Assuntos
Doença das Coronárias/tratamento farmacológico , Doença das Coronárias/cirurgia , Inibidores da Agregação Plaquetária/uso terapêutico , Stents , Aspirina/uso terapêutico , Doença das Coronárias/economia , Quimioterapia Combinada , Humanos , Inibidores da Agregação Plaquetária/economia , Ticlopidina/uso terapêuticoRESUMO
Coronary perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention. The use of both atheroablative technologies for coronary intervention and adjunctive platelet glycoprotein blockade pharmacology may increase the incidence of or risk for life-threatening bleeding complications following the occurrence of coronary artery perforation. The interventional database for 6,214 percutaneous coronary interventions performed between January 1995 and June 1999 was analyzed. Hospital charts and cine angiograms for all patients identified in the database as having had coronary perforation were reviewed. Coronary perforation complicated 0.58% of all procedures and was more commonly observed in patients with a history of congestive heart failure and following use of atheroablative interventional technologies (2.8%). There was no association of abciximab therapy with either the incidence of or classification for coronary perforation. Adverse clinical outcomes (death, emergency surgical exploration) were related to the angiographic classification of perforation and were more frequently observed in patients who experienced a class 3 coronary perforation. These data suggest that specific clinical and procedural demographic factors are associated with the occurrence and severity of angiographic coronary perforation. An angiographic perforation class-specific algorithm for treatment of coronary perforation is proposed.
Assuntos
Algoritmos , Angioplastia Coronária com Balão/instrumentação , Angioplastia a Laser/instrumentação , Anticorpos Monoclonais/efeitos adversos , Aterectomia Coronária/instrumentação , Doença das Coronárias/terapia , Vasos Coronários/lesões , Traumatismos Cardíacos/terapia , Hemorragia/induzido quimicamente , Fragmentos Fab das Imunoglobulinas/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Stents , Abciximab , Idoso , Anticorpos Monoclonais/administração & dosagem , Cineangiografia , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Feminino , Traumatismos Cardíacos/diagnóstico por imagem , Hemorragia/diagnóstico por imagem , Hemorragia/terapia , Humanos , Fragmentos Fab das Imunoglobulinas/administração & dosagem , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/administração & dosagem , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Despite proved efficacy for either dalteparin or platelet glycoprotein IIb/IIIa blockade in improving clinical outcomes of patients with non-ST-segment elevation acute coronary syndromes, algorithms guiding concomitant therapy with these agents have not been devised. The purpose of this study was to assess anticoagulant effect and clinical safety for several dose regimens of dalteparin administered in combination with abciximab during percutaneous coronary intervention (PCI). METHODS AND RESULTS: Patients undergoing PCI with standard dose abciximab received dalteparin as follows: 120 IU/kg subcutaneously (SQ) to a maximum of 10,000 U if < or =8 hours before PCI (n = 3); for PCI 8-12 hours after the SQ dose, an additional 40 IU/kg intravenously (IV) was administered (n = 1); for PCI >12 hours after SQ dalteparin or with no prior dalteparin therapy, random allocation to 40 (n = 27) or 60 (n = 28) IU/kg IV during PCI was performed. Those patients who received 60 IU/kg of dalteparin IV had a lower incidence of procedural thrombosis (0% vs 11.1%, P <.01), more consistent antithrombotic effect (anti-factor Xa activity) and a similar incidence of major bleeding (3.7% vs 2.6%) compared with patients who received 40 IU/kg of intravenous dalteparin. CONCLUSIONS: Dalteparin 60 IU/kg IV appears to be safe and effective when administered in conjunction with abciximab for percutaneous coronary intervention.
Assuntos
Angioplastia Coronária com Balão , Anticorpos Monoclonais/uso terapêutico , Dalteparina/uso terapêutico , Fibrinolíticos/uso terapêutico , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Abciximab , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos PilotoRESUMO
BACKGROUND: Placebo-controlled randomized trials of platelet glycoprotein (GP) IIb/IIIa blockade during percutaneous coronary intervention have demonstrated efficacy of these agents for reducing the risk of periprocedural ischemic events. However, cost-effectiveness of this adjunctive pharmacotherapy has been scrutinized. Extrapolation of cost-efficacy observations from clinical trials to "real world" interventional practice is problematic. METHODS: Consecutive percutaneous coronary interventions (n = 1472) performed by Ohio Heart Health Center operators at The Christ Hospital, Cincinnati, Ohio, in 1997 were analyzed for procedural and long-term (6-month) outcomes and charges. Observations on cost and efficacy (survival) were adjusted for nonrandomized abciximab allocation by means of "propensity scoring" methods. RESULTS: Abciximab therapy was associated with a survival advantage to 6 months after percutaneous coronary intervention. The average reduction in mortality rate at 6 months was 3.4% (unadjusted) and 4.9% when adjusted for nonrandomization. The average charge increment to 6 months was $1512 (unadjusted) and $950 when adjusted for nonrandomization. Patients deriving the greatest reduction in mortality rates also had a reduction in total cardiovascular charges to 6 months. Distinguishing demographics of this population included multivessel coronary intervention, coronary stent deployment, intervention within 1 week of myocardial infarction, and lower left ventricular ejection fraction. The average cost per life-year gained in this study was $2875 for all patients (unadjusted) and $1243 when adjusted for nonrandomization. CONCLUSIONS: Abciximab provides a cost-effective survival advantage in high-volume interventional practice that compares favorably with currently accepted standards. Clinical and procedural demographics associated with increased cost-effectiveness included multivessel coronary intervention, stent deployment, recent (<1 week) myocardial infarction, and impaired left ventricular function.
Assuntos
Angioplastia Coronária com Balão/mortalidade , Anticorpos Monoclonais/economia , Doença das Coronárias/economia , Fragmentos Fab das Imunoglobulinas/economia , Inibidores da Agregação Plaquetária/economia , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Abciximab , Anticorpos Monoclonais/uso terapêutico , Doença das Coronárias/mortalidade , Doença das Coronárias/terapia , Análise Custo-Benefício , Feminino , Humanos , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Prognóstico , Taxa de Sobrevida/tendênciasRESUMO
Platelet glycoprotein (GP) IIb/IIIa receptor blockade improves clinical outcomes after percutaneous coronary intervention (PCI) and for patients who present with non-ST-segment elevation acute coronary syndromes. Although this class of therapeutic agents has been defined by a common affinity for the platelet GP IIb/IIIa receptor, the 3 currently available agents differ markedly in pharmacodynamic and pharmacokinetic profile as well as receptor affinity. Differential (separate) binding sites on the GP IIb/IIIa receptor explain the observation that abciximab binding to platelets is not influenced by either tirofiban or eptifibatide. Abciximab (ReoPro, chimeric 7E3 Fab) is a low K(d) (high affinity) agent with a very short plasma t(1/2) and a prolonged duration of action at the platelet target receptor. Eptifibatide and tirofiban are high K(d) (low affinity) agents with a relatively long plasma t(1/2) and short duration of action at the platelet target receptor. These pharmacodynamic differences underlie the phenomena of gradual redistribution in abciximab binding and smooth tapering of abciximab antiplatelet effect after discontinuation of therapy. Furthermore, abciximab demonstrates affinity for both the CD11b/18 (alpha(m)beta(2) or MAC 1) and alpha(V)beta(3) (vitronectin) receptors. Although a survival advantage in favor of abciximab has been observed after PCI in both randomized controlled trials and high-volume clinical practice, no survival benefit has been observed to date after eptifibatide or tirofiban therapy for PCI. The mechanism of survival advantage after abciximab therapy has not been defined but may be distinct from the degree of platelet GP IIb/IIIa receptor inhibition during the duration of intravenous treatment. Although this important new "class" of therapeutic agent was simplistically defined by a common affinity for the GP IIb/IIIa receptor, this solitary unifying attribute may not define agent-specific benefit.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Abciximab , Anticorpos Monoclonais/farmacologia , Eptifibatida , Humanos , Fragmentos Fab das Imunoglobulinas/farmacologia , Peptídeos/farmacologia , Peptídeos/uso terapêutico , Agregação Plaquetária/efeitos dos fármacos , Inibidores da Agregação Plaquetária/farmacologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Tirofibana , Tirosina/análogos & derivados , Tirosina/farmacologia , VitronectinaAssuntos
Angioplastia Coronária com Balão/métodos , Anticorpos Monoclonais/uso terapêutico , Ponte de Artéria Coronária/efeitos adversos , Enoxaparina/uso terapêutico , Oclusão de Enxerto Vascular/terapia , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Abciximab , Idoso , Terapia Combinada , Angiografia Coronária , Ponte de Artéria Coronária/métodos , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Relação Dose-Resposta a Droga , Esquema de Medicação , Quimioterapia Combinada , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Infusões Intravenosas , Masculino , Índice de Gravidade de Doença , Resultado do Tratamento , Grau de Desobstrução VascularAssuntos
Angioplastia Coronária com Balão , Anticorpos Monoclonais/efeitos adversos , Hemorragia/induzido quimicamente , Fragmentos Fab das Imunoglobulinas/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Doenças Vasculares/induzido quimicamente , Abciximab , Anticorpos Monoclonais/uso terapêutico , Cateteres de Demora/efeitos adversos , Humanos , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Fatores de Risco , Doenças Vasculares/etiologiaRESUMO
Early coronary intervention in patients with non-ST-segment elevation myocardial infarction (MI) and unstable angina may be made safer and more efficacious with concomitant therapies, including glycoprotein IIb/IIIa inhibitors and low-molecular-weight heparins. Stent placement has been shown to improve procedural success and reduce major in-hospital complications when compared with balloon angioplasty alone in patients with unstable angina. However, unstable angina remains a major hazard for adverse coronary events in long-term follow-up after elective stent placement. The currently available glycoprotein IIb/IIIa inhibitors-eptifibatide, tirofiban, and abciximab--have each been shown to reduce ischemic events before percutaneous coronary intervention when administered to patients presenting with non-ST-segment elevation acute coronary syndromes in large clinical trials. The adjunctive role of low-molecular-weight heparins in this scenario has been largely unexplored. Enoxaparin, when given before angiography or percutaneous coronary intervention, has been shown to be superior to unfractionated heparin in preventing major coronary events. In this review, an algorithm for treatment of non-ST-segment elevation acute coronary syndromes is presented and the current role of these newer adjunctive pharmacotherapies is explored. In the future, combinations of these agents may prove to be most beneficial in patients undergoing early percutaneous coronary intervention.
Assuntos
Angina Instável/terapia , Angioplastia Coronária com Balão , Infarto do Miocárdio/terapia , Terapia Trombolítica , Abciximab , Algoritmos , Angina Instável/tratamento farmacológico , Anticorpos Monoclonais/uso terapêutico , Anticoagulantes/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , SíndromeRESUMO
BACKGROUND: Coronary artery bypass surgery (CABG) has been considered the therapy of choice for patients with unprotected left main (ULMT) coronary stenoses. Selected single-center reports suggest that the results of percutaneous intervention may now approach those of CABG. METHODS AND RESULTS: To assess the results of percutaneous ULMT treatment from a wide variety of experienced interventional centers, we requested data on consecutive patients treated after January 1, 1994, from 25 centers. One hundred seven patients were identified who were treated either electively (n=91) or for acute myocardial infarction (n=16). Of patients treated electively, 25% were considered inoperable, and 27% were considered high risk for bypass surgery. Primary treatment included stents (50%), directional atherectomy (24%), and balloon angioplasty (20%). Follow-up was 98.8% complete at 15+/-8 months. Results varied considerably, depending on presentation and treatment. For patients with acute myocardial infarction, technical success was achieved in 75%, and survival to hospital discharge was 31%. For elective patients, technical success was achieved in 98.9%, and in-hospital survival was strongly correlated with left ventricular ejection fraction (P=.003). Longer-term event (death, infarction, or bypass surgery) -free survival was correlated with ejection fraction (P<.001) and was inversely related to presentation with progressive or rest angina (P<.001). Surgical candidates with ejection fractions > or = 40% had an in-hospital survival of 98% and a 9-month event-free survival of 86+/-5%, whereas patients with ejection fractions < 40% had 67% and 22+/-12% in-hospital and 9-month event-free survivals, respectively. Nine hospital survivors (10.6%) experienced cardiac death within 6 months of hospital discharge. CONCLUSIONS: While results for selected patients appear promising, until early post-hospital discharge cardiac death can be better understood and minimized, percutaneous revascularization of ULMT stenosis should not be considered an alternative to bypass surgery for most patients. When percutaneous revascularization of ULMT is required, directional atherectomy and stenting appear to be the preferred techniques, and follow-up angiography 6 to 8 weeks after treatment is probably advisable.
Assuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Idoso , Angioplastia Coronária com Balão/métodos , Aterectomia Coronária , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Stents , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVES: We attempted to determine the relative risks and benefits of percutaneous transluminal coronary angioplasty (PTCA) and repeat coronary artery bypass grafting (re-CABG) in patients with previous coronary bypass surgery (CABG). BACKGROUND: Due to an expanding population of patients with surgically treated coronary artery disease and the natural progression of atherosclerosis, an increasing number of patients with previous CABG require repeat revascularization procedures. Although there are randomized comparative data for CABG versus medical therapy and, more recently, versus PTCA, these studies have excluded patients with previous CABG. METHODS: We retrospectively analyzed data from 632 patients with previous CABG who required either elective re-CABG (n = 164) or PTCA (n = 468) at a single center during 1987 through 1988. The PTCA and re-CABG groups were similar with respect to gender (83% vs. 85% male), age > 70 years (21% vs. 23%), mean left ventricular ejection fraction (46% vs. 48%), presence of class III or IV angina (70% vs. 63%) and three-vessel coronary artery disease (77% vs. 74%). RESULTS: Complete revascularization was achieved in 38% of patients with PTCA and 92% of those with re-CABG (p < 0.0001). The in-hospital complication rates were significantly lower in the PTCA group: death (0.3% vs. 7.3%, p < 0.0001) and Q wave myocardial infarction (MI) (0.9% vs. 6.1%, p < 0.0001). Actuarial survival was equivalent at 1 year (PTCA 95% vs. re-CABG 91%) and 6 years (PTCA 74% vs. re-CABG 73%) of follow-up (p = 0.32). Both procedures resulted in equivalent event-free survival (freedom from dealth or Q wave MI) and relief of angina; however, the need for repeat percutaneous or surgical revascularization, or both, by 6 years was significantly higher in the PTCA group (PTCA 64% vs. re-CABG 8%, p < 0.0001). Multivariate analysis identified age > 70 years, left ventricular ejection fraction < 40%, unstable angina, number of diseased vessels and diabetes mellitus as independent correlates of mortality for the entire group. CONCLUSIONS: In this nonrandomized series of patients with previous CABG requiring revascularization, an initial stategy of either PTCA or re-CABG resulted in equivalent overall survival, event-free survival and relief of angina. PTCA offers lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization procedures.
Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Idoso , Angina Pectoris/fisiopatologia , Angina Pectoris/terapia , Estudos de Avaliação como Assunto , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Estudos Longitudinais , Masculino , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
Direct percutaneous transluminal coronary angioplasty (PTCA) has emerged as effective reperfusion therapy for acute myocardial infarction; however, few data exist on its use in octogenarians. Thrombolytic therapy in this age group has reduced early mortality from approximately 30% to 20%, but is associated with an increased risk of stroke and major hemorrhage. We analyzed the acute and long-term results of direct PTCA performed on patients aged > or = 80 years at our institution between 1980 and 1993. The study group consisted of 55 patients (mean patient age 83.3 +/- 2.3 years). Infarcts were anterior in 27 patients (49%). Cardiogenic shock was present in 6 patients (11%). The mean time to reperfusion was 4.3 +/- 2.8 hours. Direct PTCA was successful in 53 patients (96%). There were no emergent bypass operations. In-hospital death occurred in 9 patients (16%), including 4 of 6 (67%) presenting in cardiogenic shock and 5 of 49 (10%) who were hemodynamically stable on presentation. Repeat PTCA for recurrent ischemia was performed in 6 patients (11%). There were no strokes during hospitalization. Bleeding complications requiring blood transfusion were present in 4 patients (7%). Thirty-day mortality was 16% and 1-year actuarial survival was 67%. Direct PTCA in patients aged > or = 80 years can be performed safely with a high procedural success rate. The clinical outcome with PTCA in this high risk subset of patients compares favorably with that reported previously for both thrombolytic and medical therapy.
Assuntos
Angioplastia Coronária com Balão , Infarto do Miocárdio/terapia , Análise Atuarial , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Angioplastia Coronária com Balão/efeitos adversos , Feminino , Humanos , Modelos Logísticos , Masculino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
Balloon angioplasty (PTCA) of left main (LM) stenoses is limited by frequent clinical restenosis. Directional coronary atherectomy (DCA) may be an effective alternative to PTCA due to its ability to achieve a greater postprocedural luminal diameter when treating bulky, eccentric plaques and aorto-ostial lesions. We analyzed the acute and long-term results following 24 DCA procedures in 22 patients with "protected" LM lesions. Acute success (residual stenosis < or = 40%, no major ischemic complications) was 88% overall, 100% in 13 planned procedures, and 73% in 11 adjunctive DCA procedures that followed suboptimal PTCA. Mean LM stenosis was reduced from 86% to 13% (P < 0.01). There were no procedural complications directly attributed to DCA. At a mean of 24 +/- 3 months, the clinical restenosis rate was 16%, survival was 100%, and event-free survival (freedom from death, MI, or repeat lesion-related interventions) was 89%. We conclude that DCA in protected LM lesions (1) can achieved excellent angiographic results with low procedural complication rates, (2) may succeed where PTCA yields suboptimal results, and (3) may provide late clinical outcomes superior to those of balloon angioplasty.
Assuntos
Aterectomia Coronária , Doença das Coronárias/cirurgia , Angioplastia Coronária com Balão , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/epidemiologia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: This study was designed to evaluate the safety and short- and long-term results of coronary angioplasty of totally occluded bypass grafts in patients with clinical conditions other than acute myocardial infarction. BACKGROUND: Total occlusion of bypass grafts after coronary artery surgery often causes recurrent ischemia. The safety and results of percutaneous transluminal coronary angioplasty in occluded bypass grafts are controversial. METHODS: All patients with dilation of a totally occluded bypass graft attempted between 1981 and 1991 were retrospectively identified from a data base. Patients treated in the setting of an acute myocardial infarction were excluded. Eighty-three patients met these criteria and constitute the study group. Hospital records, office charts and procedural reports were reviewed in all patients to supplement details available in the data base. RESULTS: The time from bypass surgery to attempted coronary angioplasty ranged from 1 to 226 months (mean time 88 months). The mean (+/- SD) duration of graft occlusion was 31 +/- 46 days (range 1 to 180). In 27 attempts the bypass graft was the only site dilated, and in 56 attempts (68%) one to six other sites (n = 101) were dilated. Angiographic success (< or = 40% residual lumen stenosis) was achieved in 61 grafts (73%) and 98 of the additional sites (97%) (p < 0.001). Major complications included one procedural death and two Q wave infarctions. Follow-up for a mean of 32 months demonstrated a 1- and 3-year actuarial survival rate of 94% and 80%, respectively. At 3 years, only 34% of patients were free of repeat angioplasty or surgery. CONCLUSIONS: Angioplasty of totally occluded bypass grafts can be successful in the majority of selected patients, although major complications can occur. Strategies for sustained patency are needed to improve the long-term results.
Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária/efeitos adversos , Oclusão de Enxerto Vascular/terapia , Idoso , Idoso de 80 Anos ou mais , Angina Pectoris/terapia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVES: The purpose of this study was to compare the mechanisms, predictors and outcome of patients with failed direct coronary angioplasty of the infarct-related artery with those in patients with successful direct angioplasty. BACKGROUND: Direct coronary angioplasty of the infarct-related artery, without antecedent thrombolytic therapy, is an effective treatment for patients with acute myocardial infarction. Concern has been expressed over high mortality rates in patients with failed direct infarct angioplasty. METHODS: All patients treated by angioplasty were prospectively entered into a computer data base. The characteristics and outcome of all patients with failed direct angioplasty were reviewed and compared with those of patients with successful direct angioplasty. RESULTS: Direct angioplasty was successful in 705 (94%) of 750 patients and unsuccessful in 45 (6%). Patients in the failure group were more likely to be in cardiogenic shock (22% vs. 7%, p < 0.003), to have had a previous myocardial infarction (44% vs. 28%, p < 0.03) and to have three-vessel coronary artery disease (44% vs. 23%, p < 0.003). Age, gender, ejection fraction, previous bypass surgery and diabetes mellitus were similar in both groups. Only the presence of multivessel coronary artery disease (p < 0.004) and cardiogenic shock (p < 0.025) were independent predictors of failed direct angioplasty. In-hospital death (31% vs. 4.8%, p < 0.001) and the need for emergency coronary artery bypass surgery (27% vs. 0.5%, p < 0.0001) were more frequent in patients with unsuccessful than in patients with successful direct angioplasty. Patients with failed direct angioplasty and in-hospital death usually had multiple high risk characteristics, including cardiogenic shock (50%), previous myocardial infarction (43%) and multivessel coronary artery disease (93%). CONCLUSIONS: Direct coronary angioplasty is an effective method for establishing reperfusion in acute myocardial infarction. Procedural failure is infrequent, usually occurring in patients with high risk baseline characteristics.
Assuntos
Angioplastia Coronária com Balão , Mortalidade Hospitalar , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão/métodos , Angioplastia Coronária com Balão/mortalidade , Angioplastia Coronária com Balão/estatística & dados numéricos , Causas de Morte , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Missouri/epidemiologia , Prognóstico , Estudos Prospectivos , Falha de Tratamento , Resultado do TratamentoAssuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Idoso , Doença das Coronárias/patologia , Doença das Coronárias/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Fatores de Risco , Fatores Sexuais , Resultado do TratamentoRESUMO
To assess the changes in myocardial function following direct coronary angioplasty, we evaluated 323 consecutive patients undergoing coronary angioplasty without antecedent thrombolytic therapy for acute myocardial infarction. Left ventricular function was evaluated using contrast ventriculography immediately preangioplasty and at the time of predismissal follow-up angiography (a mean of 7 days after infarction). The global ejection fraction increased from 52.6% to 58.9% (p less than 0.0005). Multivariate correlates of improved global left ventricular function included baseline ejection fraction less than or equal to 45%, and a patent infarct vessel at the time of predischarge follow-up angiography. Systolic function in the infarct zone improved by a mean of 30%. Logistic regression analysis identified sustained infarct vessel patency and anterior myocardial infarction as multivariate correlates of improved regional function in the infarct zone. In patients presenting with baseline ejection fractions less than or equal to 40%, the mean ejection fraction increased from 28% to 42%. Long-term survival was compromised in patients with global ejection fractions of less than or equal to 40% at the time of dismissal. Thus significant improvement in left ventricular function can be expected in the majority of patients undergoing direct infarct angioplasty. The myocardial salvage appears to be most significant in patients suffering large infarctions, and in those with sustained infarct vessel patency.
Assuntos
Angioplastia Coronária com Balão/métodos , Infarto do Miocárdio/terapia , Função Ventricular Esquerda , Idoso , Feminino , Seguimentos , Imagem do Acúmulo Cardíaco de Comporta , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Recidiva , Volume Sistólico , Taxa de Sobrevida , Fatores de Tempo , Grau de Desobstrução VascularRESUMO
The risks and long-term outcome after 845 elective percutaneous transluminal coronary angioplasties (PTCA) in patients with left ventricular (LV) dysfunction (ejection fraction less than or equal to 40%) were examined. Procedural results were compared with 8,117 consecutive procedures in patients with ejection fractions greater than 40%. The patients with LV dysfunction were older (63 vs 60 years, p less than 0.01), had a greater incidence of prior myocardial infarction (84 vs 45%, p less than 0.001), prior bypass surgery (39 vs 21%, p less than 0.001), 3-vessel disease (62 vs 33%, p less than 0.001), and class IV angina (48 vs 41%, p less than 0.01) than the control group. Angiographic success was lower (93 vs 95%, p less than 0.01), and overall procedural mortality was increased ( 4 vs 1%, p less than 0.001) in the study group. Emergency surgery rates were identical (2%). No significant difference was found in rates of nonfatal Q-wave myocardial infarction (2 vs 1%). At mean follow-up of 33.5 months, 15% of the patients with LV dysfunction required late bypass surgery, 27% underwent repeat PTCA, and 59% were angina free. Actuarial survival at 1 and 4 years was 87 and 69%, respectively. Cox regression analysis identified 3-vessel disease, age greater than or equal to 70 years, class IV angina and incomplete revascularization as correlates of long-term mortality. These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with LV dysfunction.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Doença das Coronárias/terapia , Função Ventricular Esquerda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão/mortalidade , Doença das Coronárias/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Análise de Regressão , Volume Sistólico , Taxa de SobrevidaRESUMO
Between 1981 and 1990, 1,373 patients, aged greater than or equal to 65 years (mean 71.2 +/- 4.9), underwent 1,640 multivessel percutaneous transluminal coronary angioplasty (PTCA) procedures. Of these, 224 patients (13.6%) had a left ventricular ejection fraction less than or equal to 40%, 412 (25.1%) had prior coronary artery bypass grafting (CABG) and 48 (2.9%) had left main artery dilatation. Of the 1,640 PTCA procedures, 697 were in patients with 2-vessel disease and 943 were in patients with 3-vessel disease. A mean 3.5 lesions were dilated per patient, with an overall angiographic success rate of 96%. Complete revascularization was achieved in 857 (52%). A total of 52 patients (3.2%) had a major in-hospital complication: 27 patients (1.6%) died, 24 (1.4%) had a Q-wave myocardial infarction, and 14 (0.8%) underwent emergent CABG. Stepwise logistic regression analysis identified ejection fraction less than or equal to 40% (p less than or equal to 0.001), 3-vessel disease (p less than or equal to 0.01), female gender (p less than or equal to 0.02), and PTCA between 1981 and 1985 (p less than or equal to 0.05) as independent predictors of mortality. Of the 1,373 patients, 1,023 have been followed for greater than or equal to 1 year (mean follow-up 32.5 +/- 21.3 months). There were 156 (15.2%) late deaths, 81 (7.9%) recurrent myocardial infarctions, and 162 (15.8%) coronary artery bypass operations. Actuarial survival, computed from the time of hospital discharge, was 92% at 1 year, 86% at 3 years and 78% at 5 years. Repeat PTCA was required in 371 patients (36.3%).(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão/efeitos adversos , Ponte de Artéria Coronária , Circulação Coronária , Doença das Coronárias/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Análise Multivariada , PrognósticoRESUMO
To assess the safety of direct infarct angioplasty without antecedent thrombolytic therapy, catheterization laboratory and hospital events were assessed in consecutively treated patients with infarctions involving the left anterior descending (n = 100 patients), right (n = 100), and circumflex (n = 50) coronary arteries. The groups of patients were similar for age (left anterior descending coronary artery, 59 years; right coronary artery, 58 years; circumflex coronary artery, 62 years), patients with multivessel disease (left anterior descending coronary artery, 55%; right coronary artery, 55%; circumflex coronary artery, 64%), and patients with initial grade 0/1 antegrade flow (left anterior descending coronary artery, 79%; right coronary artery, 84%; circumflex coronary artery, 90%). Cardiogenic shock was present in eight patients with infarction of the left anterior descending coronary artery, four with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery. Major catheterization laboratory events (cardioversion, cardiopulmonary resuscitation, dopamine or intra-aortic balloon pump support for hypotension, and urgent surgery) occurred in 10 patients with infarction of the left anterior descending coronary artery, eight with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery (16 of 16 shock and six of 234 nonshock patients, p less than 0.001). There was one in-laboratory death (shock patient with infarction of the left anterior descending coronary artery).(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Infarto do Miocárdio/terapia , Angioplastia Coronária com Balão/métodos , Arritmias Cardíacas/etiologia , Estudos de Avaliação como Assunto , Humanos , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Choque Cardiogênico/etiologia , Análise de SobrevidaRESUMO
The effect of early myocardial reperfusion on patterns of death after acute myocardial infarction (AMI) is unknown. Thus, the mechanism and timing of in-hospital and late deaths among a group of 614 patients treated with coronary angioplasty without antecedent thrombolytic therapy for AMI were determined. Death occurred in 49 patients (8%) before hospital discharge. Four patients died in the catheterization laboratory. Death was due to cardiogenic shock in 22 patients, acute vessel reclosure in 5 patients, was sudden in 8 patients and followed elective coronary artery bypass surgery in 8 patients. Cardiac rupture was observed in only 2 patients after failed infarct angioplasty, and did not occur among the 574 patients with successful infarct reperfusion. Intracranial hemorrhage did not occur. Multivariate predictors of in-hospital death included failed infarct angioplasty, cardiogenic shock, 3-vessel coronary artery disease and age greater than or equal to 70 years. During a follow-up period of 32 +/- 21 months (range 1 to 87), 55 patients died. The cause of death was cardiac in 36 patients, including an arrhythmic death in 23 patients and was due to circulatory failure in 13 others. One patient died of reinfarction due to late reclosure of the infarct artery. Actuarial survival curves demonstrated overall survival after hospital discharge of 95 and 87% at 1 and 4 years, respectively. Freedom from cardiac death at 1 and 4 years was 96 and 92%. Multivariate predictors of late death included 3-vessel disease, a baseline ejection fraction of less than or equal to 40%, age greater than 70 years and female gender.(ABSTRACT TRUNCATED AT 250 WORDS)