GSTM1 and GSTT1 Gene Polymorphisms with Gallbladder Carcinoma.

In order to explore the relationship between GSTM1 and GSTT1 gene polymorphisms and gallbladder cancer, so as to find a better treatment and prevention of gallbladder cancer and improve the treatment effect. In this paper, 247 patients with gallbladder cancer were selected for the experiment, including 187 male patients and 60 female patients. The total number of patients was randomly divided into two groups, namely the case group and the control group. The patients in normal condition and after treatment of tumor tissue and adjacent non-tumor tissue gene detection, and then through the logistic regression model to analyze the data. After the experiment, we found that the frequency ratio of GSTM1 and GSTT1 in gallbladder cancer patients before treatment was 57.33% and 52.37%, which was very high, which was very disadvantageous in gene detection. However, after treatment, the frequency of deletion of the two genes was 45.73% and 51.02%, which was significantly reduced. The reduced gene ratio is very beneficial to the observation of gallbladder cancer. Therefore, the surgical treatment of gallbladder cancer before the first drug after gene testing, in the understanding of various principles, will have twice the result with half the effort.

Akkermansia muciniphila improves gastric cancer treatment by modulating the immune microenvironment.

Background: Gut microbiota is pivotal in tumor occurrence and development, and there is a close relationship between Akkermansia muciniphila (AKK) and cancer immunotherapy. Methods: The effects of AKK and its outer membrane proteins on gastric cancer (GC) were evaluated in vitro and in vivo using cell counting kit-8 assay, flow cytometry, western blotting, ELISA, immunohistochemistry and immunofluorescence. Results: AKK outer membrane protein facilitated apoptosis of GC cells and exerted an immunostimulatory effect (by promoting M1 polarization of macrophages, enhancing expression of cytotoxic T-lymphocyte-related cytokines and suppressing that of Treg-related cytokines). Additionally, AKK and its formulation could inhibit tumor growth of GC and enhance the infiltration of immune cells in tumor tissues. Conclusion: AKK could improve GC treatment by modulating the immune microenvironment.

Akkermansia muciniphila (AKK) is a type of bacteria found in the human gut that is good for the immune system. We wanted to investigate the effect of AKK on cancer. We extracted a protein from AKK called Amuc. AKK and Amuc inhibited the growth of stomach cancer by encouraging the action of immune cells. AKK may therefore be able to treat stomach cancer.

Clinical significance of half-hepatic blood flow occlusion technology in patients with hepatocellular carcinoma with cirrhosis.

BACKGROUND: Most patients with primary hepatocellular carcinoma (HCC) have a history of chronic hepatitis B and usually present with varying degrees of cirrhosis. Owing to the special nature of liver anatomy, the blood vessel wall in the liver parenchyma is thin and prone to bleeding. Heavy bleeding and blood transfusion during hepatectomy are independent risk factors for liver cancer recurrence and death. Various clinical methods have been used to reduce intraoperative bleeding, and the Pringle method is most widely used to prevent blood flow to the liver. AIM: To investigate the effect of half-hepatic blood flow occlusion after patients with HCC and cirrhosis undergo hepatectomy. METHODS: This retrospective study included 88 patients with HCC and liver cirrhosis who underwent hepatectomy in our hospital from January 2017 to September 2020. Patients were divided into two groups based on the following treatment methods: the research group (n = 44), treated with half-hepatic blood flow occlusion technology and the control group (n = 44), treated with total hepatic occlusion. Differences in operation procedure, blood transfusion, liver function, tumor markers, serum inflammatory response, and incidence of surgical complications were compared between the groups. RESULTS: The operation lasted longer in the research group than in the control group (273.0 ± 24.8 min vs 256.3 ± 28.5 min, P < 0.05), and the postoperative anal exhaust time was shorter in the research group than in the control group (50.0 ± 9.7 min vs 55.1 ± 10.4 min, P < 0.05). There was no statistically significant difference in incision length, surgical bleeding, portal block time, drainage tube indwelling time, and hospital stay between the research and control groups (P > 0.05). Before surgery, there were no significant differences in serum alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin, and prealbumin levels between the research and control groups (P > 0.05). Conversely, 24 and 72 h after the operation the respective serum ALT (378.61 ± 77.49 U/L and 246.13 ± 54.06 U/L) and AST (355.30 ± 69.50 U/L and 223.47 ± 48.64 U/L) levels in the research group were significantly lower (P < 0.05) than those in the control group (ALT, 430.58 ± 83.67 U/L and 281.35 ± 59.61 U/L; AST, 416.49 ± 73.03 U/L and 248.62 ± 50.10 U/L). The operation complication rate did not significantly differ between the research group (15.91%) and the control group (22.73%; P > 0.05). CONCLUSION: Half-hepatic blood flow occlusion technology is more beneficial than total hepatic occlusion in reducing liver function injury in hepatectomy for patients with HCC and cirrhosis.

A prior myocardial infarction: how does it affect management and outcomes in recurrent acute coronary syndromes?

BACKGROUND: Despite improved secondary prevention efforts, acute coronary syndrome (ACS) recurrence among patients with prior history of coronary events remains high. The differences in presentation, management, and subsequent clinical outcomes in patients with and without a prior myocardial infarction (MI) and presenting with another episode of ACS remain unexplored. METHODS: A total of 3,624 consecutive patients admitted to the University of Michigan with ACS from January 1999 to June 2006 were studied retrospectively. In-hospital management, outcomes, and postdischarge outcomes such as death, stroke, and reinfarction in patients with and without a prior MI were compared. RESULTS: Patients with a prior MI were more likely to be older and have a higher incidence of diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease. In-hospital outcomes were not significantly different in the 2 groups, except for a higher incidence of cardiac arrest (4.3% versus 2.5%, p < 0.01) and cardiogenic shock (5.7% versus 3.9%, p = 0.01) among patients without a prior MI. However, at 6 mo postdischarge, the incidences of death (8.0% versus 4.5%, p < 0.0001) and recurrent MI (10.0% versus 5.1%, p < 0.0001) were significantly higher in patients with a prior history of MI compared with those without. CONCLUSION: Patients with prior MI with recurrent ACS remain at a higher risk of major adverse events on follow-up. This may be partly explained by the patients not being on optimal medications at presentation, as well as disease progression. Increased efforts must be directed at prevention of recurrent ACS, as well as further risk stratification of these patients to improve their overall outcomes.

Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: Earlier studies evaluating long-term survival in type A acute aortic dissection (TA-AAD) have been restricted to a small number of patients in single center experiences. We used data from a contemporary, multi-center international registry of TA-AAD patients to better understand factors associated with long-term survival. METHODS AND RESULTS: We examined 303 consecutive patients with TA-AAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2003. We included patients who were discharged alive and had documented clinical follow-up data. Kaplan-Meier survival curves were constructed to depict cumulative survival in patients from date of hospital discharge. Stepwise Cox proportional hazards analysis was performed to identify independent predictors of follow-up mortality. We found that 273 (90.1%) patients had been managed surgically and 30 (9.9%) were managed medically. Patients who were dead at follow-up were more likely to be older (63.9 versus 58.4 years, P=0.007) and to have had previous cardiac surgery (23.9% versus 10.6%, P=0.01). Survival for patients treated with surgery was 96.1%+/-2.4% and 90.5%+/-3.9% at 1 and 3 years versus 88.6%+/-12.2% and 68.7%+/-19.8% without surgery (mean follow-up overall, 2.8 years, log rank P=0.009). Multivariate analysis identified a history of atherosclerosis (relative risk (RR), 2.17; 95% confidence interval [CI], 1.08 to 4.37; P=0.03) and previous cardiac surgery (RR, 2.54; 95% CI, 1.16 to 5.57; P=0.02) as significant, independent predictors of follow-up mortality. CONCLUSIONS: Contemporary 1- and 3-year survival in patients with TA-AAD treated surgically are excellent. Independent predictors of survival during the follow-up period do not appear to be influenced by in-hospital risks but rather preexisting comorbidities.

Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: The clinical profiles and outcomes of patients treated surgically for acute type B aortic dissection (ABAD) are often reported for those in small series or for those cared for at a single institution over a long time period, during which a continuous evolution in techniques has occurred. Accordingly, we sought to evaluate the clinical features and surgical results of patients enrolled in the International Registry of Acute Aortic Dissection by identifying primary factors that influenced surgical outcome and estimating average surgical mortality for ABAD in the current era. METHODS AND RESULTS: A comprehensive analysis of 290 clinical variables and their relation to surgical outcomes for 82 patients who required surgery for ABAD (from a population of 1256 patients; mean+/-SD age, 60.6+/-15.0 years; 82.9% male) and who were enrolled in the International Registry of Acute Aortic Dissection was performed. The overall in-hospital mortality was 29.3%. Factors associated with increased surgical mortality based on univariate analysis were preoperative coma or altered consciousness, partial thrombosis of the false lumen, evidence of periaortic hematoma on diagnostic imaging, descending aortic diameter >6 cm, right ventricle dysfunction at surgery, and shorter time from the onset of symptoms to surgery. Factors associated with favorable outcomes included radiating pain, normotension at surgery (systolic blood pressure 100 to 149 mm Hg), and reduced hypothermic circulatory arrest time. The 2 independent predictors of surgical mortality were age >70 years (odds ratio, 4.32; 95% confidence interval, 1.30 to 14.34) and preoperative shock/hypotension (odds ratio, 6.05; 95% confidence interval, 1.12 to 32.49). CONCLUSIONS: The present study provides insights into current-day clinical profiles and surgical outcomes of ABAD. Knowledge about different preoperative clinical conditions may help surgeons in making treatment decisions among these high-risk patients.

Prognostic role of transesophageal echocardiography in acute type A aortic dissection.

BACKGROUND: Acute type A aortic dissection (AAD) remains a highly lethal entity for which emergent surgical correction is standard care. Prior studies have identified specific clinical findings as being predictive of outcome. The prognostic significance of specific findings on imaging studies is less well described. We sought to identify the prognostic value of transesophageal echocardiography (TEE) in medically and surgically treated patients with AAD. METHODS: We studied 522 AAD patients enrolled over 6 years in the International Registry of Acute Aortic Dissection who underwent TEE. Multivariate analysis identified independent associations of inhospital mortality, first using clinical variables (model 1), after which TEE data were added to build a final model (model 2). RESULTS: Inhospital mortality was 28.7%. Transesophageal echocardiographic evidences of pericardial effusion (P = .04), tamponade (P < .01), periaortic hematoma (P = .02), and patent false lumen (P = .08) were more frequent in nonsurvivors. Dilated ascending aorta (P = .03), dissection localized to the ascending aorta (P = .02), and thrombosed false lumen (P = .08) were less common in nonsurvivors. Model 1 identified age > or = 70 years, any pulse deficit, renal failure, and hypotension/shock as independent predictors of death. Model 2 identified dissection flap confined to ascending aorta (odds ratio 0.2, 95% CI 0.1-0.6) and complete thrombosis of false lumen (odds ratio 0.15, 95% CI 0.03-0.86) as protective. In the medically treated group, mortality was 31% for subjects with a partially or completely thrombosed false lumen versus 66% in the presence of a patent false lumen. CONCLUSIONS: Transesophageal echocardiography provides prognostic information in AAD beyond that provided by clinical risk variables.

Prognostic value of transient and sustained increase in in-hospital creatinine on outcomes of patients admitted with acute coronary syndrome.

A history of renal insufficiency or increased creatinine level on admission is associated with poor outcomes in patients with acute coronary syndrome (ACS). This study sought to determine whether in-hospital worsening of renal function, either transient or sustained, is an independent risk factor for 6-month mortality in patients admitted with ACS. A total of 1,417 patients admitted with ACS from June 2000 to May 2003 were reviewed. Patients were classified into 3 groups. Group I included patients with an increase in creatinine during hospitalization of 0.5 mg/dl that resolved by discharge. Group III included patients with an increase in creatinine of >0.5 mg/dl that did not resolve. The primary end point was 6-month mortality from any cause. Patients in groups II and III had higher 6-month mortality rates (27% and 23%, respectively; both p<0.001) compared with patients in group I (7.4%). After adjustment for known risk factors, a transient increase in creatinine remained a significant independent predictor of 6-month mortality (odds ratio 2.07, 95% confidence interval 1.14 to 3.76), although a sustained increase in creatinine showed a trend (odds ratio 1.58, 95% confidence interval 0.68 to 3.70). In conclusion, independent of a history of renal insufficiency or increased admission creatinine, in-hospital worsening of renal function is an important risk factor for 6-month mortality in patients admitted with ACS. Furthermore, return to baseline function by discharge does not protect against this risk. These findings have implications for management of these high-risk patients.

Valve surgery in octogenarians: in-hospital and long-term outcomes.

BACKGROUND: Global population aging and greater age-related incidence of ischemic, degenerative and calcific valve disease have led to an increasing number of very elderly patients being referred for valve surgery. However, their preoperative risk factors, and in-hospital and long-term outcomes have not been thoroughly investigated. METHODS: Three hundred seven consecutive patients 80 years and older (60% female; mean age 83+/-2.4 years) attending three major Italian cardiac centres to undergo valve surgery were evaluated. Seventy-nine patients underwent mitral valve surgery (isolated n=30, combined n=49) and 228 underwent aortic valve surgery (isolated n=134, combined n=94). RESULTS: The most frequent in-hospital complications were atrial arrhythmias, need for inotropic support for more than 48 h, renal insufficiency, congestive heart failure, respiratory failure, and stroke or transient ischemic attack. The in-hospital mortality rate was 9.7% (30 of 307). Multivariate logistic regression identified the following clinical variables as predictors of in-hospital death: New York Heart Association functional class IV, diabetes, hypertension, renal insufficiency at presentation, rheumatic etiology and left ventricular ejection fraction of less than 45%. Late mortality occurred in 45 of 277 patients (16.2%), but there was a substantial improvement in the New York Heart Association functional class of the 232 long-term survivors (from 3.0+/-0.7 to 1.7+/-0.6; P<0.0001). CONCLUSIONS: Surgery seems to be an effective therapeutic option for selected symptomatic octogenarians with valve disease, associated with good long-term survival and an improved functional class. Operative mortality is related more to patients' preoperative clinical status and increased comorbidity than the type of surgery per se.

Symptoms of men and women presenting with acute coronary syndromes.

This study evaluated symptom similarities and differences between men and women presenting with acute coronary syndromes (ACSs) and determined whether differences in presentation are intrinsic to patient gender or to other factors. This study was a subgroup analysis of patients from an ACS registry. We compared differences in symptom presentation between men and women and analyzed them using binary logistic regression with all variables and 2 x 2 interactions. Patient gender was forced to remain in the models. Women comprised 35% of the 1,941 patients admitted with confirmed ACS. Men were more likely to present with chest pain, left arm pain, or diaphoresis. Nausea was more common in women. Dyspnea did not differ between groups. After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest or left arm pain. We found that differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness. In conclusion, gender should be considered when evaluating patients with symptoms of ACS.

Acute limb ischemia associated with type B aortic dissection: clinical relevance and therapy.

BACKGROUND: The goal of the current study is to characterize the presentation, therapy, and outcomes of acute limb ischemia (ALI) associated with type B aortic dissection (AoD). METHODS: The prospective/retrospective International Registry for Acute Aortic Dissection (IRAD) database and a single institutional database were queried for all patients with type B AoD from 1996 to 2002. Univariate and multivariate statistics were used to delineate factors associated with morbidity and mortality outcomes. RESULTS: According to the IRAD data (n = 458), the mean age of patients was 64 years, and 70% were men. The overall mortality was 12%; of these, 6% had ALI. Pulse (3-fold) and neurologic deficits (5-fold) were more common in those with ALI (P < .001). Endovascular, but not surgical therapy, was more commonly performed in patients with ALI compared with those without ALI (31% vs 10%, P = .004). No difference in age, race, gender, or origin of dissection was observed. ALI was associated with acute renal failure (odds ratio [OR] = 2.7; 95% confidence interval [CI] 1.1-7.1; P = .048) and acute mesenteric ischemia/infarction (OR = 6.9; 95% CI 2.5-20; P < .001). Adjusting for patient characteristics, ALI was associated with death (3.5; 95% CI 1.1-10; P = .02). The single institution analysis revealed similar patient demographics and mortality in 93 AoD patients, of whom 28 had ALI. Aortic fenestration or aorto-iliac stenting was the primary therapy in 93%; surgical bypass was used in 7%. Limb salvage was 93% in those with ALI at a mean of 18 months follow-up. The number of organ systems with malperfusion was 2-fold higher at aortography than suspected preprocedure (P = .002). By stepwise regression modeling, mortality was greater in those not taking a beta-blocker (OR = 19; 95% CI 3.1-111; P = .001). CONCLUSIONS: ALI secondary to AoD is predictive of death and visceral ischemia. Endovascular therapy confers excellent limb salvage and allows diagnosis of unsuspected visceral ischemia.

The impact of time and day on the presentation of acute coronary syndromes.

BACKGROUND: The frequency of acute myocardial infarction (AMI) peaks on Mondays and in the mornings. However, the distribution of the types of acute coronary syndromes (ACS), including unstable angina (UA), has not been systematically evaluated. HYPOTHESIS: The distribution of the types of ACS and clinical presentations varies by time and day of admission. METHODS: A retrospective cohort study was conducted in 1,946 consecutive nontransfer ACS admissions (1999-2004) to a tertiary-care academic center to assess presenting clinical variables in patients admitted on days versus nights (6 P.M.-6 A.M.) and weekdays versus weekends (Friday 6 P.M.-Monday 6 A.M.). RESULTS: There were fewer ACS admissions than expected on nights and weekends (p < 0.001), but the proportion of patients with ACS presenting with ST-elevation myocardial infarction (STEMI) is 64% higher on weekends (p < 0.001) and 31% higher on nights (p = 0.022). This increased proportion with STEMI results in a greater proportion of ACS with AMI on weekends (up arrow 10%, p = 0.006) and nights (up arrow 7%, p = 0.033). Using multivariate modeling, the increase in patients with AMI on weekends was not explained by conventional risk predictors. CONCLUSIONS: Although fewer patients with ACS presented on nights and weekends, patients at those times were more likely to have an AMI, driven largely by an increased proportion with STEMI at those times. Consideration should be given to these findings when developing clinical care paradigms, health care staffing needs, and when comparing new treatment outcomes in patients with ACS.

Potential impact of the HIPAA privacy rule on data collection in a registry of patients with acute coronary syndrome.

BACKGROUND: Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule has the potential to affect data collection in outcomes research. METHODS: To examine the extent to which data collection may be affected by the HIPAA Privacy Rule, we used a quasi-experimental pretest-posttest study design to assess participation rates with informed consent in 2 cohorts of patients eligible for the University of Michigan Acute Coronary Syndrome registry. The pre-HIPAA period included telephone interviews conducted at 6 months that sought verbal informed consent from patients. In the post-HIPAA period, informed consent forms were mailed to ask for permission to call to conduct a telephone interview. The primary outcome measure was the percentage of patients who provided consent. Incremental costs associated with the post-HIPAA period were also assessed. RESULTS: The pre-HIPAA period included 1221 consecutive patients with acute coronary syndrome, and the post-HIPAA period included 967 patients. Consent for follow-up declined from 96.4% in the pre-HIPAA period to 34.0% in the post-HIPAA period (P<.01). In general, patients who returned written consent forms during the post-HIPAA period were older, were more likely to be married, and had lower mortality rates at 6 months. Incremental costs for complying with the HIPAA Privacy Rule were $8704.50 for the first year and $4558.50 annually thereafter. CONCLUSIONS: The HIPAA Privacy Rule significantly decreases the number of patients available for outcomes research and introduces selection bias in data collection for patient registries.

Low utilization of secondary preventive medications and its potential impact in patients with chronic kidney disease and acute coronary syndromes.

BACKGROUND: An estimated 11% of the population of the USA has chronic kidney disease. Cardiovascular morbidity and mortality are high among these individuals. We evaluated the impact of evidence-based, secondary preventive medications on the overall clinical outcome among this population. METHODS: We observed 2,627 consecutive patients admitted to our institution for acute coronary syndrome. The glomerular filtration rate was estimated by the four-component Modification of Diet in Renal Disease equation and the patients were stratified into groups on the basis of the guidelines of the National Kidney Foundation. Mortality and the composite event rate of death, myocardial infarction and stroke were assessed at six months. We evaluated the impact of evidence-based medications as an independent predictor of outcomes, using a logistic regression analysis. RESULTS- Patients with a relatively greater decline in the glomerular filtration rate had poorer outcomes, both in hospital and at six-month follow-up. Among those with stages III-V of chronic kidney disease, the use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) was associated with 44% lower odds of death (95% CI: 0.14-0.63), as well as 40% lower odds of the composite end-point (95% CI: 0.13-0.59) at six months. CONCLUSION: Chronic kidney disease was independently associated with mortality and major adverse cardiovascular events in a hospital registry of consecutive patients with acute coronary syndrome. Our results add to the existing body of evidence that more appropriate use of evidence-based medications, particularly statins, may significantly improve clinical outcomes in these highndash;risk patients. We should aim to improve the quality of treatment options available to patients suffering from both conditions.

Early statin therapy in elderly patients presenting with acute coronary syndrome causing less heart failure.

OBJECTIVES: Elderly patients are less likely to receive statin therapy because of concerns about their side-effects. However, 80% of deaths related to coronary heart disease occur in patients above the age of 65 years. This study evaluated the potential benefit of early administration of statins in elderly patients presenting with an acute coronary syndrome. METHODS: This was a prospective cohort study of 774 elderly patients (>65 years) with acute coronary syndrome. The patients were divided into two groups. The first group, consisting of 611 patients, received statins within the first 24 hours of admission, while the second group, consisting of 163 patients, received statins after the first 24 hours. The end points studied included death, heart failure/pulmonary edema, stroke and recurrent myocardial infarction during hospitalization. RESULTS: Multivariable logistic regression analysis, adjusting for baseline demographics, co-morbidities and chronic statin therapy, showed that the occurrence of heart failure/pulmonary edema during hospitalization was relatively lower among those who received statins within 24 hours of admission (odds ratio: 0.5, 95% CI: 0.27-0.94, p=0.03). The C statistic for the model was 0.79. CONCLUSION: Elderly patients presenting with acute coronary syndrome seem to benefit from early statin therapy, and have significantly lower rates of heart failure and pulmonary edema than those who are administered statins at a later stage.

Smoking cessation in patients with acute coronary syndrome.

BACKGROUND, In patients with acute coronary syndrome, smoking cessation rates, demographics, and management strategies havenot been well described. We hypothesized that hospitalized patients with acute coronary syndrome would have higher smoking cessation rates than other currently available therapies. In-hospital counseling and referral to cardiac rehabilitation may further improve cessation rates. METHODS, We reviewed 1098 consecutive admissions for acute coronary syndrome at the University of Michigan; 254 of thesepatients reported active smoking status on admission. Patients were divided into (i) those who continued smoking and (ii) those who quit smoking based on a 6-month telephonic interview. Clinical variables, management and therapies were com-pared for the two cohorts. RESULTS, The mean age of the 254 patients was 56 years and 65% were male. At six months, 49.2% of patients had quit smok-ing. Significant predictors of smoking cessation were coronary artery bypass grafting, pulmonary artery catheter placement, and need for mechanical ventilation. Patients who underwent cardiac rehabilitation post-discharge had a trendtoward higher cessation rates. Formal counseling during hospitalization did not seem to affect cessation rates. CONCLUSIONS, In this study, patients with acute coronary syndrome had a higher 6-month smoking cessation rate than previously published rates seen in ambulatory practice, and the more severely ill patients had higher cessation rates. Smoking cessation rates were not higher in those who received in-patient smoking counseling.

Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes.

BACKGROUND: Several individual pharmacological agents, such as antiplatelet drugs, beta-blockers, ACE inhibitors, and lipid-lowering agents, have proven efficacy in reducing mortality in patients with acute coronary syndromes. However, the impact of the combination of these agents on clinical outcomes has not been studied before. METHODS AND RESULTS: A total of 1358 consecutive patients presenting with acute coronary syndromes between January 1999 and March 2002 were identified, and data on baseline demographics, comorbidities, and in-hospital management were collected. On the basis of discharge use of evidence-based therapies, we created a composite appropriateness score depending on the number of the drugs used divided by the number of the drugs potentially indicated for each patient. The impact of the composite score on 6-month mortality was analyzed using a risk-adjusted logistic regression model. The odds ratio for death for all indicated medications used (appropriateness level IV) versus none of the indicated medications used (appropriateness level 0) was 0.10 (95% CI, 0.03 to 0.42; P<0.0001); similarly, odds ratio for appropriateness level III versus level 0 was 0.17 (95% CI, 0.04 to 0.75; P=0.0018), odds ratio for appropriateness level II versus level 0 was 0.18 (95% CI, 0.04 to 0.77; P=0.01), and odds ratio for appropriateness level I versus level 0 was 0.36 (95% CI, 0.08 to 1.75; P=0.20). CONCLUSIONS: Use of combination evidence-based medical therapies was independently and strongly associated with lower 6-month mortality in patients with acute coronary syndromes. Such therapies, most of which are generic and inexpensive today, seem to offer a marked survival advantage compared with patients in whom such therapies are omitted.

Gender-related differences in acute aortic dissection.

BACKGROUND: Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD). METHODS AND RESULTS: Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics. CONCLUSIONS: Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Differences in clinical presentation, management, and outcomes of acute type a aortic dissection in patients with and without previous cardiac surgery.

BACKGROUND: There are less data on the clinical and diagnostic imaging characteristics, management, and outcomes of patients with previous cardiac surgery (PCS) presenting with acute type A aortic dissection (AAD). METHODS AND RESULTS: In 617 patients with AAD, we evaluated the differences in the clinical characteristics, management, and in-hospital outcomes of the cohorts with and without PCS. A history of PCS was present in 100 of 617 patients. Patients with PCS were more likely to be males (P=0.02), older (P=0.014), and to have a history of previous aortic dissection (P<0.001) or aneurysms (P<0.001). In contrast, PCS patients were less likely to have presenting chest pain (P<0.001). Cardiac tamponade was less common in PCS patients (P=0.007). Fewer AAD patients with PCS underwent surgical repair (P=0.001). Hospital mortality was not adversely influenced by PCS (odds ratio [OR], 1.46; 95% confidence interval [CI], 0.81 to 2.63), but a trend for increased death was seen in patients with previous aortic valve replacement (AVR) (OR, 2.31; 95% CI, 0.98 to 5.43). Age 70 years or older, previous AVR, shock, and renal failure identified PCS patients at risk for death. CONCLUSIONS: Our study highlights differences in clinical characteristics, management, and outcomes of AAD patients with PCS. Importantly, PCS, with the exception of previous AVR, does not adversely influence early outcomes of AAD patients, including those undergoing surgical repair. However, because of otherwise dismal outcomes with medical management of AAD, our data indicate that a history of PCS (even that of previous AVR) should not preclude physicians from recommending surgical correction of type A aortic dissection in appropriate patients.

Characterizing the young patient with aortic dissection: results from the International Registry of Aortic Dissection (IRAD).

OBJECTIVES: The goal of this study was to better characterize the young patient with aortic dissection (AoD). BACKGROUND: Aortic dissection is unusual in young patients, and frequently associated with unusual presentations. METHODS: Data were collected on 951 patients diagnosed with AoD between January 1996 and November 2001. Two categories of patients, <40 years and >or=40 years, were compared using chi-square cross tabulations for categorical and Student t test for continuous data. RESULTS: Sixty-eight patients (7%) with AoD were <40 years of age. Compared with patients >or=40 years, younger patients were less likely to have a prior history of hypertension (p < 0.05); however, younger patients were more likely to have Marfan syndrome, bicuspid aortic valve, and prior aortic surgery (all, p < 0.05). Clinical presentations in the two age groups were similar; however, younger patients were less likely to be hypertensive (25% vs. 45%, p = 0.003). The proximal aortas of young AoD patients were larger (all, p < 0.05) compared with older patients. These differences in aortic size between age groups were not entirely related to Marfan syndrome. Mortality among young patients was similar to patients >or=40 years of age (22% vs. 24%, p = NS), irrespective of the site of dissection. CONCLUSIONS: Compared with older patients with AoD, young patients have unique risk factors for dissection: Marfan syndrome, bicuspid aortic valves, and larger aortic dimensions. Surprisingly, the mortality risk for young AoD patients is not lower than older AoD patients.