RESUMEN
Coronary stents reduce the rates of abrupt closure, emergency coronary artery bypass graft surgery and restenosis, but do not prevent myocardial infarction or death at six months. The financial burden of increased stent use and the difficulty in managing in-stent restenosis have provided the impetus to develop provisional stenting strategies. Patients at low risk for restenosis after balloon angioplasty may not derive additional benefit from stent implantation and may be successfully managed with percutaneous transluminal coronary angioplasty (PTCA) alone. Numerous patient, lesion and procedural predictors of restenosis have been identified. Postprocedural assessment using quantitative coronary angiography, intravascular ultrasound (IVUS), coronary flow velocity reserve (CVR) or fractional flow reserve (FFR) may further enhance the ability to predict adverse outcomes after PTCA. Several studies have been performed to investigate the feasibility of provisional stenting strategies using various modalities to identify low risk patients who could be managed with PTCA alone. An optimal or "stent-like" angiographic result after PTCA is associated with favorable clinical outcomes. Preliminary results of studies using IVUS or CVR to guide provisional stenting appear promising. Angiography alone may be inadequate to identify truly low risk patients and may need to be combined with clinical factors, assessment of recoil, IVUS or physiologic indexes. Strategies that avoid unnecessary stenting in even a small proportion of patients may have large impacts on health care costs. Provisional stenting may potentially reduce costs and rates of in-stent restenosis without compromising the quality of health care delivery.
Asunto(s)
Implantación de Prótesis Vascular , Enfermedad Coronaria/cirugía , Toma de Decisiones , Stents , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/economía , Oclusión de Injerto Vascular/diagnóstico , Oclusión de Injerto Vascular/economía , Oclusión de Injerto Vascular/prevención & control , Costos de la Atención en Salud , Humanos , Selección de Paciente , Diseño de Prótesis , Ultrasonografía IntervencionalRESUMEN
OBJECTIVES: To predict which patients might not require stent implantation, we identified clinical and angiographic characteristics associated with repeat revascularization after standard balloon angioplasty. BACKGROUND: Stents reduce the risk of repeat revascularization but are costly and may lead to in-stent restenosis, which remains difficult to treat. Identification of patients at low risk for repeat revascularization may allow clinicians to reserve stents for patients most likely to benefit. METHODS: Data from five interventional trials (5,146 patients) were pooled for analysis. We identified patients with optimal angiographic results (final diameter stenosis < or =30% and no dissection) after balloon angioplasty and determined the multivariable predictors of repeat revascularization. RESULTS: Optimal angiographic results were achieved in 18% of patients after angioplasty. The repeat revascularization rate at six months was lower for patients with optimal results (20% vs. 26%, p < 0.001) but still higher than observed in stent trials. Independent predictors of repeat revascularization were female gender (odds ratio [OR] 1.67, p = 0.01), lesion length > or =10 mm (OR 1.62, p = 0.03) and proximal left anterior descending coronary artery lesions (OR 1.62, p = 0.03). For the 8% of patients with optimal angiographic results and none of these risk factors, the repeat revascularization and target vessel revascularization rates were 14% and 8% respectively, similar to rates after stent implantation. Cost analysis estimated that $78 million per year might be saved in the U.S. with a provisional stenting strategy using these criteria compared with elective stenting. CONCLUSIONS: A combination of baseline characteristics and angiographic results can be used to identify a small group of patients at very low risk for repeat revascularization after balloon angioplasty. Provisional stenting for these low risk patients could substantially reduce costs without compromising clinical outcomes.
Asunto(s)
Angioplastia de Balón , Enfermedad Coronaria/terapia , Angioplastia de Balón/economía , Enfermedad Coronaria/economía , Costos y Análisis de Costo , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , StentsRESUMEN
Among 214 patients treated with abciximab within 24 hours of full-dose thrombolytic therapy, major bleeding occurred in 50 patients (23%; 95% confidence interval [CI] 18% to 30%) and intracranial hemorrhage occurred in 3 patients (1.4%; 95% CI 0.3% to 4%). The independent multivariate predictors of major bleeding were age (odds ratio [OR] 1.53/10 years, 95% CI 1.05 to 2.21, p = 0.03), time from thrombolytic to abciximab (OR 0.91/hour, 95% CI 0.83 to 0.99, p = 0.03), and intra-aortic balloon pump insertion (OR 4.42, 95% CI 2.00 to 9.72, p = 0.0002).
Asunto(s)
Anticuerpos Monoclonales/efectos adversos , Hemorragia/inducido químicamente , Fragmentos Fab de Inmunoglobulinas/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Abciximab , Anciano , Angioplastia , Anticuerpos Monoclonales/uso terapéutico , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Fragmentos Fab de Inmunoglobulinas/uso terapéutico , Modelos Logísticos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Infarto del Miocardio/cirugía , Isquemia Miocárdica/etiología , Isquemia Miocárdica/prevención & control , Inhibidores de Agregación Plaquetaria/uso terapéutico , Proteínas Recombinantes/uso terapéutico , Factores de Riesgo , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Insuficiencia del TratamientoRESUMEN
A retrospective study of adults with Eisenmenger syndrome assessed at a tertiary referral center was performed to identify clinical characteristics and establish prognostic determinants. Mortality and cause of death are reported with baseline clinical data correlated with mortality to identify predictors of death. Clinical events during follow-up, including heart failure, atrial arrhythmia, hemoptysis, and syncope were also reviewed. A total of 109 adults with Eisenmenger syndrome (mean +/- SD age 29 +/- 11 years, 43% men) were followed for a median of 6.3 years. Sixty-six patients (61%) had simple cardiac anatomy (13 atrial septal defect, 43 ventricular septal defect, 10 patent ductus arteriosus). The remainder (43 patients) had complex cardiac anatomy (including atrioventricular septal defect, truncus arteriosus, univentricular heart, and transposition of the great arteries). There were 33 deaths and 9 transplantations during follow-up. Median survival was 53 years. Multivariate Cox regression analysis identified age at presentation (hazard ratio [HR] 0.90), supraventricular arrhythmia (HR 3.44), precordial electrocardiogram voltage (HR 1.61/mV increase), and poor New York Heart Association functional class (HR 2.60) as independent predictors of mortality. There is a large variation in the life expectancy for adults with Eisenmenger syndrome. Baseline characteristics associated with increased mortality include younger age at presentation (associated with complex anatomy), functional class, supraventricular arrhythmia, and an electrocardiogram index for right ventricular hypertrophy.
Asunto(s)
Causas de Muerte , Complejo de Eisenmenger/mortalidad , Adulto , Complejo de Eisenmenger/diagnóstico , Complejo de Eisenmenger/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
Fabry's disease is a rare cause of cardiomyopathy. There are no previous reported cases of cardiac transplantation for end-stage cardiomyopathy secondary to Fabry's disease. Recurrence of disease in allografts following renal transplantation has been documented, but the course following heart transplantation is not known. A 53-year-old female presented with congestive heart failure and was found to have end-stage restrictive cardiomyopathy secondary to Fabry's disease, as diagnosed by endomyocardial biopsy. She underwent cardiac transplantation. Eight weeks post-transplantation, electron microscopy of an endomyocardial biopsy specimen showed concentric lamellar inclusions within myocytes similar to inclusions seen in the preoperative biopsy and the explanted heart. However, subsequent biopsies up to one year after heart transplantation did not show any such inclusions. There has been no clinical evidence of Fabry's cardiomyopathy. Heart transplantation is a viable option for end-stage Fabry's cardiomyopathy. However, long term follow-up is required to determine clinical outcome.
Asunto(s)
Enfermedad de Fabry/cirugía , Trasplante de Corazón , Enfermedad de Fabry/complicaciones , Enfermedad de Fabry/patología , Femenino , Insuficiencia Cardíaca/etiología , Humanos , Persona de Mediana EdadRESUMEN
Despite significant advances in the treatment of myocardial infarction, morbidity and mortality rates remain high. Recently completed, large, randomized trials have evaluated new therapeutic strategies for the management of ST-segment elevation acute myocardial infarction. Third generation fibrinolytic agents may offer advantages over conventional agents, such as more rapid, complete, and sustained reperfusion and greater ease of administration. However, no survival benefit has been observed. Direct thrombin inhibitors and low-molecular-weight heparins are being compared with unfractionated heparin as adjuncts to fibrinolytic therapy, and preliminary data suggest that these agents provide some clinical benefit when combined with streptokinase. More potent antiplatelet agents, such as the glycoprotein IIb/IIIa antagonists, may replace aspirin if they can be safely combined with fibrinolytic agents. These strategies are being tested in ongoing trials. Finally, agents such as adenosine and F2G may prevent reperfusion injury and improve myocardial salvage. The results of these trials have expanded our armamentarium of pharmacotherapy and should lead to improved clinical outcomes after acute myocardial infarction.
Asunto(s)
Fibrinolíticos/administración & dosificación , Infarto del Miocardio/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Animales , Quimioterapia Adyuvante , Ensayos Clínicos como Asunto , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Humanos , Masculino , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Pronóstico , Proteínas Recombinantes/uso terapéutico , Daño por Reperfusión/prevención & control , Tasa de Supervivencia , Resultado del TratamientoAsunto(s)
Causas de Muerte , Electrocardiografía , Mortalidad Hospitalaria/tendencias , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/terapia , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón/mortalidad , Colombia Británica , Urgencias Médicas , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/tendencias , Femenino , Hospitales Comunitarios , Humanos , Masculino , Infarto del Miocardio/mortalidad , Medición de Riesgo , Análisis de Supervivencia , Terapia Trombolítica/métodos , Terapia Trombolítica/mortalidad , Factores de TiempoRESUMEN
Orgaran, a heparinoid, has been used successfully in patients with heparin-induced thrombocytopenia. We report three cases in which Orgaran was combined with the glycoprotein IIbIIa receptor antagonist Reopro during coronary angioplasty. Orgaran was given as a single intravenous bolus of 1500 anti-factor Xa units. No ischemic or hemorrhagic complications occurred during or following the procedure.
Asunto(s)
Angioplastia Coronaria con Balón , Anticuerpos Monoclonales/uso terapéutico , Anticoagulantes/uso terapéutico , Sulfatos de Condroitina/uso terapéutico , Enfermedad Coronaria/terapia , Dermatán Sulfato/uso terapéutico , Heparinoides/uso terapéutico , Heparitina Sulfato/uso terapéutico , Fragmentos Fab de Inmunoglobulinas/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Abciximab , Adulto , Anciano , Quimioterapia Combinada , Femenino , Heparina/uso terapéutico , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Coronary stent deployment failure may be more common in clinical practice than generally appreciated. The incidence of failed deployment in routine clinical practice and the clinical sequelae have not been described. This study sought to determine the incidence and consequences of failed coronary stent deployment and to identify clinical and angiographic characteristics associated with deployment failure. METHODS AND RESULTS: A series of 1303 consecutive procedures involving attempted coronary stenting were reviewed retrospectively. Failed stent deployment was defined as failure of the stent to be either delivered to or adequately deployed at the target lesion site. Clinical records and angiograms were reviewed and qualitative coronary angiography was performed for all cases of failed deployment. Deployment was unsuccessful in 108 (8.3%) cases involving 134 stents. Stenting was attempted as a primary procedure in 40%, as bailout in 18%, and for suboptimal angioplasty in 43% of cases. In 87% of cases, attempts were made to withdraw the stent from the coronary artery. Stent retrieval was successful in 45%, peripheral embolization occurred in 38% of patients, and in 4% the stent dislodged in the left main artery. In 35% of cases, additional stent(s) were successfully deployed. Deployment failure was associated with an overall in-hospital adverse outcome in 19% of patients, including 16% urgent coronary artery bypass grafting, 5% nonfatal myocardial infarction, and 3 in-hospital deaths. At 6-month follow-up, 39% of patients had had at least 1 adverse clinical outcome of death, myocardial infarction, or repeat target lesion revascularization. CONCLUSIONS: Failure to deploy stents is a serious and relatively common problem that is associated with significant morbidity and mortality rates. Improved deployment strategies, including new stent designs, are required to improve procedural outcomes.
Asunto(s)
Angioplastia Coronaria con Balón , Enfermedad Coronaria/terapia , Stents , Angiografía Coronaria , Falla de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Clinical trials of the glycoprotein (GP) IIb/IIIa inhibitors have shown that these potent antiplatelet agents are effective in reducing the ischemic complications of percutaneous coronary interventions. However, even though stents are now implanted in >75% of percutaneous interventional procedures, only one study, a trial of the monoclonal antibody abciximab, has formally evaluated adjunctive GP IIb/IIIa inhibition in this setting. METHODS AND RESULTS: Eptifibatide, a nonimmunogenic and rapidly reversible inhibitor of the platelet receptor integrin IIb/IIIa, has also undergone evaluation as an adjunct to coronary intervention. In clinical trials performed heretofore, however, it has appeared to have less relative clinical efficacy than the monoclonal antibody abciximab. Since the early seminal trials, it has been recognized that the doses of eptifibatide previously used achieved only 30% to 50% of maximal platelet GP IIb/IIIa integrin inhibition. This is considerably less than the 80% level of receptor inhibition that has been proposed to prevent coronary thrombus formation in animal models and that has been achieved in clinical trials with abciximab. CONCLUSIONS: The Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial was designed to test the safety and efficacy of a high-dose, "180/2.0/180" double-bolus regimen of eptifibatide (a 180-microg/kg bolus followed 10 minutes later by a second 180-microg/kg bolus of eptifibatide combined with a 2.0-microg/kg per minute infusion) as an adjunct to nonacute percutaneous coronary intervention with stent implantation. In this report, we review the rationale, design, and methods of this clinical investigation.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Enfermedad Coronaria/terapia , Oclusión de Injerto Vascular/prevención & control , Estudios Multicéntricos como Asunto/métodos , Péptidos/administración & dosificación , Inhibidores de Agregación Plaquetaria/administración & dosificación , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Proyectos de Investigación , Eptifibatida , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/mortalidad , Humanos , Inyecciones Intravenosas , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Tasa de SupervivenciaRESUMEN
The purpose of this study was to determine if closure of the femoral artery access site using a percutaneous arterial suture device (Perclose, Menlo Park, CA) in patients undergoing coronary stenting can result in the same benefits as seen with radial artery access. A total of 218 consecutive patients underwent coronary stenting (109 femoral, 109 radial) by investigators experienced with each technique. The two groups were matched in terms of sex, age, clinical presentation (50% acute), number of vessels and lesions stented, and lesion morphology. The relative costs of the femoral and radial procedures were examined using a decision analytic model and sensitivity analysis. The suture device was not used in 20/109 patients (18%) for anatomic reasons and failed to obtain hemostasis in 9/89 patients (10%). One radial patient had an occluded radial artery postprocedure, but this was recanalized at follow-up a month later. Primary success, procedural complications, postprocedure length of stay, and the percentage of patients discharged the same day were the same in both groups. Because of the added time to deploy Perclose, total procedure time was significantly longer in the femoral group (57 +/- 22 min femoral vs. 44 +/- 22 min radial, P < 0.01). Access site complications occurred only in the femoral group. More patients were ambulatory the same day of the procedure in the radial group (95% radial vs. 56% femoral, P < 0.01). The cost of the radial approach was substantially less than the femoral approach because of lower supply costs and fewer access complications. The transradial approach is a dominant strategy for coronary stenting, offering better outcomes at lower cost. Cathet. Cardiovasc. Intervent. 49:150-156, 2000.
Asunto(s)
Catéteres de Permanencia/efectos adversos , Arteria Femoral , Hemostasis Quirúrgica/métodos , Hemorragia Posoperatoria/cirugía , Arteria Radial , Stents , Técnicas de Sutura/instrumentación , Anciano , Angioplastia Coronaria con Balón , Catéteres de Permanencia/economía , Enfermedad Coronaria/terapia , Análisis Costo-Beneficio , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Hemostasis Quirúrgica/economía , Costos de Hospital , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/diagnóstico por imagen , Estudios Prospectivos , Arteria Radial/diagnóstico por imagen , Arteria Radial/cirugía , Técnicas de Sutura/economía , Resultado del Tratamiento , Ultrasonografía DopplerRESUMEN
Bailout stenting for major dissection and threatened closure has high rates of ischemic complications. We performed a randomized trial of local heparin delivery using the infusion sleeve before bailout stenting for suboptimal angioplasty results. In phase I, 20 patients were randomized to local delivery with either 40- or 100-psi infusion pressure. In phase II, 37 patients were randomized to local delivery at 100 psi or standard therapy. Local delivery succeeded in all but one patient; overall there was no significant worsening of intimal dissection. One patient treated with 100-psi drug infusion suffered a perforation after stent placement. There were no significant differences in the composite endpoint of death, MI, CABG, urgent repeat angioplasty, and stent thrombosis at 30 days (21% vs. 0%; P = 0.18). At 6 months, the rates of myocardial infarction in phase II were 27% with local delivery vs. 10% with standard treatment (P = 0.4). Local heparin delivery in dissected vessels may be associated with increased complications and should be approached with caution.