy over the other for octogenarians remains unresolved due to limited sample size of these studies. A meta-analysis of studies comparing outcomes of on- and off-pump CABG in octogenarians was undertaken to address the issue. A literature search was conducted from 1966 through September 2016 using MEDLINE, EMBASE, Scopus and Web of Science to identify relevant articles. Primary outcomes of interest included in-hospital mortality and stroke. Secondary outcomes of interest were atrial fibrillation, acute renal failure, reoperation for bleeding, deep sternal wound infection, myocardial infarction, intensive therapy unit (ITU) stay and hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I 2 inconsistency test. All p-values were 2-sided and a 5% level was considered significant. Sixteen retrospective studies (18,685 on-pump patients and 8938 off-pump patients) were included in the systematic review. In-hospital mortality (pooled OR = 0.64, 95% CI = 0.44 to 0.93; p = 0.02), stroke rate (pooled OR = 0.61, 95% CI = 0.48 to 0.76; p < 0.001) and length of hospital stay (pooled WMD = +0.29, 95% CI = +0.02 to +0.56; p = 0.04) were significantly lower in the off-pump patients. Atrial fibrillation (p = 0.36), acute renal failure (p = 0.47), reoperation for bleeding (p = 0.99), deep sternal wound infection (p = 0.59), myocardial infarction (p = 0.93), and length of ITU stay (p = 0.27) were comparable. Off-pump compared to on-pump CABG offers surgical myocardial revascularization to octogenarians with lower in-hospital mortality, stroke rate and length of hospital stay with similar incidence of other adverse outcomes. Preferentially offering off-pump CABG to octogenarians could translate into reduced economic burden on the healthcare providers. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases.

PubMed

Cartier, R; Brann, S; Dagenais, F; Martineau, R; Couturier, A

2000-02-01

We sought to report our recent experience with off-pump coronary artery revascularization in multivessel disease. Between October 1996 and December 1998, 300 off-pump beating heart operations were performed at the Montreal Heart Institute by a single surgeon, representing 94% of all procedures undertaken during this same time frame (97% for 1998). This cohort of patients was compared with 1870 patients operated on with cardiopulmonary bypass from 1995 to 1996. Mean age, sex distribution, and preoperative risk factors were comparable for the two groups. On average, 2.92 +/- 0.8 and 2.84 +/- 0.6 grafts per patient were completed in the beating heart and cardiopulmonary bypass groups, respectively. A majority of patients (70%) had either a triple or quadruple bypass. Coronary anastomoses were achieved with myocardial mechanical stabilization and heart "verticalization." Ischemic time was shorter in the beating heart group (29.8 +/- 0.9 vs 45 +/- 0.4 minutes, P <.05). Similarly, the need for transfusion was significantly less in the beating heart group (beating heart operations, 34%; cardiopulmonary bypass, 66%; P <.005). Reduced use of postoperative intra-aortic counterpulsation, as well as a lower rise in creatine kinase MB isoenzyme, was observed in the beating heart group. Operative mortality rates (beating heart operations, 1. 3%; cardiopulmonary bypass, 2%) and perioperative myocardial infarction (beating heart operations, 3.6%; cardiopulmonary bypass, 4.2%) were comparable for the two groups. In a majority of patients, off-pump complete coronary artery revascularization is an acceptable alternative to conventional operations, yielding good results given progressive experience, rigorous technique, and adequate coronary artery stabilization.

Outcomes of repeat revascularization in diabetic patients with prior coronary surgery.

PubMed

Cole, Jason H; Jones, Ellis L; Craver, Joseph M; Guyton, Robert A; Morris, Douglas C; Douglas, John S; Ghazzal, Ziyad; Weintraub, William S

2002-12-04

This study evaluated both short- and long-term outcomes of diabetic patients who underwent repeat coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) after initial CABG. Although diabetic patients who have multivessel coronary disease and require initial revascularization may benefit from CABG as compared with PCI, the uncertainty concerning the choice of revascularization may be greater for diabetic patients who have had previous CABG. Data were obtained over 15 years for diabetic patients undergoing PCI procedures or repeat CABG after previous coronary surgery. Baseline characteristics were compared between groups, and in-hospital, 5-year, and 10-year mortality rates were calculated. Multivariate correlates of in-hospital and long-term mortality were determined. Both PCI (n = 1,123) and CABG (n = 598) patients were similar in age, gender, years of diabetes, and insulin dependence, but they varied in presence of hypertension, prior myocardial infarction, angina severity, heart failure, ejection fraction, and left main disease. In-hospital mortality was greater for CABG, but differences in long-term mortality were not significant (10 year mortality, 68% PCI vs. 74% CABG, p = 0.14). Multivariate correlates of long-term mortality were older age, hypertension, low ejection fraction, and an interaction between heart failure and choice of PCI. The PCI itself did not correlate with mortality. The increased initial risk of redo CABG in diabetic patients and the comparable high long-term mortality regardless of type of intervention suggest that, except for patients with severe heart failure, PCI be strongly considered in all patients for whom there is a percutaneous alternative.

Why is coronary collateral growth impaired in type II diabetes and the metabolic syndrome?

PubMed Central

Rocic, Petra

2012-01-01

Type II diabetes and the metabolic syndrome are strong predictors of severity of occlusive coronary disease and poorer outcomes of coronary revascularization therapies. Coronary collateral growth can provide an alternative or accessory pathway of revascularization. However, collateral growth is impaired in type II diabetes and the metabolic syndrome. Although many factors necessary for collateral growth are known and many interventions have shown promising results in animal studies, not a single attempt to induce coronary collateral growth in human clinical trials has led to satisfactory results. Accordingly, the first part of this review outlines the known deleterious effects of diabetes and the metabolic syndrome on factors necessary for collateral growth, including pro-angiogenic growth factors, endothelial function, the redox state of the coronary circulation, intracellular signaling, leukocytes and bone marrow-derived progenitors cells. The second section highlights the gaps in our current knowledge of how these factors interact with the radically altered environment of the coronary circulation in diabetes and the metabolic syndrome. The interplay between these pathologies and inadequately explored areas related to the temporal regulation of collateral remodeling and the roles of the extracellular matrix, vascular cell phenotype and pro-inflammatory cytokines are emphasized with implications to development of efficient therapies. PMID:22342811

Fondaparinux with UnfracTionated heparin dUring Revascularization in Acute coronary syndromes (FUTURA/OASIS 8): a randomized trial of intravenous unfractionated heparin during percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndromes initially treated with fondaparinux.

PubMed

Steg, Philippe Gabriel; Mehta, Shamir; Jolly, Sanjit; Xavier, Denis; Rupprecht, Hans-Juergen; Lopez-Sendon, Jose Luis; Chrolavicius, Susan; Rao, Sunil V; Granger, Christopher B; Pogue, Janice; Laing, Shiona; Yusuf, Salim

2010-12-01

There is uncertainty regarding the optimal adjunctive unfractionated heparin (UFH) regimen for percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) treated with fondaparinux. The aim of this study is to evaluate the safety of 2 dose regimens of adjunctive intravenous UFH during PCI in high-risk patients with NSTE-ACS initially treated with fondaparinux and referred for early coronary angiography. This is an international prospective cohort study of approximately 4,000 high-risk patients presenting to hospital with unstable angina or non-ST-segment elevation myocardial infarction, treated with fondaparinux as initial medical therapy, and referred for early coronary angiography with a view to revascularization. Within this cohort, 2,000 patients undergoing PCI will be eligible for enrollment into a double-blind international randomized parallel-group trial evaluating standard activated clotting time (ACT)-guided doses of intravenous UFH versus a non-ACT-guided weight-adjusted low dose. The standard regimen uses an 85-U/kg bolus of UFH if there is no platelet glycoprotein IIb/IIIa (GpIIb-IIIa) inhibitor or 60 U/kg if GpIIb-IIIa inhibitor use is planned, with additional bolus guided by blinded ACT measurements. The low-dose regimen uses a 50 U/kg UFH bolus, irrespective of planned GpIIb-IIIa use. The primary outcome is the composite of peri-PCI major bleeding, minor bleeding, or major vascular access site complications. The assessment of net clinical benefit is a key secondary outcome: it addresses the composite of peri-PCI major bleeding with death, myocardial infarction, or target vessel revascularization at day 30. FUTURA/OASIS 8 will help define the optimal UFH regimen as adjunct to PCI in high-risk NSTE-ACS patients treated with fondaparinux. Copyright © 2010 Mosby, Inc. All rights reserved.

Hydroxychloroquine Use Is Associated With Decreased Incident Cardiovascular Events in Rheumatoid Arthritis Patients.

PubMed

Sharma, Tarun S; Wasko, Mary Chester M; Tang, Xiaoqin; Vedamurthy, Deepak; Yan, Xiaowei; Cote, Jonida; Bili, Androniki

2016-01-04

Cardiovascular disease (CVD) is the leading cause of death in rheumatoid arthritis (RA) patients. This study is the first to report the association of hydroxychloroquine (an antirheumatic medication that has been associated with decreased risk of diabetes, a less atherogenic lipid profile, and antithrombotic properties) with CVD in RA. A retrospective incident RA cohort from January 1, 2001, to October 31, 2013, excluding patients with CVD prior to RA diagnosis, was constructed. Patients were categorized as hydroxychloroquine users versus nonusers and were allowed to contribute time to either group according to hydroxychloroquine exposure. The primary outcome was adjudicated incident CVD defined as a composite of coronary artery disease, stroke, transient ischemic attack, sudden cardiac death, and peripheral artery disease with arterial revascularization procedure. The secondary outcome was a composite of incident coronary artery disease, stroke, and transient ischemic attack. Cox time-varying regression models were used to estimate the association between hydroxychloroquine exposure and development of CVD, after adjusting for propensity score and relevant confounders, including demographics, CVD-related comorbidities, RA severity, and activity indicators and medications. We included 1266 RA patients, 547 hydroxychloroquine users, and 719 nonusers. During the observation period, 102 CVD events occurred, 3 in hydroxychloroquine users and 99 in nonusers. The fully adjusted Cox model showed a hazard ratio of 0.28 (95% CI 0.12-0.63, P=0.002) for incident CVD and 0.30 (95% CI 0.13-0.68, P=0.004) for incident composite coronary artery disease, stroke, and transient ischemic attack for hydroxychloroquine users versus nonusers, respectively. In this hypothesis-generating study, hydroxychloroquine use was associated with a 72% decrease in the risk of incident CVD in RA patients. If these preliminary results are confirmed in larger studies, our findings may be used as a rationale for a randomized study of hydroxychloroquine use for primary prevention of CVD in RA or nonrheumatic high-risk patients. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Use of Anticoagulants and Antiplatelet Agents in Stable Outpatients with Coronary Artery Disease and Atrial Fibrillation. International CLARIFY Registry.

PubMed

Fauchier, Laurent; Greenlaw, Nicola; Ferrari, Roberto; Ford, Ian; Fox, Kim M; Tardif, Jean-Claude; Tendera, Michal; Steg, Ph Gabriel

2015-01-01

Few data are available regarding the use of antithrombotic strategies in coronary artery disease patients with atrial fibrillation (AF) in everyday practice. We sought to describe the prevalence of AF and its antithrombotic management in a contemporary population of patients with stable coronary artery disease. CLARIFY is an international, prospective, longitudinal registry of outpatients with stable coronary artery disease, defined as prior (≥12 months) myocardial infarction, revascularization procedure, coronary stenosis >50%, or chest pain associated with evidence of myocardial ischemia. Overall, 33,428 patients were screened, of whom 32,954 had data available for analysis at baseline; of these 2,229 (6.7%) had a history of AF. Median (interquartile range) CHA2DS2-VASc score was 4 (3, 5). Oral anticoagulation alone was used in 25.7%, antiplatelet therapy alone in 52.8% (single 41.8%, dual 11.0%), and both in 21.5%. OAC use was independently associated with permanent AF (p<0.001), CHA2DS2-VASc score (p=0.006), pacemaker (p<0.001), stroke (p=0.04), absence of angina (p=0.004), decreased left ventricular ejection fraction (p<0.001), increased waist circumference (p=0.005), and longer history of coronary artery disease (p=0.008). History of percutaneous coronary intervention (p=0.004) and no/partial reimbursement for cardiovascular medication (p=0.01, p<0.001, respectively) were associated with reduced oral anticoagulant use. In this contemporary cohort of patients with stable coronary artery disease and AF, most of whom are theoretical candidates for anticoagulation, oral anticoagulants were used in only 47.2%. Half of the patients received antiplatelet therapy alone and one-fifth received both antiplatelets and oral anticoagulants. Efforts are needed to improve adherence to guidelines in these patients. ISRCTN registry of clinical trials: ISRCTN43070564.

Use of Anticoagulants and Antiplatelet Agents in Stable Outpatients with Coronary Artery Disease and Atrial Fibrillation. International CLARIFY Registry

PubMed Central

Fauchier, Laurent; Greenlaw, Nicola; Ferrari, Roberto; Ford, Ian; Fox, Kim M.; Tardif, Jean-Claude; Tendera, Michal; Steg, Ph. Gabriel

2015-01-01

Background Few data are available regarding the use of antithrombotic strategies in coronary artery disease patients with atrial fibrillation (AF) in everyday practice. We sought to describe the prevalence of AF and its antithrombotic management in a contemporary population of patients with stable coronary artery disease. Methods and Findings CLARIFY is an international, prospective, longitudinal registry of outpatients with stable coronary artery disease, defined as prior (≥12 months) myocardial infarction, revascularization procedure, coronary stenosis >50%, or chest pain associated with evidence of myocardial ischemia. Overall, 33,428 patients were screened, of whom 32,954 had data available for analysis at baseline; of these 2,229 (6.7%) had a history of AF. Median (interquartile range) CHA2DS2-VASc score was 4 (3, 5). Oral anticoagulation alone was used in 25.7%, antiplatelet therapy alone in 52.8% (single 41.8%, dual 11.0%), and both in 21.5%. OAC use was independently associated with permanent AF (p<0.001), CHA2DS2-VASc score (p=0.006), pacemaker (p<0.001), stroke (p=0.04), absence of angina (p=0.004), decreased left ventricular ejection fraction (p<0.001), increased waist circumference (p=0.005), and longer history of coronary artery disease (p=0.008). History of percutaneous coronary intervention (p=0.004) and no/partial reimbursement for cardiovascular medication (p=0.01, p<0.001, respectively) were associated with reduced oral anticoagulant use. Conclusions In this contemporary cohort of patients with stable coronary artery disease and AF, most of whom are theoretical candidates for anticoagulation, oral anticoagulants were used in only 47.2%. Half of the patients received antiplatelet therapy alone and one-fifth received both antiplatelets and oral anticoagulants. Efforts are needed to improve adherence to guidelines in these patients. Trial Registration ISRCTN registry of clinical trials: ISRCTN43070564. PMID:25915904

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis].

PubMed

Vicente, R; Pajares, A; Vicente, J L; Aparicio, R; Loro, J M; Moreno, I; Soria, A; López, A; Porta, J; de la Fuente, C; Herrera, P; Tur, A; Osseyran, F; Guillén, A; Martí, F; Llagunes, J; Mateo, E; Aguar, F; Peña, J J; Marqués, J I; Ripoll, A; Reina, C; Ferrandis, P; Muedra, V; Llopis, E; Cantó, M; García, C

2010-02-01

To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

Percutaneous Intervention in ST-Elevation Myocardial Infarction: Culprit-only or Complete Revascularization?

PubMed Central

Osório, Ana Paula Susin; de Quadros, Alexandre Schaan; Vieira, José Luiz da Costa; Portal, Vera Lucia

2017-01-01

The best approach of multivessel coronary artery disease in the context of acute myocardial infarction with ST segment elevation and primary percutaneous coronary intervention is one of the main reasons for controversy in cardiology. Although the main global guidelines do not recommend routine complete revascularization in these patients, recent randomized clinical trials have demonstrated benefit of this approach in reducing cardiovascular outcomes. For this reason, an adequate review of this evidence is essential in order to establish scientifically based strategy and achieve better outcomes for these patients who present with acute myocardial infarction. This review aims to present objectively the most recent evidence available on this topic. PMID:29185617

Solitaire™ with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke.

PubMed

Saver, Jeffrey L; Goyal, Mayank; Bonafe, Alain; Diener, Hans-Christoph; Levy, Elad I; Pereira, Vitor M; Albers, Gregory W; Cognard, Christophe; Cohen, David J; Hacke, Werner; Jansen, Olav; Jovin, Tudor G; Mattle, Heinrich P; Nogueira, Raul G; Siddiqui, Adnan H; Yavagal, Dileep R; Devlin, Thomas G; Lopes, Demetrius K; Reddy, Vivek; du Mesnil de Rochemont, Richard; Jahan, Reza

2015-04-01

Early reperfusion in patients experiencing acute ischemic stroke is critical, especially for patients with large vessel occlusion who have poor prognosis without revascularization. Solitaire™ stent retriever devices have been shown to immediately restore vascular perfusion safely, rapidly, and effectively in acute ischemic stroke patients with large vessel occlusions. The aim of the study was to demonstrate that, among patients with large vessel, anterior circulation occlusion who have received intravenous tissue plasminogen activator, treatment with Solitaire revascularization devices reduces degree of disability 3 months post stroke. The study is a global multicenter, two-arm, prospective, randomized, open, blinded end-point trial comparing functional outcomes in acute ischemic stroke patients who are treated with either intravenous tissue plasminogen activator alone or intravenous tissue plasminogen activator in combination with the Solitaire device. Up to 833 patients will be enrolled. Patients who have received intravenous tissue plasminogen activator are randomized to either continue with intravenous tissue plasminogen activator alone or additionally proceed to neurothrombectomy using the Solitaire device within six-hours of symptom onset. The primary end-point is 90-day global disability, assessed with the modified Rankin Scale (mRS). Secondary outcomes include mortality at 90 days, functional independence (mRS ≤ 2) at 90 days, change in National Institutes of Health Stroke Scale at 27 h, reperfusion at 27 h, and thrombolysis in cerebral infarction 2b/3 flow at the end of the procedure. Statistical analysis will be conducted using simultaneous success criteria on the overall distribution of modified Rankin Scale (Rankin shift) and proportions of subjects achieving functional independence (mRS 0-2). © 2015 The Authors. International Journal of Stroke published by John Wiley & Sons Ltd on behalf of World Stroke Organization.

[The Phenotype of Chronic Obstructive Pulmonary Disease With Frequent Exacerbations in the Aspect of Long-term Percutaneous Coronary Intervention Results].

PubMed

Zafiraki, V K; Namitokov, A M; Skaletsky, K V; Kosmacheva, E D; Shulzhenko, L V; Ramazanov, J M; Omarov, A A; Pershukov, I V

2017-03-01

To evaluate the results of percutaneous coronary interventions (PCI) in patients with coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD), depending on the frequency of exacerbations of COPD. We enrolled in this prospective study 103 patients with CHD and COPD who underwent PCI (n=103) including 25 who satisfied criteria of COPD phenotype with frequent exacerbations (main group). Analysis included comparison of rates and times to major adverse cardiac events (MACE - myocardial infarction, stroke, cardiac death, repeat revascularization) in the main group and other patients. Clinical and functional features of patients with major adverse cardiac events were also analyzed. Study groups did not differ significantly on demographic characteristics and the presence of comorbidity. MACE frequency was almost 2 times higher in the main group (relative risk 1.87; 95% confidence interval (CI) 1.1-3.3). There was a tendency to higher rate of MACE among patients with history of more or equal 1 COPD exacerbations in a year (40% vs. 24%, p=0.09). The following clinical and functional characteristics of COPD, were associated with MACE in remote period after PCI: frequency of exacerbations, results of the COPD Assessment Test, exercise capacity, forced expiratory volume in 1 sec. Conclusion/ COPD phenotype with frequent exacerbations in patients with CHD undergoing PCI is associated with increased risk and earlier occurrence of MACE.

Aortic Wall Extracellular Matrix Proteins Correlate with Syntax Score in Patients Undergoing Coronary Artery Bypass Surgery

PubMed Central

Chiong, Terri; Cheow, Esther S. H.; Woo, Chin C.; Lin, Xiao Y.; Khin, Lay W.; Lee, Chuen N.; Hartman, Mikael; Sze, Siu K.; Sorokin, Vitaly A.

2016-01-01

Aims: The SYNTAX score correlate with major cardiovascular events post-revascularization, although the histopathological basis is unclear. We aim to evaluate the association between syntax score and extracellular matrix histological characteristics of aortic punch tissue obtained during coronary artery bypass surgery (CABG). This analysis compares coronary artery bypass surgery patients with High and Low syntax score which were followed up for one year period. Methods and Results: Patients with High (score ≥ 33, (n=77)) and Low Syntax Scores (score ≤ 22, (n=71)) undergoing elective CABG were recruited prospectively. Baseline clinical characteristics and surgical risks were well matched. At 1 year, EMACCE (Sum of cardiovascular death, stroke, congestive cardiac failure, and limb, gut and myocardial ischemia) was significantly elevated in the High syntax group (P=0.022). Mass spectrometry (MS)-based quantitative iTRAQ proteomic results validated on independent cohort by immunohistochemistry (IHC) revealed that the High syntax group had significantly upraised Collagen I (P<0.0001) and Elastin (P<0.0001) content in ascending aortic wall. Conclusion: This study shows that aortic extracellular matrix (ECM) differ between High and Low syntax groups with up-regulation of Collagen I and Elastin level in High Syntax Score group. This identifies aortic punches collected during CABG as another biomarker source related with atherosclerosis severity and possible clinical outcome. PMID:27347220

Further Insight into the Cardiovascular Risk Calculator Controversy: The Roles of Statins, Revascularizations, and Under-Ascertainment in the Women's Health Study

PubMed Central

Cook, Nancy R.; Ridker, Paul M

2015-01-01

Importance While the Pooled Cohort Equations from the recent ACC/AHA Guideline on the Assessment of Cardiovascular Risk have over-estimated cardiovascular risk in multiple external cohorts, the reasons for the discrepancy are unclear. Objective To determine whether increased use of statins over time, incident coronary revascularization procedures, or under-ascertainment of vascular events explain over-estimation of risk in a more contemporary population. Design, Setting, and Participants 27,542 women aged 45-79 with complete ascertainment of plasma lipids and other risk factors from the Women's Health Study (WHS), a nationwide cohort of US women free of cardiovascular disease, cancer or other major illness at baseline in 1992-95. Women were followed for a median of 10 years. Main Outcomes and Measures Atherosclerotic cardiovascular disease (ASCVD), defined as any myocardial infarction, any stroke, or death due to cardiovascular cause. Results 632 women experienced an ASCVD event over follow-up. The average predicted risk from the Pooled Cohort Equations was 3.6% over 10 years, compared to an actual observed risk of 2.2%. Predicted rates were 90% higher than the observed rates in the 0-<5% and 5-<7.5% risk groups and 40% higher in the 7.5-<10% and 10%+ risk groups. Rates of statin use and revascularizations increased over follow-up time and by risk group, and in sensitivity analyses, we estimated the hypothetical rates if no women were on statins or underwent revascularization procedures. After adjustment for intervention effects of statins and revascularization as well as hypothetical confounding by indication, predicted rates remained 80% higher than observed rates in the lower two risk groups and 30% higher in the upper two risk groups. Under-ascertainment is unlikely since follow-up rates in the WHS were 97%, and overall we would need 60% more events to match the numbers predicted using the Pooled Cohort Equations. Conclusions and Relevance Neither statin use, revascularization procedures, nor under-ascertainment of events explain the discrepancy between observed rates of ASCVD in the WHS and those predicted by the ACC/AHA Pooled Cohort Equations. Other explanations include changing patterns of risk within more contemporary populations. PMID:25285455

Economic Evaluation of Complete Revascularization for Patients with Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention.

PubMed

Barton, Garry R; Irvine, Lisa; Flather, Marcus; McCann, Gerry P; Curzen, Nick; Gershlick, Anthony H

2017-06-01

To determine the cost-effectiveness of complete revascularization at index admission compared with infarct-related artery (IRA) treatment only, in patients with multivessel disease undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction. An economic evaluation of a multicenter randomized trial was conducted, comparing complete revascularization at index admission to IRA-only P-PCI in patients with multivessel disease (12-month follow-up). Overall hospital costs (costs for P-PCI procedure(s), hospital length of stay, and any subsequent re-admissions) were estimated. Outcomes were major adverse cardiac events (MACEs, a composite of all-cause death, recurrent myocardial infarction, heart failure, and ischemia-driven revascularization) and quality-adjusted life-years (QALYs) derived from the three-level EuroQol five-dimensional questionnaire. Multiple imputation was undertaken. The mean incremental cost and effect, with associated 95% confidence intervals, the incremental cost-effectiveness ratio, and the cost-effectiveness acceptability curve were estimated. On the basis of 296 patients, the mean incremental overall hospital cost for complete revascularization was estimated to be -£215.96 (-£1390.20 to £958.29), compared with IRA-only, with a per-patient mean reduction in MACEs of 0.170 (0.044 to 0.296) and a QALY gain of 0.011 (-0.019 to 0.041). According to the cost-effectiveness acceptability curve, the probability of complete revascularization being cost-effective was estimated to be 72.0% at a willingness-to-pay threshold value of £20,000 per QALY. Complete revascularization at index admission was estimated to be more effective (in terms of MACEs and QALYs) and cost-effective (overall costs were estimated to be lower and complete revascularization thereby dominated IRA-only). There was, however, some uncertainty associated with this decision. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

[Surgical cryoablation and left ventriculoplasty for electrical storm after acute myocardial infarction].

PubMed

Tobe, Satoshi; Yoshida, K; Adachi, K; Fukase, K; Tanimura, N; Yamaguchi, M

2008-03-01

A 65-year-old man was referred to our hospital to treat recent anterior myocardial infarction. Coronary artery angiography showed acute occlusion of left anterior descending coronary artery (LAD) and chronic occlusion of right coronary artery. After emergent percutaneous coronary intervention for LAD, drug-refractory electrical storm necessitating frequent electrical defibrillating cardioversion occurred. This patient successfully underwent surgical cryoablation, left ventriculoplasty and coronary revascularization. At 2 years and 10th month after the operation, he is well without limitation of daily activities and any evidence of myocardial ischemia and ventricular tachycardia.

Intravascular Ultrasound to Guide Percutaneous Coronary Interventions

PubMed Central

2006-01-01

Executive Summary Objective The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of using intravascular ultrasound (IVUS) as an adjunctive imaging tool to coronary angiography for guiding percutaneous coronary interventions. Background Intravascular Ultrasound Intravascular ultrasound is a procedure that uses high frequency sound waves to acquire 3-dimensional images from the lumen of a blood vessel. The equipment for performing IVUS consists of a percutaneous transducer catheter and a console for reconstructing images. IVUS has been used to study the structure of the arterial wall and nature of atherosclerotic plaques, and obtain measurements of the vessel lumen. Its role in guiding stent placement is also being investigated. IVUS is presently not an insured health service in Ontario. Clinical Need Coronary artery disease accounts for approximately 55% of cardiovascular deaths, the leading cause of death in Canada. In Ontario, the annual mortality rate due to ischemic heart disease was 141.8 per 100,000 population between 1995 and 1997. Percutaneous coronary intervention (PCI), a less invasive approach to treating coronary artery disease, is used more frequently than coronary bypass surgery in Ontario. The number of percutaneous coronary intervention procedures funded by the Ontario Ministry of Health and Long-term Care is expected to increase from approximately 17, 780 in 2004/2005 to 22,355 in 2006/2007 (an increase of 26%), with about 95% requiring the placement of one or more stents. Restenosis following percutaneous coronary interventions involving bare metal stents occurs in 15% to 30% of the cases, mainly because of smooth muscle proliferation and migration, and production of extracellular matrix. In-stent restenosis has been linked to suboptimal stent expansion and inadequate lesion coverage, while stent thrombosis has been attributed to incomplete stent-to-vessel wall apposition. Since coronary angiography (the imaging tool used to guide stent placement) has been shown to be inaccurate in assessing optimal stent placement, and IVUS can provide better views of the vessel lumen, the clinical utility of IVUS as an imaging tool adjunctive to coronary angiography in coronary intervention procedures has been explored in clinical studies. Method A systematic review was conducted to answer the following questions: What are the procedure-related complications associated with IVUS? Does IVUS used in conjunction with angiography to guide percutaneous interventions improve patient outcomes compared to angiographic guidance without IVUS? Who would benefit most in terms of clinical outcomes from the use of IVUS adjunctive to coronary angiography in guiding PCIs? What is the effectiveness of IVUS guidance in the context of drug-eluting stents? What is the cost-effectiveness ratio and budget impact of adjunctive IVUS in PCIs in Ontario? A systematic search of databases OVID MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, The Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) database for the period beginning in May 2001 until the day of the search, November 4, 2005 yielded 2 systematic reviews, 1 meta-analysis, 6 randomized controlled trials, and 2 non-randomized studies on left main coronary arteries. The quality of the studies ranged from moderate to high. These reports were combined with reports from a previous systematic review for analysis. In addition to qualitative synthesis, pooled analyses of data from randomized controlled studies using a random effect model in the Cochrane Review Manager 4.2 software were conducted when possible. Findings of Literature Review & Analysis Safety Intravascular ultrasound appears to be a safe tool when used in coronary interventions. Periprocedural complications associated with the use of IVUS in coronary interventions ranged from 0.5% in the largest study to 4%. Coronary rupture was reported in 1 study (1/54). Other complications included prolonged spasms of the artery after stenting, dissection, and femoral aneurysm. Effectiveness Based on pooled analyses of data from randomized controlled studies, the use of intravascular ultrasound adjunctive to coronary intervention in percutaneous coronary interventions using bare metal stents yielded the following findings: For lesions predominantly at low risk of restenosis: There were no significant differences in preintervention angiographic minimal lumen diameter between the IVUS-guided and angiography-guided groups. IVUS guidance resulted in a significantly larger mean postintervention angiographic minimal lumen diameter (weighted mean difference of 0.11 mm, P = .0003) compared to angiographic guidance alone. The benefit in angiographic minimal lumen diameter from IVUS guidance was not maintained at 6-month follow-up, when no significant difference in angiographic minimal lumen diameter could be detected between the two arms (weighted mean difference 0.08, P = .13). There were no statistically significant differences in angiographic binary restenosis rates between IVUS-guidance and no IVUS guidance (Odds ratio [OR] 0.87 in favour of IVUS, 95% Confidence Interval [CI] [0.64–1.18], P = 0.37). IVUS guidance resulted in a reduction in the odds of target lesion revascularization (repeat percutaneous coronary intervention or coronary bypass graft) compared to angiographic guidance alone. The reduction was statistically significant at a follow-up period of 6 months to 1 year, and at a follow-up period of 18 month to 2 years (OR 0.52 in favour of IVUS, 95% CI [0.33–0.81], P = .004). Total revascularization rate (either target lesion or target vessel revascularization) was significantly lower for IVUS-guided patients at 18 months to 2.5 years after intervention (OR 0.43 in favour of IVUS, 95% CI [0.29–0.63], p < .0001). There were no statistically significant differences in the odds of death (OR 1.36 in favour of no IVUS, P =0.65) or myocardial infarction (OR 0.95 in favour of IVUS, P = 0.93) between IVUS-guidance and angiographic guidance alone at up to 2.5 years of follow-up The odds of having a major cardiac event (defined as death, myocardial infarction, and target lesion or target vessel revascularization) were significantly lower for patients with IVUS guidance compared to angiographic guidance alone during follow-up periods of up to 2.5 years (OR 0.53, 95% CI [0.36–0.78], P = 0.001). Since there were no significant reductions in the odds of death or myocardial infarction, the reduction in the odds of combined events reflected mainly the reduction in revascularization rates. For lesions at High Risk of Restenosis: There is evidence from one small, randomized controlled trial (n=150) that IVUS-guided percutaneous coronary intervention in long de novo lesions (>20 mm) of native coronary arteries resulted in statistically significant larger minimal lumen Diameter, and statistically significant lower 6-month angiographic binary restenosis rate. Target vessel revascularization rate and the rate of combined events were also significantly reduced at 12 months. A small subgroup analysis of a randomized controlled trial reported no benefit in clinical or angiographic outcomes for IVUS-guided percutaneous coronary interventions in patients with diabetes compared to those guided by angiography. However, due to the nature and size of the analysis, no firm conclusions could be reached. Based on 2 small, prospective, non-randomized controlled studies, IVUS guidance in percutaneous coronary interventions of left main coronary lesions using bare metal stents or drug-eluting stents did not result in any benefits in angiographic or clinical outcomes. These findings need to be confirmed. Interventions Using Drug-Eluting Stents There is presently no evidence on whether the addition of IVUS guidance during the implantation of drug-eluting stents would reduce incomplete stent apposition, or improve the angiographic or clinical outcomes of patients. Ontario-Based Economic Analysis Cost-effectiveness analysis showed that PCIs using IVUS guidance would likely be less costly and more effective than PCIs without IVUS guidance. The upfront cost of adjunctive use of IVUS in PCIs ranged from $1.56 million at 6% uptake to $13.04 million at 50% uptake. Taking into consideration cost avoidance from reduction in revascularization associated with the use of IVUS, a net saving of $0.63 million to $5.2 million is expected. However, since it is uncertain whether the reduction in revascularization rate resulting from the use of IVUS can be generalized to clinical settings in Ontario, further analysis on the budget impact and cost-effectiveness need to be conducted once Ontario-specific revascularization rates are verified. Factors to be Considered in the Ontario Context Applicability of Findings to Ontario The interim analysis of an Ontario field evaluation that compared drug-eluting stents to bare metal stents showed that the revascularization rates in low-risk patients with bare metal stents were much lower in Ontario compared to rates reported in randomized controlled trials (7.2% vs >17 %). Even though IVUS is presently not routinely used in the stenting of low-risk patients in Ontario, the revascularization rates in these patients in Ontario were shown to be lower than those reported for the IVUS groups reported in published studies. Based on this information and previous findings from the Ontario field evaluation on stenting, it is uncertain whether the reduction in revascularization rates from IVUS guidance can be generalized to Ontario. In light of the above findings, it is advisable to validate the reported benefits of IVUS guidance in percutaneous coronary interventions involving bare metal stents in the Ontario context. Licensing Status As of January 16, 2006, Health Canada has licensed 10 intravascular ultrasound imaging systems/catheters for transluminal intervention procedures, most as class 4 medical devices. Current Funding IVUS is presently not an insured procedure under the Ontario Health Insurance Plan and there are no professional fees for this procedure. All costs related to the use of IVUS are covered within hospitals’ global budgets. A single use IVUS catheter costs approximately $900CDN and the procedure adds approximately 20 minutes to 30 minutes to a percutaneous coronary intervention procedure. Diffusion According to an expert consultant, current use of IVUS in coronary interventions in Ontario is probably limited to high-risk cases such as interventions in long lesions, small vessels, and bifurcated lesions for which images from coronary angiography are indeterminate. It was estimated that IVUS is being used in about 6% of all percutaneous coronary interventions at a large Ontario cardiac centre. Expert Opinion IVUS greatly enhances the cardiac interventionists’ ability to visualize and assess high-risk lesions such as long lesions, narrow lesions, and bifurcated lesions that may have indeterminate angiographic images. Information from IVUS in these cases facilitates the choice of the most appropriate approach for the intervention. Conclusion The use of adjunctive IVUS in PCIs using bare metal stents in lesions predominantly at low risk for restenosis had no significant impact on survival, myocardial infarction, or angiographic restenosis rates up to 2.5 years after intervention. The use of IVUS adjunctive to coronary angiography in percutaneous coronary interventions using bare metal stents in lesions predominantly at low risk for restenosis significantly reduced the target lesion and target vessel revascularization at a follow-up period of 18 months to 2.5 years. One small study suggests that adjunctive IVUS in PCIs using bare metal stents in long lesions (>20 mm) significantly improved the 6-month angiographic restenosis rate and one-year target lesion revascularization rate. These results need to be confirmed with large randomized controlled trials. Based on information from the Ontario field evaluation on stenting, it is uncertain whether the reduction in revascularization rate resulting from the use of IVUS in the placement of bare metal stents can be generalized to clinical settings in Ontario. There is presently insufficient evidence available to determine the impact of adjunctive IVUS in percutaneous interventions in high-risk lesions (other than long lesions) or in PCIs using drug-eluting stents. PMID:23074482

Coronary artery disease treatment in dialysis patients at the Hospital das Clínicas da Faculdade de Medicina de Botucatu--UNESP.

PubMed

Vieira, Paula Ferreiro; Garcia, Paula Dalsoglio; Bregagnollo, Edson Antonio; Carvalho, Fábio Cardoso; Kochi, Ana Cláudia; Martins, Antonio Sérgio; Caramori, Jaqueline Costa Teixeira; Franco, Roberto Jorge da Silva; Barretti, Pasqual; Martin, Luis Cuadrado

2007-05-01

Interventional treatment of coronary insufficiency is underemployed among dialysis patients. Studies confirming its efficacy in this set of patients are scarce. To assess the results of interventional treatment of coronary artery disease in patients undergoing dialysis. A total of 34 dialysis patients submitted to coronary angiography between September 1995 and October 2004 were divided according to presence or absence of coronary lesion, type of treatment and presence or absence of diabetes mellitus. The groups were compared according to their clinical and survival characteristics. Survival of patients undergoing interventional treatment was compared to overall survival of 146 dialysis patients at the institution in the same period. Interventional treatment was indicated to the same clinical conditions in the general population. Thirteen patients with no angiography coronary lesions presented a survival rate of 100% in 48 months as compared to 35% of 21 patients with coronary artery disease. Diabetic patients had a lower survival rate compared with non-diabetics. Angioplasty had a worse prognosis compared to surgery; however, 80% of patients undergoing angioplasty were diabetic. Seventeen patients submitted to interventional procedures presented a survival rate similar to that of the others 146 hemodialysis patients without clinical evidence of coronary disease. This small series shows that myocardial revascularization, whenever indicated, can be performed in dialysis patients. This conclusion is corroborated by similar mortality rates in two groups of patients: coronary patients submitted to revascularization and overall dialysis patients.

High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

PubMed Central

Cutting, Shawna; Regan, Elizabeth; Lee, Vivien H.; Prabhakaran, Shyam

2016-01-01

Background and Purpose Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD2 scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD2 scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD2 scores. Results Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD2 scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD2 score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions Higher ABCD2 scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk’ patients. PMID:27721312

Clinical events in coronary heart disease patients with an ejection fraction of 40% or less: 3-year follow-up results.

PubMed

Pischke, Claudia R; Elliott-Eller, Melanie; Li, Minmin; Mendell, Nancy; Ornish, Dean; Weidner, Gerdi

2010-01-01

It is unclear whether lifestyle changes can delay the need for surgical procedures in coronary heart disease (CHD) patients with asymptomatic reduced left ventricular ejection fraction (LVEF). The aim of this pilot study was to examine whether lifestyle changes can delay the need for surgical procedures in this population. We compared 3-year clinical events in 27 CHD patients eligible to receive revascularization (by insurance standards), but underwent lifestyle changes (low-fat diet, exercise, stress management) instead (intervention group [IG], LVEF < or =40%), with those of a historically matched (age, gender, LVEF, and stenosis of the 3 major coronary arteries) control group receiving usual care (UCG; n = 13) who received revascularization at study entry. Both IG and UCG patients were enrolled in the health insurance companies participating in the Multicenter Lifestyle Demonstration Project, an insurance-sponsored, community-based, secondary prevention study implemented at 8 hospital sites in the United States. At 3 months, there were more cardiac events in the UCG (6 events) than in the IG (1 event; P < .006; odds ratio = 13.27; confidence interval = 1.57-111.94). This difference was maintained over 3 years (P < .06; odds ratio = 2.75; confidence interval = 1.05-7.19). Of the 26 surviving (1 cardiac death) IG patients, 23 did not require primary revascularization. In conclusion, CHD patients with asymptomatic reduced LVEF may be able to safely delay revascularization by making changes in lifestyle with no increased risk for cardiac events or overt heart failure over 3 years.

Iatrogenic left main coronary artery dissection due to pin-hole balloon rupture: Not to be panicked….

PubMed

Jeyakumaran, Balakumaran; Raj, Ajay; Pandit, Bhagya Narayan; Kumar, Tarun; Deora, Surender

2015-12-01

Iatrogenic left main coronary artery (LMCA) dissection is a rare complication and may have devastating consequences if not immediately intervened. The management includes urgent revascularization mostly with percutaneous coronary intervention (PCI) with bail-out stenting and rarely requires coronary artery bypass graft (CABG) surgery. In clinically and hemodynamically stable patients, a conservative approach may be preferred. Here, we present a rare case of iatrogenic retrograde LMCA dissection due to pin-hole rupture of angioplasty balloon that was managed conservatively.

Comments on the 2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment Elevation.

PubMed

Barrabes, J

2015-12-01

Patients who have undergone angioplasty with stenting can be reintegrated into normal life at an early stage, thanks to the absence of sequelae associated with the procedure itself. Consequently, these patients can be involved earlier in the second stage of cardiac rehabilitation. Although rehabilitation for coronary patients follows the general guidelines used for all patients, which were developed with the secondary prevention of coronary artery atherosclerosis in mind, the specific form of rehabilitation adopted for each individual with ischemic heart disease will depend on the patient's circumstances, including the revascularization technique used. Regular physical exercise (i.e. physical training), in itself, has substantial cardiovascular benefits for both primary and secondary cardiovascular prevention. In patients who have had a myocardial infarction, training decreases mortality, increases functional capacity and improves ventricular function and remodeling. It is also thought to boost the collateral circulation. In addition, training improves endothelial function and stimulates the circulation of stem cells. It has been shown that physical training after percutaneous revascularization decreases the number of cardiac events. Moreover, in patients with stable angina, it results in fewer events than percutaneous revascularization. Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection and Appropriateness of Percutaneous Coronary Intervention

PubMed Central

Desai, Nihar R.; Bradley, Steven M.; Parzynski, Craig S.; Nallamothu, Brahmajee K.; Chan, Paul S.; Spertus, John A.; Patel, Manesh R.; Ader, Jeremy; Soufer, Aaron; Krumholz, Harlan M.; Curtis, Jeptha P.

2017-01-01

Importance Appropriate Use Criteria for coronary revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined. Objective To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. Design, Setting, Participants Multi-center, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009 and December 31, 2014 at hospitals continuously participating in NCDR-CathPCI Registry over the study period. Main Outcome Measures Proportion of non-acute PCIs classified as inappropriate at the patient- and hospital-level using the 2012 Appropriate Use Criteria for Coronary Revascularization. Results A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume for acute indications was consistent over the study period (2010: 377,540; 2014: 374,543), but the volume for non-acute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing non-acute PCI, there were significant increases in angina severity (CCS III/IV angina, 15.8% and 38.4% in 2010 and 2014 respectively), use of anti-anginal medications prior to PCI (at least 2 anti-anginal medication, 22.3% and 35.1% in 2010 and 2014 respectively), and high-risk findings on non-invasive testing (22.2% and 33.2% in 2010 and 2014 respectively) (p<0.001 for all), but only modest increases in multivessel CAD (43.7% and 47.5% in 2010 and 2014 respectively, p<0.001). The proportion (95% CI) of non-acute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%–26.6%) to 13.3% (95% CI, 13.1%–13.6%) and the absolute number of inappropriate PCIs decreased from 21,781 to 7,921. Hospital-level variation in the proportion of PCIs classified as inappropriate was persistent over the study period (median 12.6%, IQR 5.9%–22.9% in 2014). Conclusions and Relevance Since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in non-acute PCI volume. The proportion of non-acute PCIs classified as inappropriate has declined though hospital-level variation in inappropriate PCI persists. PMID:26551163

ORBIT II sub-analysis: Impact of impaired renal function following treatment of severely calcified coronary lesions with the Orbital Atherectomy System.

PubMed

Lee, Michael S; Lee, Arthur C; Shlofmitz, Richard A; Martinsen, Brad J; Hargus, Nick J; Elder, Mahir D; Généreux, Philippe; Chambers, Jeffrey W

2017-04-01

To investigate the safety and efficacy of the coronary Orbital Atherectomy System (OAS) to prepare severely calcified lesions for stent deployment in patients grouped by renal function. Percutaneous coronary intervention (PCI) of severely calcified lesions is associated with increased rates of major adverse cardiac events (MACE), including death, myocardial infarction (MI), and target vessel revascularization (TVR) compared with PCI of non-calcified vessels. Patients with chronic kidney disease (CKD) are at increased risk for MACE after PCI. The impact of CKD on coronary orbital atherectomy treatment has not been well characterized. ORBIT II was a prospective, multicenter trial in the U.S., which enrolled 443 patients with severely calcified coronary lesions. The MACE rate was defined as a composite of cardiac death, MI, and target vessel revascularization. Of the 441 patients enrolled with known estimated glomerular filtration rate (eGFR) values at baseline, 333 (75.5%) patients had eGFR < 90 ml/min/1.73 m 2 and 108 patients had eGFR ≥ 90 ml/min/1.73 m 2 . The mean eGFR at baseline in the eGFR < 90 ml/min/1.73 m 2 and eGFR ≥ 90 ml/min/1.73 m 2 groups was 65.0 ± 0.9 ml/min/1.73 m 2 and 109.1 ± 2.0 ml/min/1.73 m 2 , respectively. Freedom from MACE was lower in the eGFR < 90 ml/min/1.73 m 2 group at 30 days (87.4% vs. 96.3%, P = 0.02) and 1-year (80.6% vs. 90.7%, P = 0.02). Patients with renal impairment had a higher MACE rate through one year follow-up due to a higher rate of periprocedural MI. Interestingly, the rates of cardiac death and revascularization through 1-year were similar in patients with eGFR < 90 ml/min/1.73 m 2 and eGFR ≥ 90 ml/min/1.73 m 2 . Future studies are needed to identify the ideal revascularization strategy for patients with renal impairment and severely calcified coronary lesions. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Left subclavian artery stenting: an option for the treatment of the coronary-subclavian steal syndrome

PubMed Central

de Almeida, Bruno Lorenção; Kambara, Antonio Massamitsu; Rossi, Fabio Henrique; Moreira, Samuel Martins; de Oliveira, Eduardo Silva Jordao; Linhares Filho, Frederico Augusto de Carvalho; Metzger, Patrick Bastos; Passalacqua, Aldo Zampieri

2014-01-01

Introduction The subclavian steal syndrome is characterized by the vertebral artery flow inversion, due to a stenotic lesion in the origin of the subclavian artery. The Coronary-subclavian Steal Syndrome is a variation of the Subclavian Steal Syndrome and is characterized by inversion of flow in the Internal Thracic artery that has been used as conduct in a myocardial revascularization. Its diagnosis must be suspected in patients with difference in pulse and arterial pressure in the upper limbs, that present with angina pectoris and that have done a myocardial revascularization. Its treatment must be a surgical bypass or a transluminal angioplasty. Objective The objective is to show the left subclavian artery stenting as a safe and effective method to treat the coronary-subclavian steal syndrome. Methods Historical prospective, non-randomized trial, through revision of the hospital records of the patients treated with the stenting of the left subclavian artery, from January 2006 to September 2012. Results In the mentioned period, 4.291 miocardial revascularizations were performed with the use of the left mammary artery, and 16 patients were identified to have the Coronary-subclavian steal syndrome. All of them were submitted to endovascular treatment. The success rate was 100%; two patients experienced minor complications; none of them presented with major complications. Eleven of the 16 patients had ultrassonographic documentation of patent stent for at least one year; two patients lost follow up and other two died. Conclusion The stenting of the left subclavian artery is a good option for the treatment of the Coronary-subclavian Steal Syndrome, with high level of technical and clinical success. PMID:25140474

Use of Medicare Data to Identify Coronary Heart Disease Outcomes In the Women's Health Initiative (WHI)

PubMed Central

Hlatky, Mark A; Ray, Roberta M; Burwen, Dale R; Margolis, Karen L; Johnson, Karen C; Kucharska-Newton, Anna; Manson, JoAnn E; Robinson, Jennifer G; Safford, Monika M; Allison, Matthew; Assimes, Themistocles L; Bavry, Anthony A; Berger, Jeffrey; Cooper-DeHoff, Rhonda M; Heckbert, Susan R; Li, Wenjun; Liu, Simin; Martin, Lisa W; Perez, Marco V; Tindle, Hilary A; Winkelmayer, Wolfgang C; Stefanick, Marcia L

2015-01-01

Background Data collected as part of routine clinical practice could be used to detect cardiovascular outcomes in pragmatic clinical trials, or in clinical registry studies. The reliability of claims data for documenting outcomes is unknown. Methods and Results We linked records of Women's Health Initiative (WHI) participants aged 65 years and older to Medicare claims data, and compared hospitalizations that had diagnosis codes for acute myocardial infarction (MI) or coronary revascularization with WHI outcomes adjudicated by study physicians. We then compared the hazard ratios for active versus placebo hormone therapy based solely on WHI adjudicated events with corresponding hazard ratios based solely on claims data for the same hormone trial participants. Agreement between WHI adjudicated outcomes and Medicare claims was good for the diagnosis for MI (kappa = 0.71 to 0.74), and excellent for coronary revascularization (kappa=0.88 to 0.91). The hormone:placebo hazard ratio for clinical MI was 1.31 (95% confidence interval (CI) 1.03 to 1.67) based on WHI outcomes, and 1.29 (CI 1.00 to 1.68) based on Medicare data. The hazard ratio for coronary revascularization was 1.09 (CI 0.88 to 1.35) based on WHI outcomes and 1.10 (CI 0.89 to 1.35) based on Medicare data. The differences between hazard ratios derived from WHI and Medicare data were not significant in 1,000 bootstrap replications. Conclusion Medicare claims may provide useful data on coronary heart disease outcomes among patients aged 65 years and older in clinical research studies. Clinical Trials Registration Information www.clinicaltrials.gov, Trial Number NCT00000611 PMID:24399330

The Relation of Arm Exercise Peak Heart Rate to Stress Test Results and Outcome.

PubMed

Xian, Hong; Liu, Weijian; Marshall, Cynthia; Chandiramani, Pooja; Bainter, Emily; Martin, Wade H

2016-09-01

Arm exercise is an alternative to pharmacologic stress testing for >50% of patients unable to perform treadmill exercise, but no data exist regarding the effect of attained peak arm exercise heart rate on test sensitivity. Thus, the purpose of this investigation was to characterize the relationship of peak arm exercise heart rate responses to abnormal stress test findings, coronary revascularization, and mortality in patients unable to perform leg exercise. From 1997 until 2002, arm cycle ergometer stress tests were performed in 443 consecutive veterans age 64.1 yr (11.0 yr) (mean (SD)), of whom 253 also underwent myocardial perfusion imaging (MPI). Patients were categorized by frequency distributions of quartiles of percentage age-predicted peak heart rate (APPHR), heart rate reserve (HRR), and peak heart rate-systolic blood pressure product (PRPP). Exercise-induced ST-segment depression, abnormal MPI findings, coronary revascularization, and 12.0-yr (1.3 yr) Kaplan-Meier all-cause and cardiovascular mortality plots were then characterized by quartiles of APPHR, HRR, and PRPP. A reduced frequency of abnormal arm exercise ECG results was associated only with the lowest quartile of APPHR (≤69%) and HRR (≤43%), whereas higher frequency of abnormal MPI findings exhibited an inverse relationship trend with lower APPHR (P = 0.10) and HRR (P = 0.12). There was a strong inverse association of APPHR, HRR, and PRPP with all-cause (all P ≤ 0.01) and cardiovascular (P < 0.05) mortality. The frequency of coronary revascularization was unrelated to APPHR or HRR. Arm exercise ECG stress test sensitivity is only reduced at ≤69% APPHR or ≤43% HRR, whereas arm exercise MPI sensitivity and referral for coronary revascularization after arm exercise stress testing are not adversely affected by even a severely blunted peak heart rate. However, both all-cause mortality and cardiovascular mortality are strongly and inversely related to APPHR and HRR.

Prognostic implications of Q waves at presentation in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: An analysis of the HORIZONS-AMI study.

PubMed

Kosmidou, Ioanna; Redfors, Björn; Crowley, Aaron; Gersh, Bernard; Chen, Shmuel; Dizon, José M; Embacher, Monica; Mehran, Roxana; Ben-Yehuda, Ori; Mintz, Gary S; Stone, Gregg W

2017-11-01

Presence of Q waves on the presenting electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with worse prognosis; however, whether the prognostic value of Q waves is influenced by baseline characteristics and/or rapidity of revascularization based on the guideline-based metric of door-to-balloon time remains unknown. We hypothesized that Q waves in the presenting ECG will be predictive of long term mortality regardless of time to reperfusion. The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial enrolled 3602 patients with STEMI undergoing primary percutaneous coronary intervention. We stratified patients without prior history of myocardial infarction or coronary revascularization according to presence or absence of pathological Q waves on their presenting ECG. Associations between Q waves, death, and cardiovascular outcomes within 3 years were assessed using Cox proportional hazards regression. Among 2723 patients with evaluable ECGs, 1084 (39.8%) had Q waves on their presenting ECG. Male sex and time from symptom onset to balloon inflation were independent predictors of presence of Q waves. Patients with Q waves had higher adjusted risks of all-cause death (adjusted hazard ratio: 1.45, 95% confidence interval: 1.02-2.05, P = 0.04) and cardiac death (adjusted hazard ratio: 1.72, 95% confidence interval: 1.08-2.72, P = 0.02). The association between Q waves and cardiac death was consistent regardless of sex, diabetes status, target vessel, or door-to-balloon time (P interaction > 0.4 for all). Presence of Q waves on the presenting ECG in patients undergoing primary percutaneous coronary intervention due to STEMI is an independent predictor of mortality and adds prognostic value, regardless of sex or rapidity of revascularization. © 2017 Wiley Periodicals, Inc.

Should we consider off-pump coronary artery bypass grafting in patients with acute coronary syndrome?

PubMed

Moscarelli, Marco; Harling, Leanne; Ashrafian, Hutan; Athanasiou, Thanos

2013-03-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery bypass (OPCAB) grafting should be considered as an alternative to the conventional on-pump surgery (ONCAB) in patients presenting with acute coronary syndrome (ACS) requiring emergency revascularization. Eighty-two papers were identified by a systematic search, of which nine were judged to best answer the clinical question. Of these, one was a randomized controlled trial and the remaining eight were retrospective observational studies. The author, journal, date, patient group, country of publication, relevant outcomes, results and study weaknesses were tabulated. In total, these nine studies included 3001 patients (n = 817 OPCAB, 2184 ONCAB) undergoing emergency revascularization in the setting of ACS. The timing between the onset of ACS and operative intervention ranged from 6 to 72 h. All cases were categorized as urgent/emergent according to the National confidential enquiry into patient outcome and death classification of intervention. Six studies included patients with preoperative cardiogenic shock; however the majority of patients were haemodynamically stable at the time of surgery. Three out of nine studies showed an improvement in 30-day mortality with OPCAB although the remaining six reveal no significant mortality benefit. No difference in long-term mortality was observed between the two techniques. OPCAB was associated with significantly fewer grafts per patient (six studies) and less complete revascularization (two studies). We conclude that whilst OPCAB may have a beneficial effect on 30-day mortality in haemodynamically stable patients undergoing emergency revascularization, there is a lack of high-quality data with clearly defined patient demographics. Future studies must ensure adequate preoperative matching between OPCAB and ONCAB groups and clearly categorize haemodynamic status, disease pattern and time to surgery in order to determine the patients in whom OPCAB may confer the greatest benefit.

Racial/Ethnic Variations in Physician Recommendations for Cardiac Revascularization

PubMed Central

Ibrahim, Said A.; Whittle, Jeff; Bean-Mayberry, Bevanne; Kelley, Mary E.; Good, Chester; Conigliaro, Joseph

2003-01-01

Objectives. We sought to examine whether physician recommendations for cardiac revascularization vary according to patient race. Methods. We studied patients scheduled for coronary angiography at 2 hospitals, one public and one private, between November 1997 and June 1999. Cardiologists were interviewed regarding their recommendations for cardiac resvacularization. Results. African American patients were less likely than Whites to be recommended for revascularization at the public hospital (adjusted odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.12, 0.77) but not at the private hospital (adjusted OR = 1.69; 95% CI = 0.69, 4.14). Conclusions. Physician recommendations for cardiac revascularization vary by patient race. Further studies are needed to examine physician bias as a factor in racial disparities in cardiac care and outcomes. PMID:14534223

Real-World Multicenter Registry of Patients with Severe Coronary Artery Calcification Undergoing Orbital Atherectomy.

PubMed

Lee, Michael S; Shlofmitz, Evan; Kaplan, Barry; Alexandru, Dragos; Meraj, Perwaiz; Shlofmitz, Richard

2016-08-01

We evaluated the safety and efficacy of orbital atherectomy in real-world patients with severe coronary artery calcification (CAC). The presence of severe CAC increases the complexity of percutaneous coronary intervention as it may impede stent delivery and optimal stent expansion. Atherectomy may be an indispensable tool for uncrossable or undilatable lesions by modifying severe CAC. Although the ORBIT I and II trials report that orbital atherectomy was safe and effective for the treatment of severe CAC, patients with kidney disease, recent myocardial infarction, long diffuse disease, severe left ventricular dysfunction, and unprotected left main disease were excluded. This retrospective study included 458 consecutive patients with severe CAC who underwent orbital atherectomy followed by stenting from October 2013 to December 2015 at 3 centers. The primary endpoint of major adverse cardiac and cerebrovascular events at 30 days was 1.7%. Low rates of 30-day all-cause mortality (1.3%), myocardial infarction (1.1%), target vessel revascularization (0%), stroke (0.2%), and stent thrombosis (0.9%) were observed. Angiographic complications were low: perforation was 0.7%, dissection 0.9%, and no-reflow 0.7%. Emergency coronary artery bypass graft surgery was performed in 0.2% of patients. In the largest real-world study of patients who underwent orbital atherectomy, including high-risk patients who were not surgical candidates as well as those with very complex coronary anatomy, acute and short-term adverse clinical event rates were low. A randomized clinical trial is needed to identify the ideal treatment strategy for patients with severe CAC. © 2016 The Authors. Journal of Interventional Cardiology Published by Wiley Periodicals, Inc.

Lack of association between lipoprotein(a) genetic variants and subsequent cardiovascular events in Chinese Han patients with coronary artery disease after percutaneous coronary intervention.

PubMed

Li, Zhi-Gen; Li, Guang; Zhou, Ying-Ling; Chen, Zhu-Jun; Yang, Jun-Qing; Zhang, Ying; Sun, Shuo; Zhong, Shi-Long

2013-08-27

Elevated lipoprotein(a) [Lp(a)] levels predict cardiovascular events incidence in patients with coronary artery disease (CAD). Genetic variants in the rs3798220, rs10455872 and rs6415084 single-nucleotide polymorphisms (SNPs) in the Lp(a) gene (LPA) correlate with elevated Lp(a) levels, but whether these SNPs have prognostic value for CAD patients is unknown. The present study evaluated the association of LPA SNPs with incidence of subsequent cardiovascular events in CAD patients after percutaneous coronary intervention (PCI). TaqMan SNP genotyping assays were performed to detect the rs6415084, rs3798220 and rs10455872 genotypes in 517 Chinese Han patients with CAD after PCI. We later assessed whether there was an association of these SNPs with incidence of major adverse cardiovascular events (MACE: cardiac death, nonfatal myocardial infarction, ischemic stroke and coronary revascularization). Serum lipid profiles were also determined using biochemical methods. Only the rs6415084 variant allele was associated with higher Lp(a) levels [41.3 (20.8, 74.6) vs. 18.6 (10.3, 40.9) mg/dl, p < 0.001]. During a 2-year follow-up period, 102 patients suffered MACE, and Cox regression analysis demonstrated that elevated Lp(a) (≥30 mg/dl) levels correlated with increased MACE (adjusted HR, 1.69; 95% CI 1.13-2.53), but there was no association between LPA genetic variants (rs6415084 and rs3798220) and MACE incidence (p > 0.05). Our data did not support a relationship between genetic LPA variants (rs6415084 and rs3798220) and subsequent cardiovascular events after PCI in Chinese Han CAD patients.

Eight-year follow-up of the Clopidogrel After Surgery for Coronary Artery Disease (CASCADE) trial.

PubMed

Hage, Ali; Voisine, Pierre; Erthal, Fernanda; Larose, Éric; Glineur, David; Chow, Benjamin; Tremblay, Hugo; Fortier, Jacqueline; Ko, Gifferd; Une, Dai; Farkouh, Michael; Mesana, Thierry G; LeMay, Michel; Kulik, Alexander; Ruel, Marc

2018-01-01

In this 8 years' follow-up study, we evaluated the long-term outcomes of the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting, versus aspirin plus placebo, with respect to survival, major adverse cardiac, or major cerebrovascular events, including revascularization, functional status, graft patency, and native coronary artery disease progression. In the initial Clopidogrel After Surgery for Coronary Artery Disease trial, 113 patients were randomized to receive either daily clopidogrel (n = 56) or placebo (n = 57), in addition to aspirin, in a double-blind fashion for 1 year after coronary artery bypass grafting. All patients were re-evaluated to collect long-term clinical data. Surviving patients with a glomerular filtration rate > 30 mL/min were asked to undergo a coronary computed tomography angiogram to evaluate the late saphenous vein graft patency and native coronary artery disease progression. At a median follow-up of 7.6 years, survival rate was 85.5% ± 3.8% (P = .23 between the 2 groups). A trend toward enhanced freedom from all-cause death or major adverse cardiac or cerebrovascular events, including revascularization, was observed in the aspirin-clopidogrel group (P = .11). No difference in functional status or freedom from angina was observed between the 2 groups (P > .57). The long-term patency of saphenous vein graft was 89.11% in the aspirin-clopidogrel group versus 91.23% in the aspirin-placebo group (P = .79). A lower incidence of moderate to severe native disease progression was observed in the aspirin-clopidogrel group versus the aspirin-placebo group (7 out of 122 vs 13 out of 78 coronary segments that showed progression, respectively [odds ratio, 0.3 ± 0.2; 95% confidence interval, 0.1-0.8; P = .02]). At 8 years' follow-up, the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting exhibited a lower incidence of moderate to severe progression of native coronary artery disease and a trend toward higher freedom from major adverse cardiac or cerebrovascular events, including revascularization, or death in the aspirin-clopidogrel group. http://www.clinicaltrials.gov. Unique identifier: NCT00228423. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Does off-pump coronary artery bypass graft surgery have a beneficial effect on long-term mortality and morbidity compared with on-pump coronary artery bypass graft surgery?

PubMed

Chaudhry, Umar A R; Rao, Christopher; Harling, Leanne; Athanasiou, Thanos

2014-07-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether off-pump coronary artery bypass grafting (CABG) surgery offered superior long-term outcomes compared with on-pump CABG surgery. Best evidence papers were considered to be those that had a follow-up period of ≥5 years, had >50 patients in either cohort, did not utilize concomitant interventions nor comprised low-risk, high-risk or sub-population groups. Where potential duplicate data sets from the same institution were likely, the more credible and recently published study was included. Two hundred and fifty-six papers were found as a result of the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The 16 studies comprised 4 prospective randomized controlled trials (RCTs), with the remaining 12 retrospective, of which 8 were propensity-score matched. All 4 RCTs contained fewer than 450 participants. Two studies concluded with a survival advantage towards on-pump CABG: one, a large registry-based study, the Veterans Affairs, with >25 000 patients, and another, a propensity-matched retrospective study involving almost 8000 patients. The remaining 14 studies all provided evidence to suggest comparable long-term survival. In addition, all other long-term outcomes mentioned within these studies including angina recurrence, myocardial infarction heart failure, need for revascularization, stroke, graft patency, cognitive and quality of life showed similar results between the two groups. We conclude that off-pump CABG surgery may have similar or slightly reduced long-term survival compared with on-pump CABG surgery. Other long-term indicators such as cardiovascular or cerebrovascular events or neuro-psychological outcomes were similar between the two groups. Despite these conclusions, the evidence is limited by substantial variability in patient selection and study methods. The CORONARY (coronary artery bypass surgery off- or on-pump revascularization study) trial recently presented results, which showed no significant differences in composite outcomes at 1 year; it will be interesting to observe whether these comparable outcomes are maintained for a much longer time frame. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Left atrial enlargement increases the risk of major adverse cardiac events independent of coronary vasodilator capacity.

PubMed

Koh, Angela S; Murthy, Venkatesh L; Sitek, Arkadiusz; Gayed, Peter; Bruyere, John; Wu, Justina; Di Carli, Marcelo F; Dorbala, Sharmila

2015-09-01

Longstanding uncontrolled atherogenic risk factors may contribute to left atrial (LA) hypertension, LA enlargement (LAE) and coronary vascular dysfunction. Together they may better identify risk of major adverse cardiac events (MACE). The aim of this study was to test the hypothesis that chronic LA hypertension as assessed by LAE modifies the relationship between coronary vascular function and MACE. In 508 unselected subjects with a normal clinical (82)Rb PET/CT, ejection fraction ≥40 %, no prior coronary artery disease, valve disease or atrial fibrillation, LAE was determined based on LA volumes estimated from the hybrid perfusion and CT transmission scan images and indexed to body surface area. Absolute myocardial blood flow and global coronary flow reserve (CFR) were calculated. Subjects were systematically followed-up for the primary end-point - MACE - a composite of all-cause death, myocardial infarction, hospitalization for heart failure, stroke, coronary artery disease progression or revascularization. During a median follow-up of 862 days, 65 of the subjects experienced a composite event. Compared with subjects with normal LA size, subjects with LAE showed significantly lower CFR (2.25 ± 0.83 vs. 1.95 ± 0.80, p = 0.01). LAE independently and incrementally predicted MACE even after accounting for clinical risk factors, medication use, stress left ventricular ejection fraction, stress left ventricular end-diastolic volume index and CFR (chi-squared statistic increased from 30.9 to 48.3; p = 0.001). Among subjects with normal CFR, those with LAE had significantly worse event-free survival (risk adjusted HR 5.4, 95 % CI 2.3 - 12.8, p < 0.0001). LAE and reduced CFR are related but distinct cardiovascular adaptations to atherogenic risk factors. LAE is a risk marker for MACE independent of clinical factors and left ventricular volumes; individuals with LAE may be at risk of MACE despite normal coronary vascular function.

Association Between Adiposity and Lean Mass With Long-Term Cardiovascular Events in Patients With Coronary Artery Disease: No Paradox.

PubMed

Medina-Inojosa, Jose R; Somers, Virend K; Thomas, Randal J; Jean, Nathalie; Jenkins, Sarah M; Gomez-Ibarra, Miguel Angel; Supervia, Marta; Lopez-Jimenez, Francisco

2018-05-08

Prognosis based on body fat percentage (BF%) in patients with coronary artery disease has not been extensively studied. We tested the hypothesis that patients with coronary artery disease and increased BF% have a higher risk for major adverse cardiovascular events (MACEs) and that fat-free mass is associated with better prognosis. We included 717 patients referred to cardiac rehabilitation after coronary artery disease events or procedures who underwent air displacement plethysmography to assess BF%; 75% were men, with a mean age 61.4±11.4 years and a mean body mass index of 30±5.4 kg/m 2 . Follow-up was performed using a record linkage system. Patients were classified in sex-specific quartiles of BF% and fat-free mass index. The composite outcome of MACEs included acute coronary syndromes, coronary revascularization, stroke, or death from any cause. After a median follow-up of 3.9 years, 201 patients had a MACE. After adjusting for covariates, body mass index was not associated with MACEs ( P =0.12). However, the risk of MACEs for those in the highest BF% quartile was nearly double when compared with those in the lowest quartile (hazard ratio, 1.89; 95% confidence interval, 1.30-2.77; P =0.0008). In contrast, fat-free mass was inversely associated with MACEs. The risk of MACEs for those in the fourth fat-free mass quartile was lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.35-0.82; P =0.004), when compared with those in the first quartile. In patients with coronary artery disease, there is no obesity paradox when measuring BF% instead of body mass index. BF% is associated with a higher risk of MACEs, whereas fat-free mass is associated with a lower risk of MACEs. Body mass index was not associated with MACEs. © 2018 The Authors and Mayo Clinic. Published on behalf of the American Heart Association, Inc., by Wiley.

Resting heart rate associates with one-year risk of major adverse cardiovascular events in patients with acute coronary syndrome after percutaneous coronary intervention.

PubMed

Wang, Shao-Li; Wang, Cheng-Long; Wang, Pei-Li; Xu, Hao; Du, Jian-Peng; Zhang, Da-Wu; Gao, Zhu-Ye; Zhang, Lei; Fu, Chang-Geng; Chen, Ke-Ji; Shi, Da-Zhuo

2016-03-01

The study was to access the association between resting heart rate (RHR) and one-year risk of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI). Patients with ACS after PCI (n = 808) were prospectively followed-up for MACE. RHR was obtained from electrocardiogram. MACE was defined as a composite of cardiac death, nonfatal recurrent myocardial infarction, ischemic-driven revascularization, and ischemic stroke. The association between RHR and one-year risk of MACE was assessed using Cox proportional hazards regression model. Compared with patients with RHR >76 bpm, the adjusted hazard ratio (AHR) was 0.51 (95% confidence intervals [CI]: 0.23-1.14; P = 0.100) for patients with RHR < 61 bpm, and 0.44 (95%CI: 0.23-0.85; P = 0.014) for those with RHR 61-76 bpm. For patients with RHR ≥ 61 bpm, an increase of 10 bpm in RHR was associated with an increase by 38.0% in the risk of MACE (AHR: 1.38; 95% CI: 1.04-1.83; P = 0.026). ACS patients after PCI with RHR >76 bpm were at higher risk of MACE during one-year follow-up compared with patients with RHR 61-76 bpm. An elevated RHR ≥ 61 bpm was associated with increased risk of one-year MACE in ACS patients. © 2015 by the Society for Experimental Biology and Medicine.

Resting heart rate associates with one-year risk of major adverse cardiovascular events in patients with acute coronary syndrome after percutaneous coronary intervention

PubMed Central

Wang, Shao-Li; Wang, Cheng-Long; Wang, Pei-Li; Xu, Hao; Du, Jian-Peng; Zhang, Da-Wu; Gao, Zhu-Ye; Zhang, Lei; Fu, Chang-Geng; Chen, Ke-Ji

2015-01-01

The study was to access the association between resting heart rate (RHR) and one-year risk of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI). Patients with ACS after PCI (n = 808) were prospectively followed-up for MACE. RHR was obtained from electrocardiogram. MACE was defined as a composite of cardiac death, nonfatal recurrent myocardial infarction, ischemic-driven revascularization, and ischemic stroke. The association between RHR and one-year risk of MACE was assessed using Cox proportional hazards regression model. Compared with patients with RHR >76 bpm, the adjusted hazard ratio (AHR) was 0.51 (95% confidence intervals [CI]: 0.23–1.14; P = 0.100) for patients with RHR < 61 bpm, and 0.44 (95%CI: 0.23–0.85; P = 0.014) for those with RHR 61–76 bpm. For patients with RHR ≥ 61 bpm, an increase of 10 bpm in RHR was associated with an increase by 38.0% in the risk of MACE (AHR: 1.38; 95% CI: 1.04–1.83; P = 0.026). ACS patients after PCI with RHR >76 bpm were at higher risk of MACE during one-year follow-up compared with patients with RHR 61–76 bpm. An elevated RHR ≥ 61 bpm was associated with increased risk of one-year MACE in ACS patients. PMID:26585407

CABG Surgery Remains the best Option for Patients with Left Main Coronary Disease in Comparison with PCI-DES: Meta-Analysis of Randomized Controlled Trials

PubMed Central

Sá, Michel Pompeu Barros Oliveira; Soares, Artur Freire; Miranda, Rodrigo Gusmão Albuquerque; Araújo, Mayara Lopes; Menezes, Alexandre Motta; Silva, Frederico Pires Vasconcelos; Lima, Ricardo Carvalho

2017-01-01

Objective To compare the safety and efficacy of coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) using drug-eluting stents (DES) in patients with unprotected left main coronary artery (ULMCA) disease. Methods MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported outcomes at 1-year follow-up after PCI with DES and CABG for the treatment of ULMCA stenosis. Five studies fulfilled our eligibility criteria and they included a total of 4.595 patients (2.298 for CABG and 2.297 for PCI with DES). Results At 1-year follow-up, there was no significant difference between CABG and DES groups concerning the risk for death (risk ratio [RR] 0.973, P=0.830), myocardial infarction (RR 0.694, P=0.148), stroke (RR 1.224, P=0.598), and major adverse cerebrovascular and cardiovascular events (RR 0.948, P=0.680). The risk for target vessel revascularization (TVR) was significantly lower in the CABG group compared to the DES group (RR 0.583, P<0.001). It was observed no publication bias regarding the outcomes, but only the outcome TVR was free from substantial statistical heterogeneity of the effects. In the meta-regression, there was evidence that the factor "female gender" modulated the effect regarding myocardial infarction rates, favoring the CABG strategy. Conclusion CABG surgery remains the best option of treatment for patients with ULMCA disease, with lower TVR rates. PMID:29211222

Heart rate and use of β-blockers in Mexican stable outpatients with coronary artery disease.

PubMed

Alcocer-Gamba, Marco Antonio; Martínez-Sánchez, Carlos; Verdejo-Paris, Juan; Ferrari, Roberto; Fox, Kim; Greenlaw, Nicola; Steg Philippe, Gabriel

2015-01-01

To evaluate the use of β-blockers and to monitor heart rate in Mexican patients with coronary artery disease. CLARIFY is an outpatients registry with stable CAD. A total of 33,283 patients from 45 countries were enrolled between November 2009 and July 2010 from which 1342 were Mexican patients. The mean HR pulse was 70 bpm (beats per minute). Patients in Mexico were compared with the remaining global CLARIFY population. Patients in Mexico had a higher incidence of acute myocardial infarction and percutaneous coronary intervention, and lower incidence of revascularization surgery compared with the remaining CLARIFY population. More often, Mexican patients presented with diabetes, but less often hypertension and stroke. These patients were split into three mutually exclusive groups of HR ≤ 60 (N=263), HR 61-69 (N=356) and HR ≥ 70 (N=722). Patients with elevated HR had a higher incidence of diabetes and higher diastolic blood pressure on average than those with controlled HR. Regarding the use of β-blockers, they were used in 63.3% of patients, 2.7% showed intolerance or contraindication to treatment to monitor heart rate, and ivabradine was used in 2.3%. Out of approximately 849 patients receiving treatment of β-blockers, 52.1% had ≥ 70 bpm HR. In a large proportion of Mexican patients with stable coronary disease the HR remain elevated, > 70 bpm, even with the use of β-blockers; this requires further attention. Copyright © 2014 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.

Prospective randomized comparison of coronary bypass grafting with minimal extracorporeal circulation system (MECC) versus off-pump coronary surgery.

PubMed

Mazzei, Valerio; Nasso, Giuseppe; Salamone, Giovanni; Castorino, Filippo; Tommasini, Antonello; Anselmi, Amedeo

2007-10-16

We aimed to evaluate the clinical results and biocompatibility of the minimal extracorporeal circulation system (MECC) compared with off-pump coronary revascularization (OPCABG). In a prospective randomized study, 150 patients underwent coronary surgery with the use of MECC and 150 underwent OPCABG. End points were (1) circulating markers of inflammation and organ injury, (2) operative results, and (3) outcome at 1-year follow-up. Operative mortality and morbidity were comparable between the groups. Release of inflammatory markers was similar between groups at all time points (peak interleukin-6 167.2+/-13.5 versus 181+/-6.5 pg/mL, P=0.14, OPCABG versus MECC group, respectively). Peak creatine kinase was 419.3+/-103.5 versus 326+/-84.2 mg/dL (P=0.28), and peak S-100 protein was 0.13+/-0.08 versus 0.29+/-0.1 pg/mL (P=0.058, OPCABG versus MECC group, respectively). Length of hospital stay and use of blood products were similar between groups. Two cases of angina recurrence at 1 year in the MECC group were observed versus 5 cases observed in the OPCABG group (P=0.44). A residual perfusion defect at myocardial nuclear scan was less frequent among patients in the MECC group (3 versus 9 cases, P=0.14; odds ratio 0.32, 95% confidence interval 0.07 to 1.32). Six (OPCABG group) versus 3 (MECC group) coronary grafts were occluded or severely stenotic at 1 year (P=0.33, odds ratio 0.47, 95% confidence interval 0.09 to 2.14). Clinical results of coronary revascularization with MECC are optimal when this procedure is performed by experienced teams. Postoperative morbidity is comparable to that with OPCABG. MECC is associated with little pump-related systemic and organ injury. It may achieve the benefits of OPCABG (less morbidity in high-risk patients) while facilitating complete revascularization in the case of complex lesions unsuitable for OPCABG.

[Papillary muscle rupture complicating acute myocardial infarction--treatment with mitral valve replacement and coronary bypass surgery in acute phase].

PubMed

Kyo, S; Miyamoto, N; Yokote, Y; Ueda, K; Takamoto, S; Omoto, R

1996-06-01

Complete rupture of a papillary muscle following acute myocardial infarction is a severe complication that is typically associated with acute left ventricular failure, pulmonary edema, and relentless clinical deterioration. The reported mortality rates without surgical intervention is almost 90%, therefore, prompt operation without prolonged attempts at medical stabilization is the key to decrease operative mortality. Although the complete coronary revascularization in conjunction with mitral valve replacement is advocated in the western medical academic society, there is only a few case of conjunct surgery has been reported in Japan. Three successful cases of conjunct surgery of mitral valve replacement and coronary complete revascularization in acute phase within one week from the onset of acute myocardial infarction (AMI) are described. There were one male and two female patients with an average age of 60-year-old (range 48-67), who developed cardiogenic shock and admitted to our hospital. The average interval between onset of AMI and the appearance of mitral regurgitation (MR) was 38 hours, and that of the appearance of MR and admission was 40 hours. Surgeries were performed within 26 hours (average 13 hours) after admission. The mitral valve was replaced with a mechanical valve (St. Jude Medical Valve) and a complete coronary revasculatization was done using saphenous vein graft. The average period of operation time and aortic cross clamping time were 6 hours 22 minutes and 109 minutes respectively. The average number of coronary grafting was 2.3 (range 1-3). Postoperative recovery from cardiogenic shock was uneventful in all three patients. The average periods of ICU stay and hospital stay were 5 days and 43 days respectively. All patients have regained their social activities with mean follow up period of 52 months. Since ischemic heart disease remains the leading cause of death in such patients, it is suggested that complete coronary revascularization should be performed immediately in conjunction with valve replacement even in the acute phase after onset of AMI.

Effects of preoperative aspirin in coronary artery bypass grafting: a double-blind, placebo-controlled, randomized trial.

PubMed

Deja, Marek A; Kargul, Tomasz; Domaradzki, Wojciech; Stącel, Tomasz; Mazur, Witold; Wojakowski, Wojciech; Gocoł, Radosław; Gaszewska-Żurek, Ewa; Żurek, Paweł; Pytel, Agata; Woś, Stanisław

2012-07-01

This trial was undertaken to determine the safety and efficacy of preoperative aspirin administration in a contemporary cardiac surgical practice setting. This randomized, double-blind, parallel-group, single-center trial involved patients with stable coronary artery disease who were assigned to receive either 300 mg of aspirin or placebo the night before coronary bypass surgery. Using a random digit table, patients were allocated to receive the tablet from 1 of the 40 coded bottles containing either aspirin or placebo. Patients, surgeons, anesthetists, and investigators were all masked to treatment allocation. The primary safety end points were as follows: more than 750 mL of bleeding during the first postoperative 12 hours and more than 1000 mL of total discharge from the chest drains. The secondary efficacy end point was a composite of cardiovascular death, myocardial infarction, or repeat revascularization. A total of 390 patients were allocated to aspirin (387 analyzed) and 399 to placebo (396 analyzed). The follow-up median was 53 months. Fifty-four placebo recipients and 86 aspirin recipients bled more than 750 mL in the first 12 hours (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.25-2.63), while total chest drain discharge was above 1000 mL in 96 placebo and 131 aspirin recipients (OR, 1.60; 95% CI, 1.17-2.18). Preoperative aspirin decreased the long-term hazard of nonfatal coronary event (infarction or repeat revascularization)-hazard ratio (HR), 0.58 (95% CI, 0.33-0.99)--and tended to decrease the hazard of a major cardiac event (cardiovascular death, infarction, or repeat revascularization--HR, 0.65 [95% CI, 0.41-1.03]). Performing coronary grafts on aspirin is associated with increased postoperative bleeding but may decrease the long-term hazard of coronary events. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Pathfinding to an optimal strategy of revascularization in primary coronary intervention in patients with multivessel disease: a network meta-analysis of randomized trials.

PubMed

Komócsi, András; Kehl, Dániel; d'Ascenso, Fabrizio; DiNicolantonio, James; Vorobcsuk, András

2017-03-01

In ST-segment elevation myocardial infarction (STEMI), current guidelines discourage treatment of the non-culprit lesions at the time of the primary intervention. Latest trials have challenged this strategy suggesting benefit of early complete revascularization. We performed a Bayesian multiple treatment network meta-analysis of randomized clinical trials (RCTs) in STEMI on culprit-only intervention (CO) versus different timing multivessel revascularization, including immediate (IM), same hospitalization (SH) or later staged (ST). Outcome parameters were pooled with a random-effects model. For multiple-treatment meta-analysis, a Bayesian Markov chain Monte Carlo method was used. Eight RCTs involving 2077 patients were identified. ST and IM revascularization was associated with a decrease in major adverse cardiac events (MACEs) compared to culprit-only approach (risk ratio [RR]: 0.43 credible interval [CrI]: 0.22-0.77 and RR: 0.36 CrI: 0.24-0.54, respectively). IM was superior to SH (RR: 0.49 CrI: 0.29-0.80). With regards to myocardial infarction IM was superior to SH (RR: 0.18 CrI: 0.02-0.99). The posterior probability of being the best choice of treatment regarding the frequency of MACEs was 71.2% for IM, 28.5% for ST, 0.3% for SH and 0.05% for culprit-only approach. Results from RCTs indicate that immediate or staged revascularization of non-culprit lesions reduces major adverse events in patients after primary percutaneous coronary intervention. Differences in MACEs suggest superiority of the immediate or staged intervention; however, further randomized trials are needed to determine the optimal timing of revascularization of the non-culprit lesions.

Short-term effect of percutaneous recanalization of chronic total occlusions on QT dispersion and heart rate variability parameters

PubMed Central

Erdogan, Ercan; Akkaya, Mehmet; Bacaksız, Ahmet; Tasal, Abdurrahman; Sönmez, Osman; Asoglu, Emin; Kul, Seref; Sahın, Musa; Turfan, Murat; Vatankulu, Mehmet Akif; Göktekin, Omer

2013-01-01

Background QT dispersion (QTd), which is a measure of inhomogeneity of myocardial repolarization, increases following impaired myocardial perfusion. Its prolongation may provide a suitable substrate for life-threatening ventricular arrhythmias. We investigated the changes in QTd and heart rate variability (HRV) parameters after successful coronary artery revascularization in a patient with chronic total occlusions (CTO). Material/Methods This study included 139 successfully revascularized CTO patients (118 men, 21 women, mean age 58.3±9.6 years). QTd was measured from a 12-lead electrocardiogram and was defined as the difference between maximum and minimum QT interval. HRV analyses of all subjects were obtained. Frequency domain (LF: HF) and time domain (SDNN, pNN50, and rMSSD) parameters were analyzed. QT intervals were also corrected for heart rate using Bazett’s formula, and the corrected QT interval dispersion (QTcd) was then calculated. All measurements were made before and after percutaneous coronary intervention (PCI). Results Both QTd and QTcd showed significant improvement following successful revascularization of CTO (55.83±14.79 to 38.87±11.69; p<0.001 and 61.02±16.28 to 42.92±13.41; p<0.001). The revascularization of LAD (n=38), Cx (n=28) and RCA (n=73) resulted in decrease in HRV indices, including SDDN, rMSSD, and pNN50, but none of the variables reached statistical significance. Conclusions Successful revascularization of CTO may result in improvement in regional heterogeneity of myocardial repolarization, evidenced as decreased QTcd after the PCI. The revascularization in CTO lesions does not seem to have a significant impact on HRV. PMID:23969577

Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly: a systematic review and meta-analysis.

PubMed

Deo, Salil V; Altarabsheh, Salah E; Shah, Ishan K; Cho, Yang Hyun; McGraw, Michael; Sarayyepoglu, Basar; Medalion, Benjamin; Markowitz, Alan H; Park, Soon J

2015-04-01

Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals. Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I(2) = 0%; p < 0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p = 0.86), stroke [OR 0.7(0.4-1.1); p = 0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p = 0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Insights into coronary collateral formation from a novel porcine semiacute infarction model.

PubMed

Krackhardt, Florian; Harnoss, Jonathan M; Waliszewski, Matthias W; Ritter, Zully; Granzow, Susanne; Felsenberg, Dieter; Neumann, Konrad; Lerman, Lilian O; Hillmeister, Philipp; Gebker, Rolf; Paetsch, Ingo; Riediger, Fabian; Bramlage, Peter; Buschmann, Ivo R

2018-03-01

For patients with severe ischemic heart disease, complete revascularization by a percutaneous coronary intervention or coronary artery bypass grafting is often not achieved and may still cause residual angina. In case of progressive coronary artery occlusions, therapeutic arteriogenesis constitutes a promising strategy for increasing blood supply to the ischemic myocardium. Whether the formation of collaterals in the hypofused myocardium is angiogenetic in nature or based on preformed coronary artery anastomoses remains debatable. The objectives of this research were (i) the development of an appropriate research methodology to study a humanoid animal semiacute infarction model with low mortality and (ii) to answer the question of whether collateral revascularization follows a pre-existing 'blueprint'. A porcine model was chosen in which a step-wise vessel occlusion was performed by implantation of a copper stent into the distal left anterior descending artery. Vessel occlusion and collateral development were confirmed in vivo every 14 days up to day 56 by repeated coronary angiography and myocardial perfusion measurement using cardiac MRI. After the completion of the in-vivo imaging studies, animals were euthanized and collateral growth was evaluated using microcomputer tomography. Our porcine model of semiacute noninvasive coronary artery occlusion confirmed the existence of preformed coronary anastomoses and the proliferation of functional vessels in hypoperfused myocardium. Repetitive intra-animal MRIs showed the functional impact of these growing collaterals. The confirmation of preformed coronary anastomoses during the process of collateralization (natural bypasses) offers a preclinical avenue to carry out arteriogenetic pharmaceutical research in patients with ischemic heart disease.

Potential Utility of the SYNTAX Score 2 in Patients Undergoing Left Main Angioplasty

PubMed Central

Madeira, Sérgio; Raposo, Luís; Brito, João; Rodrigues, Ricardo; Gonçalves, Pedro; Teles, Rui; Gabriel, Henrique; Machado, Francisco; Almeida, Manuel; Mendes, Miguel

2016-01-01

Background The revascularization strategy of the left main disease is determinant for clinical outcomes. Objective We sought to 1) validate and compare the performance of the SYNTAX Score 1 and 2 for predicting major cardiovascular events at 4 years in patients who underwent unprotected left main angioplasty and 2) evaluate the long-term outcome according to the SYNTAX score 2-recommended revascularization strategy. Methods We retrospectively studied 132 patients from a single-centre registry who underwent unprotected left main angioplasty between March 1999 and December 2010. Discrimination and calibration of both models were assessed by ROC curve analysis, calibration curves and the Hosmer-Lemeshow test. Results Total event rate was 26.5% at 4 years.The AUC for the SYNTAX Score 1 and SYNTAX Score 2 for percutaneous coronary intervention, was 0.61 (95% CI: 0.49-0.73) and 0.67 (95% CI: 0.57-0.78), respectively. Despite a good overall adjustment for both models, the SYNTAX Score 2 tended to underpredict risk. In the 47 patients (36%) who should have undergone surgery according to the SYNTAX Score 2, event rate was numerically higher (30% vs. 25%; p=0.54), and for those with a higher difference between the two SYNTAX Score 2 scores (Percutaneous coronary intervention vs. Coronary artery by-pass graft risk estimation greater than 5.7%), event rate was almost double (40% vs. 22%; p=0.2). Conclusion The SYNTAX Score 2 may allow a better and individualized risk stratification of patients who need revascularization of an unprotected left main coronary artery. Prospective studies are needed for further validation. PMID:27007223

Relation of Severe Coronary Artery Narrowing to Insulin or Thiazolidinedione Use in Patients With Type 2 Diabetes Mellitus (from the Bypass Angioplasty Revascularization Investigation 2 Diabetes Study)

PubMed Central

Pop-Busui, Rodica; Lombardero, Manuel; Lavis, Victor; Forker, Alan; Green, Jennifer; Korytkowski, Mary; Sobel, Burton E.; Jones, Teresa L.Z.

2009-01-01

Patients with diabetes continue to die of coronary artery disease (CAD) at rates 2 to 4 times higher than patients without diabetes, despite advances in treatment of cardiovascular disease. The role of glycemic control therapies, independent of their glucose-lowering effects, on cardiovascular disease is a recurring question. We examined the association of glycemic control therapies with extent of CAD as measured by coronary angiogram obtained at baseline in 1,803 subjects in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial who had type 2 diabetes mellitus, documented moderate to severe CAD, and no previous cardiac revascularization procedures. The association between glycemic control therapy use recorded at baseline and percent coronary artery stenosis and myocardial jeopardy index was analyzed by multiple regression models. Insulin use at study entry was associated with 23% fewer highly stenotic lesions (≥70%) (p <0.001) and a significantly lower myocardial jeopardy index compared with subjects not on insulin, despite a worse cardiac risk factor profile, more unstable angina, and increased inflammatory markers in insulin users. Subjects taking thiazolidinediones (TZDs) for ≥6 months had 17% fewer highly stenotic lesions (p = 0.02) and significantly lower C-reactive protein, fibrinogen, and plasminogen activator inhibitor-1 levels compared with those not taking TZDs. In conclusion, this cross-sectional study of patients with type 2 diabetes mellitus and CAD showed that treatment with insulin or TZDs was associated with fewer highly stenotic lesions, independent of disease duration, glycemic control, and other risk factors. PMID:19576321

Outcomes in African Americans and whites after percutaneous coronary intervention.

PubMed

Chen, Michael S; Bhatt, Deepak L; Chew, Derek P; Moliterno, David J; Ellis, Stephen G; Topol, Eric J

2005-09-01

We aimed to determine whether African Americans and whites have different outcomes after percutaneous coronary intervention (PCI). We prospectively selected 8832 patients (707 African Americans) for long-term follow-up after PCI at our institution from 1992 to 2002. The primary outcome studied was death or myocardial infarction at 1 year. Propensity adjustment was performed to account for baseline differences between African Americans and whites. African Americans had higher rates of diabetes and less prior revascularization. Percutaneous coronary interventions in African Americans were more often urgent. Stent use was similar. Procedural success rates were similar, as were periprocedural and 30-day composite rates of death or myocardial infarction. In 1-year unadjusted outcomes, African Americans had a higher rate of death or myocardial infarction (18.0% vs 14.5%; hazard ratio (HR) = 1.25; 95% confidence interval (CI): 1.04 to 1.50; P = 0.017), but the difference was no longer significant after propensity adjustment (HR = 1.18; 95% CI: 0.98 to 1.43, P = 0.087). African Americans had a higher risk for periprocedural bleeding that persisted after propensity adjustment (adjusted odds ratio = 1.45; 95% CI: 1.14 to 1.84, P = 0.002). After PCI, African Americans have similar short-term rates of death or myocardial infarction when compared with whites but have a nonsignificant trend toward worse long-term outcomes. Our findings, when interpreted in the context of reportedly lower revascularization rates among African Americans, suggest that continued efforts to optimize the appropriate use of coronary revascularization among African Americans are warranted.

Endovascular thrombectomy for acute ischemic stroke in failed intravenous tissue plasminogen activator versus non-intravenous tissue plasminogen activator patients: revascularization and outcomes stratified by the site of arterial occlusions.

PubMed

Shi, Zhong-Song; Loh, Yince; Walker, Gary; Duckwiler, Gary R

2010-06-01

Intracranial mechanical thrombectomy is a therapeutic option for acute ischemic stroke patients failing intravenous tissue plasminogen activator (IV tPA). We compared patients treated by mechanical embolus removal in cerebral ischemia (MERCI) thrombectomy after failed IV tPA with those treated with thrombectomy alone. We pooled MERCI and Multi MERCI study patients, grouped them either as failed IV tPA or non-IV tPA, and assessed revascularization rates, procedural complications, symptomatic hemorrhage rates, clinical outcomes, and mortality. We also evaluated outcomes stratified by the occlusion site and final revascularization. Among 305 patients, 48 failed, and 257 were ineligible for IV tPA. Nonresponders to IV tPA trended toward a higher revascularization rate (73% versus 63%) and less mortality (27.7% versus 40.1%) and had similar rates of symptomatic hemorrhage and procedural complications. Favorable 90-day outcomes were similar in failed and non-IV tPA patients (38% versus 31%), with no difference according to occlusion site. Among patients failing IV tPA, good outcomes tended to occur more frequently in revascularized patients (47.1% versus 15.4%), although this relationship was attributable solely to middle cerebral artery and not internal carotid artery occlusions, with no difference in mortality. Among IV tPA-ineligible patients, revascularization correlated with good outcome (47.4% versus 4.4%) and less mortality (28.5% versus 59.6%). The risks of hemorrhage and procedure-related complications after mechanical thrombectomy do not differ with respect to previous IV tPA administration. Thrombectomy after IV tPA achieves similar rates of good outcomes, a tendency toward lower mortality, and similar revascularization rates when stratified by clot location. Good outcomes correlate with successful revascularization except with internal carotid artery occlusions in tPA-nonresponders.

Kidney stones and cardiovascular risk: a meta-analysis of cohort studies.

PubMed

Liu, Yanqiong; Li, Shan; Zeng, Zhiyu; Wang, Jian; Xie, Li; Li, Taijie; He, Yu; Qin, Xue; Zhao, Jinmin

2014-09-01

Recent epidemiologic evidence suggests an association between kidney stones and incident cardiovascular disease after adjusting for other cardiovascular risk factors, but results are inconsistent. Meta-analysis of cohort studies. Patients with kidney stones. Cohort studies with data for kidney stones and cardiovascular morbidity identified in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings through February 27, 2014. Kidney stones as determined by physician diagnosis, clinical coding, or self-reported scales. Cardiovascular disease, coronary heart disease (CHD), and stroke. 6 cohort studies that contained 49,597 patients with kidney stones and 3,558,053 controls, with 133,589 cardiovascular events, were included. Pooled results suggested that kidney stones were associated with an increased adjusted risk estimate for CHD (HR, 1.19; 95% CI, 1.05-1.35; P=0.05; n=6 cohorts) and stroke (HR, 1.40; 95% CI, 1.20-1.64; P<0.001; n=3 cohorts). In particular, kidney stones conferred HRs of 1.29 (95% CI, 1.10-1.52; n=6 cohorts) and 1.31 (95% CI, 1.05-1.65; n=4 cohorts) for myocardial infarction and coronary revascularization, respectively. Moreover, the pooled female cohorts showed a statistically significant association (HR, 1.49; 95% CI, 1.21-1.82; n=4 cohorts), whereas the male cohorts showed no association (HR, 1.15; 95% CI, 0.89-1.50; n=2 cohorts). Results may be limited by substantial heterogeneity, likelihood of residual confounding, and paucity of studies that separately evaluated for effect modification by sex. Kidney stones were associated with increased cardiovascular risk, including the risk for incident CHD or stroke. There is some suggestion that the risk may be higher in women than men. Further prospective studies are needed to determine whether the association is sex specific. Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Inadequate reporting of concomitant drug treatment in cardiovascular interventional head-to-head trials.

PubMed

Mahfoud, Felix; Böhm, Michael; Baumhäkel, Magnus

2012-04-01

Optimal revascularization strategy is still under debate in patients with coronary artery disease, particularly due to the results of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial. Although medical prevention has been clearly shown to be beneficial in coronary artery disease, it has been suggested that patients were significantly undertreated with evidence-based medications for cardiovascular protection. The purpose of the study was to evaluate concomitant medical treatment in cardiovascular interventional head-to-head trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). A systematic search of the literature regarding documentation and reports of medical treatment in cardiovascular interventional head-to-head trials with more than 500 patients comparing CABG and PCI was performed. Systematic research of the literature identified 2106 articles of potential interest. After review and selection, only 3 trials reported on medical treatment. Baseline medication was reported in the RITA (Randomized Intervention Treatment of Angina), CABRI (Coronary Angioplasty versus Bypass Revascularisation Investigation), and SYNTAX trials, and follow-up data were provided by the CABRI and SYNTAX 3-year trials only. Poor reporting of medical treatment at discharge might reflect an underestimation of secondary prevention in patients undergoing cardiac surgery or interventional procedures in head-to-head interventional trials. Thus, discussion of optimal revascularization procedure has to remain open, even in terms of concomitant medical treatment of patients. © 2012 Wiley Periodicals, Inc.

Association of Medical Liability Reform With Clinician Approach to Coronary Artery Disease Management.

PubMed

Farmer, Steven A; Moghtaderi, Ali; Schilsky, Samantha; Magid, David; Sage, William; Allen, Nori; Masoudi, Frederick A; Dor, Avi; Black, Bernard

2018-06-06

Physicians often report practicing defensive medicine to reduce malpractice risk, including performing expensive but marginally beneficial tests and procedures. Although there is little evidence that malpractice reform affects overall health care spending, it may influence physician behavior for specific conditions involving clinical uncertainty. To examine whether reducing malpractice risk is associated with clinical decisions involving coronary artery disease testing and treatment. Difference-in-differences design, comparing physician-specific changes in coronary artery disease testing and treatment in 9 new-cap states that adopted damage caps between 2003 and 2005 with 20 states without caps. We used the 5% national Medicare fee-for-service random sample between 1999 and 2013. Physicians (n = 75 801; 36 647 in new-cap states) who ordered or performed 2 or more coronary angiographies. Data were analyzed from June 2015 to January 2018. Changes in ischemic evaluation rates for possible coronary artery disease, type of initial evaluation (stress testing or coronary angiography), progression from stress test to angiography, and progression from ischemic evaluation to revascularization (percutaneous coronary intervention or coronary artery bypass grafting). We studied 36 647 physicians in new-cap states and 39 154 physicians in no-cap states. New-cap states had younger populations, more minorities, lower per-capita incomes, fewer physicians per capita, and lower managed care penetration. Following cap adoption, new-cap physicians reduced invasive testing (angiography) as a first diagnostic test compared with control physicians (relative change, -24%; 95% CI, -40% to -7%; P = .005) with an offsetting increase in noninvasive stress testing (7.8%; 95% CI, -3.6% to 19.3%; P = .17), and referred fewer patients for angiography following stress testing (-21%; 95% CI, -40% to -2%; P = .03). New-cap physicians also reduced revascularization rates after ischemic evaluation (-23%; 95% CI, -40% to -4%; P = .02; driven by fewer percutaneous coronary interventions). Changes in overall ischemic evaluation rates were similar for new-cap and control physicians (-0.05%; 95% CI, -8.0% to 7.9%; P = .98). Physicians substantially altered their approach to coronary artery disease testing and follow-up after initial ischemic evaluations following adoption of damage caps. They performed a similar number of ischemic evaluations but conducted fewer initial left heart catheterizations, referred fewer stress-tested patients for left heart catheterizations, and referred fewer patients for revascularization. These findings suggest that physicians tolerate greater clinical uncertainty in coronary artery disease testing and treatment if they face lower malpractice risk.

Costs of revascularization over eight years in the randomized and eligible patients in the Emory Angioplasty versus Surgery Trial (EAST).

PubMed

Weintraub, W S; Becker, E R; Mauldin, P D; Culler, S; Kosinski, A S; King, S B

2000-10-01

The Emory Angioplasty versus Surgery Trial (EAST) was a randomized trial that compared, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary bypass grafting (CABG) for multivessel coronary artery disease. We present the findings of the economic analysis of EAST through 8 years of follow-up and compare the cost and outcomes of patients randomized in EAST versus patients eligible but not randomized (registry patients). Charges were assessed from hospital UB82 and UB92 bills and professional charges from the Emory Clinic. Hospital charges were reduced to cost through step-down accounting methods. All costs and charges were inflated to 1997 dollars. Costs were assessed for initial hospitalization and for cumulative costs of the initial hospitalization and additional revascularization procedures up to 8 years. Total 8-year costs were $46,548 for CABG and $44,491 for PTCA (p = 0.37). Cost of CABG in the eligible registry group showed a pattern similar to that for randomized patients, but total cost of PTCA was lower for registry patients than for randomized patients. Thus, the primary procedural costs of CABG are more than those for PTCA; this cost advantage, given the limits of measurement, is largely or even completely lost for randomized patients over the course of 8 years because of additional procedures after a first revascularization by PTCA.

Applications of laser in ischemic heart disease in China

NASA Astrophysics Data System (ADS)

Chen, Mingzhe; Zhang, Yongzhen

1999-09-01

Current data demonstrate that laser coronary angioplasty is most useful in complex lesions not well suited for percutaneous transluminal coronary angioplasty (PTCA). It is not `stand-alone' procedure, and should be considered an adjunct to PTCA or stenting. To date, there are not data supporting reduction of restenosis. Direct myocardial revascularization (DMR), either transmyocardial revascularization (TMR) or percutaneous (catheter-based) myocardial revascularization (PMR), uses laser to create channels between ischemic myocardium and left ventricular cavity. Candidates include patients with chronic, severe, refractory angina and those unable to undergo angioplasty or bypass surgery because conduits or acceptable target vessels are lacking. Although the mechanisms of action of DMR have not yet been clearly elucidated, but several theories have been proposed, including channel patency, angiogenesis, and denervation. TMR, typically requiring open thoracotomy, is effective for improving myocardial perfusion and reducing angina. Pilot studies demonstrate that clinical application of PMR is feasible and safe and effective for decreasing angina. Late sequelae also remain to be determined. An ongoing randomized clinical trial is comparing PMR with conventional medical therapy in patients with severe, refractory angina and disease unamenable to angioplasty or bypass surgery.

Coronary blood flow during cardiopulmonary resuscitation in swine

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bellamy, R.F.; DeGuzman, L.R.; Pedersen, D.C.

1984-01-01

Recent papers have raised doubt as to the magnitude of coronary blood flow during closed-chest cardiopulmonary resuscitation. We will describe experiments that concern the methods of coronary flow measurement during cardiopulmonary resuscitation. Nine anesthetized swine were instrumented to allow simultaneous measurements of coronary blood flow by both electromagnetic cuff flow probes and by the radiomicrosphere technique. Cardiac arrest was caused by electrical fibrillation and closed-chest massage was performed by a Thumper (Dixie Medical Inc., Houston). The chest was compressed transversely at a rate of 66 strokes/min. Compression occupied one-half of the massage cycle. Three different Thumper piston strokes were studied:more » 1.5, 2, and 2.5 inches. Mean aortic pressure and total systemic blood flow measured by the radiomicrosphere technique increased as Thumper piston stroke was lengthened (mean +/- SD): 1.5 inch stroke, 23 +/- 4 mm Hg, 525 +/- 195 ml/min; 2 inch stroke, 33 +/- 5 mm Hg, 692 +/- 202 ml/min; 2.5 inch stroke, 40 +/- 6 mm Hg, 817 +/- 321 ml/min. Both methods of coronary flow measurement (electromagnetic (EMF) and radiomicrosphere (RMS)) gave similar results in technically successful preparations (data expressed as percent prearrest flow mean +/- 1 SD): 1.5 inch stroke, EMF 12 +/- 5%, RMS 16 +/- 5%; 2 inch stroke, EMF 30 +/- 6%, RMS 26 +/- 11%; 2.5 inch stroke, EMF 50 +/- 12%, RMS 40 +/- 20%. The phasic coronary flow signal during closed-chest compression indicated that all perfusion occurred during the relaxation phase of the massage cycle. We concluded that coronary blood flow is demonstrable during closed-chest massage, but that the magnitude is unlikely to be more than a fraction of normal.« less

Carotid Artery Stenting

PubMed Central

2018-01-01

Carotid artery stenosis is relatively common and is a significant cause of ischemic stroke, but carotid revascularization can reduce the risk of ischemic stroke in patients with significant symptomatic stenosis. Carotid endarterectomy has been and remains the gold standard treatment to reduce the risk of carotid artery stenosis. Carotid artery stenting (CAS) (or carotid artery stent implantation) is another method of carotid revascularization, which has developed rapidly over the last 30 years. To date, the frequency of use of CAS is increasing, and clinical outcomes are improving with technical advancements. However, the value of CAS remains unclear in patients with significant carotid artery stenosis. This review article discusses the basic concepts and procedural techniques involved in CAS. PMID:29171201

[Registry of non-ST elevation acute coronary syndromes in a tertiary hospital (RESCATA-SEST registry)].

PubMed

González-Pliego, José Angel; Gutiérrez-Díaz, Gonzalo Israel; Celis, Alfredo; Gudiño-Amezcua, Diego Armando

2014-01-01

To describe the clinical-epidemiologic profile and the process of care of the non-ST elevation acute coronary syndromes in a tertiary hospital. We analyzed the clinical information, the risk stratification and diagnostic methods, the revascularization therapy and the prescription trends at discharge, of patients with non-ST elevation acute coronary syndromes cared for in one year. Two hundred and eighty-three patients with mean age of 58 years were included (63% men). The largest number of non-ST elevation acute coronary syndromes (88.6%) was found between 50 to 59 years of age. The most common risk factor was hypertension; 82.5% of the patients had a low-intermediate TIMI score; residual ischemia was demonstrated in 37% and coronary obstructions were seen in 80 patients (70%). In 90%, a percutaneous coronary intervention was performed, mainly with drug-eluting Stents (87.5%). At discharge, even though antiplatelet agents and statins were prescribed in more than 90%, other drugs were indicated in a few more than 50% of patients. In this population, non-ST elevation acute coronary syndromes predominates in relatively young men, often with hypertension. To stratify risk, to look for residual ischemia and to revascularize with drug-eluting stents are common practices, but the evidence-based guidelines compliance is still suboptimal. Copyright © 2013 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. All rights reserved.

Long-Term Prognostic Value of Coronary CT Angiography in Asymptomatic Type 2 Diabetes Mellitus.

PubMed

Kang, Se Hun; Park, Gyung-Min; Lee, Seung-Whan; Yun, Sung-Cheol; Kim, Young-Hak; Cho, Young-Rak; Park, Hyun Woo; Suh, Jon; Yang, Dong Hyun; Kang, Joon-Won; Lim, Tae-Hwan; Jung, Chang Hee; Koh, Eun Hee; Lee, Woo Je; Kim, Min-Seon; Lee, Ki-Up; Park, Joong-Yeol

2016-11-01

This study sought to evaluate the long-term prognostic value of coronary computed tomography angiography (CTA) in asymptomatic patients with type 2 diabetes mellitus. There are limited data on the long-term prognostic impact of coronary CTA in asymptomatic patients with type 2 diabetes mellitus. This study analyzed clinical outcomes of 591 consecutive asymptomatic patients with type 2 diabetes mellitus who underwent coronary CTA (mean age 62.2 ± 8.3 years and 352 men [59.6%]). A cardiac event was defined as a composite of cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or late coronary revascularization. Patients were categorized into 3 groups according to severity of coronary artery disease (CAD) on coronary CTA: normal coronary arteries, nonobstructive CAD (<50%), and obstructive CAD (≥50%). One hundred sixty-eight patients (28.4%) had normal coronary arteries, whereas 236 (39.9%) patients had nonobstructive CAD and 187 (31.6%) had obstructive CAD. During the follow-up period (median 5.3 years [interquartile range: 4.7 to 5.8 years]), 37 cardiac events occurred in 29 patents: 10 cardiac deaths, 2 nonfatal myocardial infarctions, 8 cases of unstable angina, and 17 late coronary revascularizations. The 6-year event-free survival rates were 99.3 ± 0.7% in patients with normal coronary arteries, 96.7 ± 1.2% in patients with nonobstructive CAD, and 86.2 ± 3.0% in patients with obstructive CAD (log-rank p < 0.001). Asymptomatic patients with type 2 diabetes mellitus with normal coronary arteries or nonobstructive CAD on coronary CTA show excellent clinical outcomes over a follow-up period of more than 5 years, whereas prognosis is worse in patients with obstructive CAD. These findings suggest long-term prognostic value of coronary CTA for asymptomatic type 2 diabetes mellitus. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

The Role of Alcohol Consumption in the Aetiology of Different Cardiovascular Disease Phenotypes: a CALIBER Study

ClinicalTrials.gov

2013-05-28

Chronic Stable Angina; Unstable Angina; Coronary Heart Disease Not Otherwise Specified; Acute Myocardial Infarction; Heart Failure; Ventricular Arrhythmias; Cardiac Arrest; Abdominal Aortic Aneurysm; Peripheral Arterial Disease; Ischaemic Stroke; Subarachnoid Haemorrhagic Stroke; Intracerebral Haemorrhagic Stroke; Stroke Not Otherwise Specified; Sudden Cardiac Death; Unheralded Coronary Death; Mortality; Coronary Heart Disease (CHD); Cardiovascular Disease (CVD); Fatal Cardiovascular Disease (Fatal CVD); ST Elevation Myocardial Infarction (STEMI); Non-ST Elevation Myocardial Infarction (nSTEMI); Myocardial Infarction Not Otherwise Specified (MI NOS)

Effects of statins on stroke prevention in patients with and without coronary heart disease: a meta-analysis of randomized controlled trials.

PubMed

Briel, Matthias; Studer, Marco; Glass, Tracy R; Bucher, Heiner C

2004-10-15

To assess if lipid-lowering interventions (statins, fibrates, resins, n-3 fatty acids, diet) prevent nonfatal and fatal strokes in patients with and without coronary heart disease. We systematically searched the literature up to August 2002 to retrieve all randomized controlled trials of lipid-lowering interventions that reported nonfatal and fatal stroke and mortality data. The search yielded 65 trials with 200,607 patients for a meta-analysis to determine whether treatment effects differed between types of lipid-lowering interventions and between patient samples with and without coronary heart disease. The risk ratio for nonfatal and fatal stroke for statins as compared with control interventions was 0.82 (95% confidence interval [CI]: 0.76 to 0.90). The corresponding risk ratios for statins as compared with control were 0.75 (95% CI: 0.65 to 0.87) for patients with coronary heart disease and 0.77 (95% CI: 0.62 to 0.95) for those without coronary heart disease. The confidence intervals of risk ratios for nonfatal and fatal stroke associated with fibrates, resins, n-3 fatty acids, and diet all included 1, as did the confidence intervals for these interventions in patients with and without coronary heart disease. Weighted meta-regression analysis suggested a stronger association of stroke reduction with statin treatment than with the extent of cholesterol reduction. This meta-analysis suggests that statins reduce the incidence of stroke in patients with and without coronary heart disease.

Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trials†.

PubMed

Deppe, Antje-Christin; Arbash, Wasim; Kuhn, Elmar W; Slottosch, Ingo; Scherner, Maximilian; Liakopoulos, Oliver J; Choi, Yeong-Hoon; Wahlers, Thorsten

2016-04-01

In the present systematic review with meta-analysis, we sought to determine the current strength of evidence for or against off-pump and on-pump coronary artery bypass grafting (CABG) with regard to hard clinical end-points, graft patency and cost-effectiveness. We performed a meta-analysis of only randomized controlled trials (RCT) which reported at least one of the desired end-points including: (i) major adverse cardiac and cerebrovascular events (MACCE), (ii) all-cause mortality, (iii) myocardial infarction, (iv) cerebrovascular accident, (v) repeat revascularization, (vi) graft patency and (vii) cost-effectiveness. The pooled treatment effects [odds ratio (OR) or weighted mean difference, 95% confidence intervals (95% CIs)] were assessed using a fixed or random effects model. A total of 16 904 patients from 51 studies were identified after literature search of the major databases using a predefined keyword list. The incidence of MACCE did not differ between the groups, neither during the first 30 days (OR: 0.93; 95% CI: 0.82-1.04) nor for the longest available follow-up (OR: 1.01; 95% CI: 0.92-1.12). While the incidence of mid-term graft failure (OR: 1.37; 95% CI: 1.09-1.72) and the need for repeat revascularization (OR: 1.55; 95% CI: 1.33-1.80) was increased after off-pump surgery, on-pump surgery was associated with an increased occurrence of stroke (OR: 0.74; 95% CI: 0.58-0.95), renal impairment (OR: 0.79; 95% CI: 0.71-0.89) and mediastinitis (OR: 0.44; 95% CI: 0.31-0.62). There was no difference with regard to hard clinical end-points between on- or off-pump surgery, including myocardial infarction or mortality. The present systematic review emphasizes that both off- and on-pump surgery provide excellent and comparable results in patients requiring surgical revascularization. The choice for either strategy should take into account the individual patient profile (comorbidities, life expectancy, etc.) and importantly, the surgeon's experience in performing on- or off-pump CABG in their routine practice. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Chronic total occlusion in ostium of right coronary artery – retrograde approach as the first-choice method of revascularization?

PubMed Central

Kameczura, Tomasz; Surowiec, Sławomir; Januś, Bogdan; Derlaga, Bogusław; Dudek, Dariusz; Czarnecka, Danuta

2013-01-01

Recanalization of chronic total occlusion (CTO) located in the ostium may require the operator's ability to use the retrograde approach. We present a case of opening a chronically occluded right coronary artery (RCA) by the retrograde approach after an unsuccessful attempt of recanalization by classic antegrade technique. PMID:24570749

The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis.

PubMed

Nielsen, Lene H; Ortner, Nino; Nørgaard, Bjarne L; Achenbach, Stephan; Leipsic, Jonathon; Abdulla, Jawdat

2014-09-01

To systematically review and perform a meta-analysis of the diagnostic accuracy and post-test outcomes of conventional exercise electrocardiography (XECG) and single-photon emission computed tomography (SPECT) compared with coronary computed tomography angiography (coronary CTA) in patients suspected of stable coronary artery disease (CAD). We systematically searched for studies published from January 2002 to February 2013 examining the diagnostic accuracy (defined as at least ≥50% luminal obstruction on invasive coronary angiography) and outcomes of coronary CTA (≥16 slice) in comparison with XECG and SPECT. The search revealed 11 eligible studies (N = 1575) comparing the diagnostic accuracy and 7 studies (N = 216.603) the outcomes of coronary CTA vs. XECG or/and SPECT. The per-patient sensitivity [95% confidence interval (95% CI)] to identify significant CAD was 98% (93-99%) for coronary CTA vs. 67% (54-78%) (P < 0.001) for XECG and 99% (96-100%) vs. 73% (59-83%) (P = 0.001) for SPECT. The specificity (95% CI) of coronary CTA was 82% (63-93%) vs. 46% (30-64%) (P < 0.001) for XECG and 71% (60-80%) vs. 48% (31-64%) (P = 0.14) for SPECT. The odds ratio (OR) of downstream test utilization (DTU) for coronary CTA vs. XECG/SPECT was 1.38 (1.33-1.43, P < 0.001), for revascularization 2.63 (2.50-2.77, P < 0.001), for non-fatal myocardial infarction 0.53 (0.39-0.72, P < 0.001), and for all-cause mortality 1.01 (0.87-1.18, P = 0.87). The up-front diagnostic performance of coronary CTA is higher than of XECG and SPECT. When compared with XECG/SPECT testing, coronary CTA testing is associated with increased DTU and coronary revascularization. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study.

PubMed

Anastasiadis, Kyriakos; Asteriou, Christos; Antonitsis, Polychronis; Argiriadou, Helena; Grosomanidis, Vassilios; Kyparissa, Magdalena; Deliopoulos, Apostolos; Konstantinou, Dimitrios; Tossios, Paschalis

2013-10-01

A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. Prospective randomized study. All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. One hundred twenty patients were assigned randomly into 2 groups (60 in each group). Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting. Copyright © 2013 Elsevier Inc. All rights reserved.

Impact of Low Diastolic Blood Pressure on Risk of Cardiovascular Death in Elderly Patients With Coronary Artery Disease After Revascularization　- The CREDO-Kyoto Registry Cohort-1.

PubMed

Kai, Hisashi; Kimura, Takeshi; Fukuda, Kenji; Fukumoto, Yoshihiro; Kakuma, Tatsuyuki; Furukawa, Yutaka

2016-04-25

We investigated the effects of age and low diastolic blood pressure (DBP) on cardiovascular death in patients with coronary artery disease (CAD) after coronary revascularization. Stable, chronic CAD patients after coronary revascularization in the CREDO-Kyoto registry cohort-1 were allocated to the Young (≤64 years, n=2,619), Young-Old (65-74 years, n=2,932), and Old-Old (≥75 years, n=1,629) groups. Kaplan-Meier analysis showed that the crude cumulative incidence of cardiovascular death was higher in Young-Old patients with DBP <70 mmHg (P<0.001) and in Old-Old patients with DBP <60 mmHg (P=0.017), but not <70 mmHg (P=0.629), compared with each counterpart. Low DBP did not increase cardiovascular death in young patients. After adjustments with independent predictors, DBP <60 mmHg did not increase the cardiovascular death in the Old-Old group (HR=1.579 [95% CI, 0.944-2.642], P=0.082) and DBP <70 mmHg remained a predictor in the Young-Old group (HR=1.665 [1.094-2.532], P=0.017). On multivariate stepwise Cox proportional hazard regression analysis, independent predictors for cardiovascular death in low DBP patients were creatinine clearance (CCr; inversely), prior cerebrovascular disease, and aortic disease in the Young-Old group and CCr (inversely) and malignancy in the Old-Old group. DBP <60 mmHg was not an independent factor for predicting cardiovascular death in Old-Old revascularized CAD patients, whereas DBP <70 mmHg remained a predictor in the Young-Old. (Circ J 2016; 80: 1232-1241).

Coronary Artery Revascularization in Patients with Diabetes Mellitus

MedlinePlus

... Bridging Disciplines Circulation at Major Meetings Special Themed Issues Global Impact of the 2017 ACC/AHA Hypertension Guidelines Circulation Supplements Cardiovascular Case Series ECG Challenge Hospitals of History Brigham and ...

Carotid Disease Management: Surgery, Stenting, or Medication.

PubMed

Khandelwal, Priyank; Chaturvedi, Seemant

2015-09-01

Internal carotid artery stenosis accounts for about 7-10 % of ischemic strokes. Conventional risk factors such as aging, hypertension, diabetes mellitus, and smoking increase the risk for carotid atherosclerosis. All patients with carotid stenosis should receive aggressive medical therapy. Carotid revascularization with either endarterectomy or stenting can benefit select patients with severe stenosis. New clinical trials will examine the contemporary role of carotid revascularization relative to optimal medical therapy.

Stress reduction in the secondary prevention of cardiovascular disease: randomized, controlled trial of transcendental meditation and health education in Blacks.

PubMed

Schneider, Robert H; Grim, Clarence E; Rainforth, Maxwell V; Kotchen, Theodore; Nidich, Sanford I; Gaylord-King, Carolyn; Salerno, John W; Kotchen, Jane Morley; Alexander, Charles N

2012-11-01

Blacks have disproportionately high rates of cardiovascular disease. Psychosocial stress may contribute to this disparity. Previous trials on stress reduction with the Transcendental Meditation (TM) program have reported improvements in cardiovascular disease risk factors, surrogate end points, and mortality in blacks and other populations. This was a randomized, controlled trial of 201 black men and women with coronary heart disease who were randomized to the TM program or health education. The primary end point was the composite of all-cause mortality, myocardial infarction, or stroke. Secondary end points included the composite of cardiovascular mortality, revascularizations, and cardiovascular hospitalizations; blood pressure; psychosocial stress factors; and lifestyle behaviors. During an average follow-up of 5.4 years, there was a 48% risk reduction in the primary end point in the TM group (hazard ratio, 0.52; 95% confidence interval, 0.29-0.92; P=0.025). The TM group also showed a 24% risk reduction in the secondary end point (hazard ratio, 0.76; 95% confidence interval, 0.51-0.1.13; P=0.17). There were reductions of 4.9 mmHg in systolic blood pressure (95% confidence interval -8.3 to -1.5 mmHg; P=0.01) and anger expression (P<0.05 for all scales). Adherence was associated with survival. A selected mind-body intervention, the TM program, significantly reduced risk for mortality, myocardial infarction, and stroke in coronary heart disease patients. These changes were associated with lower blood pressure and psychosocial stress factors. Therefore, this practice may be clinically useful in the secondary prevention of cardiovascular disease. Clinical Trial Registration- URL: www.clinicaltrials.gov Unique identifier: NCT01299935.

Job Strain, Job Insecurity, and Incident Cardiovascular Disease in the Women’s Health Study: Results from a 10-Year Prospective Study

PubMed Central

Slopen, Natalie; Glynn, Robert J.; Buring, Julie E.; Lewis, Tené T.; Williams, David R.; Albert, Michelle A.

2012-01-01

Objectives Research about work-related stressors and cardiovascular disease (CVD) has produced mixed findings. Moreover, a paucity of data exists regarding the long-term associations between job strain and job insecurity and CVD among women. Methods We used Cox proportional hazard models to examine the relationship between job strain, job insecurity, and incident CVD over 10 years of follow-up among 22,086 participants in the Women’s Health Study (mean age 57±5 years). Results During 10 years of follow-up there were 170 myocardial infarctions (MI), 163 ischemic strokes, 440 coronary revascularizations, and 52 CVD deaths. In models adjusted for age, race, education, and income, women with high job strain (high demand, low control) were 38% more likely to experience a CVD event than their counterparts who reported low job strain (low demand, high control; Rate Ratio (RR) = 1.38, 95% Confidence Interval (CI) = 1.08–1.77), and women with active jobs (high demand, high control) were 38% more likely to experience a CVD event relative to women who reported low job strain (95% CI = 1.07–1.77). Outcome-specific analyses revealed that high job strain predicted non-fatal myocardial infarction (RR = 1.67, CI = 1.04–2.70), and coronary revascularization (RR = 1.41, CI = 1.05–1.90). No evidence of an association between job insecurity and long-term CVD risk was observed. Conclusion High strain and active jobs, but not job insecurity, were related to increased CVD risk among women. Both job strain and job insecurity were significantly related to CVD risk factors. With the increase of women in the workforce, these data emphasize the importance of addressing job strain in CVD prevention efforts among working women. PMID:22815754

Prognostic Value of Adipokines in Predicting Cardiovascular Outcome: Explaining the Obesity Paradox.

PubMed

Wolk, Robert; Bertolet, Marnie; Singh, Prachi; Brooks, Maria M; Pratley, Richard E; Frye, Robert L; Mooradian, Arshag D; Rutter, Martin K; Calvin, Andrew D; Chaitman, Bernard R; Somers, Virend K

2016-07-01

To evaluate the cardiovascular (CV) prognostic value of adipokines in a large prospective cohort of patients participating in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. The effects of the adipokine levels at baseline and change from baseline on the composite outcome (CV death, myocardial infarction, and stroke) were analyzed using unadjusted and fully adjusted Cox models in 2330 patients with type 2 diabetes and coronary artery disease who had participated in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial (from January 1, 2001, through December 1, 2008). In a fully adjusted model, baseline leptin and change from baseline leptin were protective for CV events, whereas baseline adiponectin, baseline tumor necrosis factor α (TNF-α), change from baseline TNF-α, baseline C-reactive protein (CRP), and change from baseline CRP were harmful. The effect of baseline leptin on CV events depended on the body mass index (BMI), such that the hazard ratios (HRs) varied between 0.6 and 1.4 across the BMI quintiles (interaction P=.03). The same was true for baseline adiponectin (HR varied from 0.7 to 1.7; interaction P=.01), change from baseline monocyte chemoattractant protein-1 (HR varied from 0.8 to 1.8; interaction P=.03), change from baseline TNF-α (HR varied from 0.9 to 1.4; interaction P=.02), and change from baseline IL-6 (HR varied from 0.7 to 1.8; interaction P=.005). Adipokines are independent predictors of CV events in patients with type 2 diabetes and coronary artery disease. The association between the specific adipokines and CV outcome varies depending on BMI. This reflects the complex pathophysiology of CV disease in obesity and may help explain the "obesity paradox." clinicaltrials.gov Identifier: NCT00006305. Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Lipid abnormalities in women: data for risk, data for management.

PubMed

Wenger, Nanette K

2006-01-01

In multiple randomized, controlled clinical trials, statin treatment of elevated low-density lipoprotein cholesterol in women at increased risk of or with coronary heart disease decreased the risk of coronary events: coronary death, nonfatal myocardial infarction, and myocardial revascularization procedures. Total mortality was unchanged, potentially reflecting the underrepresentation of women in these trials and consequent small number of fatal events. Statin therapy provided comparable benefit for women and men with acute coronary syndromes. Application of lipid-lowering therapy with statin drugs is currently underutilized in women, and represents an opportunity to improve clinical cardiovascular outcomes for women.

Management of coronary artery disease

NASA Astrophysics Data System (ADS)

Safri, Z.

2018-03-01

Coronary Artery Disease (CAD) is associated with significant morbidity and mortality, therefore it’s important to early and accurate detection and appropriate management. Diagnosis of CAD include clinical examination, noninvasive techniques such as biochemical testing, a resting ECG, possibly ambulatory ECG monitoring, resting echocardiography, chest X-ray in selected patients; and catheterization. Managements of CAD patients include lifestyle modification, control of CAD risk factors, pharmacologic therapy, and patient education. Revascularization consists of percutaneous coronary angioplasty and coronary artery bypass grafting. Cardiac rehabilitation should be considered in all patients with CAD. This comprehensive review highlights strategies of management in patients with CAD.

Coronary revascularization in patients with liver cirrhosis.

PubMed

Marui, Akira; Kimura, Takeshi; Tanaka, Shiro; Miwa, Senri; Yamazaki, Kazuhiro; Minakata, Kenji; Nakata, Tomohiro; Ikeda, Tadashi; Furukawa, Yutaka; Kita, Toru; Sakata, Ryuzo

2011-05-01

Liver cirrhosis is a major risk factor for cardiac surgery using cardiopulmonary bypass. However, percutaneous coronary intervention (PCI) or off-pump coronary artery bypass graft surgery (OPCABG) may be a less invasive alternative strategy. Among the 9,877 patients undergoing first PCI or CABG enrolled in the CREDO-Kyoto Registry (a registry of first-time PCI and CABG patients in Japan), 332 patients diagnosed with liver cirrhosis were entered into the study (age 67.1±9.4 years; 246 male). Liver cirrhosis was diagnosed by liver biopsy or signs of portal hypertension with characteristic morphologic liver and spleen changes. A total of 233 patients received PCI, 58 conventional on-pump CABG (CCABG), and 41 OPCABG. Median follow-up was 3.3 years. The PCI group included less complex coronary lesions such as triple vessel and left main disease (p<0.01 each). Propensity score adjusted in-hospital mortality after CCABG or OPCABG was higher than that after PCI; however, the differences were not significant (odds ratio [95% confidence interval]: 6.84 [0.52 to 90.8], p=0.14 for CCABG versus PCI; and 1.86 [0.08 to 45.8], p=0.71 for OPCABG versus PCI). Adjusted overall mortality after CCABG or CABG was lower than that after PCI, but the differences were not significant (0.66 [0.31 to 1.40], p=0.28; and 0.64 [0.28 to 1.49], p=0.31, respectively). Approximately two thirds of patients died of noncardiovascular morbidities (malignancies, including hepatocarcinoma, or hepatic decompression). Because overall noncardiovascular mortality is high among patients with liver cirrhosis, complete revascularization may not be associated with better survival outcomes. Further study is warranted to determine the impact of a coronary revascularization strategy for liver cirrhosis patients. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Statins for acute coronary syndrome.

PubMed

Vale, Noah; Nordmann, Alain J; Schwartz, Gregory G; de Lemos, James; Colivicchi, Furio; den Hartog, Frank; Ostadal, Petr; Macin, Stella M; Liem, Anho H; Mills, Edward; Bhatnagar, Neera; Bucher, Heiner C; Briel, Matthias

2011-06-15

The early period following the onset of acute coronary syndromes (ACS) represents a critical stage of coronary heart disease with a high risk for recurrent events and deaths. The short-term effects of early treatment with statins in patients suffering from ACS on patient-relevant outcomes are unclear. To assess the benefits and harms of early administered statins in patients with ACS from randomized controlled trials (RCTs). We searched CENTRAL, MEDLINE, EMBASE, and CINAHL (to 1 February 2010). No language restrictions were applied. We supplemented the search by contacting experts in the field, by reviewing reference lists of reviews and editorials on the topic, and by searching trial registries. RCTs comparing statins with placebo or usual care, initiation of statin therapy within 14 days following the onset of ACS, and follow-up of at least 30 days reporting at least one clinical outcome. Two authors independently assessed study quality and extracted data. We pooled treatment effects and calculated risk ratios (RRs) for all outcomes in the treatment and control groups using a random effects model. Eighteen studies (14,303 patients) compared early statin treatment versus placebo or usual care in patients with ACS. Compared to placebo or usual care, early statin therapy did not decrease the combined primary outcome of death, non-fatal myocardial infarction (MI), and stroke at one month (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) and four months (RR 0.93, 95% CI 0.81 to 1.06) of follow-up. There were no statistically significant risk reductions from statins for total death, total MI, total stroke, cardiovascular death, revascularization procedures, and acute heart failure at one month and at four months, although there were favorable trends related to statin use for each of these endpoints. The incidence of episodes of unstable angina was significantly reduced at four months following ACS (RR 0.76, 95% CI 0.59 to 0.96). There were nine individuals with myopathy (elevated creatinine kinase levels > 10 times the upper limit of normal) in statin treated patients (0.13%) versus one (0.015%) in the control groups. Serious muscle toxicity was mostly limited to patients treated with simvastatin 80 mg. Based on available evidence, initiation of statin therapy within 14 days following ACS does not reduce death, myocardial infarction, or stroke up to four months, but reduces the occurrence of unstable angina at four months following ACS.

In-hospital management and outcome of patients on warfarin undergoing coronary stent implantation: results of the multicenter, prospective WARfarin and coronary STENTing (WAR-STENT) registry.

PubMed

Rubboli, Andrea; Sciahbasi, Alessandro; Briguori, Carlo; Saia, Francesco; Palmieri, Cataldo; Moroni, Luigi Andrea; Calabrò, Paolo; Leone, Antonio Maria; Franco, Nicoletta; Valgimigli, Marco; Varani, Elisabetta; Santi, Michela; Pasqualini, Paola; Capecchi, Alessandro; Piccalò, Giacomo; Margheri, Massimo; di Pasquale, Giuseppe; Galvani, Marcello; Bolognese, Leonardo; Gonzini, Lucio; Maggioni, Aldo Pietro

2013-04-01

The in-hospital management of patients on warfarin undergoing coronary stent implantation (PCI-S) is variable, and the in-hospital outcome incompletely defined. To determine the adherence to the current recommendations, and the incidence of adverse events, we carried out the prospective, multicenter, observational WARfarin and coronary STENTing (WAR-STENT) registry (ClinicalTrials.gov identifier NCT00722319). All consecutive patients on warfarin undergoing PCI-S at 37 Italian centers were enrolled and followed for 12 months. Outcome measures were: major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, need for urgent revascularization, stroke, and venous thromboembolism, and major and minor bleeding. In this paper, we report the in-hospital findings. Out of the 411 patients enrolled, 92% were at non-low (ie, moderate or high) thromboembolic risk. The radial approach and bare-metal stents were used in 61% and 60% of cases, respectively. Drug-eluting stents were essentially reserved to patients with diabetes, which in turn, significantly predicted the implantation of drug-eluting stents (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.29-3.17; P=.002). The in-hospital MACE and major bleeding rates were 2.7% and 2.1%, respectively. At discharge, triple therapy (TT) of warfarin, aspirin, and clopidogrel was prescribed to 76% of patients. Prescription of TT was significantly more frequent in the non-low thromboembolic risk group. Non-low thromboembolic risk, in turn, was a significant predictor of TT prescription (OR, 11.2; 95% CI, 4.83-26.3; P<.0001). In conclusion, real-world warfarin patients undergoing PCI-S are largely managed according to the current recommendations. As a consequence, the risk of in-hospital MACE and major bleedings appears limited and acceptable.

Worsening atrioventricular conduction after hospital discharge in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: the HORIZONS-AMI trial.

PubMed

Kosmidou, Ioanna; Redfors, Björn; McAndrew, Thomas; Embacher, Monica; Mehran, Roxana; Dizon, José M; Ben-Yehuda, Ori; Mintz, Gary S; Stone, Gregg W

2017-11-01

The chronic effects of ST-segment elevation myocardial infarction (STEMI) on the atrioventricular conduction (AVC) system have not been elucidated. This study aimed to evaluate the incidence, predictors, and outcomes of worsened AVC post-STEMI in patients treated with a primary percutaneous coronary intervention (PCI). The current analysis included patients from the HORIZONS-AMI trial who underwent primary PCI and had available ECGs. Patients with high-grade atrioventricular block or pacemaker implant at baseline were excluded. Analysis of ECGs excluding the acute hospitalization period indicated worsened AVC in 131 patients (worsened AVC group) and stable AVC in 2833 patients (stable AVC group). Patients with worsened AVC were older, had a higher frequency of hypertension, diabetes, renal insufficiency, previous coronary artery bypass grafting, and predominant left anterior descending culprit lesions. Predictors of worsened AVC included age, hypertension, and previous history of coronary artery disease. Worsened AVC was associated with an increased rate of all-cause death and major adverse cardiac events (death, myocardial infarction, ischemic target vessel revascularization, and stroke) as well as death or reinfarction at 3 years. On multivariable analysis, worsened AVC remained an independent predictor of all-cause death (hazard ratio: 2.005, confidence interval: 1.051-3.827, P=0.0348) and major adverse cardiac events (hazard ratio 1.542, confidence interval: 1.059-2.244, P=0.0238). Progression of AVC system disease in patients with STEMI treated with primary PCI is uncommon, occurs primarily in the setting of anterior myocardial infarction, and portends a high risk for death and major adverse cardiac events.

A Prospective, Randomized, Open-Label, Blinded, Endpoint Study Exploring Platelet Response to Half-Dose Prasugrel and Ticagrelor in Patients with the Acute Coronary Syndrome: HOPE-TAILOR Study.

PubMed

Jin, Cai De; Kim, Moo Hyun; Bang, Junghee; Serebruany, Victor

The optimal dosing of novel oral P2Y12 receptor platelet inhibitors such as prasugrel or ticagrelor is unclear and especially challenging in East Asians. We hypothesize that half-dose prasugrel and ticagrelor may be sufficient for long-term maintenance management in Korean patients with the acute coronary syndrome (ACS) compared with conventional dosages. HOPE-TAILOR (Half Dose of Prasugrel and Ticagrelor in Platelet Response after Acute Coronary Syndromes) is a prospective, randomized, open-label, blinded, endpoint (PROBE) single-center, clinical trial. A total of 100 patients with ACS undergoing drug-eluting stent implantation will be randomly assigned to prasugrel, ticagrelor, or clopidogrel, and the patients in each treatment group will receive 1-month therapy with 100 mg q.d. aspirin plus prasugrel 10 mg q.d., ticagrelor 90 mg b.i.d., or clopidogrel 75 mg q.d., followed by half-dose prasugrel 5 mg q.d. or ticagrelor 45 mg b.i.d. for maintenance treatment but without clopidogrel dose reduction. The primary endpoint will be optimal platelet reactivity 3 months after coronary intervention, defined by VerifyNow Analyzer (PRU: 85-208) and vasodilator-stimulated phosphoprotein P2Y12 flow cytometry assay (platelet reactivity indices: 16-50%). Clinical outcomes will also be assessed, including major efficacy (composite of cardiac death, nonfatal myocardial infarction, repeat revascularization, or stroke) and safety (bleeding ≥2 according to the Bleeding Academic Research Consortium). HOPE-TAILOR is a prospective, randomized, open-label, blinded, endpoint study to explore the efficacy and safety of novel P2Y12 receptor inhibitors administered orally at half the dose in Korean patients with ACS. The results will be available late in 2017. © 2017 S. Karger AG, Basel.

Vorapaxar in atherosclerotic disease management.

PubMed

Cheng, Judy W M; Colucci, Vincent; Howard, Patricia A; Nappi, Jean M; Spinler, Sarah A

2015-05-01

To review the pharmacology, efficacy, and safety of vorapaxar, a protease activator receptor-1 (PAR-1) antagonist, in the management of atherosclerotic diseases. Peer-reviewed clinical trials and review articles were identified from MEDLINE and Current Content database (both 1966 to December 31, 2014) using the search terms vorapaxar and protease activator receptor antagonist. A total of 30 clinical studies were identified (16 clinical trials, including subanalyses, 14 related to pharmacology, pharmacokinetics, and pharmacodynamics and drug interactions). Two phase III clinical trials with vorapaxar have been published. In patients with non-ST segment elevation myocardial infarction (MI), vorapaxar failed to significantly reduce the primary efficacy end point (composite of cardiovascular death, MI, stroke, recurrent ischemia with hospitalization, and urgent coronary revascularization). Conversely, in a study of secondary prevention for patients with cardiovascular disease, the composite end point of cardiovascular death, MI, or stroke was significantly reduced. In both trials, the safety end points of major/minor bleeding were increased compared with placebo. In the secondary prevention trial, an increased incidence of intracranial hemorrhage led to the exclusion of patients with a prior history of stroke. Vorapaxar is approved for use with aspirin and/or clopidogrel in the secondary prevention of cardiovascular events in stable patients with peripheral arterial disease or a history of MI. However, the addition of vorapaxar to other antiplatelets can significantly increase the risk of bleeding. It is, therefore, essential to balance the need for further reduction of risk of thrombotic event with patient's individual bleeding risk. © The Author(s) 2015.

Relation of Carotid Artery Plaque to Coronary Heart Disease and Stroke in Chinese Patients: Does Hyperglycemia Status Matter?

PubMed

Zhou, Huanhuan; Wang, Xiaoyun; Zhu, Junya; Fish, Anne; Kong, Weimin; Li, Fan; Liu, Lin; Yuan, Xiaodan; Gao, Xin; Lou, Qingqing

2018-03-01

To examine the association of carotid artery plaque with the incident coronary heart disease and stroke events in Chinese patients and explore whether the association differs between patients with and without hyperglycemia. We evaluated plaque, and blood pressure, total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fasting serum insulin, fasting plasma glucose, 2 h postprandial glucose and Homeostasis model assessment of insulin resistance in 253 Chinese patients. T-test and X 2 test were used to compare the clinical characteristics and Binary logistic regression was applied to analyze the association of coronary heart disease and stroke between patients with and without hyperglycemia. Among 253 patients, 162 patients had hyperglycemia (i. e., diabetes, impaired glucose regulation and stress induced hyperglycemia) and 155 (61.3%) patients had plaque. Fasting plasma glucose, 2 h postprandial glucose and Homeostasis model assessment of insulin resistance, triglycerides, plaque were significantly higher in the hyperglycemia group than non-hyperglycemia. The incident coronary heart disease and stroke events in patients with plaque were 2.254 (95%CI,1.203-4.224) and 2.437 (95%CI,1.042-5.701) times higher than those without plaque, respectively. Among hyperglycemia subgroup, plaque was an independent risk factor for coronary heart disease (OR,3.075,95%CI,1.353-6.992) and stroke (OR,3.571,95%CI,1.460-8.737). The slopes (associations between coronary heart disease/stroke and plaque) were steeper in the hyperglycemia group than those in the non-hyperglycemia group (coronary heart disease OR,3.075 vs. 2.614; stroke OR,3.571 vs. 3.307). The incident coronary heart disease and stroke events in patients with plaque were higher than those without plaque, and this difference was more pronounced for patients with hyperglycemia vs. those without hyperglycemia. © Georg Thieme Verlag KG Stuttgart · New York.

Clinical outcomes in middle cerebral artery trunk occlusions versus secondary division occlusions after mechanical thrombectomy: pooled analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI trials.

PubMed

Shi, Zhong-Song; Loh, Yince; Walker, Gary; Duckwiler, Gary R

2010-05-01

The benefit of endovascular revascularization of patients with acute ischemic stroke with middle cerebral artery (MCA) secondary division (M2) occlusions as compared with MCA trunk (M1) occlusions is not known. In this analysis, we compared revascularization status and clinical outcomes in patients with angiographically confirmed MCA M1 versus isolated M2 occlusions treated with mechanical thrombectomy using the Merci Retriever devices. We retrospectively analyzed the pooled data of patients with MCA strokes from the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI trials. Patient data were dichotomized into 2 groups: MCA M1 occlusions and isolated M2 occlusions. Baseline characteristics, revascularization rates, hemorrhage rates, complications, outcomes, and mortality were evaluated for both groups. Of 178 patients with MCA occlusion treated in the MERCI and Multi MERCI trials, 84.3% had M1 lesions and 15.7% had isolated M2 lesions. Patients with isolated M2 occlusions were revascularized at a higher rate, required a lower mean number of passes, and were associated with a trend toward shorter mean procedure time than patients with M1 occlusions. No statistically significant differences were found between M2 and M1 groups for symptomatic hemorrhage, clinically significant procedural adverse events, favorable 90-day outcome, or 90-day mortality, although in all instances, the M2 outcomes were numerically better than those in M1 subjects. In multivariate analysis, final revascularization was the strongest independent predictor of good outcome at 90 days. Patients with both MCA M1 occlusions and isolated M2 occlusions can achieve a relatively high rate of revascularization and favorable clinical outcomes after mechanical thrombectomy. In fact, patients with isolated M2 occlusions had a higher rate of revascularization, required fewer passes, and had no increased complications compared with patients with M1 occlusions.

[Two cases of acute coronary syndrome after intake of Clavis Panax].

PubMed

Atar, Aslı İnci; Er, Okan; Güven, Abdullah; Eryonucu, Beyhan

2012-04-01

Atherosclerotic cardiovascular disease is an epidemic in today's world. It is one of the most common causes of hospitalization and death. Therefore, remedies to control or heal the disease are continuously sought. In addition to scientifically researched therapies, patients frequently utilize alternative medicine. However, effective and toxic doses, metabolisms, and drug interactions of the herbs and herbal nutrition supplements are largely unknown. Herein, we present two cases with acute coronary syndrome. The first case was admitted with a diagnosis of acute inferior myocardial infaction (MI) and a stent was implanted to the occluded right coronary artery (RCA). There was a 50% stenosis in his left anterior descending artery (LAD). He was admitted with a diagnosis of non-ST elevation MI (NSTEMI) 6 months later. In the coronary angiogram, there was stent restenosis in RCA, the lesion in LAD had become thrombotic and progressed to a stenosis of 90%. He was referred to surgical revascularization. The second case was admitted for acute inferior MI and a stent was implanted to the occluded circumflex artery. Two months later, he was hospitalized for NSTEMI. Progression of coronary plaques to stenosis and stent restenosis was detected and he was referred to surgical revascularization. Both patients used the product sold as Clavis Panax, which contains panax ginseng, tribulus terrestris, and oat, after their first coronary intervention. Intake of a mixture of plant extracts may have serious consequences in humans as drug interactions and side effects are unknown.

Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II.

PubMed

Campos, Carlos M; van Klaveren, David; Farooq, Vasim; Simonton, Charles A; Kappetein, Arie-Pieter; Sabik, Joseph F; Steyerberg, Ewout W; Stone, Gregg W; Serruys, Patrick W

2015-05-21

To prospectively validate the SYNTAX Score II and forecast the outcomes of the randomized Evaluation of the Xience Everolimus-Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) Trial. Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization is a prospective, randomized multicenter trial designed to establish the efficacy and safety of percutaneous coronary intervention (PCI) with the everolimus-eluting stent compared with coronary artery bypass graft (CABG) surgery in subjects with unprotected left-main coronary artery (ULMCA) disease and low-intermediate anatomical SYNTAX scores (<33). After completion of patient recruitment in EXCEL, the SYNTAX Score II was prospectively applied to predict 4-year mortality in the CABG and PCI arms. The 95% prediction intervals (PIs) for mortality were computed using simulation with bootstrap resampling (10 000 times). For the entire study cohort, the 4-year predicted mortalities were 8.5 and 10.5% in the PCI and CABG arms, respectively [odds ratios (OR) 0.79; 95% PI 0.43-1.50). In subjects with low (≤22) anatomical SYNTAX scores, the predicted OR was 0.69 (95% PI 0.34-1.45); in intermediate anatomical SYNTAX scores (23-32), the predicted OR was 0.93 (95% PI 0.53-1.62). Based on 4-year mortality predictions in EXCEL, clinical characteristics shifted long-term mortality predictions either in favour of PCI (older age, male gender and COPD) or CABG (younger age, lower creatinine clearance, female gender, reduced left ventricular ejection fraction). The SYNTAX Score II indicates at least an equipoise for long-term mortality between CABG and PCI in subjects with ULMCA disease up to an intermediate anatomical complexity. Both anatomical and clinical characteristics had a clear impact on long-term mortality predictions and decision making between CABG and PCI. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

The potential cost-effectiveness of the Diamondback 360® Coronary Orbital Atherectomy System for treating de novo, severely calcified coronary lesions: an economic modeling approach

PubMed Central

Chambers, Jeffrey; Généreux, Philippe; Lee, Arthur; Lewin, Jack; Young, Christopher; Crittendon, Janna; Mann, Marita; Garrison, Louis P.

2015-01-01

Background: Patients who undergo percutaneous coronary intervention (PCI) for severely calcified coronary lesions have long been known to have worse clinical and economic outcomes than patients with no or mildly calcified lesions. We sought to assess the likely cost-effectiveness of using the Diamondback 360® Orbital Atherectomy System (OAS) in the treatment of de novo, severely calcified lesions from a health-system perspective. Methods and results: In the absence of a head-to-head trial and long-term follow up, cost-effectiveness was based on a modeled synthesis of clinical and economic data. A cost-effectiveness model was used to project the likely economic impact. To estimate the net cost impact, the cost of using the OAS technology in elderly (⩾ 65 years) Medicare patients with de novo severely calcified lesions was compared with cost offsets. Elderly OAS patients from the ORBIT II trial (Evaluate the Safety and Efficacy of OAS in Treating Severely Calcified Coronary Lesions) [ClinicalTrials.gov identifier: NCT01092426] were indirectly compared with similar patients using observational data. For the index procedure, the comparison was with Medicare data, and for both revascularization and cardiac death in the following year, the comparison was with a pooled analysis of the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI)/Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trials. After adjusting for differences in age, gender, and comorbidities, the ORBIT II mean index procedure costs were 17% (p < 0.001) lower, approximately US$2700. Estimated mean revascularization costs were lower by US$1240 in the base case. These cost offsets in the first year, on average, fully cover the cost of the device with an additional 1.2% cost savings. Even in the low-value scenario, the use of the OAS is cost-effective with a cost per life-year gained of US$11,895. Conclusions: Based on economic modeling, the recently approved coronary OAS device is projected to be highly cost-effective for patients who undergo PCI for severely calcified lesions. PMID:26702147

The potential cost-effectiveness of the Diamondback 360® Coronary Orbital Atherectomy System for treating de novo, severely calcified coronary lesions: an economic modeling approach.

PubMed

Chambers, Jeffrey; Généreux, Philippe; Lee, Arthur; Lewin, Jack; Young, Christopher; Crittendon, Janna; Mann, Marita; Garrison, Louis P

2016-04-01

Patients who undergo percutaneous coronary intervention (PCI) for severely calcified coronary lesions have long been known to have worse clinical and economic outcomes than patients with no or mildly calcified lesions. We sought to assess the likely cost-effectiveness of using the Diamondback 360(®) Orbital Atherectomy System (OAS) in the treatment of de novo, severely calcified lesions from a health-system perspective. In the absence of a head-to-head trial and long-term follow up, cost-effectiveness was based on a modeled synthesis of clinical and economic data. A cost-effectiveness model was used to project the likely economic impact. To estimate the net cost impact, the cost of using the OAS technology in elderly (⩾ 65 years) Medicare patients with de novo severely calcified lesions was compared with cost offsets. Elderly OAS patients from the ORBIT II trial (Evaluate the Safety and Efficacy of OAS in Treating Severely Calcified Coronary Lesions) [ClinicalTrials.gov identifier: NCT01092426] were indirectly compared with similar patients using observational data. For the index procedure, the comparison was with Medicare data, and for both revascularization and cardiac death in the following year, the comparison was with a pooled analysis of the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI)/Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trials. After adjusting for differences in age, gender, and comorbidities, the ORBIT II mean index procedure costs were 17% (p < 0.001) lower, approximately US$2700. Estimated mean revascularization costs were lower by US$1240 in the base case. These cost offsets in the first year, on average, fully cover the cost of the device with an additional 1.2% cost savings. Even in the low-value scenario, the use of the OAS is cost-effective with a cost per life-year gained of US$11,895. Based on economic modeling, the recently approved coronary OAS device is projected to be highly cost-effective for patients who undergo PCI for severely calcified lesions. © The Author(s), 2015.

Downstream resource utilization following hybrid cardiac imaging with an integrated cadmium-zinc-telluride/64-slice CT device.

PubMed

Fiechter, Michael; Ghadri, Jelena R; Wolfrum, Mathias; Kuest, Silke M; Pazhenkottil, Aju P; Nkoulou, Rene N; Herzog, Bernhard A; Gebhard, Cathérine; Fuchs, Tobias A; Gaemperli, Oliver; Kaufmann, Philipp A

2012-03-01

Low yield of invasive coronary angiography and unnecessary coronary interventions have been identified as key cost drivers in cardiology for evaluation of coronary artery disease (CAD). This has fuelled the search for noninvasive techniques providing comprehensive functional and anatomical information on coronary lesions. We have evaluated the impact of implementation of a novel hybrid cadmium-zinc-telluride (CZT)/64-slice CT camera into the daily clinical routine on downstream resource utilization. Sixty-two patients with known or suspected CAD were referred for same-day single-session hybrid evaluation with CZT myocardial perfusion imaging (MPI) and coronary CT angiography (CCTA). Hybrid MPI/CCTA images from the integrated CZT/CT camera served for decision-making towards conservative versus invasive management. Based on the hybrid images patients were classified into those with and those without matched findings. Matched findings were defined as the combination of MPI defect with a stenosis by CCTA in the coronary artery subtending the respective territory. All patients with normal MPI and CCTA as well as those with isolated MPI or CCTA finding or combined but unmatched findings were categorized as "no match". All 23 patients with a matched finding underwent invasive coronary angiography and 21 (91%) were revascularized. Of the 39 patients with no match, 5 (13%, p < 0.001 vs matched) underwent catheterization and 3 (8%, p < 0.001 vs matched) were revascularized. Cardiac hybrid imaging in CAD evaluation has a profound impact on patient management and may contribute to optimal downstream resource utilization.

Cost-effectiveness of drug-eluting coronary stents in Quebec, Canada.

PubMed

Brophy, James M; Erickson, Lonny J

2005-01-01

The aim of this investigation was to assess the incremental cost-effectiveness of replacing bare metal coronary stents (BMS) with drug-eluting stents (DES) in the Province of Quebec, Canada. The strategy used was a cost-effectiveness analysis from the perspective of the health-care provider, in the province of Quebec, Canada (population 7.5 million). The main outcome measure was the cost per avoided revascularization intervention. Based on the annual Quebec rate of 14,000 angioplasties with an average of 1.7 stents per procedure and a purchase cost of $2,600 Canadian dollar (CDN) for DES, 100 percent substitution of BMS with DES would require an additional $45.1 million CDN of funding. After the benefits of reduced repeat revascularization interventions are included, the incremental cost would be $35.2 million CDN. The cost per avoided revascularization intervention (18 percent coronary artery bypass graft, 82 percent percutaneous coronary intervention [PCI]) would be $23,067 CDN. If DES were offered selectively to higher risk populations, for example, a 20 percent subgroup with a relative restenosis risk of 2.5 times the current bare metal rate, the incremental cost of the program would be $4.9 million CDN at a cost of $7,800 per avoided revascularization procedure. Break-even costs for the program would occur at DES purchase cost of $1,161 for 100 percent DES use and $1,627 for selective 20 percent DES use for high-risk patients for restenosis (RR = 2.5). Univariate and Monte Carlo sensitivity analyses indicate that the parameters most affecting the analysis are the capacity to select patients at high risk of restenosis, the average number of stents used per PCI, baseline restenosis rates for BMS, the effectiveness ratio of restenosis prevention for DES versus BMS, the cost of DES, and the revascularization rate after initial PCI. Sensitivity analyses suggest little additional health benefits but escalating cost-effectiveness ratios once a DES penetration of 40 percent has been attained. Under current conditions in Quebec, Canada, selective use of DES in high-risk patients is the most acceptable strategy in terms of cost-effectiveness. Results of such an analysis would be expected to be similar in other countries with key model parameters similar to those used in this model. This model provides an example of how to evaluate the cost-effectiveness of selective use of a new technology in high-risk patients.

Revascularization of Left Coronary System Using a Skeletonized Left Internal Mammary Artery　- Sequential vs. Separate Grafting.

PubMed

Ji, Qiang; Shi, YunQing; Xia, LiMin; Ma, RunHua; Shen, JinQiang; Lai, Hao; Ding, WenJun; Wang, ChunSheng

2017-12-25

To evaluate in-hospital and mid-term outcomes of sequential vs. separate grafting of in situ skeletonized left internal mammary artery (LIMA) to the left coronary system in a single-center, propensity-matched study.Methods and Results:After propensity score-matching, 120 pairs of patients undergoing first scheduled isolated coronary artery bypass grafting (CABG) with in situ skeletonized LIMA grafting to the left anterior descending artery (LAD) territory were entered into a sequential group (sequential grafting of LIMA to the diagonal artery and then to the LAD) or a control group (separate grafting of LIMA to the LAD). The in-hospital and follow-up clinical outcomes and follow-up LIMA graft patency were compared. Both propensity score-matched groups had similar in-hospital and follow-up clinical outcomes. Sequential LIMA grafting was not found to be an independent predictor of adverse events. During a follow-up period of 27.0±7.3 months, 99.1% patency for the diagonal site and 98.3% for the LAD site were determined by coronary computed tomographic angiography after sequential LIMA grafting, both of which were similar with graft patency of separate grafting of in situ skeletonized LIMA to the LAD. Revascularization of the left coronary system using a skeletonized LIMA resulted in excellent in-hospital and mid-term clinical outcomes and graft patency using sequential grafting.

Myocardial revascularization with miniaturized extracorporeal circulation versus off pump: Evaluation of systemic and myocardial inflammatory response in a prospective randomized study.

PubMed

Formica, Francesco; Broccolo, Francesco; Martino, Antonello; Sciucchetti, Jennifer; Giordano, Vincenzo; Avalli, Leonello; Radaelli, Gianluigi; Ferro, Orazio; Corti, Fabrizio; Cocuzza, Clementina; Paolini, Giovanni

2009-05-01

This prospective randomized study sought to verify the systemic inflammatory response, inflammatory myocardial damage, and early clinical outcome in coronary surgery with the miniaturized extracorporeal circulation system or on the beating heart. Sixty consecutive patients were randomized to miniaturized extracorporeal circulation (n = 30) or off-pump coronary revascularization (off-pump coronary artery bypass grafting, n = 30). Intraoperative and postoperative data were recorded. Plasma levels of interleukin-6 and tumor necrosis factor-alpha were measured from systemic blood intraoperatively, at the end of operation, and 24 and 48 hours thereafter. Levels of the same markers and blood lactate were measured from coronary sinus blood intraoperatively to evaluate myocardial inflammation. Markers of myocardial damage were also analyzed. One patient died in the off-pump coronary artery bypass grafting group. There was no statistical difference in early clinical outcome in both groups. Release of interleukin-6 was higher in the off-pump coronary artery bypass grafting group 24 hours after the operation (P = .03), whereas levels of tumor necrosis factor-alpha were not different in both groups. Cardiac release of interleukin-6, tumor necrosis factor-alpha, and blood lactate were not different in both groups. Release of troponin T was not significantly different in both groups. Levels of creatine kinase mass were statistically higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group, but only at the end of the operation (P < .0001). Hemoglobin levels were significantly higher in the miniaturized extracorporeal circulation group than in the off-pump coronary artery bypass grafting group after 24 hours (P = .01). Miniaturized extracorporeal circulation can be considered similar to off-pump surgery in terms of systemic inflammatory response, myocardial inflammation and damage, and early outcome.

Early Results of Coronary Endarterectomy Combined with Coronary Artery Bypass Grafting in Patients with Diffused Coronary Artery Disease

PubMed Central

Chi, Li-Qun; Zhang, Jian-Qun; Kong, Qing-Yu; Xiao, Wei; Liang, Lin; Chen, Xin-Liang

2015-01-01

Background: It is still a challenge for the cardiac surgeons to achieve adequate revascularization for diffused coronary artery disease (CAD). Coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and revascularization. In this study, short-term result of CE combined with coronary artery bypass graft (CABG) was discussed in the treatment for the diffused CAD. Methods: From January 2012 to April 2014, 221 cases of CABG were performed by the same surgeon in our unit. Among these cases, 38 cases of CE + CABG were performed, which was about 17.2% (38/221) of the cohort. All these patients were divided into two groups: CE + CABG group (Group A) and CABG alone group (Group B). All clinical data were compared between the two groups, and postoperative complications and in-hospital mortality were analyzed. The categorical and continuous variables were analyzed by Chi-square test and Student's t-test respectively. Results: Diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease were more common in group A. In this cohort, a total of 50 vessels were endarterectomized. Among them, CE was performed on left anterior descending artery in 11 cases, on right coronary artery in 29 cases, on diagonal artery in 3 cases, on intermediate artery in 2 cases, on obtuse marginal artery in 5 cases. There was no hospital mortality in both groups. The intro-aortic balloon pump was required in 3 cases in Group A (3/38), which was more often than that in Group B (3/183). At the time of follow-up, coronary computed tomography angiogram showed all the grafts with CE were patent (50/50). There is no cardio-related mortality in both groups. All these patients were free from coronary re-intervention. Conclusions: Coronary endarterectomy + CABG can offer satisfactory result for patients with diffused CAD in a short-term after the operation. PMID:26021501

Totally Endoscopic Coronary Artery Bypass for Anomalous Origin of Right Coronary Artery.

PubMed

Kuo, Chia-Cheng; Hsing, Chung-Hsi; Cheng, Bor-Chih

2017-01-01

Anomalous origin of the right coronary artery (ARCA) from the left Valsalva sinus is a rare but known cause of sudden cardiac death. Surgical revascularization techniques include coronary artery bypass grafting, unroofing, and reimplantation. We report 4 patients who underwent robot-assisted totally endoscopic coronary artery bypass (TECAB) for ARCA as an alternative surgical option. In 3 patients, a single aortocoronary saphenous vein bypass was performed, and in 1 patient the right internal mammary artery was used. All grafts are patent as shown by computed tomographic angiography or cardiac catheterization. We claim that totally endoscopic coronary artery bypass is feasible and safe for anomalous origin of the right coronary artery. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Is there a role for robotic totally endoscopic coronary artery bypass in patients with a colostomy?

PubMed

Gibber, Marc; Lehr, Eric J; Kon, Zachary N; Wehman, P Brody; Griffith, Bartley P; Bonatti, Johannes

2014-01-01

Preoperative colostomy presents a significant risk of sternal wound complications, mediastinitis, and ostomy injury in patients requiring coronary artery bypass grafting. Less invasive procedures in coronary surgery have a potential to reduce the risk of sternal wound healing problems. Robotic totally endoscopic coronary artery bypass grafting in patients with a colostomy has not been reported. We describe a case of completely endoscopic coronary surgery using the da Vinci Si system in a patient with a transverse colostomy. Single left internal mammary artery grafting to the left anterior coronary artery was performed successfully on the beating heart. We regard this technique as the least invasive method of surgical coronary revascularization with a potential to reduce the risk of surgical site infection and mediastinitis in patients with a colostomy.

Drug-Eluting Versus Bare-Metal Stents During PCI in Patients With End-Stage Renal Disease on Dialysis

PubMed Central

Chang, Tara I.; Montez-Rath, Maria E.; Tsai, Thomas T.; Hlatky, Mark A.; Winkelmayer, Wolfgang C.

2016-01-01

BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), drug-eluting stents (DES) reduce repeat revascularizations compared with bare metal stents (BMS), but their effects on death and myocardial infarction (MI) are mixed. Few studies have focused on patients with end-stage renal disease (ESRD). OBJECTIVES We compared mortality and cardiovascular morbidity during PCI with DES and with BMS in dialysis patients. METHODS We identified 36,117 dialysis patients from the U.S. Renal Data System who had coronary stenting in the U.S. between 4/23/03 and 12/31/10, and examined the association of DES versus BMS with 1-year outcomes: death; death or MI; and death, MI or repeat revascularization. We conducted a temporal analysis by dividing the study period into 3 DES eras: Transitional (4/23/03 – 6/30/04); Liberal (7/1/04 – 12/31/06); and Selective (1/1/07 – 12/31/10). RESULTS One-year event rates were high, with 38 deaths, 55 death or MI events and 71 death, MI or repeat revascularization events per 100 person-years. DES was associated with a significant 18% lower risk of death, 16% lower risk of death or MI, and 13% lower risk of death, MI or repeat revascularization, compared with BMS. DES use varied, from 56% in the Transitional era to 85% in the Liberal era and 62% in the Selective era. DES outcomes in the Liberal era were significantly better than in the Transitional Era, but not significantly better than in the Selective Era. CONCLUSIONS DES for PCI appears safe in U.S. dialysis patients, and is associated with lower rates of death, MI and repeat revascularization. PMID:27012407

Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting?

PubMed

Attia, Tamer; Koch, Colleen G; Houghtaling, Penny L; Blackstone, Eugene H; Sabik, Ellen Mayer; Sabik, Joseph F

2017-03-01

To (1) identify sex-related differences in risk factors and revascularization strategies for patients undergoing coronary artery bypass grafting (CABG), (2) assess whether these differences influenced early and late survival, and (3) determine whether clinical effectiveness of the same revascularization strategy was influenced by sex. From January 1972 to January 2011, 57,943 adults-11,009 (19%) women-underwent primary isolated CABG. Separate models for long-term mortality were developed for men and women, followed by assessing sex-related differences in strength of risk factors (interaction terms). Incomplete revascularization was more common in men than women (26% vs 22%, P < .0001), but women received fewer bilateral internal thoracic artery (ITA) grafts (4.8% vs 12%; P < .0001) and fewer arterial grafts (68% vs 70%; P < .0001). Overall, women had lower survival than men after CABG (65% and 31% at 10 and 20 years, respectively, vs 74% and 41%; P ≤ .0001), even after risk adjustment. Incomplete revascularization was associated equally (P > .9) with lower survival in both sexes. Single ITA grafting was associated with equally (P = .3) better survival in women and men. Although bilateral ITA grafting was associated with better survival than single ITA grafting, it was less effective in women-11% lower late mortality (hazard ratio, 0.89 [0.77-1.022]) versus 27% lower in men (hazard ratio, 0.73 [0.69-0.77]; P = .01). Women on average have longer life expectancies than men but not after CABG. Every attempt should be made to use arterial grafting and complete revascularization, but for unexplained reasons, sex-related differences in effectiveness of bilateral arterial grafting were identified. Copyright © 2016. Published by Elsevier Inc.

Impact of Percutaneous Coronary Revascularization of Severe Coronary Lesions on Secondary Branches.

PubMed

Cano-García, Macarena; Millán-Gómez, Mercedes; Sánchez-González, Carlos; Alonso-Briales, Juan H; Muñoz-Jiménez, Luz D; Carrasco-Chinchilla, Fernando; Domínguez-Franco, Antonio; Muñoz-García, Antonio J; Bullones-Ramírez, Juan A; Álvarez-Rubiera, Jesús M; de Mora-Martín, Manuel; de Teresa-Galván, Eduardo; Hernández-García, José M; Urbano-Carrillo, Cristóbal A; Jiménez-Navarro, Manuel F

2018-05-30

To analyze the percutaneous revascularization strategy for severe lesions in the secondary branches (SB) (diameter ≥ 2mm) of major epicardial arteries compared with conservative treatment. This study analyzed patients with severe SB lesions who underwent percutaneous revascularization treatment compared with patients who received pharmacological treatment. The study examined the percentage of branch-related events (cardiovascular death, myocardial infarction attributable to SB, or the need for revascularization of the SB). We analyzed 679 SB lesions (662 patients). After a mean follow-up of 22.2±10.5 months, there were no significant differences between the 2 treatment groups regarding the percentage of death from cardiovascular causes (1.7% vs 0.4%; P=.14), nonfatal acute myocardial infarction (AMI) (1.7% vs 1.7%; P=.96), the need for SB revascularization (4.1% vs 5.4%; P=.45) or in the total percentage of events (5.1% vs 6.3%; P=.54). The variables showing an association with event occurrence on multivariate analysis were diabetes (SHR, 2.87; 95%CI, 1.37-5.47; P=.004), prior AMI (SHR, 3.54; 95%CI, 1.77-7.30; P<.0001), SB reference diameter (SHR, 0.16; 95%CI, 0.03-0.97; P=.047), and lesion length (SHR, 3.77; 95%CI, 1.03-1.13; P<.0001). These results remained the same after the propensity score analysis. The percentage of SB-related events during follow-up is low, with no significant differences between the 2 treatment strategies. The variables associated with event occurrence in the multivariate analysis were the presence of diabetes mellitus, prior AMI, and greater lesion length. Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Coronary Endarterectomy: Recent Trends.

PubMed

Ghatanatti, Ravi; Teli, Anita

2017-08-01

Coronary Endarterectomy (CE) assures complete revascularization of the myocardium in case of diffusely diseased vessels and prevents residual ischemia. Recently cardiac surgeons are performing increasing number of coronary endarterectomy and it has evolved as an important adjuvant procedure in Coronary Artery Bypass Grafting (CABG). There are controversies regarding the efficiency of CE. CE is criticised for its higher rates of morbidity and mortality. At present the available evidence supports CE in Off Pump Coronary Artery Bypass surgery (OPCAB) and along with valvular procedures. Graft patency is better with open technique. Postoperative anticoagulation regimen though not uniform, the overall outcome remains the same. Therefore, it is important to focus on the current results to accept CE as a routine procedure like CABG.

[Coronary revascularization in patients with preoperative electrical storm].

PubMed

Kawashima, Toshiya; Naraoka, S

2007-03-01

We report 5 cases who underwent surgical coronary revascularization for subacute myocardial ischemia with preoperative electrical storm. All patients showed severe left ventricular dysfunction. Mean ejection fraction was 24.4 +/- 7.6%. Three patients had already had implantable cardioverter-defibrillator (ICD) therapy. Procedures were on-pump coronary artery bypass grafting (CABG) and mitral valvuloplasty (MVP) [case 1], on-pump CABG, MVP, left ventricular restoration (LVR) and cryoablation (case 2), and off-pump CABG (case 3-5). Case 5 necessitated conversion to on-pump for electrical storm during left circumflex artery (LCx) anastomosis. Case 3 suddenly died on the 2nd postoperative day due to electrical storm. Case 1 had recurrent attack of electrical storm postoperatively, treated by ICD, overdrive pacing, repeated intraaortic balloon pumping (IABP), deep sedation with endotracheal intubation, and finally catheter ablation. Four patients have survived 2 years (mean) postoperatively without any arrhythmia, and are all in good condition [New York Heart Association (NYHA) I] now. It was concluded that off-pump procedure was not suitable for subacute myocardial ischemia with electrical storm and that LVR with surgical cryoablation would be effective if indicated.

Transmyocardial revascularization by a 1000-watt CO2 laser: sole therapy (Abstract Only)

NASA Astrophysics Data System (ADS)

Crew, John R.; Dean, Marilyn; Jones, Reinold; Fisher, John C.

1993-05-01

The concept of transmyocardial revascularization (TMR) providing blood flow to the left heart muscle based on the reptilian heart model has now been extended from an adjunctive procedure with coronary artery bypass to sole therapy. At Seton Hospital and Medical Center TMR is now being performed for the first time in clinical trials with patients who have no other mechanism of perfusion and a history of either failed PTCA or coronary artery bypass, with angina already under maximum medical therapy with a demonstrable ischemic muscle target. Longevity and reperfusion by tomographic thallium of these laser-drilled holes has been previously demonstrated but effectiveness of these channels for primary perfusion (sole therapy) apart from normal coronary bypass collateral supply is under investigation. Phase I of the FDA study has been completed with 15 cases and now Phase II includes three other beta test sites along with alternative therapy in marginal cases as the investigational format for the next 50 cases. More than 2 year followup in the first 15 cases is presented.

Alcohol consumption and risk of stroke and coronary heart disease among Japanese women: the Japan Public Health Center-based prospective study.

PubMed

Ikehara, Satoyo; Iso, Hiroyasu; Yamagishi, Kazumasa; Kokubo, Yoshihiro; Saito, Isao; Yatsuya, Hiroshi; Inoue, Manami; Tsugane, Shoichiro

2013-11-01

The study aims to examine the association between a wide range of alcohol consumption and risk of stroke and coronary heart disease. The Japan Public Health Center-based prospective study was initiated in 1990 in Cohort I and in 1993 in Cohort II, with follow-up until 2009. The sample consisted of 47,100 women aged 40-69 years. During an average of 16.7-years, the incidence of 1846 strokes and 292 coronary heart diseases was observed. Heavy drinking (≥ 300 gethanol/week) was associated with increased risk of total stroke. The multivariable hazard ratios for heavy versus occasional drinkers were 2.19 (95% confidence interval: 1.45-3.30) for total stroke, 2.25 (1.29-3.91) for hemorrhagic stroke, 2.24 (1.05-4.76) for intraparenchymal hemorrhage, 2.26 (1.01-5.09) for subarachnoid hemorrhage and 2.04 (1.09-3.82) for ischemic stroke. In the exposure-updated analysis, the positive association between heavy drinking and risks of total stroke, hemorrhagic stroke and intraparenchymal hemorrhage became more evident. Light drinking (<150 gethanol/week) was not associated with risk of ischemic stroke. There was also no association between alcohol consumption and risk of coronary heart disease. Heavy drinking was associated with increased risk of hemorrhagic and ischemic strokes among Japanese women. © 2013.

Modelling Future Cardiovascular Disease Mortality in the United States: National Trends and Racial and Ethnic Disparities

PubMed Central

Pearson-Stuttard, Jonathan; Guzman-Castillo, Maria; Penalvo, Jose L.; Rehm, Colin D.; Afshin, Ashkan; Danaei, Goodarz; Kypridemos, Chris; Gaziano, Tom; Mozaffarian, Dariush; Capewell, Simon; O’Flaherty, Martin

2016-01-01

Background Accurate forecasting of cardiovascular disease (CVD) mortality is crucial to guide policy and programming efforts. Prior forecasts have often not incorporated past trends in rates of reduction in CVD mortality. This creates uncertainties about future trends in CVD mortality and disparities. Methods and Results To forecast US CVD mortality and disparities to 2030, we developed a hierarchical Bayesian model to determine and incorporate prior age, period and cohort (APC) effects from 1979–2012, stratified by age, gender and race; which we combined with expected demographic shifts to 2030. Data sources included the National Vital Statistics System, SEER single year population estimates, and US Bureau of Statistics 2012 National Population projections. We projected coronary disease and stroke deaths to 2030, first based on constant APC effects at 2012 values, as most commonly done (conventional); and then using more rigorous projections incorporating expected trends in APC effects (trend-based). We primarily evaluated absolute mortality. The conventional model projected total coronary and stroke deaths by 2030 to increase by approximately 18% (67,000 additional coronary deaths/year) and 50% (64,000 additional stroke deaths/year). Conversely, the trend-based model projected that coronary mortality would fall by 2030 by approximately 27% (79,000 fewer deaths/year); and stroke mortality would remain unchanged (200 fewer deaths/year). Health disparities will be improved in stroke deaths, but not coronary deaths. Conclusions After accounting for prior mortality trends and expected demographic shifts, total US coronary deaths are expected to decline, while stroke mortality will remain relatively constant. Health disparities in stroke, but not coronary, deaths will be improved but not eliminated. These APC approaches offer more plausible predictions than conventional estimates. PMID:26846769

Executive function, but not memory, associates with incident coronary heart disease and stroke.

PubMed

Rostamian, Somayeh; van Buchem, Mark A; Westendorp, Rudi G J; Jukema, J Wouter; Mooijaart, Simon P; Sabayan, Behnam; de Craen, Anton J M

2015-09-01

To evaluate the association of performance in cognitive domains executive function and memory with incident coronary heart disease and stroke in older participants without dementia. We included 3,926 participants (mean age 75 years, 44% male) at risk for cardiovascular diseases from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) with Mini-Mental State Examination score ≥24 points. Scores on the Stroop Color-Word Test (selective attention) and the Letter Digit Substitution Test (processing speed) were converted to Z scores and averaged into a composite executive function score. Likewise, scores of the Picture Learning Test (immediate and delayed memory) were transformed into a composite memory score. Associations of executive function and memory were longitudinally assessed with risk of coronary heart disease and stroke using multivariable Cox regression models. During 3.2 years of follow-up, incidence rates of coronary heart disease and stroke were 30.5 and 12.4 per 1,000 person-years, respectively. In multivariable models, participants in the lowest third of executive function, as compared to participants in the highest third, had 1.85-fold (95% confidence interval [CI] 1.39-2.45) higher risk of coronary heart disease and 1.51-fold (95% CI 0.99-2.30) higher risk of stroke. Participants in the lowest third of memory had no increased risk of coronary heart disease (hazard ratio 0.99, 95% CI 0.74-1.32) or stroke (hazard ratio 0.87, 95% CI 0.57-1.32). Lower executive function, but not memory, is associated with higher risk of coronary heart disease and stroke. Lower executive function, as an independent risk indicator, might better reflect brain vascular pathologies. © 2015 American Academy of Neurology.

Timing of angiography with a routine invasive strategy and long-term outcomes in non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) Trials.

PubMed

Damman, Peter; van Geloven, Nan; Wallentin, Lars; Lagerqvist, Bo; Fox, Keith A A; Clayton, Tim; Pocock, Stuart J; Hirsch, Alexander; Windhausen, Fons; Tijssen, Jan G P; de Winter, Robbert J

2012-02-01

This study sought to investigate long-term outcomes after early or delayed angiography in patients with non-ST-segment elevation acute coronary syndrome (nSTE-ACS) undergoing a routine invasive management. The optimal timing of angiography in patients with nSTE-ACS is currently a topic for debate. Long-term follow-up after early (within 2 days) angiography versus delayed (within 3 to 5 days) angiography was investigated in the FRISC-II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) (FIR) nSTE-ACS patient-pooled database. The main outcome was cardiovascular death or myocardial infarction up to 5-year follow-up. Hazard ratios (HR) were calculated with Cox regression models. Adjustments were made for the FIR risk score, study, and the propensity of receiving early angiography using inverse probability weighting. Of 2,721 patients originally randomized to the routine invasive arm, consisting of routine angiography and subsequent revascularization if suitable, 975 underwent early angiography and 1,141 delayed angiography. No difference was observed in 5-year cardiovascular death or myocardial infarction in unadjusted (HR: 1.06, 95% confidence interval [CI]: 0.79 to 1.42, p=0.61) and adjusted (HR: 0.93, 95% CI: 0.75 to 1.16, p=0.54) Cox regression models. In the FIR database of patients presenting with nSTE-ACS, the timing of angiography was not related to long-term cardiovascular mortality or myocardial infarction. (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes [ICTUS]; ISRCTN82153174. Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction [the Third Randomised Intervention Treatment of Angina Trials (RITA-3)]; ISRCTN07752711). Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Pleiotropic effects of cardilopin (secondary coronary prevention).

PubMed

Kapanadze, S; Dolidze, N; Bakhutashvili, Z; Chapidze, L; Shengelia, E

2005-02-01

In order to evaluate some pleiotropic effects of cardilopin (Amlodipine, EGIS Pharmaceuticals) 33 ambulatory patients were examined. During the 2-month study period on the background of cardilopin treatment there were positive changes in some parameters of coronary atherosclerosis. Pleiotropic effects of cardilopin were particularly expressed in restoring of endothelial function and inhibition of platelet aggregation. There was found tendency to reduce the degree of hyperlipoperoxidemia related to oxidative stress. Obtained results of the present trial support the use of cardilopin in all coronary heart disease patients with or without myocardial revascularization and arterial hypertension.

Prasugrel versus clopidogrel in patients with acute coronary syndromes.

PubMed

Wiviott, Stephen D; Braunwald, Eugene; McCabe, Carolyn H; Montalescot, Gilles; Ruzyllo, Witold; Gottlieb, Shmuel; Neumann, Franz-Joseph; Ardissino, Diego; De Servi, Stefano; Murphy, Sabina A; Riesmeyer, Jeffrey; Weerakkody, Govinda; Gibson, C Michael; Antman, Elliott M

2007-11-15

Dual-antiplatelet therapy with aspirin and a thienopyridine is a cornerstone of treatment to prevent thrombotic complications of acute coronary syndromes and percutaneous coronary intervention. To compare prasugrel, a new thienopyridine, with clopidogrel, we randomly assigned 13,608 patients with moderate-to-high-risk acute coronary syndromes with scheduled percutaneous coronary intervention to receive prasugrel (a 60-mg loading dose and a 10-mg daily maintenance dose) or clopidogrel (a 300-mg loading dose and a 75-mg daily maintenance dose), for 6 to 15 months. The primary efficacy end point was death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. The key safety end point was major bleeding. The primary efficacy end point occurred in 12.1% of patients receiving clopidogrel and 9.9% of patients receiving prasugrel (hazard ratio for prasugrel vs. clopidogrel, 0.81; 95% confidence interval [CI], 0.73 to 0.90; P<0.001). We also found significant reductions in the prasugrel group in the rates of myocardial infarction (9.7% for clopidogrel vs. 7.4% for prasugrel; P<0.001), urgent target-vessel revascularization (3.7% vs. 2.5%; P<0.001), and stent thrombosis (2.4% vs. 1.1%; P<0.001). Major bleeding was observed in 2.4% of patients receiving prasugrel and in 1.8% of patients receiving clopidogrel (hazard ratio, 1.32; 95% CI, 1.03 to 1.68; P=0.03). Also greater in the prasugrel group was the rate of life-threatening bleeding (1.4% vs. 0.9%; P=0.01), including nonfatal bleeding (1.1% vs. 0.9%; hazard ratio, 1.25; P=0.23) and fatal bleeding (0.4% vs. 0.1%; P=0.002). In patients with acute coronary syndromes with scheduled percutaneous coronary intervention, prasugrel therapy was associated with significantly reduced rates of ischemic events, including stent thrombosis, but with an increased risk of major bleeding, including fatal bleeding. Overall mortality did not differ significantly between treatment groups. (ClinicalTrials.gov number, NCT00097591 [ClinicalTrials.gov].) Copyright 2007 Massachusetts Medical Society.

Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial.

PubMed

Berwanger, Otavio; Santucci, Eliana Vieira; de Barros E Silva, Pedro Gabriel Melo; Jesuíno, Isabella de Andrade; Damiani, Lucas Petri; Barbosa, Lilian Mazza; Santos, Renato Hideo Nakagawa; Laranjeira, Ligia Nasi; Egydio, Flávia de Mattos; Borges de Oliveira, Juliana Aparecida; Dall Orto, Frederico Toledo Campo; Beraldo de Andrade, Pedro; Bienert, Igor Ribeiro de Castro; Bosso, Carlos Eduardo; Mangione, José Armando; Polanczyk, Carisi Anne; Sousa, Amanda Guerra de Moraes Rego; Kalil, Renato Abdala Karam; Santos, Luciano de Moura; Sposito, Andrei Carvalho; Rech, Rafael Luiz; Sousa, Antônio Carlos Sobral; Baldissera, Felipe; Nascimento, Bruno Ramos; Giraldez, Roberto Rocha Corrêa Veiga; Cavalcanti, Alexandre Biasi; Pereira, Sabrina Bernardez; Mattos, Luiz Alberto; Armaganijan, Luciana Vidal; Guimarães, Hélio Penna; Sousa, José Eduardo Moraes Rego; Alexander, John Hunter; Granger, Christopher Bull; Lopes, Renato Delascio

2018-04-03

The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management. clinicaltrials.gov Identifier: NCT01448642.

Interhospital Transfers among Medicare Beneficiaries Admitted for Acute Myocardial Infarction at Non-Revascularization Hospitals

PubMed Central

Iwashyna, Theodore J.; Kahn, Jeremy M.; Hayward, Rodney A.; Nallamothu, Brahmajee K.

2011-01-01

Background Patients with acute myocardial infarctions (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability, yet we know little about the basis for how such revascularization hospitals are selected. Methods and Results We examined interhospital transfer patterns in 71,336 AMI patients admitted to hospitals without revascularization capabilities in the 2006 Medicare claims using network analysis and regression models. A total of 31,607 (44.3%) AMI patients were transferred from 1,684 non-revascularization hospitals to 1,104 revascularization hospitals. Median time to transfer was 2 days. Median transfer distance was 26.7 miles, with 96.1% within 100 miles. In 45.8% of cases, patients bypassed a closer hospital to go to farther hospital that had a better 30-day risk standardized mortality rates. However, in 36.8% of cases, another revascularization hospital with lower 30-day risk-standardized mortality was actually closer to the original admitting non-revascularization hospital than the observed transfer destination. Adjusted regression models demonstrated that shorter transfer distances were more common than transfers to the hospitals with lowest 30-day mortality rates. Simulations suggest that an optimized system that prioritized the transfer of AMI patients to a nearby hospital with the lowest 30-day mortality rate might produce clinically meaningful reduction in mortality. Conclusions Over 40% of AMI patients admitted to non-revascularization hospitals are transferred to revascularization hospitals. Many patients are not directed to nearby hospitals with the lowest 30-day risk-standardized mortality, and this may represent an opportunity for improvement. PMID:20682917

Outcomes after percutaneous coronary artery revascularization procedures for cardiac allograft vasculopathy in pediatric heart transplant recipients: A multi-institutional study.

PubMed

Jeewa, Aamir; Chin, Clifford; Pahl, Elfriede; Atz, Andrew M; Carboni, Michael P; Pruitt, Elizabeth; Naftel, David C; Rodriguez, Rose; Dipchand, Anne I

2015-09-01

Cardiac allograft vasculopathy is an important cause of long-term graft loss. In adults, percutaneous revascularization procedures (PRPs) have variable success with high restenosis rates and little impact on graft survival. Limited data exist in pediatric recipients of transplants. Data from the Pediatric Heart Transplant Study (PHTS) were used to explore associations between PRPs and outcomes after heart transplant in patients listed ≤18 years old who received a first heart transplant between 1993 and 2009. Revascularization procedures were done in 28 of 3,156 (0.9%) patients; 13 patients had multiple PRPs giving a total of 51 PRPs performed across 15 centers. Mean recipient age at time of transplant was 7.7 ± 6.7 years; mean donor age was 15.9 ± 15.4 years. The mean time to first PRP was 5.7 ± 3.2 years. Vessels involved were left anterior descending artery (41%), right coronary artery (25%), circumflex artery (18%), other coronary branches/unknown (16%). PRPs consisted of 38 (75%) stent implantations and 13 (25%) balloon angioplasties with an overall procedural success rate of 73%. Freedom from graft loss after PRPs was 89%, 75%, and 61% at 1, 3, and 12 months. In addition, patients with transplants from donors >30 years old were found to have less freedom from the need for a revascularization procedure than patients with transplants from younger donors (p < 0.0001). In this large pediatric heart transplant cohort, use of PRPs for cardiac allograft vasculopathy was rare, likely related to procedural feasibility of the interventions. Despite technically successful interventions, graft loss occurred in 39% within 1 year post-procedure; relisting for heart transplant should be considered. Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Coronary Artery Bypass Grafting in Diabetic Patients: Complete Arterial versus Internal Thoracic Artery and Sequential Vein Grafts-A Propensity-Score Matched Analysis.

PubMed

Kunihara, Takashi; Wendler, Olaf; Heinrich, Kerstin; Nomura, Ryota; Schäfers, Hans-Joachim

2018-06-20

 The optimal choice of conduit and configuration for coronary artery bypass grafting (CABG) in diabetic patients remains somewhat controversial, even though arterial grafts have been proposed as superior. We attempted to clarify the role of complete arterial revascularization using the left internal thoracic artery (LITA) and the radial artery (RA) alone in "T-Graft" configuration on long-term outcome.  From 1994 to 2001, 104 diabetic patients with triple vessel disease underwent CABG using LITA/RA "T-Grafts" (Group-A). Using propensity-score matching, 104 patients with comparable preoperative characteristics who underwent CABG using LITA and one sequential vein graft were identified (Group-V). Freedom from all causes of death, cardiac death, major adverse cardiac event (MACE), major adverse cardiac (and cerebral) event (MACCE), and repeat revascularization at 10 years of Group-A was 60 ± 5%, 67 ± 5%, 48 ± 5%, 37 ± 5%, and 81 ± 4%, respectively, compared with 58 ± 5%, 70 ± 5%, 49 ± 5%, 39 ± 5%, and 93 ± 3% in Group-V. There were no significant differences in these end points between groups regardless of insulin-dependency. Multivariable Cox proportional hazards model identified age, left ventricular ejection fraction, renal failure, and hyperlipidemia as independent predictors for all death, age and left ventricular ejection fraction for cardiac death, sinus rhythm for both MACE and MACCE, and prior percutaneous coronary intervention for re-revascularization.  In our experience, complete arterial revascularization using LITA/RA "T-Grafts" does not provide superior long-term clinical benefits for diabetic patients compared with a combination of LITA and sequential vein graft. Georg Thieme Verlag KG Stuttgart · New York.

Prevalence, Features, and Prognostic Importance of Edge Dissection After Drug-Eluting Stent Implantation: An ADAPT-DES Intravascular Ultrasound Substudy.

PubMed

Kobayashi, Nobuaki; Mintz, Gary S; Witzenbichler, Bernhard; Metzger, D Christopher; Rinaldi, Michael J; Duffy, Peter L; Weisz, Giora; Stuckey, Thomas D; Brodie, Bruce R; Parvataneni, Rupa; Kirtane, Ajay J; Stone, Gregg W; Maehara, Akiko

2016-07-01

Intravascular ultrasound detects stent edge dissections after percutaneous coronary intervention that are not seen angiographically. This study investigated the association between stent edge dissections and clinical outcomes. ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a large-scale, prospective, multicenter study of patients undergoing drug-eluting stent implantation. In this prospective substudy, 2062 patients (2433 lesions) were evaluated with intravascular ultrasound to characterize the morphological features and clinical outcomes of stent edge dissection after percutaneous coronary intervention. The prevalence of post-percutaneous coronary intervention stent edge dissection was 6.6% per lesion (161 of 2433). Calcified plaque at the proximal stent edge (relative risk [RR]=1.72; P=0.04) and proximal stent edge expansion (RR=1.18; P=0.004) were predictors for proximal dissection; attenuated plaque at the distal stent edge (RR=3.52; P=0.004), distal reference plaque burden (RR=1.56; P<0.0001), and distal edge stent expansion (RR=1.11; P=0.02) were predictors for distal dissection. At 1-year follow-up, target lesion revascularization was more common in lesions with versus without dissection (5.2% versus 2.7%; P=0.04). Multivariable analysis indicated that residual dissection was associated with target lesion revascularization at 1-year follow-up (RR=2.67; P=0.02). Among lesions with dissection, smaller effective lumen area increased the risk of target lesion revascularization at 1-year follow-up (cutoff value of 5.1 mm(2); P=0.05). Greater stent expansion and the presence of large, calcified, and/or attenuated plaques were independent predictors of stent edge dissection. Residual stent edge dissection, especially with a smaller effective lumen area, was associated with target lesion revascularization during 1-year follow-up after drug-eluting stent implantation. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794. © 2016 American Heart Association, Inc.

Performance of the 2-hour Accelerated Diagnostic Protocol Within the American College of Radiology Imaging Network PA 4005 Cohort

PubMed Central

Mahler, Simon A.; Miller, Chadwick D.; Litt, Harold I.; Gatsonis, Constantine A.; Snyder, Bradley S.; Hollander, Judd E.

2015-01-01

Objectives The 2-hour accelerated diagnostic protocol (ADAPT) is a decision rule designed to identify emergency department (ED) patients with chest pain for early discharge. Previous studies in the Asia-Pacific region demonstrated high sensitivity (97.9% to 99.7%) for major adverse cardiac events (MACE) at 30 days. The objective of this study was to determine the validity of ADAPT for risk stratification in a cohort of U.S. ED patients with suspected acute coronary syndrome (ACS). Methods A secondary analysis of participants enrolled in the American College of Radiology Imaging Network (ACRIN) PA 4005 trial was conducted. This trial enrolled 1,369 patients at least 30 years old with symptoms suggestive of ACS. All data elements were collected prospectively at the time of enrollment. Each patient was classified as low risk or at risk by ADAPT. Early discharge rate and sensitivity for MACE, defined as cardiac death, myocardial infarction (MI), or coronary revascularization at 30 days, were calculated. Results Of 1,140 patients with complete biomarker data, MACE occurred in 31 patients (2.7%). Among 551 of the 1,140 (48.3%, 95% confidence interval [CI] = 45.4% to 51.3%), ADAPT identified for early discharge; five of the 551 (0.9%, 95% CI = 0.3% to 2.1%) had MACE at 30 days. ADAPT was 83.9% (95% CI = 66.3% to 94.5%) sensitive, identifying 26 of 31 patients with MACE. Of the five patients identified for early discharge by ADAPT with MACE, there were no deaths, one patient with MI, and five with revascularizations. Conclusions In this first North American application of the ADAPT strategy, sensitivity for MACE within 30 days was 83.9%. One missed adverse event was a MI, with the remainder representing coronary revascularizations. The effect of missing revascularization events needs further investigation. PMID:25810343

Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1·8 million participants

PubMed Central

2014-01-01

Summary Background Body-mass index (BMI) and diabetes have increased worldwide, whereas global average blood pressure and cholesterol have decreased or remained unchanged in the past three decades. We quantified how much of the effects of BMI on coronary heart disease and stroke are mediated through blood pressure, cholesterol, and glucose, and how much is independent of these factors. Methods We pooled data from 97 prospective cohort studies that collectively enrolled 1·8 million participants between 1948 and 2005, and that included 57 161 coronary heart disease and 31 093 stroke events. For each cohort we excluded participants who were younger than 18 years, had a BMI of lower than 20 kg/m2, or who had a history of coronary heart disease or stroke. We estimated the hazard ratio (HR) of BMI on coronary heart disease and stroke with and without adjustment for all possible combinations of blood pressure, cholesterol, and glucose. We pooled HRs with a random-effects model and calculated the attenuation of excess risk after adjustment for mediators. Findings The HR for each 5 kg/m2 higher BMI was 1·27 (95% CI 1·23–1·31) for coronary heart disease and 1·18 (1·14–1·22) for stroke after adjustment for confounders. Additional adjustment for the three metabolic risk factors reduced the HRs to 1·15 (1·12–1·18) for coronary heart disease and 1·04 (1·01–1·08) for stroke, suggesting that 46% (95% CI 42–50) of the excess risk of BMI for coronary heart disease and 76% (65–91) for stroke is mediated by these factors. Blood pressure was the most important mediator, accounting for 31% (28–35) of the excess risk for coronary heart disease and 65% (56–75) for stroke. The percentage excess risks mediated by these three mediators did not differ significantly between Asian and western cohorts (North America, western Europe, Australia, and New Zealand). Both overweight (BMI ≥25 to <30 kg/m2) and obesity (BMI ≥30 kg/m2) were associated with a significantly increased risk of coronary heart disease and stroke, compared with normal weight (BMI ≥20 to <25 kg/m2), with 50% (44–58) of the excess risk of overweight and 44% (41–48) of the excess risk of obesity for coronary heart disease mediated by the selected three mediators. The percentages for stroke were 98% (69–155) for overweight and 69% (64–77) for obesity. Interpretation Interventions that reduce high blood pressure, cholesterol, and glucose might address about half of excess risk of coronary heart disease and three-quarters of excess risk of stroke associated with high BMI. Maintenance of optimum bodyweight is needed for the full benefits. Funding US National Institute of Health, UK Medical Research Council, National Institute for Health Research Comprehensive Biomedical Research Centre at Imperial College Healthcare NHS Trust, Lown Scholars in Residence Program on cardiovascular disease prevention, and Harvard Global Health Institute Doctoral Research Grant. PMID:24269108

Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1·8 million participants.

PubMed

Lu, Yuan; Hajifathalian, Kaveh; Ezzati, Majid; Woodward, Mark; Rimm, Eric B; Danaei, Goodarz

2014-03-15

Body-mass index (BMI) and diabetes have increased worldwide, whereas global average blood pressure and cholesterol have decreased or remained unchanged in the past three decades. We quantified how much of the effects of BMI on coronary heart disease and stroke are mediated through blood pressure, cholesterol, and glucose, and how much is independent of these factors. We pooled data from 97 prospective cohort studies that collectively enrolled 1·8 million participants between 1948 and 2005, and that included 57,161 coronary heart disease and 31,093 stroke events. For each cohort we excluded participants who were younger than 18 years, had a BMI of lower than 20 kg/m(2), or who had a history of coronary heart disease or stroke. We estimated the hazard ratio (HR) of BMI on coronary heart disease and stroke with and without adjustment for all possible combinations of blood pressure, cholesterol, and glucose. We pooled HRs with a random-effects model and calculated the attenuation of excess risk after adjustment for mediators. The HR for each 5 kg/m(2) higher BMI was 1·27 (95% CI 1·23-1·31) for coronary heart disease and 1·18 (1·14-1·22) for stroke after adjustment for confounders. Additional adjustment for the three metabolic risk factors reduced the HRs to 1·15 (1·12-1·18) for coronary heart disease and 1·04 (1·01-1·08) for stroke, suggesting that 46% (95% CI 42-50) of the excess risk of BMI for coronary heart disease and 76% (65-91) for stroke is mediated by these factors. Blood pressure was the most important mediator, accounting for 31% (28-35) of the excess risk for coronary heart disease and 65% (56-75) for stroke. The percentage excess risks mediated by these three mediators did not differ significantly between Asian and western cohorts (North America, western Europe, Australia, and New Zealand). Both overweight (BMI ≥25 to <30 kg/m(2)) and obesity (BMI ≥30 kg/m(2)) were associated with a significantly increased risk of coronary heart disease and stroke, compared with normal weight (BMI ≥20 to <25 kg/m(2)), with 50% (44-58) of the excess risk of overweight and 44% (41-48) of the excess risk of obesity for coronary heart disease mediated by the selected three mediators. The percentages for stroke were 98% (69-155) for overweight and 69% (64-77) for obesity. Interventions that reduce high blood pressure, cholesterol, and glucose might address about half of excess risk of coronary heart disease and three-quarters of excess risk of stroke associated with high BMI. Maintenance of optimum bodyweight is needed for the full benefits. US National Institute of Health, UK Medical Research Council, National Institute for Health Research Comprehensive Biomedical Research Centre at Imperial College Healthcare NHS Trust, Lown Scholars in Residence Program on cardiovascular disease prevention, and Harvard Global Health Institute Doctoral Research Grant. Copyright © 2014 Elsevier Ltd. All rights reserved.

CT myocardial perfusion imaging: current status and future perspectives.

PubMed

Yang, Dong Hyun; Kim, Young-Hak

2017-07-01

Computed tomography myocardial perfusion (CTP) combined with coronary computed tomography angiography (CCTA) may constitute a "1-stop shop" for the noninvasive diagnosis of hemodynamically significant coronary stenosis during a single CT examination. CTP shows high diagnostic performance and provides incremental value over CCTA for the detection of hemodynamically significant coronary stenosis in patients with a high Agatston calcium score or coronary artery stents. Future studies should determine the optimal protocol and clinical value of CTP for guiding revascularization strategy and prognostication. In this article, we review the current status and future perspectives of CTP, focusing on technical considerations, clinical applications, and future research topics.

An unusual cause of ischemia after coronary bypass grafting!!

PubMed

Hammami, Rania; Charfeddine, Salma; Elleuch, Nizar; Fourati, Hela; Abid, Leila; Kammoun, Samir

2018-01-01

Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome. Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Depressive disorder, coronary heart disease, and stroke: dose-response and reverse causation effects in the Whitehall II cohort study.

PubMed

Brunner, Eric J; Shipley, Martin J; Britton, Annie R; Stansfeld, Stephen A; Heuschmann, Peter U; Rudd, Anthony G; Wolfe, Charles D A; Singh-Manoux, Archana; Kivimaki, Mika

2014-03-01

Systematic reviews examining associations of depressive disorder with coronary heart disease and stroke produce mixed results. Failure to consider reverse causation and dose-response patterns may have caused inconsistencies in evidence. This prospective cohort study on depressive disorder, coronary heart disease, and stroke analysed reverse causation and dose-response effects using four 5-year and three 10-year observation cycles (total follow up 24 years) based on multiple repeat measures of exposure. Participants in the Whitehall II study (n = 10,036, 31,395 person-observations, age at start 44.4 years) provided up to six repeat measures of depressive symptoms via the 30-item General Health Questionnaire (GHQ-30) and one measure via Center for Epidemiologic Studies Depression Scale (CES-D). The cohort was followed up for major coronary events (coronary death/nonfatal myocardial infarction) and stroke (stroke death/morbidity) through the national mortality register Hospital Episode Statistics, ECG-screening, medical records, and self-report questionnaires. GHQ-30 caseness predicted stroke over 0-5 years (age-, sex- and ethnicity-adjusted HR 1.60, 95% CI 1.1-2.3) but not over 5-10 years (HR 0.94, 95% CI 0.6-1.4). Using the last 5-year observation cycle, cumulative GHQ-30 caseness was associated with incident coronary heart disease in a dose-response manner (1-2 times a case: HR 1.12, 95% CI 0.7-1.7; 3-4 times: HR 2.06, 95% CI 1.2-3.7), and CES-D caseness predicted coronary heart disease (HR 1.81, 95% CI 1.1-3.1). There was evidence of a dose-response effect of depressive symptoms on risk of coronary heart disease. In contrast, prospective associations of depressive symptoms with stroke appeared to arise wholly or partly through reverse causation.

In-hospital switching between adenosine diphosphate receptor inhibitors in patients with acute myocardial infarction treated with percutaneous coronary intervention: Insights into contemporary practice from the TRANSLATE-ACS study.

PubMed

Bagai, Akshay; Peterson, Eric D; Honeycutt, Emily; Effron, Mark B; Cohen, David J; Goodman, Shaun G; Anstrom, Kevin J; Gupta, Anjan; Messenger, John C; Wang, Tracy Y

2015-12-01

While randomized clinical trials have compared clopidogrel with higher potency adenosine diphosphate (ADP) receptor inhibitors among patients with acute myocardial infarction, little is known about the frequency, effectiveness and safety of switching between ADP receptor inhibitors in routine clinical practice. We studied 11,999 myocardial infarction patients treated with percutaneous coronary intervention at 230 hospitals from April 2010 to October 2012 in the TRANSLATE-ACS study. Multivariable Cox regression was used to compare six-month post-discharge risks of major adverse cardiovascular events (MACE: death, myocardial infarction, stroke, or unplanned revascularization) and Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-defined bleeding between in-hospital ADP receptor inhibitor switching versus continuation of the initially selected therapy. Among 8715 patients treated initially with clopidogrel, 994 (11.4%) were switched to prasugrel or ticagrelor; switching occurred primarily after percutaneous coronary intervention (60.9%) and at the time of hospital discharge (26.7%). Among 3284 patients treated initially with prasugrel or ticagrelor, 448 (13.6%) were switched to clopidogrel; 48.2% of switches occurred after percutaneous coronary intervention and 48.0% at hospital discharge. Switching to prasugrel or ticagrelor was not associated with increased bleeding when compared with continuation on clopidogrel (2.7% vs. 3.3%, adjusted hazard ratio 0.96, 95% confidence interval 0.64-1.42, p=0.82). Switching from prasugrel or ticagrelor to clopidogrel was not associated with increased MACE (8.9% vs. 7.7%, adjusted hazard ratio 1.06, 95% confidence interval 0.75-1.49, p=0.76) when compared with continuation on the higher potency agent. In-hospital ADP receptor inhibitor switching occurs in more than one in 10 myocardial infarction patients in contemporary practice. In this observational study, ADP receptor inhibitor switching does not appear to be significantly associated with increased hazard of MACE or bleeding. © The European Society of Cardiology 2014.

Impact of dual antiplatelet therapy on outcomes among aspirin-resistant patients following coronary artery bypass grafting.

PubMed

Gasparovic, Hrvoje; Petricevic, Mate; Kopjar, Tomislav; Djuric, Zeljko; Svetina, Lucija; Biocina, Bojan

2014-05-15

Coronary artery bypass grafting is pivotal in the contemporary management of complex coronary artery disease. Interpatient variability to antiplatelet agents, however, harbors the potential to compromise the revascularization benefit by increasing the incidence of adverse events. This study was designed to define the impact of dual antiplatelet therapy (dAPT) on clinical outcomes among aspirin-resistant patients who underwent coronary artery surgery. We randomly assigned 219 aspirin-resistant patients according to multiple electrode aggregometry to receive clopidogrel (75 mg) plus aspirin (300 mg) or aspirin-monotherapy (300 mg). The primary end point was a composite outcome of all-cause death, nonfatal myocardial infarction, stroke, or cardiovascular hospitalization assessed at 6 months postoperatively. The primary end point occurred in 6% of patients assigned to dAPT and 10% of patients randomized to aspirin-monotherapy (relative risk 0.61, 95% confidence interval 0.25 to 1.51, p = 0.33). No significant treatment effect was noted in the occurrence of the safety end point. The total incidence of bleeding events was 25% and 19% in the dAPT and aspirin-monotherapy groups, respectively (relative risk 1.34, 95% confidence interval 0.80 to 2.23, p = 0.33). In the subgroup analysis, dAPT led to lower rates of adverse events in patients with a body mass index >30 kg/m(2) (0% vs 18%, p <0.01) and those <65 years (0% vs 10%, p = 0.02). In conclusion, the addition of clopidogrel in patients found to be aspirin resistant after coronary artery bypass grafting did not reduce the incidence of adverse events, nor did it increase the number of recorded bleeding events. dAPT did, however, lower the incidence of the primary end point in obese patients and those <65 years. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Stroke is predicted by low visuospatial in relation to other intellectual abilities and coronary heart disease by low general intelligence.

PubMed

Kajantie, Eero; Räikkönen, Katri; Henriksson, Markus; Leskinen, Jukka T; Forsén, Tom; Heinonen, Kati; Pesonen, Anu-Katriina; Osmond, Clive; Barker, David J P; Eriksson, Johan G

2012-01-01

Low intellectual ability is associated with an increased risk of coronary heart disease and stroke. Most studies have used a general intelligence score. We studied whether three different subscores of intellectual ability predict these disorders. We studied 2,786 men, born between 1934 and 1944 in Helsinki, Finland, who as conscripts at age 20 underwent an intellectual ability test comprising verbal, visuospatial (analogous to Raven's progressive matrices) and arithmetic reasoning subtests. We ascertained the later occurrence of coronary heart disease and stroke from validated national hospital discharge and death registers. 281 men (10.1%) had experienced a coronary heart disease event and 131 (4.7%) a stroke event. Coronary heart disease was predicted by low scores in all subtests, hazard ratios for each standard deviation (SD) lower score ranging from 1.21 to 1.30 (confidence intervals 1.08 to 1.46). Stroke was predicted by a low visuospatial reasoning score, the corresponding hazard ratio being 1.23 (95% confidence interval 1.04 to 1.46), adjusted for year and age at testing. Adjusted in addition for the two other scores, the hazard ratio was 1.40 (1.10 to 1.79). This hazard ratio was little affected by adjustment for socioeconomic status in childhood and adult life, whereas the same adjustments attenuated the associations between intellectual ability and coronary heart disease. The associations with stroke were also unchanged when adjusted for systolic blood pressure at 20 years and reimbursement for adult antihypertensive medication. Stroke is predicted by low visuospatial reasoning scores in relation to scores in the two other subtests. This association may be mediated by common underlying causes such as impaired brain development, rather than by mechanisms associated with risk factors shared by stroke and coronary heart disease, such as socio-economic status, hypertension and atherosclerosis.

Anaortic off-pump versus clampless off-pump using the PAS-Port device versus conventional coronary artery bypass grafting: mid-term results from a matched propensity score analysis of 5422 unselected patients.

PubMed

Furukawa, Nobuyuki; Kuss, Oliver; Preindl, Konstantin; Renner, André; Aboud, Anas; Hakim-Meibodi, Kavous; Benzinger, Michael; Pühler, Thomas; Ensminger, Stephan; Fujita, Buntaro; Becker, Tobias; Gummert, Jan F; Börgermann, Jochen

2017-10-01

Meta-analyses from observational and randomized studies have demonstrated benefits of off-pump surgery for hard and surrogate endpoints. In some of them, increased re-revascularization was noted in the off-pump groups, which could impact their long-term survival. Therefore, we analyzed the course of all patients undergoing isolated coronary surgery regarding the major cardiac and cerebrovascular event (MACCE) criteria. A prospective register was taken from a high-volume off-pump center recording all anaortic off-pump (ANA), clampless off-pump (PAS-Port) and conventional (CONV) coronary artery bypass operations between July 2009 and June 2015. Propensity Score Matching was performed based on 28 preoperative risk variables. We identified 935 triplets (N = 2805). Compared with CONV, in-hospital mortality of both the ANA group (OR for ANA [95% CI] 0.25 [0.06; 0.83], P = 0.021), and the PAS-Port group was lower (OR for PAS-Port [95% CI] 0.50 [0.17; 1.32], P = 0.17). In the mid-term follow-up there were no significant differences between the groups regarding mortality (HR for ANA [95%-CI] 0.83 [0.55-1.26], P = 0.38; HR for PAS-Port [95%-CI] 1.06 [0.70-1.59], P = 0.79), incidence of stroke (HR for ANA 0.81 [0.43-1.53], P = 0.52; HR for PAS-Port 0.78 [0.41-1.50], P = 0.46), myocardial infarction (HR for ANA 0.53 [0.22-1.31], P = 0.17; HR for PAS-Port 0.78 [0.37-1.66], P = 0.52) or re-revascularization rate (HR for ANA 0.99 [0.67-1.44], P = 0.94; HR for PAS-Port 0.95 [0.65-1.38], P = 0.77). Both off-pump clampless techniques were associated with lower in-hospital mortality compared with conventional CABG. The mid-term course showed no difference with regard to the MACCE criteria between anaortic off-pump, clampless off-pump using PAS-Port and conventional CABG. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Stress-induced cardiomyopathy caused by heat stroke.

PubMed

Chen, Wei-Ta; Lin, Cheng-Hsin; Hsieh, Ming-Hsiung; Huang, Chun-Yao; Yeh, Jong-Shiuan

2012-07-01

Heat stroke is defined by central nervous system abnormalities and failure of proper maintenance of thermoregulation as a result of high core body temperature ensuing from exposure to high environmental temperatures or strenuous exercise. Common complications include acute respiratory distress syndrome, disseminated intravascular coagulation, acute renal injury, hepatic injury, and rhabdomyolysis. Myocardial injury may also occur during heat stroke, resulting in cardiac enzyme increase and ST-segment changes on the ECG. Such findings might behave as diagnostic pitfalls by mimicking the presentation of coronary artery occlusive myocardial infarction. A previous case report described a patient with heat stroke and ST-segment elevation, in which the definite cause of the ST-segment elevation was unclear; however, acute myocardial infarction caused by coronary artery disease was ruled out according to the clinical signs, serial ECG changes, and serum level of cardiac biomarkers. Stress-induced cardiomyopathy (Takotsubo cardiomyopathy) was suspected, but it could not be confirmed because of the lack of coronary angiography. We herein report a case of heat stroke presenting with ST-segment elevation and cardiogenic shock. Coronary angiography was performed and coronary artery occlusive myocardial infarction was ruled out because of the presence of patent coronary arteries. Left ventriculography showed midventricular and apical hypokinesis, and stress-induced cardiomyopathy was then determined to be the appropriate diagnosis. Heat stroke causes increase of serum catecholamine levels, in which oversecretion and abnormal responses to catecholamines are a possible cause of stress-induced cardiomyopathy. Catecholamines may therefore be the key in linking heat stroke and stress-induced cardiomyopathy. Copyright © 2011. Published by Mosby, Inc.

An ischemia-guided approach for risk stratification in patients with acute coronary syndromes.

PubMed

Pepine, C J

2000-12-28

The optimal management approach for patients with non-ST-segment elevation acute coronary syndromes continues to be an issue of debate. An ischemia-guided strategy appears to be effective as an alternative to either a very conservative "wait-and-see" approach or a very aggressive routine revascularization approach. The need for another approach is supported by the lack of conclusive evidence-based results favoring an early routine invasive treatment strategy. In the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial, there were no differences in the incidence of death or myocardial infarction (MI) between patients treated with an early invasive approach and those treated with a conservative approach to treatment. Significantly worse outcomes were shown in patients assigned to an early invasive strategy in the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial at 1-year follow-up (111 clinical events in the invasive group vs 85 in the conservative group; p = 0.05). Registry information, including that from the Organization to Assess Strategies for Ischemic Syndromes (OASIS), which included approximately 8,000 patients with unstable angina or suspected MI, has even suggested an excess hazard with a routine invasive approach. Patients with non-ST-segment elevation MI observed in the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO)-IIB and Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trials also fared better with an ischemia-guided strategy. Even the recent FRagmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) trial investigators had to be very selective relative to eliminating high-risk patients in the first week and treating with intense anti-ischemic therapy and 5-7 days of low-molecular-weight heparin therapy to show an advantage for assigned revascularization. A careful clinical evaluation with attention to early risk stratification is essential in the ischemia-guided approach. The Braunwald classification for unstable angina helps identify independent clinical predictors of a poor outcome; high risk is clearly associated with Braunwald class III and type C. Electrocardiographic and biochemical markers for myocardial necrosis (cardiac troponin T or I) are important tools for assessing the presence and degree of ischemia and associated risk for adverse outcome. Noninvasive evaluation of left ventricular ejection fraction is essential for identifying those at high risk due to impaired contractile function. When these conventional markers do not provide conclusive information, noninvasive stress testing is most helpful to further identify those at highest risk for revascularization.

Use of the Impella 2.5 for prophylactic circulatory support during elective high-risk percutaneous coronary intervention.

PubMed

Alasnag, Mirvat A; Gardi, Delair O; Elder, Mahir; Kannam, Hari; Ali, Farhan; Petrina, Mircea; Kheterpal, Vipin; Hout, Mariah S; Schreiber, Theodore L

2011-01-01

Patients undergoing percutaneous coronary intervention (PCI) who are at high risk for cardiovascular collapse during the procedure may benefit from prophylactic circulatory support. The objective was to evaluate the safety and feasibility of prophylactic use of the Impella 2.5 during high-risk PCI. We used the Impella 2.5 for partial circulatory support during 60 consecutive elective high-risk PCI cases over 20 months. All patients either were deemed inoperable by the cardiac surgeons or were offered bypass surgery but declined. The patients had multiple risk factors including hypertension (95%), diabetes (52%), chronic pulmonary disease (23%), prior myocardial infarction (62%) and prior bypass surgery (18%). Forty-five percent presented with acute coronary syndrome. The mean left ventricular ejection fraction was 23%±15%. Nearly all patients had multivessel disease (93%), and 60% had left main disease. The average SYNTAX score was 30±9. Despite lesion complexity and high-risk factors, we achieved an angiographic success rate of 96%. Left main lesions were treated in 55% of the patients, and 83% of patients had multiple lesions treated. There was one procedural death. At 30 days postintervention, mortality was 5%, and rates of myocardial infarction, stroke, target vessel revascularization and urgent bypass surgery were 0%. The single-center experience reported here demonstrates that use of the Impella 2.5 during high-risk PCI in the "real world" - outside the controlled environment of a clinical trial - is safe and feasible. Copyright © 2011 Elsevier Inc. All rights reserved.

Incidence of Bradycardia and Outcomes of Patients Who Underwent Orbital Atherectomy Without a Temporary Pacemaker.

PubMed

Lee, Michael S; Nguyen, Heajung; Shlofmitz, Richard

2017-02-01

We analyzed the incidence of bradycardia and the safety of patients with severely calcified coronary lesions who underwent orbital atherectomy without the insertion of a temporary pacemaker. The presence of severely calcified coronary lesions can increase the complexity of percutaneous coronary intervention due to the difficulty in advancing and optimally expanding the stent. High-pressure inflations to predilate calcified lesions may cause angiographic complications like perforation and dissection. Suboptimal stent expansion is associated with stent thrombosis and restenosis. Orbital atherectomy safely and effectively modifies calcified plaque to facilitate optimal stent expansion. The incidence of bradycardia in orbital atherectomy is unknown. Fifty consecutive patients underwent orbital atherectomy from February 2014 to September 2016 at our institution, none of whom underwent insertion of a temporary pacemaker. The final analysis included 47 patients in this retrospective study as 3 patients were excluded because of permanent pacemaker implantation. The primary endpoint was significant bradycardia, defined as bradycardia requiring emergent pacemaker placement or a heart rate <50 bpm at the end of atherectomy. The primary endpoint occurred in 4% of all patients, all driven by patients who experienced a heart rate decreasing to <50 bpm. The major adverse cardiac and cerebral event rate was 6%, driven by death (2%) and myocardial infarction (4%). No patient experienced target-vessel revascularization, stroke, or stent thrombosis. Angiographic complications included perforation in 2%, slow-flow in 4%, and flow-limiting dissection in 0%. Significant bradycardia was uncommon during orbital atherectomy. Performing orbital atherectomy without a temporary pacemaker appears to be safe.

The role of myocardial viability in contemporary cardiac practice.

PubMed

Jamiel, Abdelrahman; Ebid, Mohamad; Ahmed, Amjad M; Ahmed, Dalia; Al-Mallah, Mouaz H

2017-07-01

Ischemic heart disease (IHD) remains the single most common cause of death worldwide. Ischemic cardiomyopathy is a major sequel of coronary artery disease. The economic health burden of IHD is substantial. In patients with old myocardial infarction (OMI), the extent of viable myocardium (VM) directly affects the short- and long-term outcome. There is a considerable collection of observational data showing substantial improvement in patients with significant left ventricular dysfunction when the need for revascularization is guided by preoperative assessment of viability and hibernation. However, a major challenge for present cardiovascular imaging is to identify better ways to assess viable but inadequately perfused myocardium and thus optimize selection of patients for coronary revascularization. Several non-invasive techniques have been developed to detect signs of viability. Hence, our aim is to provide the reader a state-of-the art review for the assessment of myocardial viability.

Coronary bypass surgery versus percutaneous coronary intervention: cost-effectiveness in Iran: a study in patients with multivessel coronary artery disease.

PubMed

Javanbakht, Mehdi; Bakhsh, Razieh Yazdani; Mashayekhi, Atefeh; Ghaderi, Hossein; Sadeghi, Masoumeh

2014-10-01

The aim of this study was to evaluate cost effectiveness of coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) with stenting from Iran society perspective. A retrospective study was carried out to estimate the annual cost and health related quality of life (HRQoL) of 109 patients who underwent coronary revascularization (PCI [n = 75] and CABG [n = 34]). A Markov model has been developed to determine the cost effectiveness of CABG compared with PCI. We used the model to calculate lifetime costs, life-years (LYs), and quality-adjusted life-years (QALYs) of each strategy. We also used probabilistic sensitivity analysis to test model robustness. We found that discounted QALY lived per person in CABG versus PCI group in 5 years, 10 years, and lifetime time horizon were (3.8 ± 0.13 versus 3.88 ± 0.14), (6.4 ± 0.23 versus 6.33 ± 0.22), and (8.74 ± 0.29 versus 8.33 ± 0.27), respectively. The estimated medical cost of CABG and PCI per patient in 5 years, 10 years, and lifetime time horizon were (USD 6,819 ± 765 versus 9,011 ± 1,816), (USD 8,852 ± 1,348 versus 12,034 ± 2,375), and (USD 14,037± 4,201 versus 18,798 ± 5,821), respectively. The incremental cost-effectiveness ratio results showed CABG is a dominate alternative in 10 years and lifetime time horizon. This study demonstrated that despite higher initial cost and lower HRQoL, CABG is a cost-effective revascularization strategy compared with PCI for patients with multivessel coronary artery disease in long-term.

Large Artery Atherosclerotic Occlusive Disease.

PubMed

Cole, John W

2017-02-01

Extracranial or intracranial large artery atherosclerosis is often identified as a potential etiologic cause for ischemic stroke and transient ischemic attack. Given the high prevalence of large artery atherosclerosis in the general population, determining whether an identified atherosclerotic lesion is truly the cause of a patient's symptomatology can be difficult. In all cases, optimally treating each patient to minimize future stroke risk is paramount. Extracranial or intracranial large artery atherosclerosis can be broadly compartmentalized into four distinct clinical scenarios based upon the individual patient's history, examination, and anatomic imaging findings: asymptomatic and symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and extracranial vertebral artery atherosclerotic disease. This review provides a framework for clinicians evaluating and treating such patients. Intensive medical therapy achieves low rates of stroke and death in asymptomatic carotid stenosis. Evidence indicates that patients with severe symptomatic carotid stenosis should undergo carotid revascularization sooner rather than later and that the risk of stroke or death is lower using carotid endarterectomy than with carotid stenting. Specific to stenting, the risk of stroke or death is greatest among older patients and women. Continuous vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy is the mainstay for stroke prevention in the setting of intracranial and vertebral artery origin atherosclerosis. Lifelong vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy are the key elements to reduce future stroke risk in the setting of large artery atherosclerosis. When considering a revascularization procedure for carotid stenosis, patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully considered.

Large Artery Atherosclerotic Occlusive Disease

PubMed Central

Cole, John W.

2017-01-01

ABSTRACT Purpose of Review: Extracranial or intracranial large artery atherosclerosis is often identified as a potential etiologic cause for ischemic stroke and transient ischemic attack. Given the high prevalence of large artery atherosclerosis in the general population, determining whether an identified atherosclerotic lesion is truly the cause of a patient’s symptomatology can be difficult. In all cases, optimally treating each patient to minimize future stroke risk is paramount. Extracranial or intracranial large artery atherosclerosis can be broadly compartmentalized into four distinct clinical scenarios based upon the individual patient’s history, examination, and anatomic imaging findings: asymptomatic and symptomatic extracranial carotid stenosis, intracranial atherosclerosis, and extracranial vertebral artery atherosclerotic disease. This review provides a framework for clinicians evaluating and treating such patients. Recent Findings: Intensive medical therapy achieves low rates of stroke and death in asymptomatic carotid stenosis. Evidence indicates that patients with severe symptomatic carotid stenosis should undergo carotid revascularization sooner rather than later and that the risk of stroke or death is lower using carotid endarterectomy than with carotid stenting. Specific to stenting, the risk of stroke or death is greatest among older patients and women. Continuous vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy is the mainstay for stroke prevention in the setting of intracranial and vertebral artery origin atherosclerosis. Summary: Lifelong vascular risk factor optimization via sustained behavioral modifications and intensive medical therapy are the key elements to reduce future stroke risk in the setting of large artery atherosclerosis. When considering a revascularization procedure for carotid stenosis, patient demographics, comorbidities, and the periprocedural risks of stroke and death should be carefully considered. PMID:28157748

National trends in carotid artery revascularization surgery.

PubMed

Dumont, Travis M; Rughani, Anand I

2012-06-01

Several randomized trials have emerged with conflicting data on the overall safety of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA). The authors hypothesize that changes in national trends correspond to publication of randomized trials, including an increase in utilization of CAS after publication of trials favorable to CAS (for example, Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS] and Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE]) and decrease in utilization of CAS after publication of trials favorable to CEA (for example, Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA3-S] and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy [SPACE]). The Nationwide Inpatient Sample was obtained for the years 1998-2008. Individual cases were isolated for principal diagnosis of unilateral or bilateral carotid artery stenosis or occlusion undergoing CEA or CAS. The percentage of CAS for all carotid revascularization procedures was calculated for each year. Perioperative inpatient morbidity, including stroke or death, were calculated and compared. The percentage of patients undergoing CAS increased yearly from the start of the observed period to the end, with the exception of a decrease in 2007. The peak utilization of CAS for carotid artery revascularization procedures was 15% of all cases in 2006. The stroke or death rate was consistent at 5% among all patients undergoing CEA for all years, while the incidence of stroke or death decreased among patients undergoing CAS from 9% in 1998 to 5% in 2008. The practice of CAS in the US is expanding, from less than 3% of all carotid artery revascularization procedures to 13% in 2008. The utilization of CAS was seen to correlate with publication of randomized trials. Utilization nearly doubled in 2005 after publication of the CAS-favorable SAPPHIRE in 2004, and decreased by 22% after publication of the CEA-favorable EVA-3S and SPACE in 2007. With the publication of Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), the authors predict a resultant increase in the rate of CAS for carotid artery disease in the upcoming years.

Benefit of Adding Ezetimibe to Statin Therapy on Cardiovascular Outcomes and Safety in Patients With Versus Without Diabetes Mellitus: Results From IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial).

PubMed

Giugliano, Robert P; Cannon, Christopher P; Blazing, Michael A; Nicolau, José C; Corbalán, Ramón; Špinar, Jindřich; Park, Jeong-Gun; White, Jennifer A; Bohula, Erin A; Braunwald, Eugene

2018-04-10

Ezetimibe, when added to simvastatin, reduces cardiovascular events after acute coronary syndrome. We explored outcomes stratified by diabetes mellitus (DM). In IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial), 18 144 patients after acute coronary syndrome with low-density lipoprotein cholesterol 50 to 125 mg/dL were randomized to 40 mg ezetimibe/simvastatin (E/S) or 40 mg placebo/simvastatin. The primary composite end point was cardiovascular death, major coronary events, and stroke. DM was a prespecified subgroup. The 4933 (27%) patients with DM were more often older and female, had had a prior myocardial infarction and revascularization, and presented more frequently with non-ST segment elevation acute coronary syndrome compared with patients without DM (each P <0.001). The median admission low-density lipoprotein cholesterol was lower among patients with DM (89 versus 97 mg/dL, P <0.001). E/S achieved a significantly lower median time-weighted average low-density lipoprotein cholesterol compared with placebo/simvastatin, irrespective of DM (DM: 49 versus 67 mg/dL; no DM: 55 versus 71 mg/dL; both P <0.001). In patients with DM, E/S reduced the 7-year Kaplan-Meier primary end point event rate by 5.5% absolute (hazard ratio, 0.85; 95% confidence interval, 0.78-0.94); in patients without DM, the absolute difference was 0.7% (hazard ratio, 0.98; 95% confidence interval, 0.91-1.04; P int =0.02). The largest relative reductions in patients with DM were in myocardial infarction (24%) and ischemic stroke (39%). No differences in safety outcomes by treatment were present regardless of DM. When stratified further by age, patients ≥75 years of age had a 20% relative reduction in the primary end point regardless of DM ( P int =0.91), whereas patients <75 years of age with DM had greater benefit than those without ( P int =0.011). When stratified by the TIMI (Thrombolysis in Myocardial Infarction) Risk Score for Secondary Prevention, all patients with DM demonstrated benefit with E/S regardless of risk. In contrast, among patients without DM, those with a high risk score experienced a significant (18%) relative reduction in the composite of cardiovascular death, myocardial infarction, and ischemic stroke with E/S compared with placebo/simvastatin, whereas patients without DM at low or moderate risk demonstrated no benefit with the addition of ezetimibe to simvastatin ( P int =0.034). In IMPROVE-IT, the benefit of adding ezetimibe to statin was enhanced in patients with DM and in high-risk patients without DM. URL: https://www.clinicaltrials.gov. Unique identifier: NCT00202878. © 2017 American Heart Association, Inc.

Short-term clinical outcomes after off-pump coronary artery bypass grafting at a single Veterans Affairs Medical Center.

PubMed

Lushaj, Entela B; Schreiner, Athanasia; Jonuzi, Besa; Badami, Abbasali; DeOliveira, Nilto; Lozonschi, Lucian

2016-05-17

We retrospectively assessed the outcomes after coronary revascularization at a single Veterans Affairs Medical Center when a strategy of assigning higher risk patients to off-pump coronary artery bypass grafting (CABG) was employed. Over a 5 year period all consecutive patients that underwent CABG at our VA Medical Center were assigned to a surgeon who either performs the CABG exclusively off-pump or to one who performed the CABG on-pump. The higher risk patients were assigned preferentially for off-pump revascularization. VASQIP (VA Hospitals Surgical Quality Improvement Program) data between 10/2007 and 12/2012 were retrospectively reviewed at our VA Medical Center and the short term outcomes were assessed. A total of 252 consecutive patients underwent off-pump CABG (n = 170) and on-pump CABG (n = 82). There were significantly more patients with low LVEF (<45 %; p = 0.008) and cerebrovascular disease in the off-pump group (p = 0.024). The number of patients smoking at the time of surgery was significantly higher in the off-pump group (p = 0.002) as well. The 30-day composite morbidity and mortality was 6 % for all CABG patients and significantly lower with off-pump vs. on-pump CABG (3.5 % vs. 11 %; p = 0.019). There were no conversions from off-pump to on-pump surgery. A selective strategy to direct higher risk patients towards an off-pump revascularization yielded favorable outcomes in an unselected veteran population treated at a single VA Medical Center over a 5 year period.

Anti-Inflammatory Targets for the Treatment of Reperfusion Injury in Stroke

PubMed Central

Mizuma, Atsushi; Yenari, Midori A.

2017-01-01

While the mainstay of acute stroke treatment includes revascularization via recombinant tissue plasminogen activator or mechanical thrombectomy, only a minority of stroke patients are eligible for treatment, as delayed treatment can lead to worsened outcome. This worsened outcome at the experimental level has been attributed to an entity known as reperfusion injury (R/I). R/I is occurred when revascularization is delayed after critical brain and vascular injury has occurred, so that when oxygenated blood is restored, ischemic damage is increased, rather than decreased. R/I can increase lesion size and also worsen blood barrier breakdown and lead to brain edema and hemorrhage. A major mechanism underlying R/I is that of poststroke inflammation. The poststroke immune response consists of the aberrant activation of glial cell, infiltration of peripheral leukocytes, and the release of damage-associated molecular pattern (DAMP) molecules elaborated by ischemic cells of the brain. Inflammatory mediators involved in this response include cytokines, chemokines, adhesion molecules, and several immune molecule effectors such as matrix metalloproteinases-9, inducible nitric oxide synthase, nitric oxide, and reactive oxygen species. Several experimental studies over the years have characterized these molecules and have shown that their inhibition improves neurological outcome. Yet, numerous clinical studies failed to demonstrate any positive outcomes in stroke patients. However, many of these clinical trials were carried out before the routine use of revascularization therapies. In this review, we cover mechanisms of inflammation involved in R/I, therapeutic targets, and relevant experimental and clinical studies, which might stimulate renewed interest in designing clinical trials to specifically target R/I. We propose that by targeting anti-inflammatory targets in R/I as a combined therapy, it may be possible to further improve outcomes from pharmacological thrombolysis or mechanical thrombectomy. PMID:28936196

Cumulative clinical trial data on atorvastatin for reducing cardiovascular events: the clinical impact of atorvastatin.

PubMed

Bybee, Kevin A; Lee, John H; O'Keefe, James H

2008-04-01

Since the 1990s a multitude of statin trials have definitively demonstrated the ability of statin therapy to reduce the risk of adverse coronary heart disease (CHD) events. Among these, the Atorvastatin Landmarks program - a group of 32 major atorvastatin trials - has assessed the efficacy and safety of atorvastatin across its full dose range and has helped illustrate its effectiveness in treatment of cardiovascular disease and its related disorders and also in non-cardiovascular outcomes. This paper will review the major atorvastatin clinical trials and report the important findings and their clinical significance. Clinical trials with atorvastatin have established significant reductions in cardiovascular events in patients with and without CHD. Studies show that high-dose atorvastatin will reduce LDL to approximately 70 mg/dL in many patients and improve cardiac outcomes. Current evidence suggests that high-dose atorvastatin can halt and, in some cases, reverse atherosclerotic progression. A study of diabetic patients showed atorvastatin decreased the occurrence of acute CHD events, coronary revascularizations, and stroke. Atorvastatin has been found to be effective for reducing nonfatal myocardial infarctions and fatal CHD in hypertensive patients with three or more additional risk factors. High-dose atorvastatin was found to be effective in reducing risk of recurrent stroke in patients with prior cerebrovascular events, has been shown to benefit patients suffering a recent acute coronary syndrome, and to slow cognitive decline in preliminary studies of patients with Alzheimer's disease. Atorvastatin has been associated with reduced progression of mild chronic kidney disease; however, in a randomized trial of patients with end stage renal disease on hemodialysis, atorvastatin showed no statistically significant benefit. Limitations of this review include lack of generalizability of the atorvastatin trial data to other statins, lack of head to head outcome trials involving the newer more potent statins, and the relatively short study durations (none exceeded 5 years) when atherosclerosis is typically a decades-long disease. A compelling body of evidence documents that atorvastatin reduces major cardiovascular events in both secondary and primary prevention of CHD and in a broad range of patients and disease conditions. Furthermore, throughout its dose range, atorvastatin is safe and well tolerated.

Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room.

PubMed

Zhao, David X; Leacche, Marzia; Balaguer, Jorge M; Boudoulas, Konstantinos D; Damp, Julie A; Greelish, James P; Byrne, John G; Ahmad, Rashid M; Ball, Stephen K; Cleator, John H; Deegan, Robert J; Eagle, Susan S; Fong, Pete P; Fredi, Joseph L; Hoff, Steven J; Jennings, Henry S; McPherson, John A; Piana, Robert N; Pretorius, Mias; Robbins, Mark A; Slosky, David A; Thompson, Annemarie

2009-01-20

This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room. The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved. Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings. Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients. Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

[Systemic coronary surgery in the beating heart. Experience in 250 cases].

PubMed

Cartier, R; Bouchard, D; Martineau, R; Couturier, A

1999-01-01

To report our recent experience with off-pump coronary artery revascularization in multi-vessel disease. Between October 1996 and August 1998, 250 off-pump (OP) procedures were completed at the Montreal Heart Institute, representing more than 90% of all procedures done during the same time frame (97% for 1998). These patients have been compared to 1870 patients operated upon under cardiopulmonary bypass during the years 1995-1996 (CPB). Mean age, sexe distribution, and preoperative risk factors were comparable for both groups. On average 2.89 +/- 0.8 and 2.84 +/- 0.6 grafts/patient were completed in OP and CPB groups respectively. A majority (70%) of patients had either a triple or quadruple bypass. Coronary anastomoses were achieved with myocardial mechanical stabilization and heart "verticalization". Ischemic time was shorter in the OP group (29.8 +/- 0.9 vs 45 +/- 0.4 min, p < 0.05). Similarly, need for transfusion was significantly less (OP: 34 vs CPB: 66%, p < 0.005). Use of postoperative intra-aortic counterpulsation as well as the raise of CK-MB were lesser in the OP group. Operative mortality (OP: 1.6%, vs CPB: 2%, p = ns) and perioperative myocardial infarction rate (OP: 3.6% vs CPB: 4.2) were comparable for both groups. Off-pump complete coronary artery revascularization is an acceptable alternative to conventional surgery in a majority of patients with good results given progressive experience, rigorous technique, and adequate coronary artery stabilization.

Reproducibility and clinical potential of myocardial mass at risk calculated by a novel software utilizing cardiac computed tomography information.

PubMed

Sumitsuji, Satoru; Ide, Seiko; Siegrist, Patrick T; Salah, Youssef; Yokoi, Kensuke; Yoshida, Masatoki; Awata, Masaki; Yamasaki, Keita; Tachibana, Kouichi; Kaneda, Hideaki; Nanto, Shinsuke; Sakata, Yasushi

2016-07-01

To select the best revascularization strategy a correct understanding of the ischemic territory and the coronary anatomy is crucial. Stress myocardial perfusion single photon emission computed tomography (SPECT) is the gold standard to assess ischemia, however, SPECT has important limitations such as lack of coronary anatomical information or false negative results due to balanced ischemia in multi-vessel disease. Angiographic scores are based on anatomical characteristics of coronary arteries but they lack information on the extent of jeopardized myocardium. Cardiac computed tomography (CCT) has the ability to evaluate the coronary anatomy and myocardium in one sequence, which is theoretically the ideal method to assess the myocardial mass at risk (MMAR) for any target lesion located at any point in the coronary tree. In this study we analyzed MMAR of the three main coronary arteries and three major side branches; diagonal (Dx), obtuse marginal (OM), and posterior descending artery (PDA) in 42 patients with normal coronary arteries using an algorithm based on the Voronoi method. The distribution of MMAR among the three main coronary arteries was 44.3 ± 5.6 % for the left anterior descending artery, 28.2 ± 7.3 % for the left circumflex artery, and 26.8 ± 8.6 % for the right coronary artery. MMAR of the three major side branches was 11.3 ± 3.9 % for the Dx, 12.6 ± 5.2 % for the OM and 10.2 ± 3.4 % for the PDA. Intra- and inter-observer analysis showed excellent correlation (r = 0.97; p < 0.0001 and r = 0.95; p < 0.0001, respectively). In conclusion, CCT-based MMAR assessment is reliable and may offer important information for selection of the optimal revascularization procedure.

Differences in Short- and Long-Term Mortality Associated With BMI Following Coronary Revascularization.

PubMed

Terada, Tasuku; Forhan, Mary; Norris, Colleen M; Qiu, Weiyu; Padwal, Raj; Sharma, Arya M; Nagendran, Jayan; Johnson, Jeffrey A

2017-04-14

The association between obesity and mortality risks following coronary revascularization is not clear. We examined the associations of BMI (kg/m 2 ) with short-, intermediate-, and long-term mortality following coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with different coronary anatomy risks and diabetes mellitus status. Data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry were analyzed. Using normal BMI (18.5-24.9) as a reference, multivariable-adjusted hazard ratios for all-cause mortality within 6 months, 1 year, 5 years, and 10 years were individually calculated for CABG and PCI with 4 prespecified BMI categories: overweight (25.0-29.9), obese class I (30.0-34.9), obese class II (35.0-39.9), and obese class III (≥40.0). The analyses were repeated after stratifying for coronary risks and diabetes mellitus status. The cohorts included 7560 and 30 258 patients for CABG and PCI, respectively. Following PCI, overall mortality was lower in patients with overweight and obese class I compared to those with normal BMI; however, 5- and 10-year mortality rates were significantly higher in patients with obese class III with high-risk coronary anatomy, which was primarily driven by higher mortality rates in patients without diabetes mellitus (5-year adjusted hazard ratio, 1.78 [95% CI, 1.11-2.85] and 10-year adjusted hazard ratio, 1.57 [95% CI, 1.02-2.43]). Following CABG, overweight was associated with lower mortality risks compared with normal BMI. Overweight was associated with lower mortality following CABG and PCI. Greater long-term mortality in patients with obese class III following PCI, especially in those with high-risk coronary anatomy without diabetes mellitus, warrants further investigation. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

A Structured Review of Antithrombotic Therapy in Peripheral Artery Disease With a Focus on Revascularization: A TASC (InterSociety Consensus for the Management of Peripheral Artery Disease) Initiative.

PubMed

Hess, Connie N; Norgren, Lars; Ansel, Gary M; Capell, Warren H; Fletcher, John P; Fowkes, F Gerry R; Gottsäter, Anders; Hitos, Kerry; Jaff, Michael R; Nordanstig, Joakim; Hiatt, William R

2017-06-20

Peripheral artery disease affects >200 million people worldwide and is associated with significant limb and cardiovascular morbidity and mortality. Limb revascularization is recommended to improve function and quality of life for symptomatic patients with peripheral artery disease with intermittent claudication who have not responded to medical treatment. For patients with critical limb ischemia, the goals of revascularization are to relieve pain, help wound healing, and prevent limb loss. The baseline risk of cardiovascular and limb-related events demonstrated among patients with stable peripheral artery disease is elevated after revascularization and related to atherothrombosis and restenosis. Both of these processes involve platelet activation and the coagulation cascade, forming the basis for the use of antiplatelet and anticoagulant therapies to optimize procedural success and reduce postprocedural cardiovascular risk. Unfortunately, few high-quality, randomized data to support use of these therapies after peripheral artery disease revascularization exist, and much of the rationale for the use of antiplatelet agents after endovascular peripheral revascularization is extrapolated from percutaneous coronary intervention literature. Consequently, guideline recommendations for antithrombotic therapy after lower limb revascularization are inconsistent and not always evidence-based. In this context, the purpose of this structured review is to assess the available randomized data for antithrombotic therapy after peripheral arterial revascularization, with a focus on clinical trial design issues that may affect interpretation of study results, and highlight areas that require further investigation. © 2017 American Heart Association, Inc.

Endovascular Versus Open Surgical Intervention in Patients with Takayasu's Arteritis: A Meta-analysis.

PubMed

Jung, Jae Hyun; Lee, Young Ho; Song, Gwan Gyu; Jeong, Han Saem; Kim, Jae-Hoon; Choi, Sung Jae

2018-06-01

Although medical treatment has advanced, surgical treatment is needed to control symptoms of Takayasu's arteritis (TA), such as angina, stroke, hypertension, or claudication. Endovascular or open surgical intervention is performed; however, there are few comparative studies on these methods. This meta-analysis and systematic review aimed to examine the outcome of surgical treatment of TA. A meta-analysis comparing outcomes of endovascular and open surgical intervention was performed using MEDLINE and Embase. This meta-analysis included only observational studies, and the evidence level was low to moderate. Data were pooled and analysed using a fixed or random effects model with the I 2 statistic. The included studies involved a total of 770 patients and 1363 lesions, with 389 patients treated endovascularly and 420 treated by surgical revascularization. Restenosis was more common with endovascular than open surgical intervention (odds ratio [OR] 5.18, 95% confidence interval [CI] 2.78-9.62; p < .001). In subgroup analysis according to the involved lesions, endovascular intervention patients showed more restenosis than open surgical intervention patients in the coronary artery, supra-aortic branches, and renal artery. In both the active and inactive stages, restenosis was more common in those treated endovascularly than in those treated by open surgery. However, stroke occurred less often with endovascular intervention than with open surgical intervention (OR 0.33, 95% CI 0.12-0.90; p = .003). Mortality and complications other than stroke and mortality did not differ between endovascular and open surgical intervention. This meta-analysis has shown a lower risk of restenosis with open surgical intervention than with endovascular intervention. Stroke was generally more common with open surgical intervention than with endovascular intervention. However, there were differences according to the location of the lesion, and the risk of stroke in open surgery is higher when the supra-aortic branches are involved rather than the renal arteries. Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Diabetes mellitus: a prothrombotic state Implications for outcomes after coronary revascularization

PubMed Central

Cola, Clarissa; Brugaletta, Salvatore; Yuste, Victoria Martín; Campos, Bieito; Angiolillo, Dominick J; Sabaté, Manel

2009-01-01

Coronary stent thrombosis is a serious problem in the drug-eluting stent era. Despite aggressive antiplatelet therapy during and after percutaneous coronary intervention (PCI), the incidence of sub-acute stent thrombosis remains approximately 0.5%–2%, which may represent a catastrophic clinical situation. Both procedural factors and discontinuation of antiplatelet therapy are normally associated with this event. We report on simultaneous stent thromboses of two drug-eluting stents implanted in two different vessels, which resulted in a life-threatening clinical condition. Possible contributing factors that led to synergistic thrombotic effects are discussed. PMID:19436654

Validating the EXCEL hypothesis: a propensity score matched 3-year comparison of percutaneous coronary intervention versus coronary artery bypass graft in left main patients with SYNTAX score ≤32.

PubMed

Capodanno, Davide; Caggegi, Anna; Capranzano, Piera; Cincotta, Glauco; Miano, Marco; Barrano, Gionbattista; Monaco, Sergio; Calvo, Francesco; Tamburino, Corrado

2011-06-01

The aim of this study is to verify the study hypothesis of the EXCEL trial by comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in an EXCEL-like population of patients. The upcoming EXCEL trial will test the hypothesis that left main patients with SYNTAX score ≤ 32 experience similar rates of 3-year death, myocardial infarction (MI), or cerebrovascular accidents (CVA) following revascularization by PCI or CABG. We compared the 3-year rates of death/MI/CVA and death/MI/CVA/target vessel revascularization (MACCE) in 556 patients with left main disease and SYNTAX score ≤ 32 undergoing PCI (n = 285) or CABG (n = 271). To account for confounders, outcome parameters underwent extensive statistical adjustment. The unadjusted incidence of death/MI/CVA was similar between PCI and CABG (12.7% vs. 8.4%, P = 0.892), while MACCE were higher in the PCI group compared to the CABG group (27.0% vs. 11.8%, P < 0.001). After propensity score matching, PCI was not associated with a significant increase in the rate of death/MI/CVA (11.8% vs. 10.7%, P = 0.948), while MACCE were more frequently noted among patients treated with PCI (28.8% vs. 14.1%, P = 0.002). Adjustment by means of SYNTAX score and EUROSCORE, covariates with and without propensity score, and propensity score alone did not change significantly these findings. In an EXCEL-like cohort of patients with left main disease, there seems to be a clinical equipoise between PCI and CABG in terms of death/MI/CVA. However, even in patients with SYNTAX score ≤ 32, CABG is superior to PCI when target vessel revascularization is included in the combined endpoint. Copyright © 2011 Wiley-Liss, Inc.

Management of Patients with Cardiac Arrest Complicating Myocardial Infarction in New York Before and After Public Reporting Policy Changes

PubMed Central

Strom, Jordan B.; McCabe, James M.; Waldo, Stephen W.; Pinto, Duane; Kennedy, Kevin F.; Feldman, Dmitriy N.; Yeh, Robert W.

2017-01-01

Background In 2010, New York State began excluding selected patients with cardiac arrest and coma from publicly reported mortality statistics after percutaneous coronary intervention (PCI). We evaluated the effects of this exclusion on rates of coronary angiography, revascularization, and mortality among patients with acute myocardial infarction (AMI) and cardiac arrest. Methods and Results Using statewide hospitalization files, we identified discharges for AMI and cardiac arrest 1/2003–12/2013 in New York and several comparator states. A difference-in-differences approach was used to evaluate the likelihood of coronary angiography, revascularization, and in-hospital mortality before and after 2010. A total of 26,379 patients with AMI and cardiac arrest (5,619 in New York) were included. Of these, 17,141 (65%) underwent coronary angiography, 12,183 (46.2%) underwent PCI and 2,832 (10.7%) underwent CABG. Prior to 2010, cardiac arrest patients in New York were less likely to undergo PCI compared with referent states (aRR 0.79, 95% CI 0,73–0.85, p<0.001). This relationship was unchanged after the policy change (aRR 0.82, 95% CI 0.76–0.89, interaction p = 0.359). Adjusted risks of in-hospital mortality between New York and comparator states after 2010 were also similar (aRR 0.94, 95% CI 0.87–1.02, p = 0.152 for post- vs. pre-2010 in New York, aRR 0.88, 95% CI 0.84–0.92, p <0.001 for comparator states; interaction p = 0.103). Conclusions Exclusion of selected cardiac arrest cases from public reporting was not associated with changes in rates of PCI or in-hospital mortality in New York. Rates of revascularization in New York for cardiac arrest patients were lower throughout. PMID:28495895

Outcome by Exercise Echocardiography in Patients with Low Pretest Probability of Coronary Artery Disease.

PubMed

Peteiro, Jesus; Bouzas-Mosquera, Alberto; Broullon, Javier; Sanchez-Fernandez, Gabriel; Perez-Cebey, Lucia; Yañez, Juan; Martinez, Dolores; Vazquez-Rodriguez, Jose M

2016-08-01

Recommendations for testing in patients with low pretest probability of coronary artery disease differ in guidelines from no testing at all to different tests. The aim of this study was to assess the value of exercise echocardiography (ExE) to define outcome in this population. A retrospective analysis was conducted of 1,436 patients with low pretest probability of coronary artery disease (<15%) who underwent initial ExE. Overall mortality, major adverse cardiac events (MACEs), defined as cardiac death or nonfatal myocardial infarction, and revascularization during follow-up, were assessed. Ischemia (development of new wall motion abnormalities with exercise) and fixed wall motion abnormalities were measured. The mean age was 50 ± 12 years. Resting wall motion abnormalities were seen in 13 patients (0.9%) and ischemia in 108 (7.5%). During follow-up, 38 patients died, 10 of cardiac death (annualized death rate, 0.39%); 20 patients had MACEs (annualized MACE rate, 0.21%); and 48 patients (29 with ischemia) underwent revascularization (annualized revascularization rate, 0.51%). The number and percentage of MACEs in the abnormal and normal ExE groups were similar (two [1.7%] vs 18 [1.4%], P = .70), as was the annualized MACE rate (0.31% vs 0.21%, P = .50). Peak left ventricular ejection fraction exhibited a nonsignificant trend for predicting MACEs (P = .11). The number of studies needed to detect an abnormal finding was 12.6 and to detect a patient with extensive ischemia was 26.1. ExE offers limited prognostic information in patients with low pretest probability of coronary artery disease. The small number of abnormal findings on ExE and low event rates and the large number of studies needed to detect an abnormal finding limit further the value of imaging in this population. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Effective secondary prevention through cardiac rehabilitation after coronary revascularization and predictors of poor adherence to lifestyle modification and medication. Results of the ICAROS Survey.

PubMed

Griffo, Raffaele; Ambrosetti, Marco; Tramarin, Roberto; Fattirolli, Francesco; Temporelli, Pier Luigi; Vestri, Anna Rita; De Feo, Stefania; Tavazzi, Luigi

2013-08-20

Secondary prevention is a priority after coronary revascularization. We investigate the impact of a cardiac rehabilitation (CR) program on lifestyle, risk factors and medication modifications and analyze predictors of poor behavioral changes and events in patients after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Multicenter (n=62), prospective, longitudinal survey in post-CABG or -PCI consecutive patients after a comprehensive CR program. Cardiac risk factors, lifestyle habits, medication and 1 year cardiovascular events were collected. Logistic regression analyzed the association between risk factors, events and predictors of non-adherence to treatment and lifestyle. At 1 year, of the 1262 patients (66 ± 10 years, CABG 69%, PCI 31%), 94% were taking antiplatelet agents (vs. 91.8% at CR admission and 91.7% at CR discharge, p=ns), 87% statins (vs. 67.5%, p<.0001, and 86.3%, p=ns), 80.7% beta-blockers (vs. 67.4%, p<.0001, and 88.8%, p=ns), and 81.1% ACE inhibitors (vs. 57.5% p<.0001, and 77.7%, p=ns). 89.9% of the patients showed good adherence to treatment, 72% adhered to diet and 51% to exercise recommendations; 74% of smokers stopped smoking. Younger age was predictive of smoking resumption (OR 8.9, CI 3.5-22.8). Pre-event sedentary lifestyle (OR 3.3, CI 1.3-8.7) was predictive of poor diet. Older patients with comorbidity (OR 3.1; CI, 1.8-5.2) tended to persist in sedentary lifestyle and discontinue therapy and diet recommendations. Age, diabetes, smoking and PCI indication were predictors of recurrent CV events which occurred in 142 patients. Participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1 year and provides further confirmation of the benefit of secondary prevention. Several clinical characteristics may predict poor behavioral changes. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Percutaneous coronary intervention strategies and prognosis for graft lesions following coronary artery bypass grafting

PubMed Central

LIU, YIN; ZHOU, XIUJUN; JIANG, HUA; GAO, MINGDONG; WANG, LIN; SHI, YUTIAN; GAO, JING

2015-01-01

The purpose of this study was to compare the prognosis of graft-percutaneous coronary intervention (PCI) and native vessel (NV)-PCI, drug-eluting stents (DESs) and bare-metal stents (BMSs) for the treatment of graft lesions following coronary artery bypass grafting (CABG), and to determine the risk factors for major adverse cardiac events (MACEs). A total of 289 patients who underwent PCI following CABG between August 2005 and March 2010 were retrospectively analyzed. The effects on survival were compared among patients who underwent NV- and graft-PCI, and DES and BMS implantation. Additionally, the risk factors for MACEs following PCI for graft lesions were analyzed. The findings showed that MACE-free and revascularization-free survival rates were significantly higher in the NV-PCI group compared with those in the graft-PCI group. There were 63 cases (29.0%) of MACEs in the DES group and 25 cases (52.1%) in the BMS group. In patients undergoing NV-PCI, the DES group had significantly fewer MACEs and less target vessel revascularization (TVR) than the BMS group. In patients undergoing graft-PCI, the DES group showed a tendency for fewer MACEs and a lower incidence of cardiac mortality, myocardial infarction and TVR compared with the BMS group. Diabetes, an age of >70 years and graft-PCI were independent risk factors for MACEs in patients post-PCI. It is concluded that NV-PCI has superior long-term outcomes compared with graft-PCI, and should therefore be considered as the first-line treatment for graft disease following CABG. Despite this, graft-PCI remains a viable option. DESs are the first choice for graft-PCI due to their safety and efficacy and their association with reduced mortality and MACE rate. Diabetes, older age and graft-PCI are independent risk factors for MACEs in patients post-CABG who are undergoing revascularization. PMID:26136874

Late adverse events after implantation of sirolimus-eluting stent and bare-metal stent: long-term (5-7 years) follow-up of the Coronary Revascularization Demonstrating Outcome study-Kyoto registry Cohort-2.

PubMed

Natsuaki, Masahiro; Morimoto, Takeshi; Furukawa, Yutaka; Nakagawa, Yoshihisa; Kadota, Kazushige; Yamaji, Kyohei; Ando, Kenji; Shizuta, Satoshi; Shiomi, Hiroki; Tada, Tomohisa; Tazaki, Junichi; Kato, Yoshihiro; Hayano, Mamoru; Abe, Mitsuru; Tamura, Takashi; Shirotani, Manabu; Miki, Shinji; Matsuda, Mitsuo; Takahashi, Mamoru; Ishii, Katsuhisa; Tanaka, Masaru; Aoyama, Takeshi; Doi, Osamu; Hattori, Ryuichi; Kato, Masayuki; Suwa, Satoru; Takizawa, Akinori; Takatsu, Yoshiki; Shinoda, Eiji; Eizawa, Hiroshi; Takeda, Teruki; Lee, Jong-Dae; Inoko, Moriaki; Ogawa, Hisao; Hamasaki, Shuichi; Horie, Minoru; Nohara, Ryuji; Kambara, Hirofumi; Fujiwara, Hisayoshi; Mitsudo, Kazuaki; Nobuyoshi, Masakiyo; Kita, Toru; Kimura, Takeshi

2014-04-01

Late adverse events such as very late stent thrombosis (VLST) or late target-lesion revascularization (TLR) after first-generation sirolimus-eluting stents (SES) implantation have not been yet fully characterized at long term in comparison with those after bare-metal stent (BMS) implantation. Among 13 058 consecutive patients undergoing first percutaneous coronary intervention in the Coronary REvascularization Demonstrating Outcome study-Kyoto registry Cohort-2, 5078 patients were treated with SES only, and 5392 patients were treated with BMS only. During 7-year follow-up, VLST and late TLR beyond 1 year after SES implantation occurred constantly and without attenuation at 0.24% per year and at 2.0% per year, respectively. Cumulative 7-year incidence of VLST was significantly higher in the SES group than that in the BMS group (1.43% versus 0.68%, P<0.0001). However, there was no excess of all-cause death beyond 1 year in the SES group as compared with that in the BMS group (20.8% versus 19.6%, P=0.91). Cumulative incidences of late TLR (both overall and clinically driven) were also significantly higher in the SES group than in the BMS group (12.0% versus 4.1%, P<0.0001 and 8.5% versus 2.6%, P<0.0001, respectively), leading to late catch-up of the SES group to the BMS group regarding TLR through the entire 7-year follow-up (18.8% versus 25.2%, and 10.6% versus 10.2%, respectively). Clinical presentation as acute coronary syndrome was more common at the time of late SES TLR compared with early SES TLR (21.2% and 10.0%). Late catch-up phenomenon regarding stent thrombosis and TLR was significantly more pronounced with SES than that with BMS. This limitation should remain the target for improvements of DES technology.

Clinical outcomes with Biolimus (A9)™ eluting stent, 'BioMatrix' in diabetic patients--interim results from multicenter post market surveillance registry in India.

PubMed

Seth, Ashok; Hiremath, Shirish; Dani, Sameer; Kapoor, Sunil; Jain, R K; Abhaichand, Rajpal; Trivedi, Shailendra; Kaul, Upendra; Patil, Aruna; Khemnar, Bhushan; Rangnekar, Hrishikesh

2013-01-01

The objective of this registry is to establish safety and efficacy of BioMatrix, BioMatrix™-Biolimus A9™ eluting stent in diabetic population in India. Diabetes mellitus is a major predisposing factor for coronary artery disease. Prognosis for diabetic population patients presenting with coronary artery disease who undergo coronary revascularization is inferior to non diabetics and remains an independent risk factor of restenosis, need for revascularization, and overall mortality. Stent thrombosis is a potential complication of first generation, permanent polymer drug-eluting stents. Biodegradable polymer is a good relief in this era and its utility in diabetic patients will be a major advantage for them. 334 patients with diabetes mellitus and requiring angioplasty, implanted with BioMatrix stent were followed at 1, 6, 12 and 24 months who entered in a multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, 12 and 24 months. The mean age was 58.71 ± 9.2 years, 81% were males, comorbidity index was 1.6 ± 1.02, and 59.1% presented with acute coronary syndrome. The incidence of adverse event rates was: MACE 1.27%. There were no incidences of myocardial infarction (MI) and target vessel revascularization (TVR). Definite stent thrombosis occurred only in 2 patients. In this registry of diabetic population treated with BioMatrixTM-Biolimus A9TM eluting stent (BioMatrix), the reported incidence of MACE and ST were much lower than previously published results. The 1- and 2-year follow-up result supports favorable clinical outcomes of using BioMatrix stents as a suitable alternative to contemporary DES available during PCI in diabetic patients. Copyright © 2013 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Fractional flow reserve vs. angiography in guiding management to optimize outcomes in non-ST-segment elevation myocardial infarction: the British Heart Foundation FAMOUS–NSTEMI randomized trial

PubMed Central

Layland, Jamie; Oldroyd, Keith G.; Curzen, Nick; Sood, Arvind; Balachandran, Kanarath; Das, Raj; Junejo, Shahid; Ahmed, Nadeem; Lee, Matthew M.Y.; Shaukat, Aadil; O'Donnell, Anna; Nam, Julian; Briggs, Andrew; Henderson, Robert; McConnachie, Alex; Berry, Colin; Hannah, Andrew; Stewart, Andrew; Metcalfe, Malcolm; Norrie, John; Chowdhary, Saqib; Clark, Andrew; Henderson, Robert; Balachandran, Kanarath; Berry, Colin; Baird, Gordon; O'Donnell, Anna; Sood, Arvind; Curzen, Nick; Das, Raj; Ford, Ian; Layland, Jamie; Junejo, Shahid; Oldroyd, Keith

2015-01-01

Aim We assessed the management and outcomes of non-ST segment elevation myocardial infarction (NSTEMI) patients randomly assigned to fractional flow reserve (FFR)-guided management or angiography-guided standard care. Methods and results We conducted a prospective, multicentre, parallel group, 1 : 1 randomized, controlled trial in 350 NSTEMI patients with ≥1 coronary stenosis ≥30% of the lumen diameter assessed visually (threshold for FFR measurement) (NCT01764334). Enrolment took place in six UK hospitals from October 2011 to May 2013. Fractional flow reserve was disclosed to the operator in the FFR-guided group (n = 176). Fractional flow reserve was measured but not disclosed in the angiography-guided group (n = 174). Fractional flow reserve ≤0.80 was an indication for revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). The median (IQR) time from the index episode of myocardial ischaemia to angiography was 3 (2, 5) days. For the primary outcome, the proportion of patients treated initially by medical therapy was higher in the FFR-guided group than in the angiography-guided group [40 (22.7%) vs. 23 (13.2%), difference 95% (95% CI: 1.4%, 17.7%), P = 0.022]. Fractional flow reserve disclosure resulted in a change in treatment between medical therapy, PCI or CABG in 38 (21.6%) patients. At 12 months, revascularization remained lower in the FFR-guided group [79.0 vs. 86.8%, difference 7.8% (−0.2%, 15.8%), P = 0.054]. There were no statistically significant differences in health outcomes and quality of life between the groups. Conclusion In NSTEMI patients, angiography-guided management was associated with higher rates of coronary revascularization compared with FFR-guided management. A larger trial is necessary to assess health outcomes and cost-effectiveness. PMID:25179764

Clinical outcomes with Biolimus (A9)™ eluting stent, ‘BioMatrix’ in diabetic patients – interim results from multicenter post market surveillance registry in India

PubMed Central

Seth, Ashok; Hiremath, Shirish; Dani, Sameer; Kapoor, Sunil; Jain, R.K.; Abhaichand, Rajpal; Trivedi, Shailendra; Kaul, Upendra; Patil, Aruna; Khemnar, Bhushan; Rangnekar, Hrishikesh

2013-01-01

Objective The objective of this registry is to establish safety and efficacy of BioMatrix, BioMatrix™-Biolimus A9™ eluting stent in diabetic population in India. Background Diabetes mellitus is a major predisposing factor for coronary artery disease. Prognosis for diabetic population patients presenting with coronary artery disease who undergo coronary revascularization is inferior to non diabetics and remains an independent risk factor of restenosis, need for revascularization, and overall mortality. Stent thrombosis is a potential complication of first generation, permanent polymer drug-eluting stents. Biodegradable polymer is a good relief in this era and its utility in diabetic patients will be a major advantage for them. Methods 334 patients with diabetes mellitus and requiring angioplasty, implanted with BioMatrix stent were followed at 1, 6, 12 and 24 months who entered in a multicenter registry in India. We analyzed the incidence of major adverse cardiac events (MACE) and stent thrombosis (ST) at 1, 6, 12 and 24 months. Results The mean age was 58.71 ± 9.2 years, 81% were males, comorbidity index was 1.6 ± 1.02, and 59.1% presented with acute coronary syndrome. The incidence of adverse event rates was: MACE 1.27%. There were no incidences of myocardial infarction (MI) and target vessel revascularization (TVR). Definite stent thrombosis occurred only in 2 patients. Conclusion In this registry of diabetic population treated with BioMatrixTM-Biolimus A9TM eluting stent (BioMatrix), the reported incidence of MACE and ST were much lower than previously published results. The 1- and 2-year follow-up result supports favorable clinical outcomes of using BioMatrix stents as a suitable alternative to contemporary DES available during PCI in diabetic patients. PMID:24206882

Trends in Coronary Revascularization and Ischemic Heart Disease-Related Mortality in Israel.

PubMed

Blumenfeld, Orit; Na'amnih, Wasef; Shapira-Daniels, Ayelet; Lotan, Chaim; Shohat, Tamy; Shapira, Oz M

2017-02-17

We investigated national trends in volume and outcomes of percutaneous coronary angioplasty (PCI), coronary artery bypass grafting (CABG), and ischemic heart disease-related mortality in Israel. Using International Classification of Diseases 9th and 10th revision codes, we linked 5 Israeli national databases, including the Israel Center for Disease Control National PCI and CABG Registries, the Ministry of Health Hospitalization Report, the Center of Bureau of Statistics, and the Ministry of Interior Mortality Report, to assess the annual PCI and CABG volume, procedural mortality, comorbidities, and ischemic heart disease-related mortality between 2002 and 2014. Trends over time were analyzed using linear regression, assuming a Poisson distribution. A total of 298 390 revascularization procedures (PCI: 255 724, CABG: 42 666) were performed during the study period. PCI volume increased by 9% from 2002 to 2008 (387.4/100 000 to 423.2/100 000), steadily decreasing by 10.5% to 378.5/100 000 in 2014 ( P =0.70 for the trend). CABG volume decreased by 59% (109.0/100 000 to 45.2/100 000) from 2002 to 2013, leveling at 46.4/100 000 ( P <0.0001). PCI/CABG ratio increased from 3.6 in 2002 to 8.5 in 2013, slightly decreasing to 8.2 by 2014 ( P <0.0001). In-hospital procedural mortality remained stable (PCI: 1.2-1.6%, P =0.34, CABG: 3.7-4.4%, P =0.29) despite a significant change in patient clinical profile. During the course of the study, ischemic heart disease-related mortality decreased by 46% (84.6-46/100 000, P <0.001). We observed a dramatic change in coronary revascularization procedures type and volume, and a marked decrease in ischemic heart disease-related mortality in Israel. The reasons for the observed changes remain unclear and need to be further investigated. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Transmyocardial laser revascularization in the acute ischaemic heart: no improvement of acute myocardial perfusion or prevention of myocardial infarction.

PubMed

Eckstein, F S; Scheule, A M; Vogel, U; Schmid, S T; Miller, S; Jurmann, M J; Ziemer, G

1999-05-01

Transmyocardial laser revascularization (TMLR) has been used to provide enhanced myocardial perfusion in patients not suitable for coronary revascularization or angioplasty. This study investigates the acute changes in myocardial perfusion after TMLR with a Holmium:Yttrium-Aluminium-Garnet (YAG) laser with a thermal imaging camera in a model of acute ischaemia, and confirms its midterm effects by post-mortem investigation of magnetic resonance imaging and histopathological examination. Acute myocardial ischaemia was induced by occlusion of the dominant diagonal branch in ten sheep. Perfusion measurements were undertaken first in the unaffected myocardium, then after temporary occlusion of the coronary to obtain a control measurement for ischaemic myocardium. Myocardial perfusion was then evaluated during reperfusion after release of coronary occlusion. Then the coronary was permanently occluded and 20.5+/-2 channels were drilled with the Holmium:YAG laser and perfusion was measured again. The other four sheep served as control with untreated ischaemia. All animals were sacrificed after 28 days following administration of gadolinium i.v. to serve as contrast medium for magnetic resonance tomography. The hearts were subjected to magnetic resonance tomography and histopathological examination. Intraoperative perfusion measurements revealed a decreased perfusion after temporary occlusion and an increased perfusion in reperfused myocardium. After TMLR, no improvement of myocardial perfusion above the ischaemic level could be shown. Magnetic resonance images could neither confirm patent laser channels nor viable myocardium within ischaemic areas. On histology no patent endocardial laser channel could be detected. The transmural features were myocardial infarct with scar tissue. In the presented sheep model with acute ischaemia, TMLR with a Holmium:YAG laser did not provide acute improvement of myocardial perfusion as assessed by a thermal imaging camera. This would suggest no direct contribution of newly created laser channels to myocardial perfusion. As chronic effects are concerned, no perfused laser channels could be identified by later magnetic resonance imaging or histology.

[Face replantation using labial artery for revascularization. Case report].

PubMed

de la Parra-Márquez, Miguel; Mondragón-González, Sergio; López-Palazuelos, Jaime; Naal-Mendoza, Norberto; Rangel-Flores, Jesús María

2013-01-01

Restoration of the face function and cosmetic appearance after a traumatic complex wound is a challenge for the plastic surgeon. Worldwide, few cases have been reported about face replantation. To present the case of the first partial face replantation reported in the national bibliography, using the labial artery for revascularization. On June 19th 2011, a 7 years old male presented to the emergency room of the Mexican Institute of Social Security at Monterrey, Mexico, 4 hours after a partial face amputation secondary to a dog bite. The amputated segment was composed of 75% of the upper lip, 33% of the lower lip, oral commissure and 75% of the left cheek. The labial coronary artery and vein were anastomosed with 11-0 nylon sutures and the miorraphy of the orbicularis oris, the depressor anguli oris and the depressor labii inferioris with 4-0 vycril sutures. Six months after the surgery, the functional and aesthetic outcomes were excellent with reestablishment of total labial continence and total recovery of articulation of words. amputations of any facial component should be initially managed with replantation. The function and cosmetics are better than any other technique of reconstruction. The labial coronary artery is an excellent choice for revascularization up to 25% of the face (lips and cheek).

Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization

PubMed Central

Kones, Richard

2010-01-01

The objectives in treating angina are relief of pain and prevention of disease progression through risk reduction. Mechanisms, indications, clinical forms, doses, and side effects of the traditional antianginal agents – nitrates, β-blockers, and calcium channel blockers – are reviewed. A number of patients have contraindications or remain unrelieved from anginal discomfort with these drugs. Among newer alternatives, ranolazine, recently approved in the United States, indirectly prevents the intracellular calcium overload involved in cardiac ischemia and is a welcome addition to available treatments. None, however, are disease-modifying agents. Two options for refractory angina, enhanced external counterpulsation and spinal cord stimulation (SCS), are presented in detail. They are both well-studied and are effective means of treating at least some patients with this perplexing form of angina. Traditional modifiable risk factors for coronary artery disease (CAD) – smoking, hypertension, dyslipidemia, diabetes, and obesity – account for most of the population-attributable risk. Individual therapy of high-risk patients differs from population-wide efforts to prevent risk factors from appearing or reducing their severity, in order to lower the national burden of disease. Current American College of Cardiology/American Heart Association guidelines to lower risk in patients with chronic angina are reviewed. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that in patients with stable angina, optimal medical therapy alone and percutaneous coronary intervention (PCI) with medical therapy were equal in preventing myocardial infarction and death. The integration of COURAGE results into current practice is discussed. For patients who are unstable, with very high risk, with left main coronary artery lesions, in whom medical therapy fails, and in those with acute coronary syndromes, PCI is indicated. Asymptomatic patients with CAD and those with stable angina may defer intervention without additional risk to see if they will improve on optimum medical therapy. For many patients, coronary artery bypass surgery offers the best opportunity for relieving angina, reducing the need for additional revascularization procedures and improving survival. Optimal medical therapy, percutaneous coronary intervention, and surgery are not competing therapies, but are complementary and form a continuum, each filling an important evidence-based need in modern comprehensive management. PMID:20859545

Epidemiological characteristics, management and early outcomes of acute coronary syndromes in Greece: The PHAETHON study.

PubMed

Andrikopoulos, G; Terentes-Printzios, D; Tzeis, S; Vlachopoulos, C; Varounis, C; Nikas, N; Lekakis, J; Stakos, D; Lymperi, S; Symeonidis, D; Chrissos, D; Kyrpizidis, C; Alexopoulos, D; Zombolos, S; Foussas, S; Κranidis, Α; Oikonomou, Κ; Vasilikos, V; Andronikos, P; Dermitzakis, Α; Richter, D; Fragakis, N; Styliadis, I; Mavridis, S; Stefanadis, C; Vardas, P

In view of recent therapeutic breakthroughs in acute coronary syndromes (ACS) and essential demographic and socioeconomic changes in Greece, we conducted the prospective, multi-center, nationwide PHAETHON study (An Epidemiological Cohort Study of Acute Coronary Syndromes in the Greek Population) that aimed to recruit a representative cohort of ACS patients and examine current management practices and patient prognosis. The PHAETHON study was conducted from May 2012 to February 2014. We enrolled 800 consecutive ACS patients from 37 hospitals with a proportional representation of all types of hospitals and geographical areas. Patients were followed for a median period of 189 days. Outcome was assessed with a composite endpoint of death, myocardial infarction, stroke, urgent revascularization and urgent hospitalization for cardiovascular causes. The mean age of patients was 62.7 years (78% males). The majority of patients (n=411, 51%) presented with ST-elevation myocardial infarction (STEMI), whereas 389 patients presented with NSTEMI (n=303, 38%) or UA (n=86, 11%). Overall, 58.8% of the patients had hypertension, 26.5% were diabetic, 52.5% had dyslipidemia, 71.1% had a smoking history (current or past), 25.8% had a family history of coronary artery disease (CAD) and 24.1% had a prior history of CAD. In STEMI patients, 44.5% of patients were treated with thrombolysis, 38.9% underwent a coronary angiogram (34.1% were treated with primary percutaneous coronary intervention) and 16.5% did not receive urgent treatment. The pain-to-door time was 169 minutes. During hospitalization, 301 (38%) patients presented one or more complications, and 13 died (1.6%). During follow-up, 99 (12.6%) patients experienced the composite endpoint, and 21 died (2.7%). The PHAETHON study provided valuable insights into the epidemiology, management and outcome of ACS patients in Greece. Management of ACS resembles the management observed in other European countries. However, several issues still to be addressed by public authorities for the timely and proper management of ACS. Copyright © 2016 Hellenic Cardiological Society. Published by Elsevier B.V. All rights reserved.

The Prognostic Effects of Coronary Disease Severity and Completeness of Revascularization on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

PubMed

Witberg, Guy; Regev, Ehud; Chen, Shmuel; Assali, Abbid; Barbash, Israel M; Planer, David; Vaknin-Assa, Hana; Guetta, Victor; Vukasinovic, Vojislav; Orvin, Katia; Danenberg, Haim D; Segev, Amit; Kornowski, Ran

2017-07-24

The study sought to examine the effect of coronary artery disease (CAD) on mortality in patients undergoing transcatheter aortic valve replacement (TAVR). CAD is common in the TAVR population. However, there are conflicting data on the prognostic significance of CAD and its treatment in this population. The authors analyzed 1,270 consecutive patients with severe aortic stenosis (AS) undergoing TAVR at 3 Israeli centers. They investigated the association of CAD severity (no CAD, nonsevere CAD [i.e., SYNTAX score (SS) <22], severe CAD [SS >22]) and revascularization completeness ("reasonable" incomplete revascularization [ICR] [i.e., residual SS <8]; ICR [residual SS >8]) with all-cause mortality following TAVR using a Cox proportional hazards ratio model adjusted for multiple prognostic variables. Of the 1,270 patients, 817 (64%) had no CAD, 331 (26%) had nonsevere CAD, and 122 (10%) had severe CAD. Over a median follow-up of 1.9 years, 311 (24.5%) patients died. Mortality was higher in the severe CAD and the ICR groups, but not in the nonsevere CAD or "reasonable" ICR groups, versus no CAD. After multivariate adjustment, both severe CAD (hazard ratio: 2.091; p = 0.017) and ICR (hazard ratio: 1.720; p = 0.031) were associated with increased mortality. Only severe CAD was associated with increased mortality post-TAVR. More complete revascularization pre-TAVR may attenuate the association of severe CAD and mortality. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Validity of the Talk Test for exercise prescription after myocardial revascularization.

PubMed

Zanettini, Renzo; Centeleghe, Paola; Franzelli, Cristina; Mori, Ileana; Benna, Stefania; Penati, Chiara; Sorlini, Nadia

2013-04-01

For exercise prescription, rating of perceived exertion is the subjective tool most frequently used in addition to methods based on percentage of peak exercise variables. The aim of this study was the validation of a subjective method widely called the Talk Test (TT) for optimization of training intensity in patients with recent myocardial revascularization. Fifty patients with recent myocardial revascularization (17 by coronary artery bypass grafting and 33 by percutaneous coronary intervention) were enrolled in a cardiac rehabilitation programme. Each patient underwent three repetitions of the TT during three different exercise sessions to evaluate the within-patient and between-operators reliability in assessing the workload (WL) at TT thresholds. These parameters were then compared with the data of a final cardiopulmonary exercise testing, and the WL range between the individual aerobic threshold (AeT) and anaerobic threshold (AnT) was considered as the optimal training zone. The within-patient and between-operators reliability in assessing TT thresholds were satisfactory. No significant differences were found between patients' and physiotherapists' evaluations of WL at different TT thresholds. WL at Last TT+ was between AeT and AnT in 88% of patients and slightly

Intractable Electrical Storm After Coronary Artery Bypass Grafting Originating in Abnormal Purkinje Fibers.

PubMed

Tokunaga, Chiho; Tsukada, Toru; Sakamoto, Hiroaki; Naruse, Yoshihisa; Yoshida, Kentaro; Sekiguchi, Yukio; Imai, Akito; Aonuma, Kazutaka; Hiramatsu, Yuji

2016-01-01

Electrical storm is a rare but critical complication following revascularization in patients with ischemic heart disease. We report the case of a 67-year-old man who developed drug refractory intractable electrical storm after emergent coronary artery bypass grafting for ischemic cardiomyopathy. The electrical storm was successfully eliminated by percutaneous endocardial radiofrequency catheter ablation targeting the abnormal Purkinje-related triggering ventricular premature contractions in a low-voltage zone. © 2015 Wiley Periodicals, Inc.

Optimal Use of Available Claims to Identify a Medicare Population Free of Coronary Heart Disease

PubMed Central

Kent, Shia T.; Safford, Monika M.; Zhao, Hong; Levitan, Emily B.; Curtis, Jeffrey R.; Kilpatrick, Ryan D.; Kilgore, Meredith L.; Muntner, Paul

2015-01-01

We examined claims-based approaches for identifying a study population free of coronary heart disease (CHD) using data from 8,937 US blacks and whites enrolled during 2003–2007 in a prospective cohort study linked to Medicare claims. Our goal was to minimize the percentage of persons at study entry with self-reported CHD (previous myocardial infarction or coronary revascularization). We assembled 6 cohorts without CHD claims by requiring 6 months, 1 year, or 2 years of continuous Medicare fee-for-service insurance coverage prior to study entry and using either a fixed-window or all-available look-back period. We examined adding CHD-related claims to our “base algorithm,” which included claims for myocardial infarction and coronary revascularization. Using a 6-month fixed-window look-back period, 17.8% of participants without claims in the base algorithm reported having CHD. This was reduced to 3.6% using an all-available look-back period and adding other CHD claims to the base algorithm. Among cohorts using all-available look-back periods, increasing the length of continuous coverage from 6 months to 1 or 2 years reduced the sample size available without lowering the percentage of persons with self-reported CHD. This analysis demonstrates approaches for developing a CHD-free cohort using Medicare claims. PMID:26443420

Heart Rate and Initial Presentation of Cardiovascular Diseases (Caliber)

ClinicalTrials.gov

2013-09-17

Abdominal Aortic Aneurysm; Coronary Heart Disease NOS; Unheralded Coronary Death; Intracerebral Haemorrhage; Heart Failure; Ischemic Stroke; Myocardial Infarction; Stroke; Peripheral Arterial Disease; Stable Angina Pectoris; Subarachnoid Haemorrhage; Transient Ischemic Attack; Unstable Angina; Cardiac Arrest, Sudden Cardiac Death

Robotic totally endoscopic coronary artery bypass for isolated ostial stenosis of the left coronary artery

PubMed Central

Kuo, Chia-Cheng; Hsing, Chung-Hsi; Chen, Chun-I; Lee, Chen-Hui

2017-01-01

Isolated ostial stenosis (IOS) is a rare disease that encroaches on aorto-coronary junction of uncertain etiology. All distal coronary vessels present normally. IOS occurs predominantly in premenopausal young women with few risk factors for atherosclerotic disease. Here, we report a 40-year-old woman who had experienced crescendo angina for 4 months. Surgical revascularization was achieved by robotic totally endoscopic coronary artery bypass (TECAB) with left internal thoracic artery (LITA) graft. She resumed her daily tasks without difficulties 1 week after the operation. Postoperative computed tomographic angiography disclosed good opacification of the LITA graft and distal runoff. Robotic TECAB is a potentially feasible alternative for IOS patients, particularly in premenopausal young woman, with obvious benefits of cosmetic appearance and speedy recovery. PMID:29312766

Resource utilization and outcome among patients with selective versus nonselective troponin testing.

PubMed

Campbell, Alex R; Rodriguez, Alexander J; Larson, David M; Strauss, Craig E; Garberich, Ross F; Partridge, Matthew F; Henry, Timothy D; Sharkey, Scott W

2018-05-01

In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. Troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for resource utilization and outcome. Therefore, we examined selective versus nonselective troponin testing with respect to patient characteristics, resource utilization, and outcome. This retrospective 1-year study included all patients with troponin testing at a U.S. emergency department. Testing was classified as selective (ACS) or nonselective (non-ACS) based on admission ICD-9 codes. Troponin upper reference limit (URL) was ≥99th percentile. Among 47,053 patients, troponin was measured in 9109 (19%) of whom 5764 were hospitalized. Admission diagnosis was non-ACS in 4427 (77%) and ACS in 1337 (23%). Non-ACS patients were older, 71±17 versus 65±16 years, with longer hospital stay, 77 versus 32 h, and greater 1-year mortality 22% versus 6.7%; P<.001. In patients with troponin ≥URL, revascularization was performed in 64 (4.7%) of non-ACS versus 213 (48%) of ACS; P<.001. In patients with troponin 80% of the non-ACS population CONCLUSIONS: Contemporary troponin testing is frequently nonselective. The non-ACS and ACS populations differ significantly regarding clinical characteristics, revascularization rates, and outcomes. Troponin elevation is a powerful predictor of 1-year mortality in non-ACS, this association reveals an opportunity for risk stratification and targeted therapy. In patients with suspected acute coronary syndrome (ACS), troponin testing is effective for diagnosis and prognosis. However, troponin testing has now expanded to include patients without suspected ACS. This nonselective troponin testing has unknown consequences for hospital resource utilization and patient outcome. Our findings demonstrate contemporary troponin testing is largely nonselective (77% of testing was performed in patients without acute coronary syndrome). In comparison to patients with acute coronary syndrome, those with non-acute coronary syndrome are older, with longer hospital stay, lower revascularization rates, and greater 1-year mortality. Troponin elevation identifies a high-risk population in both acute coronary syndrome and non-acute coronary syndrome populations, yet effective treatment for the latter is lacking. Copyright © 2018. Published by Elsevier Inc.

Comparison of carotid endarterectomy and stenting in real world practice using a regional quality improvement registry

PubMed Central

Nolan, Brian W.; De Martino, Randall R.; Goodney, Philip P.; Schanzer, Andres; Stone, David H.; Butzel, David; Kwolek, Christopher J.; Cronenwett, Jack L.

2013-01-01

Objective Carotid artery stenting (CAS) vs endarterectomy (CEA) remains controversial and has been the topic of recent randomized controlled trials. The purpose of this study was to compare the practice and outcomes of CAS and CEA in a real world setting. Methods This is a retrospective analysis of 7649 CEA and 430 CAS performed at 17 centers from 2003 to 2010 within the Vascular Study Group of New England (VSGNE). The primary outcome measures were (1) any in-hospital stroke or death and (2) any stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery were excluded. Multivariate logistic regression was performed to identify predictors of stroke or death in patients undergoing CAS. Results CEA was performed in 17 centers by 111 surgeons, while CAS was performed in 6 centers by 30 surgeons and 8 interventionalists. Patient characteristics varied by procedure. Patients undergoing CAS had a higher prevalence of coronary artery disease, congestive heart failure, diabetes, and prior ipsilateral CEA. Embolic protection was used in 97% of CAS. Shunts were used in 48% and patches in 86% of CEA. The overall in-hospital stroke or death rate was higher among patients undergoing CAS (2.3% vs 1.1%; P = .03). Overall stroke, death, or MI (2.8% CAS vs 2.1% CEA; P = .32) were not different. Asymptomatic patients had similar rates of stroke or death (CAS 0.73% vs CEA 0.89%; P = .78) and stroke, death, or MI (CAS 1.1% vs CEA 1.8%; P = .40). Symptomatic patients undergoing CAS had higher rates of stroke or death (5.1% vs 1.6%; P = .001), and stroke, death, or MI (5.8% vs 2.7%; P = .02). By multivariate analysis, major stroke (odds ratio, 4.5; 95% confidence interval [CI], 1.9–10.8), minor stroke (2.7; CI, 1.5–4.8), prior ipsilateral CEA (3.2, CI, 1.7–6.1), age >80 (2.1; CI, 1.3–3.4), hypertension (2.6; CI, 1.0–6.3), and a history of chronic obstructive pulmonary disease (1.6; CI, 1.0–2.4) were predictors of stroke or death in patients undergoing carotid revascularization. Conclusions In our regional vascular surgical practices, the overall outcomes of CAS and CEA are similar for asymptomatic patients. However, symptomatic patients treated with CAS are at a higher risk for stroke or death. (J Vasc Surg 2012;56:990-6.) PMID:22579135

Characteristics and risk factors of cerebrovascular accidents after percutaneous coronary interventions in patients with history of stroke.

PubMed

Zhang, Hua; Feng, Li-qun; Bi, Qi; Wang, Yu-ping

2010-06-01

Percutaneous coronary intervention (PCI) is a well-established method for managing coronary diseases. However, the increasing use of PCI has led to an increased incidence of acute cerebrovascular accidents (CVA) related to PCI. In this study, we investigated the characteristics and risk factors of CVA after PCI in patients with known stroke history. Between January 1, 2005 and March 1, 2009, 621 patients with a history of stroke underwent a total of 665 PCI procedures and were included in this retrospective study. Demographic and clinical characteristics, previous medications, procedures, neurologic deficits, location of lesion and in-hospital clinical outcomes of patients who developed a CVA after the cardiac catheterization laboratory visit and before discharge were reviewed. Acute CVA was diagnosed in 53 (8.5%) patients during the operation or the perioperative period. Seventeen patients suffered from transient ischemic attack, thirty-four patients suffered from cerebral infarction and two patients suffered from cerebral hemorrhage. The risk factors for CVA after PCI in stroke patients were: admission with an acute coronary syndrome, use of an intra-aortic balloon pump, urgent or emergency procedures, diabetes mellitus, and poor left ventricular systolic function, arterial fibrillation, previous myocardial infarction, dyslipidemia, tobacco use, and no/irregular use of anti-platelet medications. The incidence of CVA during and after PCI in patients with history of stroke is much higher than that in patients without history of stroke. Patients with atrial fibrillation, previous myocardial infarction, diabetes mellitus, dyslipidemia, tobacco use, and no or irregular use of anti-platelet medications were at higher risk for recurrent stroke. This study showed a strong association between acute coronary syndromes and in-hospital stroke after PCI.

Racial and socioeconomic disparities in access to mechanical revascularization procedures for acute ischemic stroke.

PubMed

Attenello, Frank J; Adamczyk, Peter; Wen, Ge; He, Shuhan; Zhang, Katie; Russin, Jonathan J; Sanossian, Nerses; Amar, Arun P; Mack, William J

2014-02-01

Mechanical revascularization procedures performed for treatment of acute ischemic stroke have increased in recent years. Data suggest association between operative volume and mortality rates. Understanding procedural allocation and patient access patterns is critical. Few studies have examined these demographics. Data were collected from the 2008 Nationwide Inpatient Sample database. Patients hospitalized with ischemic stroke and the subset of individuals who underwent mechanical thrombectomy were characterized by race, payer source, population density, and median wealth of the patient's zip code. Demographic data among patients undergoing mechanical thrombectomy procedures were examined. Stroke admission demographics were analyzed according to thrombectomy volume at admitting centers and patient demographics assessed according to the thrombectomy volume at treating centers. Significant allocation differences with respect to frequency of mechanical thrombectomy procedures among stroke patients existed according to race, expected payer, population density, and wealth of the patient's zip code (P < .0001). White, Hispanic, and Asian/Pacific Islander patients received endovascular treatment at higher rates than black and Native American patients. Compared with the white stroke patients, black (P < .001), Hispanic (P < .001), Asian/Pacific Islander (P < .001), and Native American stroke patients (P < .001) all demonstrated decreased frequency of admission to hospitals performing mechanical thrombectomy procedures at high volumes. Among treated patients, blacks (P = .0876), Hispanics (P = .0335), and Asian/Pacific Islanders (P < .001) demonstrated decreased frequency in mechanical thrombectomy procedures performed at high-volume centers when compared with whites. While present, socioeconomic disparities were not as consistent or pronounced as racial differences. We demonstrate variances in endovascular acute stroke treatment allocation according to racial and socioeconomic factors in 2008. Efforts should be made to monitor and address potential disparities in treatment utilization. Published by Elsevier Inc.

Stress perfusion magnetic resonance imaging to detect coronary artery lesions in children.

PubMed

Vijarnsorn, Chodchanok; Noga, Michelle; Schantz, Daryl; Pepelassis, Dion; Tham, Edythe B

2017-05-01

Stress perfusion cardiovascular magnetic resonance (CMR) is used widely in adult ischemic heart disease, but data in children is limited. We sought to evaluate feasibility, accuracy and prognostic value of stress CMR in children with suspected coronary artery disease (CAD). Stress CMR was reviewed from two pediatric centers over 5 years using a standard pharmacologic protocol. Wall motion abnormalities, perfusion deficits and late enhancement were correlated with coronary angiogram (CAG) when available, and clinical status at 1 year follow-up for major adverse cardiovascular events (MACE; coronary revascularization, non-fatal myocardial infarction and death due to CAD) was recorded. Sixty-four stress perfusion CMR studies in 48 children (10.9 ± 4.8 years) using adenosine; 59 (92%) and dipyridamole; 5 (8%), were reviewed. Indications were Kawasaki disease (39%), post arterial switch operation (12.5%), post heart transplantation (12.5%), post anomalous coronary artery repair (11%), chest pain (11%), suspected myocarditis or CAD (3%), post coronary revascularization (3%), and others (8%). Twenty-six studies were performed under sedation. Of all studies performed, 66% showed no evidence of ischemia or infarction, 28% had perfusion deficits and 6% had late gadolinium enhancement (LGE) without perfusion deficit. Compared to CAG, the positive predictive value (PPV) of stress CMR was 80% with negative predictive value (NPV) of 88%. At 1 year clinical follow-up, the PPV and NPV of stress CMR to predict MACE were 78 and 98%. Stress-perfusion CMR, in combination with LGE and wall motion-analysis is a feasible and an accurate method of diagnosing CAD in children. In difficult cases, it also helps guide clinical intervention by complementing conventional CAG with functional information.

The Association between Triglyceride/High-Density Lipoprotein Cholesterol Ratio and All-Cause Mortality in Acute Coronary Syndrome after Coronary Revascularization

PubMed Central

Wan, Ke; Zhao, Jianxun; Huang, Hao; Zhang, Qing; Chen, Xi; Zeng, Zhi; Zhang, Li; Chen, Yucheng

2015-01-01

Aims High triglycerides (TG) and low high-density lipoprotein cholesterol (HDL-C) are cardiovascular risk factors. A positive correlation between elevated TG/HDL-C ratio and all-cause mortality and cardiovascular events exists in women. However, utility of TG to HDL-C ratio for prediction is unknown among acute coronary syndrome (ACS). Methods Fasting lipid profiles, detailed demographic data, and clinical data were obtained at baseline from 416 patients with ACS after coronary revascularization. Subjects were stratified into three levels of TG/HDL-C. We constructed multivariate Cox-proportional hazard models for all-cause mortality over a median follow-up of 3 years using log TG to HDL-C ratio as a predictor variable and analyzing traditional cardiovascular risk factors. We constructed a logistic regression model for major adverse cardiovascular events (MACEs) to prove that the TG/HDL-C ratio is a risk factor. Results The subject’s mean age was 64 ± 11 years; 54.5% were hypertensive, 21.8% diabetic, and 61.0% current or prior smokers. TG/HDL-C ratio ranged from 0.27 to 14.33. During the follow-up period, there were 43 deaths. In multivariate Cox models after adjusting for age, smoking, hypertension, diabetes, and severity of angiographic coronary disease, patients in the highest tertile of ACS had a 5.32-fold increased risk of mortality compared with the lowest tertile. After adjusting for conventional coronary heart disease risk factors by the logistic regression model, the TG/HDL-C ratio was associated with MACEs. Conclusion The TG to HDL-C ratio is a powerful independent predictor of all-cause mortality and is a risk factor of cardiovascular events. PMID:25880982

Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals

PubMed Central

Hong, Juliette S.; Carey, Evan; Grunwald, Gary K.; Joynt Maddox, Karen; Maddox, Thomas M.

2018-01-01

Importance The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. Objectives To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Design, Setting, and Participants Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Exposures Receipt of an elective coronary revascularization at a VA vs CC facility. Main Outcomes and Measures Access to care as measured by travel distance, 30-day mortality, and costs. Results In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. Conclusions and Relevance In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending. PMID:29299607

Comparison of Accessibility, Cost, and Quality of Elective Coronary Revascularization Between Veterans Affairs and Community Care Hospitals.

PubMed

Barnett, Paul G; Hong, Juliette S; Carey, Evan; Grunwald, Gary K; Joynt Maddox, Karen; Maddox, Thomas M

2018-02-01

The Veterans Affairs (VA) Community Care (CC) Program supplements VA care with community-based medical services. However, access gains and value provided by CC have not been well described. To compare the access, cost, and quality of elective coronary revascularization procedures between VA and CC hospitals and to evaluate if procedural volume or publicly reported quality data can be used to identify high-value care. Observational cohort study of veterans younger than 65 years undergoing an elective coronary revascularization, controlling for differences in risk factors using propensity adjustment. The setting was VA and CC hospitals. Participants were veterans undergoing elective percutaneous coronary intervention (PCI) and veterans undergoing coronary artery bypass graft (CABG) procedures between October 1, 2008, and September 30, 2011. The analysis was conducted between July 2014 and July 2017. Receipt of an elective coronary revascularization at a VA vs CC facility. Access to care as measured by travel distance, 30-day mortality, and costs. In the 3 years ending on September 30, 2011, a total of 13 237 elective PCIs (79.1% at the VA) and 5818 elective CABG procedures (83.6% at the VA) were performed in VA or CC hospitals among veterans meeting study inclusion criteria. On average, use of CC was associated with reduced net travel by 53.6 miles for PCI and by 73.3 miles for CABG surgery compared with VA-only care. Adjusted 30-day mortality after PCI was higher in CC compared with VA (1.54% for CC vs 0.65% for VA, P < .001) but was similar after CABG surgery (1.33% for CC vs 1.51% for VA, P = .74). There were no differences in adjusted 30-day readmission rates for PCI (7.04% for CC vs 7.73% for VA, P = .66) or CABG surgery (8.13% for CC vs 7.00% for VA, P = .28). The mean adjusted PCI cost was higher in CC ($22 025 for CC vs $15 683 for VA, P < .001). The mean adjusted CABG cost was lower in CC ($55 526 for CC vs $63 144 for VA, P < .01). Neither procedural volume nor publicly reported mortality data identified hospitals that provided higher-value care with the exception that CABG mortality was lower in small-volume CC hospitals. In this veteran cohort, PCIs performed in CC hospitals were associated with shorter travel distance but with higher mortality, higher costs, and minimal travel savings compared with VA hospitals. The CABG procedures performed in CC hospitals were associated with shorter travel distance, similar mortality, and lower costs. As the VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimize veteran outcomes and VA spending.

Comparison of Clinical Characteristics and Outcomes of Patients With Versus Without Diabetes Mellitus and With Versus Without Angina Pectoris (from the Duke Databank for Cardiovascular Disease).

PubMed

Banks, Adam; Broderick, Samuel; Chiswell, Karen; Shaw, Linda; Devore, Adam; Fiuzat, Mona; O'Connor, Christopher; Felker, Gary Michael; Velazquez, Eric; Mentz, Robert

2017-06-01

Angina pectoris (AP) has different prognostic implications in various populations. Patients with diabetes mellitus (DM) may experience neuropathy such that AP may not be perceived in the setting of coronary artery disease (CAD). The prognostic utility of AP in DM patients with CAD is not well known. We analyzed patients with CAD who underwent coronary angiography at Duke University from 2002 to 2011 and compared patients with and without AP within the previous 6 weeks stratified by DM status. We used multivariable Cox regression to assess the association between AP and the outcomes of cardiovascular (CV) hospitalization/revascularization, all-cause mortality/myocardial infarction/revascularization, and all-cause mortality. Of 17,211 patients with CAD, 5,284 (31%) had DM and AP was present in 69% of DM and 67% of non-DM. After risk adjustment, the risk of CV hospitalization/revascularization and all-cause mortality/myocardial infarction/revascularization in patients with and without AP was similar regardless of DM status (all p ≥0.05). In patients with or without DM, AP was associated with lower all-cause mortality compared with no AP (adjusted hazard ratio 0.89, 95% confidence interval 0.82 to 0.97, p = 0.005 for DM patients). The relation between AP status and clinical outcomes was not dependent on DM status (all interaction p >0.10). In conclusion, in patients with CAD, AP was associated with similar risk for CV hospitalization and revascularization and lower all-cause mortality compared with patients without AP regardless of DM status. Future studies are needed to assess whether these findings are related to increased severity of disease in those without AP or whether AP leads to differential management that improves survival. Copyright © 2017 Elsevier Inc. All rights reserved.

Edifoligide and long-term outcomes after coronary artery bypass grafting: PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) 5-year results.

PubMed

Lopes, Renato D; Williams, Judson B; Mehta, Rajendra H; Reyes, Eric M; Hafley, Gail E; Allen, Keith B; Mack, Michael J; Peterson, Eric D; Harrington, Robert A; Gibson, C Michael; Califf, Robert M; Kouchoukos, Nicholas T; Ferguson, T Bruce; Lorenz, Todd J; Alexander, John H

2012-09-01

Edifoligide, an E2F transcription factor decoy, does not prevent vein graft failure or adverse clinical outcomes at 1 year in patients undergoing coronary artery bypass grafting (CABG). We compared the 5-year clinical outcomes of patients in PREVENT IV treated with edifoligide and placebo to identify predictors of long-term clinical outcomes. A total of 3,014 patients undergoing CABG with at least 2 planned vein grafts were enrolled. Kaplan-Meier curves were generated to compare the long-term effects of edifoligide and placebo. A Cox proportional hazards model was constructed to identify factors associated with 5-year post-CABG outcomes. The main outcome measures were death, myocardial infarction (MI), repeat revascularization, and rehospitalization through 5 years. Five-year follow-up was complete in 2,865 patients (95.1%). At 5 years, patients randomized to edifoligide and placebo had similar rates of death (11.7% and 10.7%, respectively), MI (2.3% and 3.2%), revascularization (14.1% and 13.9%), and rehospitalization (61.6% and 62.5%). The composite outcome of death, MI, or revascularization occurred at similar frequency in patients assigned to edifoligide and placebo (26.3% and 25.5%, respectively; hazard ratio 1.03 [95% CI 0.89-1.18], P = .721). Factors associated with death, MI, or revascularization at 5 years included peripheral and/or cerebrovascular disease, time on cardiopulmonary bypass, lung disease, diabetes mellitus, and congestive heart failure. Up to a quarter of patients undergoing CABG will have a major cardiac event or repeat revascularization procedure within 5 years of surgery. Edifoligide does not affect outcomes after CABG; however, common identifiable baseline and procedural risk factors are associated with long-term outcomes after CABG. Copyright © 2012 Mosby, Inc. All rights reserved.

Fast revascularization of the injured area is essential to support zebrafish heart regeneration

PubMed Central

Marín-Juez, Rubén; Marass, Michele; Gauvrit, Sebastien; Rossi, Andrea; Lai, Shih-Lei; Materna, Stefan C.; Black, Brian L.; Stainier, Didier Y. R.

2016-01-01

Zebrafish have a remarkable capacity to regenerate their heart. Efficient replenishment of lost tissues requires the activation of different cell types including the epicardium and endocardium. A complex set of processes is subsequently needed to support cardiomyocyte repopulation. Previous studies have identified important determinants of heart regeneration; however, to date, how revascularization of the damaged area happens remains unknown. Here, we show that angiogenic sprouting into the injured area starts as early as 15 h after injury. To analyze the role of vegfaa in heart regeneration, we used vegfaa mutants rescued to adulthood by vegfaa mRNA injections at the one-cell stage. Surprisingly, vegfaa mutants develop coronaries and revascularize after injury. As a possible explanation for these observations, we find that vegfaa mutant hearts up-regulate the expression of potentially compensating genes. Therefore, to overcome the lack of a revascularization phenotype in vegfaa mutants, we generated fish expressing inducible dominant negative Vegfaa. These fish displayed minimal revascularization of the damaged area. In the absence of fast angiogenic revascularization, cardiomyocyte proliferation did not occur, and the heart failed to regenerate, retaining a fibrotic scar. Hence, our data show that a fast endothelial invasion allows efficient revascularization of the injured area, which is necessary to support replenishment of new tissue and achieve efficient heart regeneration. These findings revisit the model where neovascularization is considered to happen concomitant with the formation of new muscle. Our work also paves the way for future studies designed to understand the molecular mechanisms that regulate fast revascularization. PMID:27647901

Thrombus Aspiration in ThrOmbus containing culpRiT lesions in Non-ST-Elevation Myocardial Infarction (TATORT-NSTEMI): study protocol for a randomized controlled trial

PubMed Central

2013-01-01

Background Current guidelines recommend thrombus aspiration in patients with ST-elevation myocardial infarction (STEMI); however, there are insufficient data to unequivocally support thrombectomy in patients with non-STEMI (NSTEMI). Methods/Design The TATORT-NSTEMI (Thrombus Aspiration in ThrOmbus containing culpRiT lesions in Non-ST-Elevation Myocardial Infarction) trial is a prospective, controlled, multicenter, randomized, open-label trial enrolling 460 patients. The hypothesis is that, against a background of early revascularization, adjunctive thrombectomy leads to less microvascular obstruction (MO) compared with conventional percutaneous coronary intervention (PCI) alone, as assessed by cardiac magnetic resonance imaging (CMR) in patients with NSTEMI. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary endpoint is the extent of late MO assessed by CMR. Secondary endpoints include early MO, infarct size, and myocardial salvage assessed by CMR as well as enzymatic infarct size and angiographic parameters, such as thrombolysis in myocardial infarction flow post-PCI and myocardial blush grade. Furthermore, clinical endpoints including death, myocardial re-infarction, target vessel revascularization, and new congestive heart failure will be recorded at 6 and 12 months. Safety will be assessed by the incidence of bleeding and stroke. Summary The TATORT-NSTEMI trial has been designed to test the hypothesis that thrombectomy will improve myocardial perfusion in patients with NSTEMI and relevant thrombus burden in the culprit vessel reperfused by early PCI. Trial registration The trial is registered under http://www.clinicaltrials.gov: NCT01612312. PMID:23782681

Cost Effectiveness of Revascularization Strategies: Results from The American College of Cardiology Foundation and The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies (ASCERT)

PubMed Central

Zhang, Zugui; Kolm, Paul; Grau-Sepulveda, Maria V.; Ponirakis, Angelo; O’Brien, Sean M.; Klein, Lloyd W.; Shaw, Richard E.; McKay, Charles; Shahian, David M.; Grover, Frederick L.; Mayer, John E.; Garratt, Kirk N.; Hlatky, Mark; Edwards, Fred H.; Weintraub, William S.

2017-01-01

BACKGROUND The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) Collaboration on the Comparative Effectiveness of Revascularization Strategies (ASCERT) was a large observational study designed to compare the long-term effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) to treat coronary artery disease (CAD) over 4 to 5 years. OBJECTIVES We examined the cost effectiveness of CABG compared to PCI for stable ischemic heart disease. METHODS The STS and ACCF databases were linked to the Centers for Medicare and Medicaid Services claims data. Costs for the index and observation period (2004 to 2008) hospitalizations were assessed by diagnosis-related group Medicare reimbursement rates; costs beyond the observation period were estimated from average Medicare participant per capita expenditure. Effectiveness was measured via mortality and life expectancy data. Cost and effectiveness comparisons were adjusted using propensity score matching with the incremental cost-effectiveness ratio (ICER) expressed as cost per quality-adjusted life year (QALY) gained. RESULTS CABG patients (n = 86,244) and PCI patients (n = 103,549) were at least 65-yearsold with 2 or 3-vessel CAD. Adjusted costs were higher for CABG for the index hospitalization, study period, and lifetime by $10,670, $8,145, and $11,575, respectively. Patients undergoing CABG gained an adjusted average of 0.2525 and 0.3801 life-years relative to PCI over the observation period and lifetime, respectively. The life-time ICER of CABG compared to PCI was $30,454/QALY gained. CONCLUSIONS Over a period of 4 years or longer, patients undergoing CABG had better outcomes but at higher costs than those undergoing PCI. PMID:25572503

Does coronary Atherosclerosis Deserve to be Diagnosed earlY in Diabetic patients? The DADDY-D trial. Screening diabetic patients for unknown coronary disease.

PubMed

Turrini, Fabrizio; Scarlini, Stefania; Mannucci, Caterina; Messora, Roberto; Giovanardi, Paolo; Magnavacchi, Paolo; Cappelli, Carlo; Evandri, Valeria; Zanasi, Andrea; Romano, Stefania; Cavani, Rita; Ghidoni, Italo; Tondi, Stefano; Bondi, Marco

2015-07-01

To evaluate if screening and treatment of asymptomatic coronary artery disease (CAD) are effective in preventing first cardiac event in diabetics. Diabetic patients without known CAD were randomly assigned to undergo a screening for silent myocardial ischemia followed by revascularization or to continue follow-up. The reduction of cardiac death (CD) or nonfatal myocardial infarction (MI) represented the primary aim; secondary aim was the prevention of heart failure (HF). From September 2007 to May 2012, 520 patients (62 years; 104 female) were enrolled. Silent CAD was found in 20 of 262 patients (7.6%), revascularization was performed in 12 (4.6%). After a mean follow-up of 3.6 years 12 events (4.6%) occurred in the study group and 14 (5.4%) in the follow-up (HR=0.849, 95% CI: 0.393-1.827, P=0.678). The occurrence of first HF episode did not differ between groups: 2 (0.8%) in screened and 7 (2.7%) in follow-up (HR=0.273, 95% CI: 0.057-1.314, P=0.083). Subgroup analysis revealed a significantly lower HF episodes among patients with intermediate cardiovascular risk (Log rank P=0.022). Additionally, when CD and MI were analysed within subgroups, a significant lower number of CDs was observed among older than 60 years (P=0.044). Screening and revascularization of silent CAD in diabetics, failed to demonstrate a significant reduction in cardiac events and HF episodes. However, our data indicate that further research is warranted in patients older than 60 years and those with an intermediate cardiovascular risk. CLINICALTRIALS.GOV: NCT00547872. Copyright © 2015. Published by Elsevier B.V.

Natriuretic peptides and integrated risk assessment for cardiovascular disease: an individual-participant-data meta-analysis.

PubMed

Natriuretic Peptides Studies Collaboration; Willeit, Peter; Kaptoge, Stephen; Welsh, Paul; Butterworth, Adam; Chowdhury, Rajiv; Spackman, Sarah; Pennells, Lisa; Gao, Pei; Burgess, Stephen; Freitag, Daniel; Sweeting, Michael; Wood, Angela; Cook, Nancy; Judd, Suzanne; Trompet, Stella; Nambi, Vijay; Olsen, Michael; Everett, Brendan; Kee, Frank; Ärnlöv, Johan; Salomaa, Veikko; Levy, Daniel; Kauhanen, Jussi; Laukkanen, Jari; Kavousi, Maryam; Ninomiya, Toshiharu; Casas, Juan-Pablo; Daniels, Lori; Lind, Lars; Kistorp, Caroline; Rosenberg, Jens; Mueller, Thomas; Rubattu, Speranza; Panagiotakos, Demosthenes; Franco, Oscar; de Lemos, James; Luchner, Andreas; Kizer, Jorge; Kiechl, Stefan; Salonen, Jukka; Goya Wannamethee, S; de Boer, Rudolf; Nordestgaard, Børge; Andersson, Jonas; Jørgensen, Torben; Melander, Olle; Ballantyne, Christie; DeFilippi, Christopher; Ridker, Paul; Cushman, Mary; Rosamond, Wayne; Thompson, Simon; Gudnason, Vilmundur; Sattar, Naveed; Danesh, John; Di Angelantonio, Emanuele

2016-10-01

Guidelines for primary prevention of cardiovascular diseases focus on prediction of coronary heart disease and stroke. We assessed whether or not measurement of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) concentration could enable a more integrated approach than at present by predicting heart failure and enhancing coronary heart disease and stroke risk assessment. In this individual-participant-data meta-analysis, we generated and harmonised individual-participant data from relevant prospective studies via both de-novo NT-proBNP concentration measurement of stored samples and collection of data from studies identified through a systematic search of the literature (PubMed, Scientific Citation Index Expanded, and Embase) for articles published up to Sept 4, 2014, using search terms related to natriuretic peptide family members and the primary outcomes, with no language restrictions. We calculated risk ratios and measures of risk discrimination and reclassification across predicted 10 year risk categories (ie, <5%, 5% to <7·5%, and ≥7·5%), adding assessment of NT-proBNP concentration to that of conventional risk factors (ie, age, sex, smoking status, systolic blood pressure, history of diabetes, and total and HDL cholesterol concentrations). Primary outcomes were the combination of coronary heart disease and stroke, and the combination of coronary heart disease, stroke, and heart failure. We recorded 5500 coronary heart disease, 4002 stroke, and 2212 heart failure outcomes among 95 617 participants without a history of cardiovascular disease in 40 prospective studies. Risk ratios (for a comparison of the top third vs bottom third of NT-proBNP concentrations, adjusted for conventional risk factors) were 1·76 (95% CI 1·56-1·98) for the combination of coronary heart disease and stroke and 2·00 (1·77-2·26) for the combination of coronary heart disease, stroke, and heart failure. Addition of information about NT-proBNP concentration to a model containing conventional risk factors was associated with a C-index increase of 0·012 (0·010-0·014) and a net reclassification improvement of 0·027 (0·019-0·036) for the combination of coronary heart disease and stroke and a C-index increase of 0·019 (0·016-0·022) and a net reclassification improvement of 0·028 (0·019-0·038) for the combination of coronary heart disease, stroke, and heart failure. In people without baseline cardiovascular disease, NT-proBNP concentration assessment strongly predicted first-onset heart failure and augmented coronary heart disease and stroke prediction, suggesting that NT-proBNP concentration assessment could be used to integrate heart failure into cardiovascular disease primary prevention. British Heart Foundation, Austrian Science Fund, UK Medical Research Council, National Institute for Health Research, European Research Council, and European Commission Framework Programme 7. Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.

Computed Tomography-Derived Fractional Flow Reserve in the Detection of Lesion-Specific Ischemia: An Integrated Analysis of 3 Pivotal Trials.

PubMed

Xu, Rende; Li, Chenguang; Qian, Juying; Ge, Junbo

2015-11-01

Invasive fractional flow reserve (FFR) is the gold standard for the determination of physiologic stenosis severity and the need for revascularization. FFR computed from standard acquired coronary computed tomographic angiography datasets (FFRCT) is an emerging technology which allows calculation of FFR using resting image data from coronary computed tomographic angiography (CCTA). However, the diagnostic accuracy of FFRCT in the evaluation of lesion-specific myocardial ischemia remains to be confirmed, especially in patients with intermediate coronary stenosis. We performed an integrated analysis of data from 3 prospective, international, and multicenter trials, which assessed the diagnostic performance of FFRCT using invasive FFR as a reference standard. Three studies evaluating 609 patients and 1050 vessels were included. The total calculated sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FFRCT were 82.8%, 77.7%, 60.8%, 91.6%, and 79.2%, respectively, for the per-vessel analysis, and 89.4%, 70.5%, 69.7%, 89.7%, and 78.7%, respectively, for the per-patient analysis. Compared with CCTA alone, FFRCT demonstrated significantly improved accuracy (P < 0.001) in detecting lesion-specific ischemia. In patients with intermediate coronary stenosis, FFRCT remained both highly sensitive and specific with respect to the diagnosis of ischemia. In conclusion, FFRCT appears to be a reliable noninvasive alternative to invasive FFR, as it demonstrates high accuracy in the determination of anatomy and lesion-specific ischemia, which justifies the performance of additional randomized controlled trials to evaluate both the clinical benefits and the cost-effectiveness of FFRCT-guided coronary revascularization.

Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis.

PubMed

Foy, Andrew J; Dhruva, Sanket S; Peterson, Brandon; Mandrola, John M; Morgan, Daniel J; Redberg, Rita F

2017-11-01

Coronary computed tomography angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing. To compare the clinical effectiveness of CCTA with that of functional stress testing for patients with suspected CAD. A systematic literature search was conducted in PubMed and MEDLINE for English-language randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016. Researchers selected randomized clinical trials that compared a primary strategy of CCTA with that of functional stress testing for patients with suspected CAD and reported data on patient clinical events and changes in therapy. Two reviewers independently extracted data from and assessed the quality of the trials. This analysis followed the PRISMA statement for reporting systematic reviews and meta-analyses and used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials. The Mantel-Haenszel method was used to conduct the primary analysis. Summary relative risks were calculated with a random-effects model. The outcomes of interest were all-cause mortality, cardiac hospitalization, myocardial infarction, invasive coronary angiography, coronary revascularization, new CAD diagnoses, and change in prescription for aspirin and statins. Thirteen trials were included, with 10 315 patients in the CCTA arm and 9777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months. There were no statistically significant differences between CCTA and functional stress testing in death (1.0% vs 1.1%; risk ratio [RR], 0.93; 95% CI, 0.71-1.21) or cardiac hospitalization (2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21), but CCTA was associated with a reduction in the incidence of myocardial infarction (0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96). Patients undergoing CCTA were significantly more likely to undergo invasive coronary angiography (11.7% vs 9.1%; RR, 1.33; 95% CI, 1.12-1.59) and revascularization (7.2% vs 4.5%; RR, 1.86; 95% CI, 1.43-2.43). They were also more likely to receive a diagnosis of new CAD and to have initiated aspirin or statin therapy. Compared with functional stress testing, CCTA is associated with a reduced incidence of myocardial infarction but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. Despite these differences, CCTA is not associated with a reduction in mortality or cardiac hospitalizations.

Noninvasive detection of increased carotid artery temperature in patients with coronary artery disease predicts major cardiovascular events at one year: Results from a prospective multicenter study.

PubMed

Toutouzas, Konstantinos; Benetos, Georgios; Koutagiar, Iosif; Barampoutis, Nikolaos; Mitropoulou, Fotini; Davlouros, Periklis; Sfikakis, Petros P; Alexopoulos, Dimitrios; Stefanadis, Christodoulos; Siores, Elias; Tousoulis, Dimitris

2017-07-01

Limited prospective data have been reported regarding the impact of carotid inflammation on cardiovascular events in patients with coronary artery disease (CAD). Microwave radiometry (MWR) is a noninvasive, simple method that has been used for evaluation of carotid artery temperature which, when increased, predicts 'inflamed' plaques with vulnerable characteristics. We prospectively tested the hypothesis that increased carotid artery temperature predicts future cerebro- and cardiovascular events in patients with CAD. Consecutive patients from 3 centers, with documented CAD by coronary angiography, were studied. In both carotid arteries, common carotid intima-media thickness and plaque thickness were evaluated by ultrasound. Temperature difference (ΔT), measured by MWR, was considered as the maximal temperature along the carotid artery minus the minimum; ΔT ≥0.90 °C was assigned as high. Major cardiovascular events (MACE, death, stroke, myocardial infarction or revascularization) were recorded during the following year. In total, 250 patients were studied; of them 40 patients (16%) had high ΔT values in both carotid arteries. MACEs occurred in 30% of patients having bilateral high ΔT versus 3.8% in the remaining patients (p<0.001). Bilateral high ΔT was independently associated with increased one-year MACE rate (HR = 6.32, 95% CI 2.42-16.53, p<0.001, by multivariate cox regression hazard model). The addition of ΔT information on a baseline model based on cardiovascular risk factors and extent of CAD significantly increased the prognostic value of the model (c-statistic increase 0.744 to 0.845, p dif  = 0.05) CONCLUSIONS: Carotid inflammation, detected by MWR, has an incremental prognostic value in patients with documented CAD. Copyright © 2017 Elsevier B.V. All rights reserved.

The role of niacin in raising high-density lipoprotein cholesterol to reduce cardiovascular events in patients with atherosclerotic cardiovascular disease and optimally treated low-density lipoprotein cholesterol Rationale and study design. The Atherothrombosis Intervention in Metabolic syndrome with low HDL/high triglycerides: Impact on Global Health outcomes (AIM-HIGH).

PubMed

2011-03-01

The aim of this study was to test the hypothesis that patients with atherosclerotic cardiovascular (CV) disease optimally treated on a statin but with residual atherogenic dyslipidemia (low high-density lipoprotein cholesterol [HDL-C] and high triglycerides) will benefit from addition of niacin with fewer CV events compared with placebo. Statin monotherapy trials have found 25%-35% CV risk reduction relative to placebo, leaving significant residual risk. Patients with atherogenic dyslipidemia have substantially increased CV risk. Participants were men and women with established CV disease and atherogenic dyslipidemia. Lipid entry criteria varied by gender and statin dose at screening. All participants received simvastatin (or simvastatin plus ezetimibe) at a dose sufficient to maintain low-density lipoprotein cholesterol (LDL-C) 40-80 mg/dL (1.03-2.07 mmol/L). Participants were randomized to extended-release niacin or matching placebo. The primary end point was time to occurrence of the first of the following: coronary heart disease death, nonfatal myocardial infarction, ischemic stroke, hospitalization for acute coronary syndrome, or symptom-driven coronary or cerebral revascularization. This event-driven trial will have 85% power to show a 25% reduction in primary event frequency after 850 patients have experienced a primary outcome event. AIM-HIGH completed enrollment in April 2010. Follow-up is expected to continue through 2012. AIM-HIGH was designed to determine whether treating residual dyslipidemia with niacin further reduces cardiovascular events in patients with CV disease on a statin at target levels of low-density lipoprotein cholesterol. Copyright © 2011 Mosby, Inc. All rights reserved.

Benefits & risks of statin therapy for primary prevention of cardiovascular disease in Asian Indians – A population with the highest risk of premature coronary artery disease & diabetes

PubMed Central

Enas, Enas A.; Kuruvila, Arun; Khanna, Pravien; Pitchumoni, C.S.; Mohan, Viswanathan

2013-01-01

Several reviews and meta-analyses have demonstrated the incontrovertible benefits of statin therapy in patients with cardiovascular disease (CVD). But the role for statins in primary prevention remained unclear. The updated 2013 Cochrane review has put to rest all lingering doubts about the overwhelming benefits of long-term statin therapy in primary prevention by conclusively demonstrating highly significant reductions in all-cause mortality, major adverse cardiovascular events (MACE) and the need for coronary artery revascularization procedures (CARPs). More importantly, these benefits of statin therapy are similar at all levels of CVD risk, including subjects at low (<1% per year) risk of a MACE. In addition to preventing myocardial infarction (MI), stroke, and death, primary prevention with statins is also highly effective in delaying and avoiding expensive CARPs such as angioplasties, stents, and bypass surgeries. There is no evidence of any serious harm or threat to life caused by statin therapy, though several adverse effects that affect the quality of life, especially diabetes mellitus (DM) have been reported. Asian Indians have the highest risk of premature coronary artery disease (CAD) and diabetes. When compared with Whites, Asian Indians have double the risk of CAD and triple the risk of DM, when adjusted for traditional risk factors for these diseases. Available evidence supports the use of statin therapy for primary prevention in Asian Indians at a younger age and with lower targets for low-density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein (non-HDL-C), than those currently recommended for Americans and Europeans. Early and aggressive statin therapy offers the greatest potential for reducing the continuing epidemic of CAD among Indians. PMID:24434254

COMBINATION THERAPY EFFECTIVENESS OF EZETIMIBE AND ATORVASTATIN IN PATIENTS WITH ACUTE CORONARY SYNDROME.

PubMed

Japaridze, L; Sadunishvili, M; Megreladze, I

2016-03-01

Atorvastatin reduces low-density lipoprotein (LDL) cholesterol levels and the risk of cardiovascular events, but whether the addition of ezetimibe (EZE) , a nonstatin drug that reduces intestinal cholesterol absorption, can reduce the rate of cardiovascular events further is not known. We conducted a 16-week one-center, prospective, randomized, and open-label clinical trial, involving 323 patients who had been hospitalized for an acute coronary syndrome within the preceding 14 days. They were received atorvastatin 20 mg during 28 days and after that 292 patients, who had LDL cholesterol levels≥1.81 mmol/L, were randomized to ezetimibe 10 mg/day co-administered with atorvastatin therapy (EZE+Statin) or doubling their current atorvastatin dose. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, unstable angina requiring rehospitalization, coronary revascularization (≥30 days after randomization), or nonfatal stroke. At 16 weeks, the mean LDL cholesterol level during the study was 1.60 mmol per liter in the atorvastatine-ezetimibe group, as compared with 1.91 mmol per liter in the atorvastatin-monotherapy group (p<0.001). The Kaplan-Meier survival rate at 16 weeks were 88 .1 % in the atorvastatin-ezetimibe group and 77.0 % in the atorvastatin monotherapy group (absolute risk reduction, 11.1 percentage points; hazard ratio, 2.099 ; 95% confidence interval, 1.165 to 3.781; p=0.014). Patients receiving ezetimibe and statin were more likely to achieve target LDL-C after 16 weeks compared to patients doubling their statin dose. When added to statin therapy, ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes. Ezetimibe/statin combination therapy was well tolerated among this patients, without safety concerns.

Catheter-based treatment of coronary artery disease: past, present, and future.

PubMed

Holmes, David R; Williams, David O

2008-08-01

September 2007 marked the 30-year anniversary of the first human percutaneous coronary intervention, an index event that changed the course of modern-day cardiovascular care. Before that first procedure, adult invasive cardiology focused on diagnostic angiography as well as hemodynamic assessment of structural heart disease. Since that initial procedure, percutaneous coronary intervention has become the most frequently performed coronary revascularization procedure worldwide. Several factors have been responsible for this dramatic paradigm shift, the most prominent being identification of opportunities for technical improvement and the application of innovation and investigation in concert with colleagues, professional societies, and industry. These approaches will continue to be of paramount importance as new technologies are brought to bear on an increasingly broader group of patients with cardiovascular disease.

Early menopause predicts future coronary heart disease and stroke: the Multi-Ethnic Study of Atherosclerosis.

PubMed

Wellons, Melissa; Ouyang, Pamela; Schreiner, Pamela J; Herrington, David M; Vaidya, Dhananjay

2012-10-01

Cardiovascular disease is the number one killer of women. Identifying women at risk of cardiovascular disease has tremendous public health importance. Early menopause is associated with increased cardiovascular disease events in some predominantly white populations, but not consistently. Our objective was to determine if self-reported early menopause (menopause at an age <46 y) identifies women as at risk for future coronary heart disease or stroke. The study population came from the Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 years enrolled in 2000-2002 and followed up until 2008. The association between a personal history of early menopause (either natural menopause or surgical removal of ovaries at an age <46 y) and future coronary heart disease and stroke was assessed in 2,509 women (ages 45-84 y; 987 white, 331 Chinese, 641 black, and 550 Hispanic) from the Multi-ethnic Study Atherosclerosis who were free of cardiovascular disease at baseline. Of 2,509 women, 693 (28%) reported either surgical or natural early menopause. In survival curves, women with early menopause had worse coronary heart disease and stroke-free survival (log rank P = 0.008 and P = 0.0158). In models adjusted for age, race/ethnicity, Multi-ethnic Study Atherosclerosis site, and traditional cardiovascular disease risk factors, this risk for coronary heart disease and stroke remained (hazard ratio, 2.08; 95% CI, 1.17-3.70; and hazard ratio, 2.19; 95% CI, 1.11-4.32, respectively). Early menopause is positively associated with coronary heart disease and stroke in a multiethnic cohort, independent of traditional cardiovascular disease risk factors.

Early Menopause Predicts Future Coronary Heart Disease and Stroke: The Multi-Ethnic Study of Atherosclerosis (MESA)

PubMed Central

Wellons, Melissa; Ouyang, Pamela; Schreiner, Pamela J; Herrington, David M; Vaidya, Dhananjay

2012-01-01

Objective Cardiovascular disease is the number one killer of women. Identifying women at risk of cardiovascular disease has tremendous public health importance. Early menopause is associated with increased cardiovascular disease events in some predominantly white populations, but not consistently. Our objective was to determine if a self-reported early menopause (menopause at an age <46) identifies women as at risk for future coronary heart disease or stroke. Methods The study population came from the Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 years enrolled in 2000–2002 and followed up until 2008. The association between a personal history of early menopause (either natural menopause or surgical removal of ovaries at an age <46) and future coronary heart disease and stroke was assessed in 2509 women (ages 45–84, 987 White, 331 Chinese, 641 Black, 550 Hispanic) from the Multi-Ethnic Study Atherosclerosis, who were free of cardiovascular disease at baseline. Results 693/2509 (28%) of women reported either surgical or natural early menopause. In survival curves, women with early menopause had worse coronary heart disease and stroke-free survival (log rank p=<0.008 and 0.0158). In models adjusted for age, race/ethnicity, Multi-Ethnic Study Atherosclerosis site and traditional cardiovascular disease risk factors, this risk for coronary heart disease and stroke remained (HR 2.08, 95% CI 1.17, 3.70 and 2.19, 95% CI 1.11, 4.32, respectively). Conclusions Early menopause is positively associated with coronary heart disease and stroke in a multiethnic cohort, independent of traditional cardiovascular disease risk factors. PMID:22692332

Long-term results of sequential vein coronary artery bypass grafting compared with totally arterial myocardial revascularization: a propensity score-matched follow-up study†.

PubMed

Garatti, Andrea; Castelvecchio, Serenella; Canziani, Alberto; Corain, Livio; Generali, Tommaso; Mossuto, Eugenio; Gagliardotto, Piervincenzo; Anastasia, Luigi; Salmaso, Luigi; Giacomazzi, Francesca; Menicanti, Lorenzo

2014-12-01

The aim of the study was to analyse the early and long-term outcomes of a consecutive series of patients who underwent sequential coronary artery bypass grafting (CABG) and to compare them with a matched population of totally arterial revascularized patients. From January 1994 to December 1996, 209 patients underwent total arterial myocardial revascularization at our institution [arterial (ART) group]. In the same period, 2097 patients underwent CABG with left internal thoracic artery on left anterior descending and great saphenous vein on the right and circumflex branches sequentially [sequential vein (SV) group]. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups (209 vs 243 patients in the ART group and SV group, respectively). In-hospital mortality was 1% in the ART group and 0.4% in the SV group (P = 0.86). Mean follow-up was 14 ± 4 years. Long-term survival was comparable among the two study groups [actuarial 5- and 15-year survival rates were 97 vs 93% and 82 vs 79% in the ART group and the SV group, respectively (P = 0.29)]. At follow-up, recurrence of angina (17 vs 18%; P = 0.99), acute myocardial infarction (MI) (3 vs 5%; P = 0.72) and repeated percutaneous coronary intervention (19 vs 21%; P = 0.69) were similar in the ART group compared with the SV group. In the Cox regression analysis, type of revascularization was not an independent predictor of any long-term outcomes (death or major adverse cardiac events). In asymptomatic patients, exercise stress test at follow-up was comparable between the two groups (P = 0.14). Sequential vein CABG appears to have good early and long-term clinical outcomes. Also, early and long-term incidence of acute MI was not significantly higher in the SV group. However, further studies with a larger population are warranted in order to confirm the present results. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Friable but treatable: coronary artery dissections in Ehlers-Danlos syndrome.

PubMed

Zago, Alexandre C; Matte, Bruno S

2013-01-01

Vascular Ehlers-Danlos syndrome is a rare connective tissue disorder associated with arterial dissection or rupture. Percutaneous coronary intervention (PCI) is often critical in patients with this syndrome because their coronary arteries are prone to dissection, enhancing the risk of stent borders dissection when conventional stent deployment pressures are used. Coronary artery bypass graft (CABG) treatment for these patients may also raise concerns because the left internal mammary artery is probably friable. Therefore, coronary artery revascularization in vascular Ehlers-Danlos syndrome either using PCI or CABG is challenging due to the arteries friability. A small number of cases have been published describing the friability of the vessels and associated complications; nevertheless, the optimum treatment remains unclear. We report the case of a 54-year-old woman treated successfully with PCI and CABG in two different acute coronary syndrome episodes, in which specific technical issues related to both procedures were decisive. Copyright © 2011 Wiley Periodicals, Inc.

Best way to revascularize patients with main stem and three-vessel lesions. Patients should be operated!

PubMed

Reichenspurner, H; Conradi, L; Cremer, J; Mohr, F W

2010-09-01

Despite established guidelines for the treatment of coronary artery disease (CAD) by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), everyday clinical practice has proven to differ substantially with even the most complex coronary lesions being targeted by PCI today. However, an abundancy of clinical trials, both observational and randomized has proven the superiority of coronary surgery over PCI in almost every type of multivessel or left main CAD in symptomatic patients. This holds true also for 'hard' endpoints like cardiac death or myocardial infarction as recently demonstrated by the landmark SYNTAX trial. These results have lead to the wording of appropriateness criteria, which integrate current guidelines, evidence from clinical trials and interdisciplinary expert opinion and which express essentially the same message as the SYNTAX trial: "CABG remains the standard of care for patients with three-vessel or left main coronary artery disease"

Single Coronary Artery with Aortic Regurgitation

DOE Office of Scientific and Technical Information (OSTI.GOV)

Katsetos, Manny C.; Toce, Dale T.

An isolated single coronary artery can be associated with normal life expectancy; however, patients are at an increased risk of sudden death. A case is reported of a 54-year-old man with several months of chest pressure with activity. On exercise Sestamibi stress testing, the patient developed a hypotensive response with no symptoms and minimal electrocardiographic changes. Nuclear scanning demonstrated reversible septal and lateral perfusion defects consistent with severe ischemia. Coronary angiography revealed a single coronary artery with the right coronary artery arising from the left main. There were high-grade stenotic lesions in the left anterior descending and circumflex arteries withmore » only moderate atherosclerotic disease in the right coronary artery. An aortogram showed 2-3+ aortic regurgitation, with an ejection fraction of 45% on ventriculography. The patient underwent four-vessel revascularization and aortic valve replacement and did well postoperatively.« less

Chelation therapy after the Trial to Assess Chelation Therapy: results of a unique trial

PubMed Central

Avila, Maria D.; Escolar, Esteban; Lamas, Gervasio A.

2014-01-01

Purpose of review EDTA chelation therapy has been in off-label use for the treatment of atherosclerosis. We review the results of the first large-scale randomized trial of this treatment. Recent findings The trial to assess chelation therapy was a $30 million National Institutes of Health-funded study of the safety and efficacy of EDTA-based chelation infusions in 1708 post-myocardial infarction (MI) patients. The trial to assess chelation therapy demonstrated a significant (P = 0.035) 18% reduction in a combined primary endpoint of death, MI, stroke, coronary revascularization, or hospitalization for angina. In diabetic patients the benefit was more extreme, with a 41% relative reduction in risk (P = 0.0002) and a 43% reduction in total mortality (P = 0.011). Safety data were favorable. A reduction of oxidative stress by chelation of toxic metals has been proposed as a possible mechanism of action. Summary Recent research suggests that EDTA chelation may be a well-tolerated and effective treatment for post-MI patients. Future replication and mechanistic studies are important prior to implementation in all post-MI patients. PMID:25023079

Partially anaortic clampless off-pump coronary artery bypass prevents neurologic injury compared to on-pump coronary surgery: a propensity score-matched study on 286 patients.

PubMed

Bassano, Carlo; Bovio, Emanuele; Uva, Floriano; Iacobelli, Simona; Iasevoli, Nicola; Farinaccio, Andrea; Ruvolo, Giovanni

2016-09-01

Anaortic coronary artery bypass proved to prevent early neurologic injury compared to on-pump CABG. The Cardica PAS-Port(®) is a fully automated device that might be able to perform proximal aorto-venous anastomoses without an increased embolic risk. We evaluated early post-operative neurologic outcome in a matched population following clampless OPCAB (CCAB: either "all-arterial" or with automatically anastomosed venous grafts) or on-pump CABG. 366 consecutive patients were submitted to isolated coronary bypass by a single surgeon experienced in both off and on-pump procedures between January 2009 and December 2013. Of these patients, 223 underwent a clampless off-pump revascularization. After propensity score matching, 143 pairs were selected, who received either off-pump or on-pump surgery. In the off-pump group, CCAB was performed with an all-arterial approach (n = 33) or with automated proximal anastomosis of the venous graft(s) by means of the Cardica PAS-Port(®) connector (n = 110). Neurologic injury was defined as non-reversible (NRNI: lethal coma or stroke) or reversible (RNI: TIA or delirium). Operative mortality was 2.4 % (CCAB 1.4 %; CABG 3.5 %; p = 0.14). The global rate of early neurologic injury was 5.6 % (CCAB 2.1 vs. CABG 9.1 %; p = 0.006). Incidence was 1.4 % for NRNI (CCAB 0 vs. CABG 2.8 %; p = 0.04) and 4.2 % for RNI (CCAB 2.1 vs. CABG 6.3 %; p = 0.06). No differences were found among other major perioperative outcomes. CCAB prevents both early post-operative RNI and NRNI. This result can be achieved with a totally anaortic strategy and also with the aid of a fully automated device for proximal aorto-venous anastomoses.

Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study.

PubMed

Chandrasekhar, Jaya; Baber, Usman; Sartori, Samantha; Aquino, Melissa; Kini, Annapoorna S; Rao, Sunil; Weintraub, William; Henry, Timothy D; Farhan, Serdar; Vogel, Birgit; Sorrentino, Sabato; Ge, Zhen; Kapadia, Samir; Muhlestein, Joseph B; Weiss, Sandra; Strauss, Craig; Toma, Catalin; DeFranco, Anthony; Effron, Mark B; Keller, Stuart; Baker, Brian A; Pocock, Stuart; Dangas, George; Mehran, Roxana

2018-03-01

Potent P2Y 12 inhibitors might offer enhanced benefit against thrombotic events in complex percutaneous coronary intervention (PCI). We examined prasugrel use and outcomes according to PCI complexity, as well as analyzing treatment effects according to thienopyridine type. PROMETHEUS was a multicentre observational study that compared clopidogrel vs prasugrel in acute coronary syndrome patients who underwent PCI (n = 19,914). Complex PCI was defined as PCI of the left main, bifurcation lesion, moderate-severely calcified lesion, or total stent length ≥ 30 mm. Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke, or unplanned revascularization. Outcomes were adjusted using multivariable Cox regression for effect of PCI complexity and propensity-stratified analysis for effect of thienopyridine type. The study cohort included 48.9% (n = 9735) complex and 51.1% (n = 10,179) noncomplex patients. Second generation drug-eluting stents were used in 70.1% complex and 66.2% noncomplex PCI patients (P < 0.0001). Complex PCI was associated with greater adjusted risk of 1-year MACE (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.20-1.39; P < 0.001). Prasugrel was prescribed in 20.7% of complex and 20.1% of noncomplex PCI patients (P = 0.30). Compared with clopidogrel, prasugrel significantly decreased adjusted risk for 1-year MACE in complex PCI (HR, 0.79; 95% CI, 0.68-0.92) but not noncomplex PCI (HR, 0.91; 95% CI, 0.77-1.08), albeit there was no evidence of interaction (P interaction = 0.281). Despite the use of contemporary techniques, acute coronary syndrome patients who undergo complex PCI had significantly higher rates of 1-year MACE. Adjusted magnitude of treatment effects with prasugrel vs clopidogrel were consistent in complex and noncomplex PCI without evidence of interaction. Copyright © 2018. Published by Elsevier Inc.

Sex-related differences in outcomes among men and women under 55 years of age with acute coronary syndrome undergoing percutaneous coronary intervention: Results from the PROMETHEUS study.

PubMed

Chandrasekhar, Jaya; Baber, Usman; Sartori, Samantha; Faggioni, Michela; Aquino, Melissa; Kini, Annapoorna; Weintraub, William; Rao, Sunil; Kapadia, Samir; Weiss, Sandra; Strauss, Craig; Toma, Catalin; Muhlestein, Brent; DeFranco, Anthony; Effron, Mark; Keller, Stuart; Baker, Brian; Pocock, Stuart; Henry, Timothy; Mehran, Roxana

2017-03-01

Young women undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) experience greater adverse events than men, potentially due to under-treatment. We sought to compare the 1-year outcomes by sex in patients ≤55 years of age from a contemporary PCI cohort. PROMETHEUS was a retrospective multicenter observational US study comparing outcomes in clopidogrel and prasugrel treated patients following ACS PCI. MACE was defined as a composite of death, myocardial infarction, stroke or unplanned revascularization. Clinically significant bleeding was defined as bleeding requiring transfusion or hospitalization. Hazard ratios were generated using multivariable Cox proportional hazards regression. The study cohort included 4,851 patients of which 1,162 (24.0%) were women and 3,689 (76.0%) were men. In this cohort, the prevalence of diabetes (41.0 vs. 27.9%) and chronic kidney disease (12.7 vs. 7.2%) was higher among women compared with men. Irrespective of sex, prasugrel was used in less than one-third of patients (31.8% in men vs. 28.1% in women, P = 0.01). Unadjusted, 1-year MACE (21.1% vs. 16.2%, P < 0.001) and bleeding (3.6% vs. 2.2%, P = 0.01) was significantly higher in women compared with men, but these results were no longer significant after adjustment for risk (HR 1.13, 95% CI 0.94-1.36 for MACE and HR 1.31, 95% CI 0.85-2.04 for bleeding). Women ≤ 55 years of age undergoing ACS PCI have significantly greater comorbidities than young men. Despite a higher risk clinical phenotype in women, prasugrel use was significantly lower in women than men. Female sex was associated with a significantly higher risk of 1-year MACE and bleeding than male sex, findings that are attributable to baseline differences. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Long-Term Survival Prediction for Coronary Artery Bypass Grafting: Validation of the ASCERT Model Compared With The Society of Thoracic Surgeons Predicted Risk of Mortality.

PubMed

Lancaster, Timothy S; Schill, Matthew R; Greenberg, Jason W; Ruaengsri, Chawannuch; Schuessler, Richard B; Lawton, Jennifer S; Maniar, Hersh S; Pasque, Michael K; Moon, Marc R; Damiano, Ralph J; Melby, Spencer J

2018-05-01

The recently developed American College of Cardiology Foundation-Society of Thoracic Surgeons (STS) Collaboration on the Comparative Effectiveness of Revascularization Strategy (ASCERT) Long-Term Survival Probability Calculator is a valuable addition to existing short-term risk-prediction tools for cardiac surgical procedures but has yet to be externally validated. Institutional data of 654 patients aged 65 years or older undergoing isolated coronary artery bypass grafting between 2005 and 2010 were reviewed. Predicted survival probabilities were calculated using the ASCERT model. Survival data were collected using the Social Security Death Index and institutional medical records. Model calibration and discrimination were assessed for the overall sample and for risk-stratified subgroups based on (1) ASCERT 7-year survival probability and (2) the predicted risk of mortality (PROM) from the STS Short-Term Risk Calculator. Logistic regression analysis was performed to evaluate additional perioperative variables contributing to death. Overall survival was 92.1% (569 of 597) at 1 year and 50.5% (164 of 325) at 7 years. Calibration assessment found no significant differences between predicted and actual survival curves for the overall sample or for the risk-stratified subgroups, whether stratified by predicted 7-year survival or by PROM. Discriminative performance was comparable between the ASCERT and PROM models for 7-year survival prediction (p < 0.001 for both; C-statistic = 0.815 for ASCERT and 0.781 for PROM). Prolonged ventilation, stroke, and hospital length of stay were also predictive of long-term death. The ASCERT survival probability calculator was externally validated for prediction of long-term survival after coronary artery bypass grafting in all risk groups. The widely used STS PROM performed comparably as a predictor of long-term survival. Both tools provide important information for preoperative decision making and patient counseling about potential outcomes after coronary artery bypass grafting. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Relation of Waist-Hip Ratio to Long-Term Cardiovascular Events in Patients With Coronary Artery Disease.

PubMed

Medina-Inojosa, Jose R; Batsis, John A; Supervia, Marta; Somers, Virend K; Thomas, Randal J; Jenkins, Sarah; Grimes, Chassidy; Lopez-Jimenez, Francisco

2018-04-15

We aimed to assess the association between measures of obesity and outcomes in coronary artery disease (CAD) patients. We included consecutive patients referred to cardiac rehabilitation for previous CAD events, who were classified using body mass index (BMI) groups and gender-specific tertiles of waist-to-hip ratio (WHR). Follow-up was ascertained using a population-based, record linkage system. Major cardiovascular event (MACE) was defined as the composite outcome including acute coronary syndromes, coronary revascularization, ventricular arrhythmias, stroke, or death from any cause. We used Cox proportional hazards models adjusted for potential confounders. The cohort included 1,529 patients (74% men), 63.1 ± 12.5 years (mean age ± SD), of whom 40% were obese by BMI. Eighty-eight percent of men and 57% of women were classified as having central obesity by WHR. Median follow-up was 5.7 years and 415 patients had MACE. After adjustment, a high WHR tertile was a significant predictor for MACE in women (hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.16, 2.94, p = 0.01) but not in men (HR 0.92, 95% CI 0.69, 1.22, p = 0.54). This relation in women persisted after further adjustment for BMI (HR 1.75, 95% CI 1.07, 2.87, p = 0.03). Obesity by BMI was not associated with MACE in either men (HR 1.07, 95% CI 0.76, 1.51, p = 0.69) or women (HR 0.98, 95% CI 0.62, 1.56, p = 0.95). In conclusion, WHR is associated with a higher risk of MACE among women with CAD but not in men. There was no obesity paradox when assessing obesity by BMI in patients with CAD when including nonfatal events. Copyright © 2018 Elsevier Inc. All rights reserved.

Troponin elevation in acute ischemic stroke (TRELAS) - protocol of a prospective observational trial

PubMed Central

2011-01-01

Background Levels of the cardiac muscle regulatory protein troponin T (cTnT) are frequently elevated in patients with acute ischemic stroke and elevated cTnT predicts poor outcome and mortality. The pathomechanism of troponin release may relate to co-morbid coronary artery disease and myocardial ischemia or, alternatively, to neurogenic cardiac damage due to autonomic activation after acute ischemic stroke. Therefore, there is uncertainty about how acute ischemic stroke patients with increased cTnT levels should be managed regarding diagnostic and therapeutic workup. Methods/Design The primary objective of the prospective observational trial TRELAS (TRoponin ELevation in Acute ischemic Stroke) is to investigate the frequency and underlying pathomechanism of cTnT elevation in acute ischemic stroke patients in order to give guidance for clinical practice. All consecutive patients with acute ischemic stroke admitted within 72 hours after symptom onset to the Department of Neurology at the Campus Benjamin Franklin of the University Hospital Charité will be screened for cTnT elevations (i.e. >= 0.05 μg/l) on admission and again on the following day. Patients with increased cTnT will undergo coronary angiography within 72 hours. Diagnostic findings of coronary angiograms will be compared with age- and gender-matched patients presenting with Non-ST-Elevation myocardial infarction to the Department of Cardiology. The primary endpoint of the study will be the occurrence of culprit lesions in the coronary angiogram indicating underlying co-morbid obstructive coronary artery disease. Secondary endpoints will be the localization of stroke in the cerebral imaging and left ventriculographic findings of wall motion abnormalities suggestive of stroke-induced global cardiac dysfunction. Discussion TRELAS will prospectively determine the frequency and possible etiology of troponin elevation in a large cohort of ischemic stroke patients. The findings are expected to contribute to clarify pathophysiologic concepts of co-morbid cardiac damage in ischemic stroke patients and also to provide a basis for clinical recommendations for cardiac workup of such patients. Trial registration clinicaltrials.gov NCT01263964 PMID:21824425

Management of moyamoya syndrome in patients with Noonan syndrome.

PubMed

Gupta, Mihir; Choudhri, Omar A; Feroze, Abdullah H; Do, Huy M; Grant, Gerald A; Steinberg, Gary K

2016-06-01

A few isolated reports have described an association between Noonan syndrome and cerebrovascular abnormalities, including moyamoya syndrome. These reports have been limited to pediatric patients presenting with recurrent transient ischemic attacks (TIA) or headaches. Management has primarily been pharmacologic, with only one prior report of surgical revascularization to our knowledge. We report four cases of Noonan syndrome patients presenting with headaches and/or sensorimotor strokes in childhood that caused unilateral sensorimotor impairment. Cerebral angiography and MRI revealed bilateral moyamoya syndrome. All patients underwent successful bilateral extracranial-to-intracranial revascularization. The first patient was a 10-year-old girl who presented following a hemorrhagic stroke and recovered well after indirect bypass. The second patient was an adult with a history of childhood stroke whose symptoms progressed in adulthood. She underwent a direct bypass and improved, but continued to experience TIA at her 4 year follow-up. The third patient was a 7-year-old girl with headaches and a new onset TIA who failed pharmacological therapy and subsequently underwent bilateral indirect bypass. The fourth patient was a 24-year-old woman with worsening headaches and an occluded left middle cerebral artery from unilateral moyamoya syndrome. A left sided direct bypass was completed given delayed MRI perfusion with poor augmentation. To our knowledge these are the first reported surgical cases of combined Noonan and moyamoya syndrome. These cases highlight the need to recognize moyamoya syndrome in patients with Noonan syndrome. Early surgical revascularization should be pursued in order to prevent symptom progression. Copyright © 2015 Elsevier Ltd. All rights reserved.

Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology.

PubMed

Sacks, David; Black, Carl M; Cognard, Christophe; Connors, John J; Frei, Donald; Gupta, Rishi; Jovin, Tudor G; Kluck, Bryan; Meyers, Philip M; Murphy, Kieran J; Ramee, Stephen; Rüfenacht, Daniel A; Bernadette Stallmeyer, M J; Vorwerk, Dierk

2013-02-01

In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. It is intended that these benchmarks be used in a quality assurance program to assess and improve processes and outcomes in acute stroke revascularization. Members of the writing group were appointed by the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society of Cardiac Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. The writing group reviewed the relevant literature from 1986 through February 2012 to create an evidence table summarizing processes and outcomes of care. Performance metrics and thresholds were then created by consensus. The guideline was approved by the sponsoring societies. It is intended that this guideline be fully updated in 3 years. In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. These include process measures of time to imaging, arterial puncture, and revascularization and measures of clinical outcome up to 90 days. Quality improvement guidelines are provided for endovascular acute ischemic stroke revascularization procedures. Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.

Effect of darapladib on major coronary events after an acute coronary syndrome: the SOLID-TIMI 52 randomized clinical trial.

PubMed

O'Donoghue, Michelle L; Braunwald, Eugene; White, Harvey D; Steen, Dylan P; Lukas, Mary Ann; Tarka, Elizabeth; Steg, P Gabriel; Hochman, Judith S; Bode, Christoph; Maggioni, Aldo P; Im, KyungAh; Shannon, Jennifer B; Davies, Richard Y; Murphy, Sabina A; Crugnale, Sharon E; Wiviott, Stephen D; Bonaca, Marc P; Watson, David F; Weaver, W Douglas; Serruys, Patrick W; Cannon, Christopher P; Steen, Dylan L

2014-09-10

Lipoprotein-associated phospholipase A2 (Lp-PLA2) has been hypothesized to be involved in atherogenesis through pathways related to inflammation. Darapladib is an oral, selective inhibitor of the Lp-PLA2 enzyme. To evaluate the efficacy and safety of darapladib in patients after an acute coronary syndrome (ACS) event. SOLID-TIMI 52 was a multinational, double-blind, placebo-controlled trial that randomized 13,026 participants within 30 days of hospitalization with an ACS (non-ST-elevation or ST-elevation myocardial infarction [MI]) at 868 sites in 36 countries. Patients were randomized to either once-daily darapladib (160 mg) or placebo on a background of guideline-recommended therapy. Patients were followed up for a median of 2.5 years between December 7, 2009, and December 6, 2013. The primary end point (major coronary events) was the composite of coronary heart disease (CHD) death, MI, or urgent coronary revascularization for myocardial ischemia. Kaplan-Meier event rates are reported at 3 years. During a median duration of 2.5 years, the primary end point occurred in 903 patients in the darapladib group and 910 in the placebo group (16.3% vs 15.6% at 3 years; hazard ratio [HR], 1.00 [95% CI, 0.91-1.09]; P = .93). The composite of cardiovascular death, MI, or stroke occurred in 824 in the darapladib group and 838 in the placebo group (15.0% vs 15.0% at 3 years; HR, 0.99 [95% CI, 0.90-1.09]; P = .78). There were no differences between the treatment groups for additional secondary end points, for individual components of the primary end point, or in all-cause mortality (371 events in the darapladib group and 395 in the placebo group [7.3% vs 7.1% at 3 years; HR, 0.94 [95% CI, 0.82-1.08]; P = .40). Patients were more likely to report an odor-related concern in the darapladib group vs the placebo group (11.5% vs 2.5%) and also more likely to report diarrhea (10.6% vs 5.6%). In patients who experienced an ACS event, direct inhibition of Lp-PLA2 with darapladib added to optimal medical therapy and initiated within 30 days of hospitalization did not reduce the risk of major coronary events. clinicaltrials.gov Identifier: NCT01000727.

Prognostic value of calcium score and coronary flow velocity reserve in asymptomatic diabetic patients.

PubMed

Dikic, Miodrag; Tesic, Milorad; Markovic, Zeljko; Giga, Vojislav; Djordjevic-Dikic, Ana; Stepanovic, Jelena; Beleslin, Branko; Jovanovic, Ivana; Mladenovic, Ana; Seferovic, Jelena; Ostojic, Miodrag; Arandjelovic, Aleksandra

2015-09-04

The risk stratification of patients with diabetes mellitus (DM) is a major objective for the clinicians, and it can be achieved by coronary flow velocity reserve (CFVR) or with coronary artery calcium score (CS). CS evaluates underlying coronary atherosclerotic plaque burden and CFVR estimates both presence of coronary artery stenosis and microvascular function. Consequently, CFVR may provide unique risk information beyond the extent of coronary atherosclerosis. Our aim is to assess joint prognostic value of CFVR and CS in asymptomatic DM patients. We prospectively included 200 asymptomatic patients (45,5 % male, mean age 57,35 ± 11,25), out of which, there were 101 asymptomatic patients with DM and 99 asymptomatic patients without DM, but with one or more conventionally risk factors for coronary artery disease. We analyzed clinical, biochemical, metabolic, inflammatory parameters, CS by Agatston method, transthoracic Doppler echocardiography CFVR of left anterior descending artery and echocardiographic parameters. Total CS and CS LAD were significantly higher, while mean CFVR was lower in diabetics compared to the nondiabetics. During 1 year follow-up, 24 patients experienced cardio-vascular events (one cardiovascular death, two strokes, three myocardial infarctions, nine new onsets of unstable angina and nine myocardial revascularizations): 19 patients with DM and five non DM patients, (p = 0,003). Overall event free survival was significantly higher in non DM group, compared to the DM group (94,9 % vs. 81,2 %, p = 0,002 respectively), while the patients with CS ≥200 and CFVR <2 had the worst outcome during 1 year follow up in the whole study population as well as in the DM group. At multivariable analysis CFVR on LAD (HR 12.918, 95 % CI 3.865-43.177, p < 0.001) and total CS (HR 13.393, 95 % CI 1.675-107.119, p = 0.014) were independent prognostic predictors of adverse events in DM group of patients. Both CS and CFVR provide independent and complementary prognostic information in asymptomatic DM patients. When two parameters are analyzed together, the risk stratification ability improves, even when DM patients are analyzed together with non DM patients. As a result, DM patients with CS ≥200 and CFVR <2 had the worst outcome. Consequently, the use of two tests identified subset of patients who can derive the most benefit from the intensive prevention measures.

Routine Angiographic Follow-Up versus Clinical Follow-Up after Percutaneous Coronary Intervention in Acute Myocardial Infarction

PubMed Central

Kim, Yong Hoon; Her, Ae-Young; Choi, Byoung Geol; Shim, Minsuk; Choi, Se Yeon; Byun, Jae Kyeong; Li, Hu; Kim, Woohyeun; Kang, Jun Hyuk; Choi, Jah Yeon; Park, Eun Jin; Park, Sung Hun; Lee, Sunki; Na, Jin Oh; Choi, Cheol Ung; Lim, Hong Euy; Kim, Eung Ju; Park, Chang Gyu; Seo, Hong Seog; Oh, Dong Joo

2017-01-01

Purpose Differences in the utility of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) are not well understood. The present study aimed to compare the 3-year clinical outcomes of RAF and CF in AMI patients who underwent PCI with drug-eluting stents (DES). Materials and Methods A total of 774 consecutive AMI patients who underwent PCI with DES were enrolled. RAF was performed at 6 to 9 months after index PCI (n=425). The remaining patients were medically managed and clinically followed (n=349); symptom-driven events were captured. To adjust for any potential confounders, a propensity score matched analysis was performed using a logistic regression model, and two propensity-matched groups (248 pairs, n=496, C-statistic=0.739) were generated. Cumulative clinical outcomes up to 3 years were compared between RAF and CF groups. Results During the 3-year follow-up period, the cumulative incidences of revascularization [target lesion revascularization: hazard ratio (HR), 2.40; 95% confidence interval (CI), 1.18–4.85; p=0.015, target vessel revascularization (TVR): HR, 3.33; 95% CI, 1.69–6.58; p=0.001, non-TVR: HR, 5.64; 95% CI, 1.90–16.6; p=0.002] and major adverse cardiac events (MACE; HR, 3.32; 95% CI, 1.92–5.73; p<0.001) were significantly higher in the RAF group than the CF group. However, the 3-year incidences of death and myocardial infarction were not different between the two groups. Conclusion RAF following index PCI with DES in AMI patients was associated with increased incidences of revascularization and MACE. Therefore, CF seems warranted for asymptomatic patients after PCI for AMI. PMID:28540983

Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study

PubMed Central

Ebrahim, S; May, M; Ben, S; McCarron, P; Frankel, S; Yarnell, J; Davey, S

2002-01-01

Objective: To examine the relation between frequency of sexual intercourse and risk of ischaemic stroke and coronary heart disease. Design: Cohort study with 20 year follow up. Setting: The town of Caerphilly, South Wales and five adjacent villages. Subjects: 914 men aged 45–59 years at time of recruitment in 1979 to 1983. Main outcome measures: Ischaemic stroke and coronary heart disease, all first events and fatal events. Results: Of the 914 men studied, 197 (21.5%) reported sexual intercourse less often than once a month, 231 (25.3%) reported sexual intercourse twice or more a week, and the remaining 486 (53.2%) men fell into the intermediate category. Frequency of sexual intercourse was not associated with all first ischaemic stroke events: age adjusted odds ratios (95% CI) for intermediate and low frequency of sexual intercourse of 0.61 (0.32 to 1.16) and 0.71 (0.34 to 1.49) respectively compared with the reference category of high frequency. A graded relation with fatal coronary heart disease events was observed in events recorded up to 10 years. The age adjusted relative risk (95% CI) of fatal coronary heart disease contrasting low frequency of sexual intercourse (that is, less than monthly) with the highest group (at least twice a week) was 2.80 (1.13 to 6.96, test for trend, p=0.04) which was not attenuated by adjustment for a wide range of potential confounders. Longer follow up to 20 years showed attenuation of this risk with odds of 1.69 (95% CI 0.90 to 3.20), contrasting low frequency of sexual intercourse with the highest group. Conclusions: The differential relation between frequency of sexual intercourse, stroke and coronary heart disease suggests that confounding is an unlikely explanation for the observed association with fatal coronary heart disease events. Middle aged men should be heartened to know that frequent sexual intercourse is not likely to result in a substantial increase in risk of strokes, and that some protection from fatal coronary events may be an added bonus. PMID:11812807

Nonemergency PCI at hospitals with or without on-site cardiac surgery.

PubMed

Jacobs, Alice K; Normand, Sharon-Lise T; Massaro, Joseph M; Cutlip, Donald E; Carrozza, Joseph P; Marks, Anthony D; Murphy, Nancy; Romm, Iyah K; Biondolillo, Madeleine; Mauri, Laura

2013-04-18

Emergency surgery has become a rare event after percutaneous coronary intervention (PCI). Whether having cardiac-surgery services available on-site is essential for ensuring the best possible outcomes during and after PCI remains uncertain. We enrolled patients with indications for nonemergency PCI who presented at hospitals in Massachusetts without on-site cardiac surgery and randomly assigned these patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that had cardiac surgery services available. A total of 10 hospitals without on-site cardiac surgery and 7 with on-site cardiac surgery participated. The coprimary end points were the rates of major adverse cardiac events--a composite of death, myocardial infarction, repeat revascularization, or stroke--at 30 days (safety end point) and at 12 months (effectiveness end point). The primary end points were analyzed according to the intention-to-treat principle and were tested with the use of multiplicative noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness). A total of 3691 patients were randomly assigned to undergo PCI at a hospital without on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery (917 patients). The rates of major adverse cardiac events were 9.5% in hospitals without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at 30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98; 95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of death, myocardial infarction, repeat revascularization, and stroke (the components of the primary end point) did not differ significantly between the groups at either time point. Nonemergency PCI procedures performed at hospitals in Massachusetts without on-site surgical services were noninferior to procedures performed at hospitals with on-site surgical services with respect to the 30-day and 1-year rates of clinical events. (Funded by the participating hospitals without on-site cardiac surgery; MASS COM ClinicalTrials.gov number, NCT01116882.).

Pooled diagnostic accuracy of resting distal to aortic coronary pressure referenced to fractional flow reserve: The importance of resting coronary physiology.

PubMed

Maini, Rohit; Moscona, John; Sidhu, Gursukhman; Katigbak, Paul; Fernandez, Camilo; Irimpen, Anand; Mogabgab, Owen; Ward, Charisse; Samson, Rohan; LeJemtel, Thierry

2018-04-29

Both resting and hyperemic physiologic methods to guide coronary revascularization improve cardiovascular outcomes compared with angiographic guidance alone. Fractional flow reserve (FFR) remains underutilized due to concerns regarding hyperemia, prompting study of resting distal to aortic coronary pressure (Pd/Pa). Pd/Pa is a vasodilator-free resting index unlike FFR. While Pd/Pa is similar to another resting index, instantaneous wave-free ratio (iFR), it is a whole-cycle measurement not limited to the wave-free diastolic period. Pd/Pa is not validated clinically although multiple accuracy studies have been performed. Our meta-analysis examines the overall diagnostic accuracy of Pd/Pa referenced to FFR, the accepted invasive standard of ischemia. We searched PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through August 9, 2017 addressing the diagnostic accuracy of Pd/Pa referenced to FFR < 0.80. The following keywords were used: "distal coronary artery pressure" OR "Pd/Pa" AND "fractional flow reserve" OR "FFR." In total, 14 studies comprising 7004 lesions were identified. Pooled diagnostic accuracy estimates of Pd/Pa versus FFR < 0.80 were: sensitivity, 0.77 (95% CI, 0.75-0.78); specificity, 0.82 (0.81-0.83); positive likelihood ratio, 4.7 (3.3-6.6); negative likelihood ratio, 0.29 (0.24-0.34); diagnostic odds ratio, 18.1 (14.4-22.6); area under the summary receiver-operating characteristic curve of 0.88; and diagnostic accuracy of 0.80 (0.76-0.83). Pd/Pa shows adequate agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. Pd/Pa has the potential to guide coronary revascularization with easier application and availability compared with iFR and FFR. © 2018, Wiley Periodicals, Inc.

Prognosis of patients with non-ST-segment-elevation myocardial infarction and nonobstructive coronary artery disease: propensity-matched analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial.

PubMed

Planer, David; Mehran, Roxana; Ohman, E Magnus; White, Harvey D; Newman, Jonathan D; Xu, Ke; Stone, Gregg W

2014-06-01

Troponin elevation is a risk factor for mortality in patients with non-ST-segment-elevation acute coronary syndromes. However, the prognosis of patients with troponin elevation and nonobstructive coronary artery disease (CAD) is unknown. Our objective was therefore to evaluate the impact of nonobstructive CAD in patients with non-ST-segment-elevation acute coronary syndromes and troponin elevation enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. In the ACUITY trial, 3-vessel quantitative coronary angiography was performed in a formal substudy of 6921 patients presenting with non-ST-segment-elevation acute coronary syndromes. Patients with elevated admission troponin levels were stratified by the presence or absence of obstructive CAD (any lesion with quantitative diameter stenosis >50%). Propensity score matching was performed to adjust for baseline characteristics. Of 2442 patients with elevated troponin, 197 (8.8%) had nonobstructive CAD. Maximum diameter stenosis was 87.4 (73.2, 100.0) versus 22.6 (19.2, 25.7; P<0.0001) in patients with versus without obstructive CAD, respectively. Propensity matching yielded 117 patients with nonobstructive CAD and 331 patients with obstructive CAD, with no significant baseline differences between groups. In the matched cohort, overall 1-year mortality was significantly higher in patients with nonobstructive CAD (5.2% versus 1.6%; hazard ratio [95% confidence interval]=3.44 [1.05, 11.28]; P=0.04), driven by greater noncardiac mortality. Conversely, recurrent myocardial infarction and unplanned revascularization rates were significantly higher in patients with obstructive CAD. Patients with non-ST-segment-elevation acute coronary syndromes and elevated troponin levels but without obstructive CAD, while having low rates of subsequent myocardial infarction and unplanned revascularization, are still at considerable risk for 1-year mortality from noncardiac causes. http://www.clinicaltrials.gov. Unique identifier: NCT00093158. © 2014 American Heart Association, Inc.

Fifteen percent of myocardial infarctions and coronary revascularizations explained by family history unrelated to conventional risk factors. The Reykjavik Cohort Study.

PubMed

Andresdottir, M B; Sigurdsson, G; Sigvaldason, H; Gudnason, V

2002-11-01

Aims To examine the relationship between history of myocardial infarction in first-degree relatives and the risk of developing coronary heart disease (myocardial infarction or coronary revascularization). Methods and Results A total of 9328 males and 10062 females, randomly selected residents of the Reykjavik area, aged 33-81 years, were examined in the period from 1967 to 1996 in a prospective cohort study. Cardiovascular risk assessment was based on characteristics at baseline. Information on history of myocardial infarction in first-degree relatives was obtained from a health questionnaire. Mean follow-up was 18 and 19 years for men and women, respectively. During follow-up 2700 men and 1070 women developed coronary heart disease. Compared with subjects without a family history, the hazard ratio of coronary heart disease was 1.75 (95% confidence interval, CI, 1.59-1.92) for men and 1.83 (95% CI, 1.60-2.11) for women, with one or more first-degree relatives with myocardial infarction. The risk factor profile was significantly worse in individuals with a positive family history. After allowance for these risk factors, the hazard ratio was still highly significant, 1.66 (CI, 1.51-1.82) and 1.64 (CI, 1.43-1.89) for men and women, respectively. Family history of myocardial infarction was attributed to 15.1% of all cases of coronary heart disease in men and 16.6% in women, independent of other known risk factors. Conclusion Family history of myocardial infarction increases the risk of developing coronary heart disease in both men and women and is largely independent of other classic risk factors. Approximately 15% of all myocardial infarctions can be attributed to familial factors that have not been measured in the study or remain to be elucidated. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.

Transmyocardial revascularization: the magic of drilling holes in the heart

NASA Astrophysics Data System (ADS)

Verdaasdonck, Rudolf M.

2000-01-01

Drilling holes in myocardial tissue using high-power lasers has shown to be effective in relieving angina in patients in an end-stage coronary heart disease who do not respond to medication and are unsuitable for standard revascularization techniques. An overview is presented of the interaction of various laser systems with myocardial tissue and the many experimental and clinical studies that have been conducted to elucidate the mechanism of the therapeutic effect of transmyocardial (laser) revascularization (TMR or TMLR). An angina relief of 2 classes with an acceptable mortality (5 - 10 %) and morbidity (20 - 30 %) rate is achieved in the majority of patients. Adverse effects can be minimized by critical patient selection and by a percutaneous approach (PMR). There is no significant difference in the results between the treatment modalities. The acute beneficial effect of TMLR might be attributed to sympathetic denervation. The combined thermal and mechanical injury has shown to provoke an angiogenic response that may be enhanced by adding growth factors. Consequent improvement of the myocardial reperfusion and functionality has been observed but needs further verification with, e.g., high-resolution scintigraphic techniques. Based on the experience in over 7000 patients, TMLR shows to be an effective and safe procedure resulting in a significant improvement in the quality of life for a carefully selected patient group suffering from end-stage coronary disease.

Prevalence of Regional Myocardial Thinning and Relationship With Myocardial Scarring in Patients With Coronary Artery Disease

PubMed Central

Shah, Dipan J.; Kim, Han W.; James, Olga; Parker, Michele; Wu, Edwin; Bonow, Robert O.; Judd, Robert M.; Kim, Raymond J.

2014-01-01

Importance Regional left ventricular (LV) wall thinning is believed to represent chronic transmural myocardial infarction and scar tissue. However, recent case reports using delayed-enhancement cardiovascular magnetic resonance (CMR) imaging raise the possibility that thinning may occur with little or no scarring. Objective To evaluate patients with regional myocardial wall thinning and to determine scar burden and potential for functional improvement. Design, Setting, and Patients Investigator-initiated, prospective, 3-center study conducted from August 2000 through January 2008 in 3 parts to determine (1) in patients with known coronary artery disease (CAD) undergoing CMR viability assessment, the prevalence of regional wall thinning (end-diastolic wall thickness ≤5.5 mm), (2) in patients with thinning, the presence and extent of scar burden, and (3) in patients with thinning undergoing coronary revascularization, any changes in myocardial morphology and contractility. Main Outcomes and Measures Scar burden in thinned regions assessed using delayed-enhancement CMR and changes in myocardial morphology and function assessed using cine-CMR after revascularization. Results Of 1055 consecutive patients with CAD screened, 201 (19% [95% CI, 17% to 21%]) had regional wall thinning. Wall thinning spanned a mean of 34% (95% CI, 32% to 37% [SD, 15%]) of LV surface area. Within these regions, the extent of scarring was 72% (95% CI, 69% to 76% [SD, 25%]); however, 18% (95% CI, 13% to 24%) of thinned regions had limited scar burden (≤50% of total extent). Among patients with thinning undergoing revascularization and follow-up cine-CMR (n=42), scar extent within the thinned region was inversely related to regional (r=−0.72, P<.001) and global (r=−0.53, P<.001) contractile improvement. End-diastolic wall thickness in thinned regions with limited scar burden increased from 4.4 mm (95% CI, 4.1 to 4.7) to 7.5 mm (95% CI, 6.9 to 8.1) after revascularization (P<.001), resulting in resolution of wall thinning. On multivariable analysis, scar extent had the strongest association with contractile improvement (slope coefficient, −0.03 [95% CI, −0.04 to −0.02]; P<.001) and reversal of thinning (slope coefficient, −0.05 [95% CI, −0.06 to −0.04]; P<.001). Conclusions and Relevance Among patients with CAD referred for CMR and found to have regional wall thinning, limited scar burden was present in 18% and was associated with improved contractility and resolution of wall thinning after revascularization. These findings, which are not consistent with common assumptions, warrant further investigation. PMID:23462787

Do we need invasive confirmation of cardiac magnetic resonance results?

PubMed

Siastała, Paweł; Kądziela, Jacek; Małek, Łukasz A; Śpiewak, Mateusz; Lech, Katarzyna; Witkowski, Adam

2017-01-01

Coronary artery revascularization is indicated in patients with documented significant obstruction of coronary blood flow associated with a large area of myocardial ischemia and/or untreatable symptoms. There are a few invasive or noninvasive methods that can provide information about the functional results of coronary artery narrowing. The application of more than one method of ischemia detection in one patient to reevaluate the indications for revascularization is used in case of atypical or no symptoms and/or borderline stenosis. To evaluate whether the results of cardiac magnetic resonance need to be reconfirmed by the invasive functional method. The hospital database revealed 25 consecutive patients with 29 stenoses who underwent cardiac magnetic resonance (CMR) and fractional flow reserve (FFR) between the end of 2010 and the end of 2014. The maximal time interval between CMR and FFR was 6 months. None of the patients experienced any clinical events or underwent procedures on coronary arteries between the studies. According to the analysis, the agreement of CMR perfusion with the FFR method was at the level of 89.7%. Assuming that FFR is the gold standard in assessing the severity of stenoses, the sensitivity of CMR perfusion was 90.9%. The percentage of non-severe lesions which were correctly identified in CMR was 88.9%. The study shows that CMR perfusion is a highly sensitive method to detect hemodynamically significant CAD and exclude nonsevere lesions. With FFR as the reference standard, the diagnostic accuracy of MR perfusion to detect ischemic CAD is high.

Intraoperative left subclavian artery occlusion with left hand ischaemia and steal syndrome in the left internal thoracic artery

PubMed Central

Jelenc, Matija; Kneževič, Ivan; Stankovič, Milenko; Geršak, Borut

2012-01-01

We present a case of a 62-year old man with a left main stenosis, left coronary artery dominance, normal ejection fraction and no valvular pathology, and status post right carotid artery stenting, who was scheduled for elective coronary revascularization. We performed off-pump coronary revascularization, anastomosing the left internal thoracic artery to the left anterior descending artery, and three separate saphenous vein grafts to the intermediate artery and the first and second obtuse marginals, respectively. Proximally, the right internal thoracic artery was used as the inflow for all three venous grafts due to a heavily calcified ascending aorta. During the construction of the distal anastomoses to the obtuse marginals, the arterial pressure in the left radial artery suddenly dropped. The left hand was found to be pale and pulseless. A femoral artery catheter was placed for pressure monitoring and the anastomoses were completed as planned. Intraoperative transit-time graft flow measurement showed a reversed flow in the left internal thoracic artery. Postoperatively, angiography was performed showing a subtotal stenosis of the proximal left subclavian artery. The artery was dilated and stented. The postoperative course was uneventful and the patient was discharged on the 12th postoperative day. PMID:22767542

[ECG and ST-elevation myocardial infarction in multivessel coronary disease].

PubMed

Slavich, Gianaugusto; Spedicato, Leonardo; Poli, Stefano; Sappa, Roberta; Piccoli, Gianluca

2010-12-01

Percutaneous coronary intervention is the first-line treatment for ST-elevation myocardial infarction. In the setting of multivessel disease, concomitant reperfusion of all obstructed vessels is controversial, notably when the culprit vessel cannot be easily identified. We describe two cases with acute inferior-posterior myocardial infarction (ST-segment elevation in the inferior leads and ST-segment depression in the precordial leads). In the first case, angiography revealed severe three-vessel disease and the culprit vessel could not be identified. Following standard pharmacological therapy, the clinical picture and the ECG pattern improved, so that coronary revascularization was postponed. In the second case, angiography showed two-vessel disease with total occlusion of the right coronary and left circumflex arteries, which was treated with coronary angioplasty and drug-eluting stent implantation on the right coronary artery. In patients who undergo coronary angioplasty immediately, careful reading of the ECG can be a reliable tool for the identification of the culprit vessel in ST-elevation myocardial infarction associated with multivessel disease, allowing to choose the appropriate reperfusion strategy.

Contemporary medical therapies of atherosclerotic carotid artery disease.

PubMed

Cheng, Suk F; Brown, Martin M

2017-03-01

Contemporary medical therapy consists of identification and treatment of all patient-modifiable vascular risk factors. Specific atherosclerotic disease therapies are designed to reduce the risk of thrombosis, and the disease progression in order to reduce the risk of future cardiovascular events. Contemporary medical management emphasizes the need to support the patient in achieving lifestyle modifications and to adjust medication to achieve individualized target values for specific quantifiable risk factors. Antiplatelet therapy in the form of aspirin or clopidogrel is routinely used for the prevention of ischemic stroke in patients who have had a transient ischemic attack or stroke. There is evidence from a recent trial that the use of combination antiplatelet therapy with aspirin and clopidogrel started within 24 hours of minor stroke or transient ischemic attack reduces the risk of recurrent stroke compared to the use of aspirin alone, and therefore we use aspirin plus clopidogrel in recently symptomatic patients with carotid stenosis pending carotid revascularization. Anticoagulation with heparins or vitamin K antagonist is not recommended except in patients at risk for cardio-embolic events. Lowering blood pressure to target levels has been shown to slow down the progression of carotid artery stenosis and reduces the intima-media thickness of the carotid plaque, while lowering lipid levels with statins has become an essential element in the medical therapy of carotid artery stenosis. Diabetes management should be optimized. Lifestyle choices, including tobacco smoking, physical inactivity, unhealthy diet, obesity, and excessive alcohol intake, are all important modifiable vascular risk factors. The combination of dietary modification, physical exercise, and use of aspirin, a statin, and an antihypertensive agent can be expected to give a cumulative relative stroke risk reduction of 80%. The evidence suggests that intensive medical therapy is so effective that carotid revascularization may no longer be necessary in many of the patients in whom carotid surgery or stenting is currently performed. Two large ongoing trials are therefore comparing the risks and benefits of carotid revascularization versus intensive medical therapy alone. Copyright © 2017 Elsevier Inc. All rights reserved.

Family history does not predict angiographic localization or severity of coronary artery disease.

PubMed

Banerjee, Amitava; Lim, Chris C S; Silver, Louise E; Heneghan, Carl; Welch, Sarah J V; Mehta, Ziyah; Banning, Adrian P; Rothwell, Peter M

2012-04-01

Family history of MI is an established risk factor for coronary artery disease and subclinical atherosclerosis. Maternal MI and maternal stroke are more common in females than males presenting with acute coronary syndromes (ACS), suggesting sex-specific heritability, but the effects of family history on location and extent of coronary artery disease are unknown. In a prospective, population-based study (Oxford Vascular Study) of all patients with ACS, family history data for stroke and MI were analysed by sex of proband and affected first degree relatives (FDRs), and coronary angiograms were reviewed, where available. Of 835 probands with one or more ACS, 623 (420 males) had incident events and complete family history data. 351 patients with incident events (56.3%; 266 males) underwent coronary angiography. Neither angiographic disease localization nor severity were associated with sex-of-parent/sex-of-offspring in men or women. Sex-specific family history data do not predict angiographic localization of coronary disease in patients presenting with ACS. Maternal stroke and maternal MI probably affect ACS in females by a mechanism unrelated to atherosclerosis or coronary anatomy. However, family history data may still be useful in risk prediction and prognosis of ACS. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

PubMed Central

Zaidat, Osama O; Castonguay, Alicia C; Nogueira, Raul G; Haussen, Diogo C; English, Joey D; Satti, Sudhakar R; Chen, Jennifer; Farid, Hamed; Borders, Candace; Veznedaroglu, Erol; Binning, Mandy J; Puri, Ajit; Vora, Nirav A; Budzik, Ron F; Dabus, Guilherme; Linfante, Italo; Janardhan, Vallabh; Alshekhlee, Amer; Abraham, Michael G; Edgell, Randall; Taqi, Muhammad Asif; Khoury, Ramy El; Mokin, Maxim; Majjhoo, Aniel Q; Kabbani, Mouhammed R; Froehler, Michael T; Finch, Ira; Ansari, Sameer A; Novakovic, Roberta; Nguyen, Thanh N

2018-01-01

Background Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice. Methods Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH). Results A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH. Conclusion The TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations. PMID:28963367

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry.

PubMed

Zaidat, Osama O; Castonguay, Alicia C; Nogueira, Raul G; Haussen, Diogo C; English, Joey D; Satti, Sudhakar R; Chen, Jennifer; Farid, Hamed; Borders, Candace; Veznedaroglu, Erol; Binning, Mandy J; Puri, Ajit; Vora, Nirav A; Budzik, Ron F; Dabus, Guilherme; Linfante, Italo; Janardhan, Vallabh; Alshekhlee, Amer; Abraham, Michael G; Edgell, Randall; Taqi, Muhammad Asif; Khoury, Ramy El; Mokin, Maxim; Majjhoo, Aniel Q; Kabbani, Mouhammed R; Froehler, Michael T; Finch, Ira; Ansari, Sameer A; Novakovic, Roberta; Nguyen, Thanh N

2018-06-01

Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice. Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH). A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH. The TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Coronary artery bypass grafting in octogenarians: only when percutaneous coronary intervention is not feasible?

PubMed

Nicolini, Francesco

2015-11-01

The aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients older than 80 years. The review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation. It is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.

Causes of Death Following PCI Versus CABG in Complex CAD: 5-Year Follow-Up of SYNTAX.

PubMed

Milojevic, Milan; Head, Stuart J; Parasca, Catalina A; Serruys, Patrick W; Mohr, Friedrich W; Morice, Marie-Claude; Mack, Michael J; Ståhle, Elisabeth; Feldman, Ted E; Dawkins, Keith D; Colombo, Antonio; Kappetein, A Pieter; Holmes, David R

2016-01-05

There are no data available on specific causes of death from randomized trials that have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI). The purpose of this study was to investigate specific causes of death, and its predictors, after revascularization for complex coronary disease in patients. An independent Clinical Events Committee consisting of expert physicians who were blinded to the study treatment subclassified causes of death as cardiovascular (cardiac and vascular), noncardiovascular, or undetermined according to the trial protocol. Cardiac deaths were classified as sudden cardiac, related to myocardial infarction (MI), and other cardiac deaths. In the randomized cohort, there were 97 deaths after CABG and 123 deaths after PCI during a 5-year follow-up. After CABG, 49.4% of deaths were cardiovascular, with the greatest cause being heart failure, arrhythmia, or other causes (24.6%), whereas after PCI, the majority of deaths were cardiovascular (67.5%) and as a result of MI (29.3%). The cumulative incidence rates of all-cause death were not significantly different between CABG and PCI (11.4% vs. 13.9%, respectively; p = 0.10), whereas there were significant differences in terms of cardiovascular (5.8% vs. 9.6%, respectively; p = 0.008) and cardiac death (5.3% vs. 9.0%, respectively; p = 0.003), which were caused primarily by a reduction in MI-related death with CABG compared with PCI (0.4% vs. 4.1%, respectively; p <0.0001). Treatment with PCI versus CABG was an independent predictor of cardiac death (hazard ratio: 1.55; 95% confidence interval: 1.09 to 2.33; p = 0.045). The difference in MI-related death was seen largely in patients with diabetes, 3-vessel disease, or high SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) trial scores. During a 5-year follow-up, CABG in comparison with PCI was associated with a significantly reduced rate of MI-related death, which was the leading cause of death after PCI. Treatments following PCI should target reducing post-revascularization spontaneous MI. Furthermore, secondary preventive medication remains essential in reducing events post-revascularization. (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

International Survey on the Management of Wake-Up Stroke.

PubMed

de Castro-Afonso, Luís Henrique; Nakiri, Guilherme Seizem; Pontes-Neto, Octávio Marques; dos Santos, Antônio Carlos; Abud, Daniel Giansante

2016-01-01

Patients who wake up having experienced a stroke while asleep represent around 20% of acute stroke admissions. According to international guidelines for the management of acute stroke, patients presenting with wake-up stroke are not currently eligible to receive revascularization treatments. In this study, we aimed to assess the opinions of stroke experts about the management of patients with wake-up stroke by using an international multicenter electronic survey. This study consisted of 8 questions on wake-up stroke treatment. Two hundred invitations to participate in the survey were sent by e-mail. Fifty-nine participants started the survey, 4 dropped out before completing it, and 55 completed the full questionnaire. We had 55 participants from 22 countries. In this study, most stroke experts recommended a recanalization treatment for wake-up stroke. However, there was considerable disagreement among experts regarding the best brain imaging method and the best recanalization treatment. The results of ongoing randomized trials on wake-up stroke are urgently needed.