Left Main Coronary Artery Revascularization in Patients with Impaired Renal Function: Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting.

INTRODUCTION: The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function. METHODS: This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS: Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19-15.76], p < 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79-3.73]; p < 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71-1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90-1.39], p = 0.312). CONCLUSIONS: PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function.

Clinical Presentation and Outcome of Patients With Spontaneous Coronary Artery Dissection Versus Atherosclerotic Coronary Plaque Dissection.

BACKGROUND: Atherosclerotic coronary plaque dissection (ACPD) is one cause of acute coronary syndrome (ACS) caused by underlying atherosclerosis. Spontaneous coronary artery dissection (SCAD) occurs outside the setting of atherosclerosis among young women and individuals with few or no conventional atherosclerotic risk factors, and has emerged as an important cause of ACS, and sudden death. A comparison between ACPD and SCAD has not been previously addressed in the literature. Our study will compare ACPD and SCAD. METHODS: Patients with confirmed diagnosis of SCAD and ACPD were retrospectively identified from 30 centers in 4 Arab Gulf countries between January 2011 and December 2017. In-hospital (ventricular tachycardia/ventricular fibrillation, myocardial infarction (MI), percutaneous coronary intervention, dissection extension, cardiogenic shock, death, implantable cardioverter-defibrillator placement) and follow-up (MI, de novo SCAD, spontaneous superior mesenteric artery dissection, death) events were compared between them. RESULTS: Eighty-three cases of SCAD and 48 ACPD were compared. ACPD patients were more frequently male (91.67% vs. 49.40%, P < 0.001) and older (58.5 vs. 44, P < 0.001). Cardiovascular risk factors were more prevalent in patients with ACPD, including diabetes mellitus (60.4% vs. 25.3%), dyslipidemia (62.5% vs. 38.5%), and hypertension (62.5% vs. 31.3%), P < 0.001. Hospital presentation of ST-elevation MI was diagnosed in 48% of SCAD versus 27% of ACPD patients (P = 0.012). SCAD patients received medical-only treatment in 40% of cases and ACPD in 21% (P = 0.042). In-hospital and follow-up events were comparable in both groups (P = 0.25). CONCLUSIONS: Despite a completely different pathophysiology of ACS between SCAD and ACPD, in-hospital and follow-up events were comparable.

Cardiac resynchronization therapy in patients with postero-lateral scar by cardiac magnetic resonance: A systematic review and meta-analysis.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure, but up to one third of patients may not respond to CRT. A transmural postero-lateral (TMPL) wall scar in the left ventricle (LV) or over the LV pacing site may attenuate clinical and echocardiographic response to CRT. METHODS AND RESULTS: We systematically searched PubMed, EMBASE, and Cochrane databases for studies examining the association between Cardiac magnetic resonance (CMR)-determined postero-lateral or LV pacing site scar and clinical and echocardiographic response to CRT. Eleven prospective studies were included. The presence of TMPL scar on pre-implant CMR was associated with a 75% lower chance of echocardiographic response to CRT, and a similarly lower chance of clinical response. Significant scar over LV pacing site on pre-implant CMR was also associated with a 46% lower chance of echocardiographic response to CRT, and a 67% lower chance of clinical response. CONCLUSIONS: The presence of transmural postero-lateral scar or significant scar within the LV pacing site detected by pre-implant CMR is associated with a lower rate of clinical or echocardiographic response to CRT.

Test ordering for preventive health care among family medicine residents.

OBJECTIVE: To determine which screening tests family medicine residents order as part of preventive health care. DESIGN: A cross-sectional survey. SETTING: Alberta and Ontario. PARTICIPANTS: First- and second-year family medicine residents at the University of Alberta in Edmonton, the University of Calgary in Alberta, and McMaster University in Hamilton, Ont, during the 2011 to 2012 academic year. MAIN OUTCOME MEASURES: Demographic information, Likert scale ratings assessing ordering attitudes, and selections from a list of 38 possible tests that could be ordered for preventive health care for sample 38-year-old and 55-year-old female and male patients. Descriptive and comparative statistics were calculated. RESULTS: A total of 318 of 482 residents (66%) completed the survey. Recommended or appropriate tests were ordered by 82% (for cervical cytology) to 95% (for fasting glucose measurement) of residents. Across the different sample patients, residents ordered an average of 3.3 to 5.7 inappropriate tests per patient, with 58% to 92% ordering at least 1 inappropriate test per patient. The estimated average excess costs varied from $38.39 for the 38-year-old man to $106.46 for the 55-year-old woman. More regular use of a periodic health examination screening template did not improve ordering (P = .88). CONCLUSION: In general, residents ordered appropriate preventive health tests reasonably well but also ordered an average of 3.3 to 5.7 inappropriate tests for each patient. Training programs need to provide better education for trainees around inappropriate screening and work hard to establish good ordering behaviour in preparation for entering practice.

Bacterially synthesized folate and supplemental folic acid are absorbed across the large intestine of piglets.

A large pool of folate exists in the large intestine of humans. Preliminary evidence, primarily in vitro, suggests that this folate may be bioavailable. The purpose of this study was to test the hypothesis that supplemental folic acid and bacterially synthesized folate are absorbed across the large intestine of piglets. The pig was used as an animal model because it resembles the human in terms of folate absorption, at least in the small intestine. A tracer of [3H]-folic acid or [3H]-para-aminobenzoic acid ([3H]-PABA), a precursor of bacterially synthesized folate, was injected into the cecum of 11-day-old piglets. Feces and urine were collected for 3 days. Thereafter, piglets were killed, and livers and kidneys harvested. [3H]-Folate was isolated from biological samples by affinity chromatography using immobilized milk folate binding proteins and counted using a scintillation counter. In piglets injected with [3H]-folic acid, the feces, liver, urine and kidneys accounted for 82.1%, 12.3%, 3.9% and 1.7% of recovered [3H]-folate, respectively. In piglets injected with [3H]-PABA, the amount of recovered bacterially synthesized folate in the feces, liver and urine was 85.1%, 0.4% and 14.6%, respectively. Twenty-three percent and 13% of tritium were recovered in samples examined (liver, kidney, fecal and urine) from piglets injected with [3H]-folic acid and [3H]-PABA, respectively. Using our estimates of [3H]-folic acid absorption and the total and percent monoglutamyl folate content of piglet feces, we predict that at least 18% of the dietary folate requirement for the piglet could be met by folate absorption across the large intestine.